1. Gen Path Lab 10-16-08 MHD Normal Pictures are from internets
Pathology Pictures are from Robbins
Other stuff was on MHD Website
Jackie 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 urine
What is the organ?
Kidney, gross—see light colored (pale) parts, kind of wedge-shaped=think necrosis
Also see a clot up above the necrotic area indicating ischemia
Kidney, histology—see some blood (vascular congestion) around the light colored pale parts on virtual microscopy
Don’t forget to identify glomerulus and neighboring tubule
In area of infarct Glomerulus have lost nuclei---nuclei are ghosts
You do see some nuclei—those cells are neutrophils (leukocytes)
Been called b/c the cells are dying—the cytoplasm leak initiates the acute response
Characteristic 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 tissue
Vessels dilated with RBC
Pathologic Process? Ischemic or Infarct Necrosis
Why? 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 normal
and 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 necrotic
and normal kidney.

5. Normal Kidney Glomerulus Note cells have nuclei!

6. Figure 1-19 Coagulative and liquefactive necrosis
Figure 1-19 Coagulative and liquefactive necrosis. A, Kidney infarct exhibiting coagulative necrosis, with loss of nuclei and clumping of cytoplasm but with preservation of basic outlines of glomerular and tubular architecture.
B, A focus of liquefactive necrosis in the kidney caused by fungal infection. The focus is filled with white cells and cellular debris, creating a renal abscess that obliterates the normal architecture.
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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 irritation
Inflammatory response
Hemoptysis
Coughing up the blood that is in his alveolus from the other circulation
He has metastatic colon cancer and a swollen left leg.
Swollen leg makes us think DVT to the lung
Remember cancer patients are hypercoagulable
Also immobility will cause clots to form

8. Case 2
On virtual histology you see lots of blood in the alveolar spaces
Note you can tell arteries b/c they have more thick walls
There are some pulmonary artery thrombi
When you look on the walls of the thrombi you see strands, it is starting to set
This is a Hemorrhagic Necrosis (infarct)
Why? The lung has a dual blood supply
One blood supply is infarcted, and the other blood supply bleeds into it
What 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 kidney
It 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 shaped
Pulmonary infarcts are typically pyramidal with base at the pleura
Only about 10% of pulmonary emboli actually cause infarction.
Why?
In patients with adequate cardiovascular function, the bronchial arterial supply
can often sustain the lung parenchyma despite obstruction
of the pulmonary arterial system. .

11. Hemorrhage into
infarcted lung
alveoli
Infarcted alveolar septa
(note no nuclei—are “ghost like”)

12. Pulmonary arterial thrombus

13. Figure 4-17 Large “saddle” embolus derived from a lower extremity deep venous thrombosis and now impacted in a pulmonary artery branch.
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14. B, Sharply demarcated white infarct in the spleen.
Figure 4-19 Examples of infarcts. A, Hemorrhagic, roughly wedge-shaped pulmonary infarct.
B, Sharply demarcated white infarct in the spleen.
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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, grossly
See fibrinous exudate (do not write “pus” in patient charts)
See normal pink on left hand side, then see dark purple area
Appendicitis, virtual histology
see neutrophils—look for their segmented nucleus
They are filling the lumen along with the purulent exudate
Cells with orange granules—eosinophils
Mononuclear cells are probably lymphocytes
Look at serosal surface (the outside)—see pink strands w/lymphocytes, that is the fibrinous exudate (white) that we saw grossly on the surface
Look at mucosal surface—is partially necrotic

17. Mucosal
necrosis
Be sure to compare
acutely inflamed
appendix with normal
appendix
Inflammation throughout all layers of appendix

18. Normal Appendix

19. Serosal inflammation, predominantly neutrophils

20. For comparison, a normal appendix is shown above.
Figure Acute appendicitis. The inflamed appendix shown below is red, swollen, and covered with a fibrinous exudate.
For comparison, a normal appendix is shown above.
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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 diverticulum
Food retention, multiple episodes of infection
Tags on body parts-A for autopsy; S for Surgical resection
Note that inflammation of prolonged duration—active inflammation, tissue destruction, attempts at repair are proceeding simultaneously
Presence of Mononuclear cells: Macrophage, Lymphocytes and Plasma Cells
Healing will be by fibrosis

22. Esophageal
mucosa
Submucosal chronic inflammation—see ink-drop looking cells
Which are lymphocytes (don’t see multi-segmented cells)
Remember plasma cells have nucleus on side and “tail” of cytoplasm along it

23. Mononuclear inflammatory cells, predominantly lymphocytes
THINK CHRONIC INFLAMMATION;
Non-granulomatous (no granulomas w/frustrated TMMI)

24. Normal Esophagus w/clean submucosa

25. General Pathology Concepts, Case 6 Tuberculosis: Caseous Necrosis
54 year-old male with low-grade fever, cough and weight loss for 2 months
Man 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 lymph
The cut surface of the lung reveals a subpleural granuloma (arrow).
The subcarinal lymph nodes contain caseating necrosis (*).

27. Caseating
granuloma
Central necrosis
Normal looking alveoli

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 inflammation
Granulomas 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, lymphocytes
and a giant cell (arrow).

30. necrosis
Activated (epithelioid) macrophages

31. TB says “Hi! I’m in your macrophage causing problems!”

32. Figure 8-30 Primary pulmonary tuberculosis,
Ghon complex.
Ghon complex just means that the caseous necrosis is both in the lung and in the lymph node.
The gray-white parenchymal focus is under the pleura in the lower part of the upper lobe. Hilar lymph nodes with caseation are seen on the left.
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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 Histology
Cervix should only have a simple columnar epithelium, glands come to surface in endocervix
This cervix has a huge lining to it—metaplasia
Stratified squamous instead
Metaplasia just means one mature type of cell is replaced by another mature type
Note that the lung goes from columnar to squamous when there is smoking
Why 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 partially
lined by simple columnar epithelium (arrow).

36. Normal Cervix simple columnar epithelium

37. Normal on Left, Metaplasia on Right. Cervix.

38. Figure 1-7 Squamous dysplasia of the cervix, a precursor of squamous cell carcinoma.
There is a lack of orientation of the squamous cells throughout the upper two thirds of the epithelium. Many of the nuclei are enlarged, are hyperchromatic, and have irregular nuclear margins.
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39. General Pathology Concepts, Case 11: Lipoma
40 year-old female with subcutaneous nodule in outer thigh.
Was non-tender, soft, movable
Nodule was excised, and the cut surface was yellow and lobulated
Looks encapsulated, is well-circumscribed
Encapsulated 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 neoplasm
On virtual histology note the capsule on the edges
The fat cells are not trying to penetrate the capsule
Fat cells just look like spaces
Well differentiated adipocytes with no evidence of atypia

41. Thin fibrous capsule
adipocytes

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/IVC
D = Duodenum (except for its first portion)
P = Pancreas (the head and neck of the pancreas (but not the tail)
U = Ureters
C = Colon (only the ascending and descending branches, but not the transverse or sigmoid )
K = Kidneys
E = Esophagus
R = Rectum
Also- 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 legs
Right ureter—increased pressure to kidney (hydronephrosis)
Retroperitoneal mass
Malignant 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 fibrocytes
They are infiltrating the fat and are highly atypical (pleomorphic)
See mitotic figures on virtual histology
This is not good—you usually see mitotic figures in malignancy
No capsule—it is infiltrating things—look at interface
The cells do not look like normal cells, they are atypic

45. On low power, high cellularity is appreciated.

46. mitosis
The neoplastic cells are highly atypical, pleomorphic and have
large, 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 encapsulated
Encapsulated tissue is compressed by the slowly expanding tumor
When 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 - Breast
Description: The surgical specimen consists of a bisected fibroadenoma.
The neoplasm is well circumscribed, grey-white and multilobated.

49. Adipose tissue
“Capsule” and compressed breast tissue
Stromal component
Epithelial component

50. Stroma with well differentiated cells which lack atypia
Epithelial cells, lack atypia (are uniform, do not vary in size or shape)

51. Figure Fibroadenoma showing compressed, elongated ducts surrounded by neoplastic stromal tissue.
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52. Figure 23-1 Normal breast anatomy and anatomical location of common breast lesions.
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53. Figure 7-14 Fibroadenoma of the breast.
The tan-colored, encapsulated small tumor is sharply demarcated from the whiter breast tissue.
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54. Figure 23-28 A, This mammogram shows a well-circumscribed mass
Figure A, This mammogram shows a well-circumscribed mass. Although the most common lesion would be a fibroadenoma, other benign (e.g., fibrous lesions or PASH) and malignant (e.g., medullary or mucinous carcinomas) lesions can also have this appearance. B, Fibroadenoma. A rubbery, white, well-circumscribed mass is clearly demarcated from the surrounding yellow adipose tissue. The fibroadenoma does not contain adipose tissue and therefore appears denser than the surrounding normal tissue on mammogram.
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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 neoplasm
Tumors 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 pearl
Malignant squamous cells trying to re-capitulate and mimic normal squamous mucosa
by forming keratin pearl

58. Intracell bridges
Mitosis
Nests of atypical, pleomorphic
squamous 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 cancer
Causes
Chronic irritation (e.g., dentures)
All forms of tobacco use, alcohol abuse, human papillomavirus (HPV)
Locations
Vermilion border lower lip (most common site)
Buccal mucosa, hard and soft palates, floor of the mouth

60. Figure 17-3/Goljan: Leukoplakia of the tongue with invasive squamous cell carcinoma. Discrete raised white patches are evident on both sides of the tongue.
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