(Optionally: A. Container is labeled - __. The specimen is received in formalin and consists of ) 1 fragment(s) of pink-tan tissue with a vaguely recognizable mucosal surface. The tissue measures __ cm. (The surgical margin is inked black. The specimen is bisected and entirely submitted for microscopic examination in one cassette.)
Microscopic evaluation
Anatomic/Histologic location
Describe mucosa as squamous (or ectocervical), endocervical (generally mucinous and glandular) or transformation zone mucosa.
Squamous (or ectocervical) mucosa at left and endocervical (mucinous) mucosa at right, in an example with abrupt transition.
Transformation zone mucosa, consisting of a mix of stratified squamous epithelium and mucinous glands, in an example with gradual transition.
Endocervical mucosa, with mucinous columnar epithelium and mucinous glands. H&E stain
However, the endocervical mucosa may appear columnar and non-mucinous.
A cervical biopsy may contain nabothian cysts, which are single or multiple cysts that contain mucin, lined by a single layer of columnar, cuboidal to flat cells with variable amounts of mucinous cytoplasm and small, basal, round to oval nuclei with fine chromatin, without conspicuous nucleoli or mitotic activity.[1]
The anatomic level of the transformation zone varies:[2] Type 1: Completely ectocervical (common under hormonal influence). Type 2: Endocervical component but fully visible (common before puberty). Type 3: Endocervical component, not fully visible (common after menopause).
If you see fragments of non-mucinous epithelium and glands, it is likely endometrial, so evaluate it like an endometrial curetting.
Pathologies
edit
Look for cervical dysplasia. It is mainly seen as nuclei with hyperchromasia, coarse chromatin and irregular contours.[3]
Spectrum from normal to high grade SIL.[4]
Further information: Cervical dysplasia
edit Other common findings:
Acute cervicitis, having a largely neutrophilic intra-epithelial infiltrate.
Endocervical polyp: With endocervical epithelium and glands (mucinous columnar linings), edematous stroma and clear congestion. H&E stain.[5]
Example report
Endocervix, curettings: Fragments of squamous and endocervical glandular epithelium without significant histopathologic changes. Negative for dysplasia.
|
Notes
- ↑ For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
Main page
References
- ↑ Gulisa Turashvili, M.D., Ph.D.. Cervix Benign / nonneoplastic epithelial lesions. Nabothian cysts.. Pathology Outlines. Last author update: 1 February 2021. Last staff update: 4 April 2022}}
- ↑ International Federation for Cervical Pathology and Colposcopy (IFCPC) classification. References:
-. Transformation zone (TZ) and cervical excision types. Royal College of Pathologists of Australasia. - Jordan, J.; Arbyn, M.; Martin-Hirsch, P.; Schenck, U.; Baldauf, J-J.; Da Silva, D.; Anttila, A.; Nieminen, P.; et al. (2008). "European guidelines for quality assurance in cervical cancer screening: recommendations for clinical management of abnormal cervical cytology, part 1
". Cytopathology 19 (6): 342–354. doi:10.1111/j.1365-2303.2008.00623.x. ISSN 0956-5507. PMID 19040546.
- ↑ Khaled J. Alkhateeb, M.B.B.S., Ziyan T. Salih, M.D.. HSIL / CIN II / CIN III. PathologyOutlines. Topic Completed: 29 March 2021. Minor changes: 9 February 2022
- ↑ Source image by Ed Uthman from Houston, TX, USA. Creative Commons Attribution 2.0 Generic (CC BY 2.0) license
- ↑ Anissa Ben Amor.. Cervical Ectropion. StatPearls, National Center for Biotechnology Information. Last Update: November 14, 2021.
- This book is distributed under the terms of the Creative Commons Attribution 4.0 International License
Image sources
Cervical cone
Unless otherwise specified, the primary focus is any cervical neoplasia.
Fixation
Generally 10% neutral buffered formalin.
See also: General notes on fixation
Gross processing
- Measure length, as well as the transverse and sagittal diameter of the ectocervical surface.[1]
- Optionally, weight the sample.[1]
- Note the symmetry of the sample, and the position of the cervical canal.[1]
- Note whether the circumference is complete. If not, and the directions are indicated on the cone, determine the approximate position of the defect.[1]
- Cones excised by knife should be inked on the excision surfaces. Those excised by laser do not need inking.[1]
Selection and trimming
- If the cone is more than 1 cm long, take transverse slices from the top of the cone and towards the ectocervix, and stop when approximately 1 cm of the ectocervical portion of the cone remains.
- Cut the portion into radial or sagittal slices. Sagittal slices are made perpendicularly to the portion surface, and should be divided into at least the four quadrants.[note 1][1]
In cases where the cone is small and fragmented, try to orient the preparations and divide them if possible to obtain sagittal slices.[1]
See also: General notes on gross processing
Microscopic evaluation
Anatomic/Histologic location
Describe mucosa as squamous (or ectocervical), endocervical (generally mucinous and glandular) and/or transformation zone mucosa.
Squamous (or ectocervical) mucosa at left and endocervical (mucinous) mucosa at right, in an example with abrupt transition.
Transformation zone mucosa, consisting of a mix of stratified squamous epithelium and mucinous glands, in an example with gradual transition.
Endocervical mucosa, with mucinous columnar epithelium and mucinous glands. H&E stain
The anatomic level of the transformation zone varies:[2] Type 1: Completely ectocervical (common under hormonal influence). Type 2: Endocervical component but fully visible (common before puberty). Type 3: Endocervical component, not fully visible (common after menopause).
Cervical dysplasia
edit
Look for cervical dysplasia. It is mainly seen as nuclei with hyperchromasia, coarse chromatin and irregular contours.[3]
Spectrum from normal to high grade SIL.[4]
Further information: Cervical dysplasia
Radicality
Locations of non-radicality should be reported in relation to tissue markings (such as needles), or in terms of quadrants or corresponding to a clock face, based on the patient being in supine position.
Look whether there is normal epithelium on each side of all slices where neoplasia is seen, and when the epithelium is missing in any direction, consider ordering additional serial sections or step sections.
HPV changes
Also look koilocytic changes of human papillomavirus (HPV), with such cells typically displaying:
- Nuclear enlargement (two to three times normal size).
- Irregularity of the nuclear membrane contour, creating a wrinkled or raisinoid appearance.
- A darker than normal staining pattern in the nucleus, known as hyperchromasia.
- Perinuclear cytoplasmic vacuolization ("nuclear halo").
Other findings
edit Other common findings:
Acute cervicitis, having a largely neutrophilic intra-epithelial infiltrate.
Endocervical polyp: With endocervical epithelium and glands (mucinous columnar linings), edematous stroma and clear congestion. H&E stain.[5]
Microscopy report
If a neoplasia is found, the report should include:[1]
- The histolopathological type and degree of differentiation
- Location and extent
- Radicality
High-grade squamous intraepithelial lesion (CIN-2), present at 3:00 to 12:00. All margins of excision are negative for CIN-2.
|
Example report in a normal case:
Cervix at transformation zone without significant histopathologic changes. Negative for neoplasia/carcinoma.
|
Endometrial polyp
Author:
Mikael Häggström [note 2]
Comprehensiveness
On this resource, the following formatting is used for comprehensiveness:
- Minimal depth
- (Moderate depth)
- ((Comprehensive))
Fixation
Generally 10% neutral buffered formalin.
See also: General notes on fixation
Microscopic evaluation
The main objectives are:
- Making a diagnosis of endometrioid polyp. An endometrial polyp may be diagnosed in the presence of 2 of the following 3:
- Thick-walled vessels
- Collagenous stroma
- Epithelium on at least 3 sides
- Look for signs of atypia or malignancy.
Endometrial polyp (without atypia), with a thick-walled blood vessel in middle - typical of endometrial polyps. Glands are regular.
Endometrial polyp (without atypia), with tubal metaplasia (black arrow, showing ciliated epithelium) and a thick-walled blood vessel (white arrow). The stroma is hemorrhagic in this case.
Myometrium (smooth muscle cells) versus endometrial stroma (more cellular) versus endometrial polyp stroma (more collagenous).[image 1]
Atypia (mainly seen as signs of endometrial intraepithelial neoplasia (EIN), which has the following criteria:[6] - Architectural gland crowding - Altered cytology relative to background glands - Minimum size of 1 mm - Exclusion of adenocarcinoma - Exclusion of mimics Mitoses should also preferably be seen.
Endometrial adenocarcinoma[7] arising in an endometrial polyp. These are most commonly endometrioid, in which case low-grade carcinoma is distinguished from hyperplasia with atypia by the presence of glandular crowding with endometrial stromal exclusion, and significant cribriform, confluent glandular, labyrinthine, papillary/villoglandular, or non-squamous solid architecture.[8]
Subserosal pedunculated uterine leiomyomas may present as endometrial polyps. They typically show smooth muscle in a fascicular pattern[9] Further information: Smooth muscle tumor
Reporting
Most importantly:
- Benign versus malignant (or presence or absence of atypia.)
- ((The size of the polyp.))
- ((The type of epithelium at both the surface and gland coverings.))
Example of a minimal report:
Benign endometrial polyp.
|
See also: General notes on reporting
Notes
- ↑ Each slice may be individually numbered.
- ↑ For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
Main page
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 Monica Dahlgren, Janne Malina, Anna Måsbäck, Otto Ljungberg. Stora utskärningen. KVAST (Swedish Society of Pathology). Retrieved on 2019-09-26.
- ↑ International Federation for Cervical Pathology and Colposcopy (IFCPC) classification. References:
-. Transformation zone (TZ) and cervical excision types. Royal College of Pathologists of Australasia. - Jordan, J.; Arbyn, M.; Martin-Hirsch, P.; Schenck, U.; Baldauf, J-J.; Da Silva, D.; Anttila, A.; Nieminen, P.; et al. (2008). "European guidelines for quality assurance in cervical cancer screening: recommendations for clinical management of abnormal cervical cytology, part 1
". Cytopathology 19 (6): 342–354. doi:10.1111/j.1365-2303.2008.00623.x. ISSN 0956-5507. PMID 19040546.
- ↑ Khaled J. Alkhateeb, M.B.B.S., Ziyan T. Salih, M.D.. HSIL / CIN II / CIN III. PathologyOutlines. Topic Completed: 29 March 2021. Minor changes: 9 February 2022
- ↑ Source image by Ed Uthman from Houston, TX, USA. Creative Commons Attribution 2.0 Generic (CC BY 2.0) license
- ↑ Anissa Ben Amor.. Cervical Ectropion. StatPearls, National Center for Biotechnology Information. Last Update: November 14, 2021.
- This book is distributed under the terms of the Creative Commons Attribution 4.0 International License
- ↑ Owings, Richard A.; Quick, Charles M. (2014). "Endometrial Intraepithelial Neoplasia
". Archives of Pathology & Laboratory Medicine 138 (4): 484–491. doi:10.5858/arpa.2012-0709-RA. ISSN 1543-2165.
- ↑ Stewart, Colin J.R.; Crum, Christopher P.; McCluggage, W. Glenn; Park, Kay J.; Rutgers, Joanne K.; Oliva, Esther; Malpica, Anais; Parkash, Vinita; et al. (2019). "Guidelines to Aid in the Distinction of Endometrial and Endocervical Carcinomas, and the Distinction of Independent Primary Carcinomas of the Endometrium and Adnexa From Metastatic Spread Between These and Other Sites
". International Journal of Gynecological Pathology 38: S75–S92. doi:10.1097/PGP.0000000000000553. ISSN 0277-1691.
- "Figures - available via license: Creative Commons Attribution 4.0 International"
- ↑ Rabban, Joseph T.; Gilks, C. Blake; Malpica, Anais; Matias-Guiu, Xavier; Mittal, Khush; Mutter, George L.; Oliva, Esther; Parkash, Vinita; et al. (2019). "Issues in the Differential Diagnosis of Uterine Low-grade Endometrioid Carcinoma, Including Mixed Endometrial Carcinomas
". International Journal of Gynecological Pathology 38: S25–S39. doi:10.1097/PGP.0000000000000512. ISSN 0277-1691.
- ↑ Mohamed Mokhtar Desouki. Uterus - Stromal tumors - Leiomyoma. pathology Outlines. Topic Completed: 1 August 2011. Revised: 15 December 2019
Image sources
Endometrial curettings
Gross processing
- Generally submit all tissue for microscopy, even larger volumes.
- Look for products of conception if indicated from referral and/or history
Microscopic evaluation
Describe the anatomic/histologic type of epithelium.
Look mainly for:
Anatomic/histologic epithelium type
(Determine the type or phase of the endometrium:) edit
In contrast, endocervical mucosa typically consists of mucinous columnar epithelium and mucinous glands. Evaluate this like a cervical biopsy or cervical cone.
The most superficial layer of the endometrium usually consists of a simple columnar epithelium.
Postmenopausal (atrophic) endometrium: Thin epithelium, and scattered glands lined by columnar cells with small inactive nuclei, supported by a dense fibrous stroma of spindle cells. (H&E stain)
The phases of endometrium through the menstrual cycle:
Proliferative endometrium: long curving glands (G) and some stromal edema (H&E stain)
Secretory endometrium: Prominent glands (G), which have a dilated lumen and an irregular outer border stretching down into the basal compartment. In the luminal (functional) layer immune cells are readily detected (most of these are likely to be macrophages and uterine natural killer (uNK) cells), as are areas of decidualised fibroblasts (DEC) close to arterioles. (H&E stain)
If you want to specify the phase by day, then it's more accurate to state it as days past ovulation where applicable, since the follicular phase may vary substantially.
Hyperplasia, atypa and/or malignancy
- Look for signs of atypia or malignancy:
edit
Endometrial intraepithelial neoplasia (EIN), has the following criteria:[2] - Architectural gland crowding - Altered cytology relative to background glands - Minimum size of 1 mm - Exclusion of adenocarcinoma - Exclusion of mimics Mitoses should also preferably be seen.
Endometrial adenocarcinoma[3], most commonly endometrioid, in which case low-grade carcinoma is distinguished from hyperplasia with atypia by the presence of glandular crowding with endometrial stromal exclusion, and significant cribriform, confluent glandular, labyrinthine, papillary/villoglandular, or non-squamous solid architecture.[4]
Microscopy report
Example in a normal case:
(Endometrial curettings: Benign proliferative endometrium and endocervical mucosa without significant histopathologic changes.) Negative for neoplasia ((or viral cytopathic changes)).
|
Endometrial thickening
Hysterectomy sampling
A regular hysterectomy grossing is performed, but with the following sampling:[5]
- 2 longitudinal sections through ecto/endocervix (1 anterior and 1 posterior)
- 2 longitudinal sections through upper endocervix/lower uterine segment (1 anterior and 1 posterior), immediately adjacent to the sections taken from the cervix
- 4 full-thickness representative sections of endomyometrium (2 anterior and 2 posterior)
- Transversely section the remaining anterior and posterior endomyometrium (~1 cm thick). Submit the entire endometrium from the lower uterine segment to the fundus, maintaining orientation.
- Submit entire fimbriae (longitudinally sectioned) and 2 representative cross-sections on each side.
Microscopic evaluation
- Look for signs of atypia or malignancy:
edit
Endometrial intraepithelial neoplasia (EIN), has the following criteria:[2] - Architectural gland crowding - Altered cytology relative to background glands - Minimum size of 1 mm - Exclusion of adenocarcinoma - Exclusion of mimics Mitoses should also preferably be seen.
Endometrial adenocarcinoma[7], most commonly endometrioid, in which case low-grade carcinoma is distinguished from hyperplasia with atypia by the presence of glandular crowding with endometrial stromal exclusion, and significant cribriform, confluent glandular, labyrinthine, papillary/villoglandular, or non-squamous solid architecture.[4]
Reporting
Most importantly:
- Presence or absence of atypia.
Hysterectomy
For a freshly received uterus, generally gross it fresh to include either opening it up (small specimen, no suspected malignancy seen) and/or serial sectioning, in order to let the formalin penetrate it properly. Ensure the endometrium is immersed in the formalin (such as having the serosa oriented upwards).
See also: General notes on fixation
Comprehensiveness
On this resource, the following formatting is used for comprehensiveness:
- Minimal depth
- (Moderate depth)
- ((Comprehensive))
- Other legend
<< Decision needed between alternatives separated by / signs >>
{{Common findings / In case of findings}}
[[Comments]]
Link to another page
Gross processing
Gross examination
For orientation:
- The round ligament lies anterior to the tubes and ovaries.[8]
- The peritoneum extends further down along the cervix posteriorly than anteriorly.[9] Its ends bluntly posteriorly and sharply anteriorly.[9]
When received the same day as the surgery, perform the following steps at least to serial sectioning before putting (back) in formalin, preferably with paper towels between slices, so that it fixes properly:[8]
- (Remove the adnexa.[8] Weigh the uterus without the adnexa.)
- Perform a general inspection
- Measure the 3 dimensions, including the cervix. (Also measure the length of the cervix, the maximum diameter of the cervix, and the width of the cervical os.)
- (Ink the surgical margin of the cervix for orientation, such as black on the posterior side.)
- Open the uterus by transmural radial cuts on both sides of the uterine cavity.[note 1] The cavity is sometimes be squeezed or rolled around a leiomyoma, and you'll you have to improvise and perhaps go around the leiomyoma to open the cavity properly.
- Inspect the mucosa. If any polyps: Further information: Endometrial polyp
If more extensive tumor, gross as per endometrial cancer
- Serially section through almost the entire depth of the myometrium at approximately 1 cm intervals, still keeping the specimen together.
- Measure the thickness of the mucosa and myometrium
- Inspect the myometrium. If any tumor: Further information: Smooth muscle tumor
Gross pathology of extensive adenomyosis, contrasted to normal myometrium at bottom in right image.
Gross report
Applicable in bleeding disorders, pain, leiomyoma and endometrial hyperplasia:[8]
Components:[8]
- (Shape of uterus and adnex)
- Measurements
- Mucosa, such as smooth or irregular.
- (Even the absence of) any polyps. Further information: Endometrial polyp
- Mucosal and endometrial thickness. Further information: Endometrial thickening
- (Even the absence of) any smooth muscle tumor. Further information: Smooth muscle tumor
- Example
(A. Labeled - __. The specimen is received in formalin and consists of a resected) uterus with cervix [and bilateral fallopian tubes and ovaries]. The uterus and cervix measure __ ((cm superior to inferior)) x __ ((cm cornu to cornu)) x __ cm ((anterior to posterior,)) and weighs ___ grams. The serosa is [tan-pink and smooth]. The cervix measures ___ cm in diameter and ___ cm in length. The ectocervical mucosa is [tan-pink and smooth] and the cervical os[ is patent] and measures ___ cm in diameter. The specimen is bisected in the coronal plane. The endocervical canal is [patent and displays a tan-pink smooth mucosa]. The endometrial cavity is [triangular] and is lined by[ smooth] endometrium measuring [0.1] cm in average thickness. The myometrium measures up to ___ cm in thickness.[
- It displays __ intramural leiomyomata measuring up to __ cm in greatest diameter.
] The right ovary measures ___ cm and has a [tan-pink and smooth] capsule. Cut sections show [no gross lesions]. The right fallopian tube measures ___ cm in length and ___ cm in average diameter. The serosa [is tan-pink and smooth]. Cut sections reveal a small patent lumen and no gross lesions. The left ovary measures ___ cm and has a [tan-pink and smooth] capsule. Cut sections show [no gross lesions].The left fallopian tube measures ___ cm in length and ___ cm in average diameter. The serosa [is tan-pink and smooth]. Cut sections reveal a small patent lumen and no gross lesions. Representative sections are submitted for microscopic examination in ___ cassettes.
|
Slices for microscopy
Applicable in bleeding disorders, pain, leiomyoma and endometrial hyperplasia:[8]
Submit:[8][10]
- One, (two - at 6 and 12 o'clock), ((or four)) cross-sections from any accompanying ectocervix/endocervix (aiming to include the transformation zone). In subtotal extirpation, a cross-section is taken from the lower resection border.
- ((A transverse slice through the endocervix, possibly divided into two.))
- Endometrium and myometrium, by one slice from the front and one from the back wall of the corpus.
- {{Any mucosal parts with macroscopically abnormal appearance, including polyps.}}
- {{For any area suspicious for malignancy, submit a full cross-section of the uterine wall that includes the serosa. Use multiple contiguous cassettes if needed.}}
- {{Samples from all smooth muscle tumors >5 cm in diameter.}} Further information: Smooth muscle tumor
A specific sampling scheme is used in: Endometrial thickening
See also:
Microscopic evaluation
Look for signs of malignancy:
Cervix
edit
Look for cervical dysplasia. It is mainly seen as nuclei with hyperchromasia, coarse chromatin and irregular contours.[11]
Spectrum from normal to high grade SIL.[12]
Further information: Cervical dysplasia
edit Other common findings:
Acute cervicitis, having a largely neutrophilic intra-epithelial infiltrate.
Endocervical polyp: With endocervical epithelium and glands (mucinous columnar linings), edematous stroma and clear congestion. H&E stain.[13]
Uterine body
(Determine the type or phase of the endometrium:) edit
In contrast, endocervical mucosa typically consists of mucinous columnar epithelium and mucinous glands. Evaluate this like a cervical biopsy or cervical cone.
The most superficial layer of the endometrium usually consists of a simple columnar epithelium.
Postmenopausal (atrophic) endometrium: Thin epithelium, and scattered glands lined by columnar cells with small inactive nuclei, supported by a dense fibrous stroma of spindle cells. (H&E stain)
The phases of endometrium through the menstrual cycle:
Proliferative endometrium: long curving glands (G) and some stromal edema (H&E stain)
Secretory endometrium: Prominent glands (G), which have a dilated lumen and an irregular outer border stretching down into the basal compartment. In the luminal (functional) layer immune cells are readily detected (most of these are likely to be macrophages and uterine natural killer (uNK) cells), as are areas of decidualised fibroblasts (DEC) close to arterioles. (H&E stain)
If you want to specify the phase by day, then it's more accurate to state it as days past ovulation where applicable, since the follicular phase may vary substantially.
- Main pathologic findings
edit
Endometrial intraepithelial neoplasia (EIN), has the following criteria:[2] - Architectural gland crowding - Altered cytology relative to background glands - Minimum size of 1 mm - Exclusion of adenocarcinoma - Exclusion of mimics Mitoses should also preferably be seen.
Endometrial adenocarcinoma[15], most commonly endometrioid, in which case low-grade carcinoma is distinguished from hyperplasia with atypia by the presence of glandular crowding with endometrial stromal exclusion, and significant cribriform, confluent glandular, labyrinthine, papillary/villoglandular, or non-squamous solid architecture.[4]
Adenomyosis (endometrial glands in the myometrium). Look at these at high magnification to exclude dysplasia, as for endometrium.
Microscopy report
Examples of reports:
- Normal cases
- [note 2]
Uterus, cervix, bilateral tubes and ovaries, abdominal hysterectomy and bilateral salpingo-oophorectomy:
- Benign cervix.
- Benign inactive endometrium.
- {{Leiomyomata and adenomyosis.}}
- Benign ovaries.
- Benign fallopian tubes.
- Negative for malignancy.
|
Microscopy of hysterectomy shows ecto and endocervix without atypia. The glands have columnar epithelium without atypia.
In the uterine cavity, there is endometrial mucosa with ordinary thickness and regularly arranged endometrial glands. (Optionally: Description of likely menstrual phase.) Sharp delimitation between endometrium and myometrium. The myometrium contains no focal changes. No evidence of malignancy.
|
- Endometrial intraepithelial neoplasia
Uterus, cervix, bilateral tubes and ovaries, hysterectomy and bilateral salpingo-oophorectomy:
- Endometrial intraepithelial neoplasia; entire endometrial/myometrial junction submitted for microscopic exam.
- Benign lower uterine segment.
- Benign bilateral tubes and ovaries.
|
Smooth muscle tumor
Smooth muscle tumor (in this case leiomyoma).
Gross processing
Gross examination
When finding fibroids (spherical tumors with whorled pattern, which in the uterus can be presumed to be smooth muscle tumors), examine and describe:[8]
- Location. If in the uterus:
- Intramural/submucosal/subserosal (see image)
- (Posterior/anterior/right or left lateral.)
- Number of tumors, if multiple. May be described simply as "multiple".
- Size (may be described as "up to ___ cm in greatest dimension".
- (Presence or absence of any hemorrhage or necrosis.)
- ((Demarcation))
Selection
In case of hysterectomy, submit pieces from all fibroids >5 cm in diameter.[8]
Submit any macroscopically abnormal parts of the fibroids (hemorrhagic, necrotic, brittle or softening areas, and areas with blurry delimitation).[8]
For fibroids that are significantly calcified, a gross-only description as a calcified fibroid is generally sufficient, without the need to decalcify it to dissect it or sample from it.[note 3]
Microscopic examination
Distinguish leiomyoma (benign) from leiomyosarcoma (malignant) by looking at the latter's criteria:[16]
- Marked cellular atypia
- Mitoses: > 10 mitoses/10 high power fields
- Necrosis
Diagnosis of conventional leiomyosarcoma requires 2 of these 3 histologic features.[16]
Leiomyomas typically show smooth muscle in a fascicular pattern (arrows point at fascicles).[17][image 1]
Leiomyoma, with areas where the cellularity is relatively lower (left) and higher (right).
Leiomyoma with nuclear pleomorphism, yet within benign limits.
Leiomyoma with palisading pattern
Leiomyosarcoma: Variable atypia, often with cytoplasmic vacuoles at both ends of nuclei, and frequent mitoses.[18]
Epithelioid leiomyosarcoma
Further information: Evaluation of tumors
Microscopic report
Report:
- Microscopic findings, including any visible linings
- Diagnosis or most probable one
- Any linings or borders.
Example, for a cervical polyp:
Polyp lined by a single layer of columnar epithelium consistent with endometrium. The interior consists of smooth muscles in a whorled pattern. No atypia. The finding is consistent with a pedunculated submucosal leiomyoma.
|
Intrauterine device
Gross processing
These are generally just visually described, with no samples for microscopic examination. Example report:
T-shaped item with metal-coated arms and stem (Optionally: consistent with an intrauterine device with copper), with attached threads measuring 6.5 cm each.
|
Products of conception
Gross processing
Look up the gestational age of the pregnancy.
- Look for fetal tissue (fetus, fetal membranes or chorionic villi). They are generally easier to distinguish from decidua (which is maternal tissue) when fragments are put in clear fluid and shaken, with chorionic villi having a consistency like orange pulp, whereas decidua is more rubbery. The fluid may be formalin if no sample for genetic workup is needed. If chorionic villi are found, no lengthy search is needed for other kinds of fetal tissue, just a quick look for obvious ones. Membranous material is less reliable, and may still indicate further sampling. Inspect any found fetal tissue for gross anomalies. If found, submit one piece of the fetus and one piece of the placenta.[19]
Fresh chorionic villi (arrows), surrounded by decidua, at 10 weeks of gestational age.
Chorionic villi (arrow) become more characteristic when held in fluid, having a fibrillary shape
Fresh chorionic villi (left) compared to decidua (right).
Chorionic villi become more pale when fixed in formalin.
Macropathology of fixed umbilical cord, amnion and chorionic villi at 7-13 weeks of gestational age
Fresh chorionic villi in a term placenta for comparison, being more granular.
- If fetal parts are not visually found, search for diagnostic placental tissue, which is soft and shaggy or spongy (as opposed to membranous, which is likely to be decidua or blood clots).[19]
- If no fetal or placental tissue is found, all presented tissue generally needs to be submitted.
(If transported or processed together with other cases, put any chorionic villi in thin-mesh cassettes or tissue bags to limit contamination).[note 4]
Gross report
(Labeled - products of conception.) The specimen (is received <<fresh / in formalin>>) and consists of multiple fragments of soft tan-pink decidua, blood clots and amniotic sac measuring about 5 cc in aggregate. The intact amniotic sac measures 2.3 cm in greatest dimension. Fetal tissue is identified within the amniotic sac, measuring 1.0 cm in crown-rump length. Representative sections are submitted for microscopic examination (in 1 cassette).
|
Microscopy
The most important is to detect the presence of chorionic villi.
Products of conception, with chorionic villi (arrow) among decidualized endometrium
Immature chorionic villi, having loose stroma and few capillaries.
Necrotic chorionic villi in a tubal pregnancy.
Scantly cellular decidua may look like chorionic villi, but lack the thick trophoblastic lining.
In the absence of chorionic villi, look for implantation site intermediate trophoblasts (ISITs):
ISITs, having relatively large and dark nuclei.
Histology of decidua for comparison, having smaller and brighter nuclei.
- In the absence of both chorionic villi and ISITs, preferably perform cytokeratin immunostaining of each tissue sample, such as CAM5.2.[20]
- In the absence of chorionic villi and ISITs even after staining, call the clinician, since there may be an ectopic pregnancy.
Microscopy report
Examples:
((Products of conception:)) Products of conception, including immature chorionic villi, corresponding to first trimester pregnancy. ((Spontaneous abortion, clinically.))
|
((Products of conception:)) Fragments of focally necrotic decidua and implantation site, consistent with intrauterine products of conception. Negative for chorionic villi.
|
Fallopian tube
Gross processing
(Look in the history for any intra-fallopian coils (Essure devices).)[note 5]
- For sterilization
- Measure length and average diameter of each tube
- Serially section at 3-4 mm intervals,[21] or 2-3 mm if suspected malignant (including BRCA mutation).[22] Submit
- Submit 1 (or 3) circumferential transverse sections. If the specimen is only a segment of the tube of less than <5mm((, ink the surgical cut surfaces and)) submit all tissue.[21]
Example gross report:
(A. Labeled - __. The specimen is received in formalin and consists of) two fimbriated segments of fallopian tube measuring __ cm in length and __ cm in average diameter. On sectioning, each displays a patent lumen. No gross abnormalities are identified. The tubes are unoriented. The specimen is serially cross-sectioned and representative sections are submitted for microscopic examination in two cassettes.
|
Microscopic examination
Fallopian tubes may be substantially edematous and congested, which can generally be attributed to surgery, in which case it does not need mention in the report.
- Ensure there is at least one full cross-section from each tube, and take further samples otherwise.
- Check for patency of the lumen.
Tumor
The most common tumor of the fallopian tubes is adenomatoid tumor:[23]
An adenomatoid tumor of the fallopian tube, low magnification, displaying infiltrative-like borders.
High magnification of the same case, showing the typical[23] features of tubular spaces of varying size composed of flattened cells resembling endothelium.
Reporting
Example of a normal report in sterilization:
(Right and left fallopian tubes, ((laparoscopic)) bilateral salpingectomy:) Complete cross-sections of histologically unremarkable fallopian tubes.
|
When included in a uterus specimen, normal tubes and ovaries may simply be mentioned as:
Bilateral fallopian tubes and ovaries, unremarkable.
|
Histopathology of an ectopic pregnancy in a fallopian tube, with chorionic villi and implantation site changes Further information: Products of conception .
When done for ectopic pregnancy, report any rupture, either from the gross report or from microscopy, for example:
Benign ruptured fallopian tube with ectopic products of conception, including degenerated immature chorionic villi and implantation site with fresh hemorrhage.
|
Further information: Products of conception
Notes
- ↑
- In the US, the cut goes from side to side, through the cervix and uterine cavity, keeping the anterior and posterior halves attached by a relatively thin connection left at the fundus. It is done by cutting with scissors with the blunt end in the cervix and then uterine cavity, or by a blade guided on each side by the shanks of a pair of forceps inserted through the cervix.
- In Sweden, the uterus is usually opened at the front in the midline, optionally with an incision towards each corner.
It can be done by scissors, or by inserting a probe or forceps to guide a long blade.
- ↑ The first example is used in Connecticut, and the second example is used in Sweden.
- ↑ When a fibroid has calcifications it has been there a long time, and can be assumed to be benign.
- ↑ Chorionic villi are promiscuous contaminants of other tissues, and may cause a false positive finding for another cassette containing products of conception.
- Carll T, Fuja C, Antic T, Lastra R, Pytel P (2022). "Tissue Contamination During Transportation of Formalin-Fixed, Paraffin-Embedded Blocks.
". Am J Clin Pathol 158 (1): 96-104. doi:10.1093/ajcp/aqac014. PMID 35195717. Archived from the original. .
- ↑ For a case with intra-fallopian coils in the medical records, an inability to find them on gross processing must be noted in order to raise the possibility of coil expulsion.
Main page
References
- ↑ Rao, Shalinee; Sundaram, Sandhya; Narasimhan, Raghavan (2009). "Biological behavior of preneoplastic conditions of the endometrium: A retrospective 16-year study in south India
". Indian Journal of Medical and Paediatric Oncology 30 (4): 131. doi:10.4103/0971-5851.65335. ISSN 0971-5851.
- Figure- available via license: Creative Commons Attribution 2.0 Generic
- ↑ 2.0 2.1 2.2 Owings, Richard A.; Quick, Charles M. (2014). "Endometrial Intraepithelial Neoplasia
". Archives of Pathology & Laboratory Medicine 138 (4): 484–491. doi:10.5858/arpa.2012-0709-RA. ISSN 1543-2165.
- ↑ Stewart, Colin J.R.; Crum, Christopher P.; McCluggage, W. Glenn; Park, Kay J.; Rutgers, Joanne K.; Oliva, Esther; Malpica, Anais; Parkash, Vinita; et al. (2019). "Guidelines to Aid in the Distinction of Endometrial and Endocervical Carcinomas, and the Distinction of Independent Primary Carcinomas of the Endometrium and Adnexa From Metastatic Spread Between These and Other Sites
". International Journal of Gynecological Pathology 38: S75–S92. doi:10.1097/PGP.0000000000000553. ISSN 0277-1691.
- "Figures - available via license: Creative Commons Attribution 4.0 International"
- ↑ 4.0 4.1 4.2 Rabban, Joseph T.; Gilks, C. Blake; Malpica, Anais; Matias-Guiu, Xavier; Mittal, Khush; Mutter, George L.; Oliva, Esther; Parkash, Vinita; et al. (2019). "Issues in the Differential Diagnosis of Uterine Low-grade Endometrioid Carcinoma, Including Mixed Endometrial Carcinomas
". International Journal of Gynecological Pathology 38: S25–S39. doi:10.1097/PGP.0000000000000512. ISSN 0277-1691.
- ↑ Nicole Cipriani (2020-06-22). Gross Pathology Manual. The University of Chicago Department of Pathology.
- ↑ Rao, Shalinee; Sundaram, Sandhya; Narasimhan, Raghavan (2009). "Biological behavior of preneoplastic conditions of the endometrium: A retrospective 16-year study in south India
". Indian Journal of Medical and Paediatric Oncology 30 (4): 131. doi:10.4103/0971-5851.65335. ISSN 0971-5851.
- Figure- available via license: Creative Commons Attribution 2.0 Generic
- ↑ Stewart, Colin J.R.; Crum, Christopher P.; McCluggage, W. Glenn; Park, Kay J.; Rutgers, Joanne K.; Oliva, Esther; Malpica, Anais; Parkash, Vinita; et al. (2019). "Guidelines to Aid in the Distinction of Endometrial and Endocervical Carcinomas, and the Distinction of Independent Primary Carcinomas of the Endometrium and Adnexa From Metastatic Spread Between These and Other Sites
". International Journal of Gynecological Pathology 38: S75–S92. doi:10.1097/PGP.0000000000000553. ISSN 0277-1691.
- "Figures - available via license: Creative Commons Attribution 4.0 International"
- ↑ 8.0 8.1 8.2 8.3 8.4 8.5 8.6 8.7 8.8 8.9 Monica Dahlgren, Janne Malina, Anna Måsbäck, Otto Ljungberg. Stora utskärningen. KVAST (Swedish Society of Pathology). Retrieved on 2019-09-26.
- ↑ 9.0 9.1 . General Specimen Orientation Tips. The University of Michigan (2020-01-29).
- ↑ Nicole Cipriani (2020-06-22). Gross Pathology Manual. The University of Chicago Department of Pathology.
- ↑ Khaled J. Alkhateeb, M.B.B.S., Ziyan T. Salih, M.D.. HSIL / CIN II / CIN III. PathologyOutlines. Topic Completed: 29 March 2021. Minor changes: 9 February 2022
- ↑ Source image by Ed Uthman from Houston, TX, USA. Creative Commons Attribution 2.0 Generic (CC BY 2.0) license
- ↑ Anissa Ben Amor.. Cervical Ectropion. StatPearls, National Center for Biotechnology Information. Last Update: November 14, 2021.
- This book is distributed under the terms of the Creative Commons Attribution 4.0 International License
- ↑ Rao, Shalinee; Sundaram, Sandhya; Narasimhan, Raghavan (2009). "Biological behavior of preneoplastic conditions of the endometrium: A retrospective 16-year study in south India
". Indian Journal of Medical and Paediatric Oncology 30 (4): 131. doi:10.4103/0971-5851.65335. ISSN 0971-5851.
- Figure- available via license: Creative Commons Attribution 2.0 Generic
- ↑ Stewart, Colin J.R.; Crum, Christopher P.; McCluggage, W. Glenn; Park, Kay J.; Rutgers, Joanne K.; Oliva, Esther; Malpica, Anais; Parkash, Vinita; et al. (2019). "Guidelines to Aid in the Distinction of Endometrial and Endocervical Carcinomas, and the Distinction of Independent Primary Carcinomas of the Endometrium and Adnexa From Metastatic Spread Between These and Other Sites
". International Journal of Gynecological Pathology 38: S75–S92. doi:10.1097/PGP.0000000000000553. ISSN 0277-1691.
- "Figures - available via license: Creative Commons Attribution 4.0 International"
- ↑ 16.0 16.1 Paulette Mhawech-Fauceglia, M.D.. Uterus - Smooth muscle tumors - Leiomyosarcoma. Pathology Outlines. Topic Completed: 5 December 2019. Minor changes: 11 August 2020
- ↑ Mohamed Mokhtar Desouki. Uterus - Stromal tumors - Leiomyoma. Pathology Outlines. Topic Completed: 1 August 2011. Revised: 15 December 2019
- ↑ Vijay Shankar, M.D.. Soft tissue - Smooth muscle - Leiomyosarcoma - general. Pathology Outlines. Topic Completed: 1 November 2012. Revised: 11 September 2019
- ↑ 19.0 19.1 . Gross Pathology Manual, By The University of Chicago Department of Pathology - Products of Conception. Retrieved on 2020-08-13.
- ↑ Konoplev SN, Dimashkieh HH, Stanek J (2004). "Cytokeratin immunohistochemistry: a procedure for exclusion of pregnancy in chorionic villi-negative specimen.
". Placenta 25 (2-3): 146-52. doi:10.1016/S0143-4004(03)00188-7. PMID 14972447. Archived from the original. .
- ↑ 21.0 21.1 Kerryn Ireland-Jenkin and Marsali Newman. Ovary and fallopian tube -benign setting. Royal College of Pathologists of Australasia. Retrieved on 2020-10-16.
- ↑ Crum, Christopher P.; Mckeon, Frank D.; Xian, Wa (2012). "The Oviduct and Ovarian Cancer
". Clinical Obstetrics and Gynecology 55 (1): 24–35. doi:10.1097/GRF.0b013e31824b1725. ISSN 0009-9201.
- ↑ 23.0 23.1 Nicole Riddle, Jamie Shutter. Fallopian tubes & broad ligament - Fallopian tube tumors - Adenomatoid tumor. Pathology Outlines. Topic Completed: 1 September 2013. Minor changes: 13 December 2019
Image sources
Ovary
Gross processing
"Long" and "short" axis. [1]
The ovary is cut in the longitudinal plane (through the "long axis").
Ovaries, including those with cysts, are almost never inked.
Gross report
Template:
(A. Labeled - __. The specimen is received in formalin and consists of) an ovary measuring ___. The ovarian capsule is tan-pink and smooth. Cut sections reveal solid, white and whorled parenchyma, and no gross lesions. Representative sections are submitted for microscopic examination in __ cassettes.
|
Microscopic examination
Signet ring cell carcinoma metastasis to the ovary, also called Krukenberg tumor: Gross pathology (top, cross-section at right) and histopathology at low and high magnification. [2]
Apart from any obvious tumor, also look for signet ring cells, which is a major feature of metastatic tumors to the ovary.
Placenta
Gross processing
- Determine the shape of the placenta
- Look for any accessory lobes
- Determine the completeness of placental membranes, opacity, color and consistency (slimy/slippery?)
- Determine the point of rupture from nearest margin
- Note where the membranes are inserted
- Examine the umbilical cord
- Measure the distance between the insertion point and the nearest placental margin
- Measure the cord length and give proximal and distal diameter. In placental pathology, the proximal umbilical cord refers to the segment closest to the placenta, and distal is the segment closest to the fetus.[note 1]
- Count the number of vessels away from the insertion
- Weigh the trimmed disk, after having trimmed away the cord and membranes, and after having removed excess amounts of loose retroplacental blood clots over the maternal surface.
- Examine the fetal surface (chorionic plate):
- Note its color, in particular if it is green (often faint and tan-green, brown-green to yellow-green (which indicates meconium staining).
- Look for any pathologies including granular excrescences, subchorionic fibrin or subamniotic hemorrhage
- Look at the integrity and extent of the vasculature, including any traumatic damage. Also palpate the vasculature for any thrombosis. If a thrombus is grossly found for a live birth, the baby may have thrombosis, so the finding must immediately be reported to the clinician in care of the baby.
- Examine the maternal surface (basal plate) for completeness, adherent blood clots, depressions, calcifications and fibrin
- Take a membrane roll and cord sections, before sectioning the placenta
- With the fetal surface down on the cutting board, cut the placenta at 1cm intervals so that it can be reconstructed.
Making a fetal membrane roll.
Placental tissue after cutting, here showing severe intervillositis, with dark red and soggy tissue.
- Palpate the parencyhmal sections for areas of induration.
- Note the color of the parenchyma and describe any pale areas, cysts, thrombi, increased fibrin, calcifications and infarcts. For possible infarcts, estimate the total amount of infarcted tissue as a percentage of the placental volume. Infarction is clinically significant if it involves at least 5-10% of the placental volume.
Gross pathology of placental disorders. [3]
If you see a true knot (rather than "false knots" which are merely bulges or protuberances that may look like knots), report whether the diameter of the cord is significantly different before versus after the knot (which is a sign of constriction caused by the knot).
Tissue selection
- Distal (toward fetus) membrane roll and cross section of distal cord. It should include the area of rupture.
- Proximal (toward placenta) membrane roll and cross section of proximal cord ( 2-3 cm from insertion). They should include membranes up to the chorionic plate.
A membrane roll is created by cutting a strip, about 3 cm wide, of membrane, from the rupture site to the placental insertion. Hold the edge with forceps and roll it around the forceps, and then cut a transverse section of the roll. Cord sections should be no thicker than 4mm.
- Placental section including fetal surface ( full thickness if possible)
- Placental section including maternal surface (full thickness if possible)
- Any lesions or abnormalities
Avoid taking placental sections near the margin. (If transported or processed together with other cases, put the placental in thin-mesh cassettes or tissue bags to limit contamination).[note 2]
Example report:
Container A. Labeled "bladder tumor". The specimen is received in formalin and consists of multiple fragments of tan-gray, friable soft tissue measuring about __ x __ x __ cm in aggregate. The specimen is entirely submitted for microscopic examination in __ cassettes.
|
Gross report
Placenta weight by gestational age.
Example in a normal case:
(A. Labeled with patient's name and medical record number. The specimen is received fresh and consists of a) placenta with attached membranes and umbilical cord. The membranes are tan-red( with a marginal insertion. The site of rupture is __ cm from the nearest placental margin. There is no accessory lobe.) The trimmed placental weight is __ gramsTemplate:Comprehensive-begin-Corresponding to the __th percentile for the gestational age)). The placental disc measures __ cm and varies in thickness from __ to __ cm. The umbilical cord is tan-pink and eccentrically inserted(, __ cm from the nearest placental margin, and measures __ cm in length, __ cm in proximal diameter and __ cm in distal diameter.) Cut sections of the cord reveal three blood vessels. The fetal surface is blue-pink, smooth with normal vasculature and << minimal / moderate / major>> subchorionic fibrin deposition. The maternal surface is complete with <<minimal / moderate / major>> physiologic calcifications. Sectioning reveals a red, spongy, homogenous parenchyma without gross lesions. (Representative sections are submitted for microscopic examination in 4 cassettes.)
KEY OF SECTIONS (example):
- 1- distal membranes and umbilical cord
- 2- proximal membranes and umbilical cord
- 3- placental section including fetal surface
- 4- placental section including maternal surface
|
Microscopic examination
- Look for inflammation, especially by the fetal surface in the intervillous spaces and around the fetal blood vessels.
Acute subchorionic intervillositis, with neutrophils (annotated) in Langhan’s layer of fibrinoid (by the fetal surface, at the base of a chorionic villus, seen at top right).
On the other hand, a small amount of intervillous neutrophils by the fetal surface like this is insignificant.
Umbilical cord: Acute phlebitis and funisitis (inflammation of a vein and the connective tissue, respectively) with neutrophils.
Acute chorioamnionitis, with neutrophils in the chorion. Also seen are fibrin thrombi, which indicate a severe fetal inflammatory response.[4]
Acute choriodeciduitis, with neutrophils seen in the chorion and decidua.
- At least if there is a suspicion of meconium in the amniotic fluid (from clinical history and/or the gross exam), look for the following histopathologic signs of it:[5]
The pigment-laden macrophages are presumably meconium-laden "meconiophages", the pathologic diagnosis can be termed "meconium histocytosis"
Other relatively common findings
Calcifications, are normal in term placentas. Report if seen in a placenta younger than 36 weeks of gestational age.[6]
Chorangiosis, an abundance of blood vessels within the chorionic villi.
Increased syncytial knotting of chorionic villi, with two knots pointed out. Causes include both hypoxia and hyperoxia.[7]
Microscopy report
Generally, also include major gross findings, such as an area of placental abruption.
Example of normal report:
(Placenta, <<vaginal/Caesarean>> delivery:) Third trimester placenta with term villous histology. Placental weight (__ gm), at __th percentile for gestational age. Membranes without significant histopathologic changes((, negative for chorioamnionitis)). Trivascular umbilical cord, with no significant histopathologic changes((, negative for funisitis)).
|
Mild to moderate inflammation in the decidua alone can be ignored (as it is most commonly a physiological response and doesn't have a clinical significance for the fetus).
Example in a twin placenta:
Twin placenta, Caesarean section:
- Third trimester dichorionic, diamniotic twin placenta.
- Villous morphology histologically appropriate for gestational age.
- Placental weight approximately 25th percentile for gestational age.
- Two three-vessel umbilical cords.
- Negative for chorioamnionitis and funisitis.
|
Vulva
Gross processing
Generally as per skin.
Microscopic examination
Histopathology of high-grade squamous intraepithelial lesion (HSIL) of vulva (left in image) with full thickness dysplasia, compared to normal epithelium at right.
Mainly look for squamous vulvar intraepithelial lesions:
- Low-grade squamous intraepithelial lesion (LSIL):[8]
- Acanthosis, papillomatosis, and/or atypical koilocytosis in upper layers
- Usually mild atypia and mitoses, limited to the lower third of stratum spinosum and basale
- Binucleated epithelial cells
- High-grade squamous intraepithelial lesion (HSIL):[8]
- Enlarged atypical nuclei and mitoses involving middle and upper third of the epithelium.
- Also telling are atypical mitoses and/or extension in hair follicles and skin appendages.
Staging of vulvar cancer
Tumors of the vulva are staged as per the AJCC, 8th Ed:[9]
Primary tumor (T)
|
TNM
|
FIGO
|
Criteria
|
TX
|
|
Primary tumor cannot be assessed
|
T0
|
|
No evidence of a primary tumor
|
Tisa
|
|
Carcinoma in situ (preinvasive)
|
T1a
|
IA
|
Lesions ≤2 cm, confined to the vulva or perineum and with stromal invasion ≤1 mmb
|
T1b
|
IB
|
Lesions >2 cm or any size with stromal invasion >1 mm, confined to the vulva or perineum
|
T2
|
II
|
Tumor of any size with extension to adjacent perineal structures (distal third of the urethra, distal third of the vagina, anal involvement)
|
T3
|
IVA
|
Tumor of any size with extension to any of the following proximal two thirds of the urethra, proximal two thirds of the vagina, bladder mucosa, or rectal mucosa or fixed to pelvic bone
|
Regional lymph nodes (N)
|
TNM
|
FIGO
|
Criteria
|
NX
|
|
Regional lymph nodes cannot be assessed
|
N0
|
|
No regional lymph node metastasis
|
N1
|
|
1 or 2 regional (inguinofemoral) lymph nodes with the following features (see N1a, N1b)
|
N1a
|
IIIA
|
1 or 2 lymph node metastases, each < 5 mm
|
N1b
|
IIIA
|
1 regional lymph node metastasis ≥5 mm
|
N2
|
|
Regional (inguinofemoral) lymph nodes with the following features (see N2a, N2b, N2c)
|
N2a
|
IIIB
|
3 or more lymph node metastases, each < 5 mm
|
N2b
|
IIIB
|
2 or more regional lymph node metastases ≥5 mm
|
N2c
|
IIIC
|
Regional lymph node metastasis with extracapsular spread
|
N3
|
IVA
|
Fixed or ulcerated regional lymph node metastasis
|
Distant metastasis (M)
|
TNM
|
FIGO
|
Criteria
|
M0
|
|
No distant metastasis
|
M1
|
IVB
|
Distant metastasis (including to pelvic lymph nodes)
|
Cervical cytology
Clinical information
It is not necessary to look through more than readily available reports from previous cervical cytologies.
Magnification
While being fairly new to cervical cytology, preferably start looking at a high magnification such as 20x objective (with 10x eye piece). For suspicious findings, you may magnify up to maximum. On the other hand, once the pattern feels repetitive you can try switching to a slightly lower magnification such as 10x.
Adequacy
Adequacy should always be stated, either as "Satisfactory" or "Unsatisfactory". For estimating the number of cells, determine the following:
- The area of your field of view at high power (see the Evaluation chapter)
- The total size of the relevant area on the microscope slide. A ThinPrep is about 360 mm2.
- Look at 10 representative high power fields (HPFs) within that area, and calculate the average number of cells per high power field.
HPF example on a ThinPrep (about 360 mm 2). If 10 fields gives a total of 40 cells, it will be 4 cells per HPF. The area of this field is 0.23 mm 2. Therefore, total cellularity is estimated to be: 4 cells * 360mm 2 / 0.23mm 2 = 6260 cells.
You may count 10 fields either across the slide, or 5 fields in each direction.[10]
Total number of cells = Average number of cells per HPF * |
Total size of area HPF area
|
Conventional smear cellularity should be at least 8,000 cells. Liquid-based cytology cellularity should be at least 5,000 cells. Also a conventional smear is inadequate if >75% of cells are obscured by blood, exudate or air-drying artefact.[10]
Eventually you will be able to tell when most cases are adequate or inadequate without performing a detailed calculation.
Transformation zone presence
Squamous metaplasia also counts as endocervix. Typical features are annotated. Pap stain.
State whether the endocervical/transformation zone is present or absent. Count an endocervical component as present if there are 10 or more endocervical or squamous metaplastic cells.[11]
Endocervical cells can be viewed from the side as nuclear polarity (margination towards the same side as others) in a “picket-fence” configuration.
Sheets of endocervical cells have a honeycomb pattern.
In patients with previous hysterectomy, simply report glandular or squamous metaplastic cells as such, rather than stating the presence of a transformation zone, since they are likely vaginal in origin in such patients.[12]
Very common findings
For reporting, acute inflammation should be a background of ample dispersed neutrophils, and not only aggregates of neutrophils with cells or mucus.
Vaginal squamous cell with normal vaginal flora versus bacterial vaginosis on Pap stain. Normal vaginal flora (left) is predominantly rod-shaped Lactobacilli, whereas in bacterial vaginosis (right) there are clue cells, covered in bacteria. A significant amount of clue cells can be reported as "Shift in vaginal flora suggestive of bacterial vaginosis".
Candida, seen as pseudohyphae.
Main conditions to exclude or confirm
Squamous atypia, seen mainly as cells with increased nucleus/cytoplasm ratio, nuclear hyperchromasia and irregular nuclear outline.
Atypical squamous cells of undetermined significance (ASCUS), with only few slightly atypical cells
Low-grade squamous intraepithelial lesion (LSIL), here compared to an unremarkable intermediate squamous cell.
High-grade squamous intraepithelial lesion (HSIL), showing even more prominent features, and decreased cytoplasm, causing a high nuclear/cytoplasmic ratio.
Cytopathology of squamous cell carcinoma, keratinizing variant, with typical features.[13] Pap stain.
LSIL and changes consistent with human papillomavirus (HPV), which is the presence of koilocytes, which show perinuclear cavitation, binucleation, nuclear hyperchromasia, and nuclear enlargement.
Cytopathology of squamous cell carcinoma, nonkeratinizing variant, with typical features. [14] Pap stain. Necrotic debris (dirty background) is a feature that generally makes a HSIL case "suspicious for invasive squamous cell carcinoma". [15] In contrast to the more distinct keratinizing variant, these findings are overall less specific, and most can be seen in other cancers such as adenocarcinoma as well (which, however, tends to have fine chromatin) [16]
Distinguish HPV-changes from glycogenated squamous cells. Glycogen confers a yellowish color to the cytoplasm. It can look like the perinuclear cavitation of koilocytes, but has more rounded edges.
Clinical implication
If you are uncertain of the degree of dysplasia, it can be useful to look up how much difference it will likely make for the management of the patient. You may make an Internet search for the management of abnormal cervical screening in your region (such as The ASCCP tool for management in the US). A change from close follow-up to colposcopy is not that big of a deal, but if one of the alternatives will lead to a diagnostic excision, make sure that the case is looked upon by commensurate expertise.
Report
Example in a normal case:
Cervical/endocervical ThinPrep:
- Negative for intraepithelial lesion or malignancy (NILM).
|
Male reproductive system
Phimosis
Gross processing
Generally sample one or two representative sections in a cassette, in addition to sections of any grossly visible lesions.
See also: General notes on gross processing
Microscopic evaluation
Look for:
Optionally, note any sclerosis and/or fibrosis.
Reporting
- Description of objective findings, and any suspected underlying disease.
- Presence or absence of dysplasia.
Vas deferens
Gross processing in sterilization
In sterilization:[19]
- Measure length and diameter.
- Serially section
- Submit 2 cross sections measuring 5 mm in length.
Communicate to the histology lab to section the specimen as tubular structures, in order to get proper cross-sections.
Microscopic examination in sterilization
Confirm that there is a complete cross-section from each side. Example images of normal vas deferens:
Report
Example report:
Right and left vas deferens segments, excisions: Complete cross-sections of vasa deferentia without significant histopathologic changes.
|
Skin
Suspected malignant skin excisions
Author:
Mikael Häggström [note 3]
Suspected malignant skin excisions:
Fixation
Generally 10% neutral buffered formalin.
See also: General notes on fixation
Common targets
If directly suspected from the referral, see:
Gross processing
Gross examination
Note:
- Color
- Well-defined or diffuse border
- Size
- Any elevation
Tissue selection
Tissue selection from suspected malignant skin lesions, by lesion size:[21][note 4]
<4 mm |
4 - 8 mm |
9 - 15 mm
|
|
|
|
In table above, each top image shows recommended lines for cutting out slices to be submitted for further processing. Bottom image shows which side of the slice that should be put to microtomy. Dashed lines here mean that either side could be used.
Further information: Gross processing of skin excisions
Microscopic evaluation
If the lesion was pigmented on gross examination, evaluate as a dark skin focality. If not:
Look for atypical cells, possibly by scrolling through the epidermis at intermediate magnification and then through the dermis at a lower magnification. If atypical cells are found, look for:
- Similarity to squamous cells: See below:
Squamous cell-like skin proliferations: Differential diagnosis
Main differential diagnoses and their characteristics:[22]
Actinic keratosis: Atypical keratinocytes that do not span the full thickness of the epidermis (or, in Bowenoid variant, are less disordered with less nuclear atypia and crowding).
Keratoacanthoma: Symmetrical and circumscribed proliferation of keratinocytes, with central horn plug, with epidermis that extends over the tumor. It can be regarded as a highly differentiated SCC.
Crush artifacts: Needles used to orient the skin sample may create crush artifacts (black arrow) mimicking cellular atypia with mainly hypereosinophilia and nuclear pleomorphism. Image also shows folding artifacts (white arrows).
Adnexal carcinomas: Squamous differentiation, but does not show connection with the epidermis and highlights adnexal features.
Adenosquamous carcinoma: Mixed glandular and squamous differentiation.
Verruca vulgaris: Marked hyperkeratosis and papillomatosis. Rete ridges slope inward at the borders of the lesion.
Verrucous squamous cell carcinoma[note 5]: Exophytic squamous proliferation with marked papillomatosis and low atypia and the presence of koilocyte-like changes. Found in head and neck locations, as well as in the genitalia and sole of the foot.
Inverted follicular keratosis:[note 6]: Sharply circumscribed endophytic verrucous proliferation with prominent squamous features.
Seborrheic keratosis: Acanthosis, absence of atypia, pseudo-horn cysts, in inflamed lesions, mitoses may be present.
Bowenoid papulosis: Atypical keratinocytes and mitoses. Histology similar to Bowen’s disease.
A melanoma may have relatively plentiful eosinophilic cytoplasm, and be seemingly continuous with the squamous epithelium (at left in image), thus resembling a squamous cell carcinoma. However, the nesting of cells at right in the image is more characteristic of a melanoma.
Metastasis: Personal medical history of the patient, nodular proliferation without connection to epidermis, immunohistochemical evaluation. Squamous-cell carcinoma metastasis from lungs to the skin is pictured.
General benign imitators of skin malignancy
Further workup of malignant findings
In case of skin cancer, determine whether the peripheral/radial and deep margins are clear, close or continuous.[23][note 7] A close margin has various definitions for different malignancies, but for basal-cell carcinoma and cutaneous squamous cell carcinoma it is defined as being closer than 1 mm from the edge (but yet non-continuous with it),[23][24] but 2-3 mm for melanoma.[25]
Previous biopsy
(At least if there is a known previous biopsy, look for changes that are consistent with a biopsy site, to confirm that it was taken from the excised area.) Such changes in the skin include:
- Granulation tissue in more fresh biopsies
- Dense collagen
- Fibrosis with vertical blood vessels
- Fibrosis that replaces solar elastosis
Reporting
Preferably see specific article on the condition at hand, if available.
- Optionally, the presence of a keratinized squamous epithelium.
- Any abnormalities, generally preceded by location in terms of epidermal, dermal or more specific layers thereof.
- If malignant:
- Degree of differentiation
- Radicality, mainly into either of the following: edit
- >___ mm (Definitions vary for the distance as per Further workup of malignant findings above): "Clear margins" (or: "Clear margins at over __ mm")((or the exact distance thereof)).))
- <___ mm but not continuous with edge: "Close margins at __ mm at (location). [[Locations are mainly the deep edge, or the (superior/inferior/medial/lateral) radial edge.]]." Numbers are generally given at an exactness of 0.1 mm.[23]
- Continuous with margin: "Not radically excised at (location)."
- For skin shave biopsies, non-radicality may be reported as: "Extending to base and peripheral edges of biopsy" (as they may not be regarded as "margins" on a biopsy).
- Perineural or vascular invasion if present.
Notes
- ↑ In contrast, in embryology and fetal medicine, the proximal umbilical cord refers to the segment closest to the fetus:
- Wyburn GM (1939). "The formation of the umbilical cord and the umbilical region of the anterior abdominal wall.
". J Anat 73 (Pt 2): 289-310.9. PMID 17104757. PMC: 1252509. Archived from the original. . Harvey J. Kliman, M.D., Ph.D. (2006-10-29). The Umbilical Cord (from The Encyclopedia of Reproduction). Yale School of Medicine.
- ↑ Chorionic villi are promiscuous contaminants of other tissues, and may cause a false positive finding for a cassette containing products of conception.
- Carll T, Fuja C, Antic T, Lastra R, Pytel P (2022). "Tissue Contamination During Transportation of Formalin-Fixed, Paraffin-Embedded Blocks.
". Am J Clin Pathol 158 (1): 96-104. doi:10.1093/ajcp/aqac014. PMID 35195717. Archived from the original. .
- ↑ For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
- ↑ The excision example shows a superficial basal cell carcinoma.
- ↑ - Buschke–Löwenstein tumor is an alternative name for verrucous squamous cell carcinoma in the ano-genital region.
- Carcinoma cuniculatum is a characteristic form of verrucous squamous cell carcinoma on the sole.
- ↑ Inverted follicular keratosis is generally thought to be a rare variant of seborrheic keratosis, but this position is not universally accepted.
- Karadag, AyseSerap; Ozlu, Emin; Uzuncakmak, TugbaKevser; Akdeniz, Necmettin; Cobanoglu, Bengu; Oman, Berkant (2016). "Inverted follicular keratosis successfully treated with imiquimod
". Indian Dermatology Online Journal 7 (3): 177. doi:10.4103/2229-5178.182354. ISSN 2229-5178.
- ↑ "Peripheral" or "radial" margins are preferred rather than "lateral", since a "lateral" margin may be interpreted as opposite to the "medial margin".
Main page
References
- ↑ Pellerito, John; Polak, Joseph F. (2012). Introduction to Vascular Ultrasonography
(6th ed.). Elsevier Health Sciences. p. 559. ISBN 978-1-4557-3766-6.
- ↑ Nakamura, Yoshiaki; Hiramatsu, Ayako; Koyama, Takafumi; Oyama, Yu; Tanaka, Ayuko; Honma, Koichi (2014). "A Krukenberg Tumor from an Occult Intramucosal Gastric Carcinoma Identified during an Autopsy
". Case Reports in Oncological Medicine 2014: 1–5. doi:10.1155/2014/797429. ISSN 2090-6706.
- Creative Commons Attribution 3.0 Unported (CC BY 3.0) license
- ↑ Chen, Yukun; Zhang, Zhuomin; Wu, Chenyan; Davaasuren, Dolzodmaa; Goldstein, Jeffery A.; Gernand, Alison D.; Wang, James Z. (2020). "AI-PLAX: AI-based placental assessment and examination using photos
". Computerized Medical Imaging and Graphics 84: 101744. doi:10.1016/j.compmedimag.2020.101744. ISSN 08956111.
- Fig 5- available via license: Creative Commons Attribution 4.0 International.
- ↑ Kim, Chong Jai; Romero, Roberto; Chaemsaithong, Piya; Chaiyasit, Noppadol; Yoon, Bo Hyun; Kim, Yeon Mee (2015). "Acute chorioamnionitis and funisitis: definition, pathologic features, and clinical significance
". American Journal of Obstetrics and Gynecology 213 (4): S29–S52. doi:10.1016/j.ajog.2015.08.040. ISSN 00029378.
- ↑ Mandolin S. Ziadie. Placenta - Nonneoplastic placental conditions and abnormalities - Noninfectious - Meconium staining. Pathology Outlines. Topic Completed: 1 October 2011. Minor changes: 27 August 2020
- ↑ Chapter 3. Placental Calcification: Its Processes and Impact on Pregnancy, Kachewar, Sushil (2013). Calcification : processes, determinants and health impact
. New York: Nova Science Publishers, Inc. ISBN 978-1-62618-155-7. OCLC 840507829.
- ↑ Heazell AE, Moll SJ, Jones CJ, Baker PN, Crocker IP (2007). "Formation of syncytial knots is increased by hyperoxia, hypoxia and reactive oxygen species.
". Placenta 28 Suppl A: S33-40. doi:10.1016/j.placenta.2006.10.007. PMID 17140657. Archived from the original. .
- ↑ 8.0 8.1 Matthias Choschzick. Vulva, vagina & female urethra - Squamous carcinoma and precursor lesions - HPV associated SIL. PathologyOutlines. Topic Completed: 6 January 2021. Minor changes: 11 June 2021
- ↑ Amin, Mahul (2017). AJCC cancer staging manual
(8 ed.). Switzerland: Springer. ISBN 978-3-319-40617-6. OCLC 961218414.
- For access, see the Secrets chapter of Patholines. - Copyright note: The AJCC, 8th Ed. is published by a company in Switzerland, and the tables presented therein are Public Domain because they consist of tabular information without literary or artistic innovation, and therefore do not fulfil the inclusion criterion of the Swiss Copyright Act (CopA) which applies to "literary and artistic intellectual creations with individual character" (see Federal Act on Copyright and Related Rights (Copyright Act, CopA) of 9 October 1992 (Status as of 1 January 2022)). edit
- ↑ 10.0 10.1 . Criteria for adequacy of a cervical cytology sample. EuroCytology. Retrieved on 2022-08-29.
- ↑ Cibas, Edmund S.; Ducatman, Barbara S. (2021). Cytology : diagnostic principles and clinical correlates
. Philadelphia, PA. p. 9. ISBN 978-0-323-63637-7. OCLC 1138033641.
- ↑ Ramirez NC, Sastry LK, Pisharodi LR (2000). "Benign glandular and squamous metaplastic-like cells seen in vaginal Pap smears of post hysterectomy patients: incidence and patient profile.
". Eur J Gynaecol Oncol 21 (1): 43-8. PMID 10726617. Archived from the original. .
- ↑ - Image annotated by Mikael Häggström
- Reference for entries: Gulisa Turashvili, M.D., Ph.D.. Cervix - Squamous cell carcinoma and variants. Pathology Outlines. Last author update: 24 September 2020. Last staff update: 4 April 2022. - Source image from National Cancer Institute (Public Domain)
- ↑ - Image annotated by Mikael Häggström
- Reference for entries: Gulisa Turashvili, M.D., Ph.D.. Cervix - Squamous cell carcinoma and variants. Pathology Outlines. Last author update: 24 September 2020. Last staff update: 4 April 2022. - Source image by Ravi Mehrotra, Anurag Gupta, Mamta Singh and Rahela Ibrahim (Creative Commons Attribution 2.0 Generic license.)
- ↑ Alrajjal A, Pansare V, Choudhury MSR, Khan MYA, Shidham VB (2021). "Squamous intraepithelial lesions (SIL: LSIL, HSIL, ASCUS, ASC-H, LSIL-H) of Uterine Cervix and Bethesda System.
". Cytojournal 18: 16. doi:10.25259/Cytojournal_24_2021. PMID 34345247. PMC: 8326095. Archived from the original. .
- ↑ Authors: Caroline I.M. Underwood, M.D., Alexis Musick, B.S., Carolyn Glass, M.D., Ph.D.. Adenocarcinoma overview. Pathology Outlines. Last staff update: 19 July 2022
- ↑ Clemmensen, Ole J.; Krogh, John; Petri, Michael (1988). "The Histologic Spectrum of Prepuces from Patients with Phimosis
". The American Journal of Dermatopathology 10 (2): 104–108. doi:10.1097/00000372-198804000-00002. ISSN 0193-1091.
- ↑ Alcides Chaux, Antonio L. Cubilla. Penis and scrotum - Inflammatory lesions - Phimosis. PathologyOutlines. Topic Completed: 1 February 2010. Revised: 13 February 2019
- ↑ . Vas Deferens (Sterilization). Gross Pathology Manual - By The University of Chicago Department of Pathology. Retrieved on 2021-08-27.
- ↑ Vas deferens image available in Public Domain. See https://patholines.org/File:Vas_deferens.jpg
- ↑ There are many variants for the processing of skin excisions. These examples use aspects from the following sources:
". Ochsner J 5 (2): 22–33. 2003. PMID 22826680. PMC: 3399331. Archived from the original. .
- With a "standard histologic examination" that, in addition to the lesion, only includes one section from each side along the longest diameter of the specimen. - It also shows an example of circular coverage, with equal coverage distance in all four directions. - The entire specimen may be submitted if the risk of malignancy is high.
- ↑ Initially copied from: Paolino, Giovanni; Donati, Michele; Didona, Dario; Mercuri, Santo; Cantisani, Carmen (2017). "Histology of Non-Melanoma Skin Cancers: An Update
". Biomedicines 5 (4): 71. doi:10.3390/biomedicines5040071. ISSN 2227-9059.
"This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/)."
- ↑ 23.0 23.1 23.2 David Slater, Paul Barrett. Standards and datasets for reporting cancers - Dataset for histopathological reporting of primary cutaneous basal cell carcinoma. The Royal College of Pathologists. February 2019
- ↑ 1 mm as cutoff for close margin: Brodie M Elliott, Benjamin R Douglass, Daniel McConnell, Blair Johnson, Christopher Harmston (2018-12-14). New Zealand Medical Journal.
- ↑ Page 406 in: Klaus J. Busam, Richard A Scolyer, Pedram Gerami (2018). Pathology of Melanocytic Tumors
. Elsevier Health Sciences. ISBN 9780323508681.
Image sources
Basal-cell carcinoma
Author:
Mikael Häggström [note 1]
Nodular basal-cell carcinoma.
Basal-cell carcinoma (BCC):
Fixation
Generally 10% neutral buffered formalin.
See also: General notes on fixation
Gross processing
Gross examination
Note:
- Color
- Well-defined or diffuse border
- Size
- Any elevation
Tissue selection
Tissue selection from suspected malignant skin lesions, by lesion size:[1][note 2]
<4 mm |
4 - 8 mm |
9 - 15 mm
|
|
|
|
In table above, each top image shows recommended lines for cutting out slices to be submitted for further processing. Bottom image shows which side of the slice that should be put to microtomy. Dashed lines here mean that either side could be used.
Further information: Gross processing of skin excisions
Microscopic evaluation
Broadly consists of determining the following:
- Whether it is basal-cell carcinoma or a differential diagnosis.
- Aggressiveness pattern
- Radicality
Optionally, further subtyping of basal-cell carcinoma can be made.
Characteristics
Nests of cells appearing similar to epidermal basal cells, and are usually well differentiated.[2]
Palisading is a typical feature.
Cleft formation is fairly specific, but may not be seen in smaller nests.
Basal-cell carcinomas may be pigmented as shown (but consider the possibility of melanoma in such cases).
In uncertain cases, immunohistochemistry using BerEP4 can be used, having a high sensitivity and specificity in detecting only BCC cells.[3]
Differential diagnoses
Main histological differential diagnoses of basal cell carcinoma:
- Hair follicles
Hair follicles: Peripheral sections may look like nests, but do not display atypia, and nuclei are smaller.
Also, hair follicles generally display more distinct features when looking at adjacent levels.
Hair follicle tissue may be superficial, resembling a superficial basal-cell carcinoma.
The edges of hair follicle cells may resemble palisades, but are less pronounced, and are generally more diffusely delineated compared to surroundings.
- Squamous-cell carcinoma
Squamous-cell carcinoma of the skin is generally distinguishable by for example relatively more cytoplasm, horn cyst formation and absence of palisading and cleft formations.
edit
Yet, a high prevalence means a relatively high incidence of borderline cases. In such cases, look particularly at the surface and attempt to classify as either of the following:
Basal-cell carcinoma with squamous cell metaplasia or metatypical (squamoid) basal-cell carcinoma. It is basal-cell carcinoma with subepidermal (but no intraepidermal) areas resembling squamous-cell carcinoma.
Basaloid squamous-cell carcinoma, in this case showing a biplastic pattern with basaloid elements associated with both conventional dysplastic squamous surface (arrow heads) and conventional squamous cell carcinoma (arrow).[4]
In unclear cases, the most useful immunohistochemistry marker appears to be MOC-31, which essentially always stains metatypical basal-cell carcinomas but not basaloid squamous-cell carcinomas.[5] UEA-1 appears to be the second most useful marker, staining almost all basaloid squamous-cell carcinomas but only a few metatypical basal-cell carcinomas.[5]
- Others[6]
Trichoblastoma: Absence of cleft, rudimentary hair germs, papillary mesenchymal bodies.
Adenoid cystic carcinoma: Lack of basaloid cells disposed in peripheral palisades; adenoid-cystic lesion without connection to the epidermis; absence of artefactual clefts
Trichoepithelioma:[note 3] Rims of collagen bundles, calcification, follicular/sebaceous/infundibular differentiation and cut artefacts. Cytokeratin (CK)20+, p75+, Pleckstrin homology-like domain family A member 1 + (PHLDA1+), common acute lymphoblastic leukemiaantigen + (CD10+) in tumor stroma, CK 6-, Ki-67- and Androgen Rceptor- (AR-)
Merkel cell carcinoma: Cells arranged in a diffuse, trabecular and/or nested pattern, involving also the subcutis. Mouse Anti-Cytokeratin (CAM) 5.2+, CK20+, S100-, human leukocyte common antigen- ( LCA-), thyroid transcription factor 1- (TTF1-)
Aggressiveness
Aggressiveness can be classified as low-level aggressive, moderately aggressive and highly aggressive, based mainly the cohesion of cancer cells, but also upon other histopathologic subtypes:
- Low-level aggressive patterns
Nodular. Also known as "classic basal-cell carcinoma". It accounts for 50% of all BCC.[6] It typically has relatively cohesive aggregates of basaloid cells with well-defined borders, showing palisading and one or more clefts.[6] Central necrosis with eosinophilic, granular features may be also present, as well as mucin. The heavy aggregates of mucin determine a cystic structure. Calcification may be also present, especially in long-standing lesions.[6] Mitotic activity is usually not so evident, but a high mitotic rate may be present in more aggressive lesions.[6]
Fibroepitheliomatous pattern: anastomosing basaloid epithelial strands enclosing round islands of fibrous stroma[8]
- Moderately aggressive pattern
- Highly aggressive patterns
Cicatricial or morphoeic pattern: Narrow strands and nests of basaloid cells, typically with sharp edges, surrounded by dense sclerotic stroma.[9]
Micronodular pattern: Small and closely spaced nests.
Radicality
Determine if there are basal-cell formations continuous with resection margins, or if they are closer or farther than 1 mm from the closest edge.[10] If closer, measure the distance.
If uncertain, immunohistochemistry with BerEP4 helps in distinguishing the BCC cells.
Comparison H&E stain (left) with BerEP4 immunohistochemistry staining (right) on a pathological section having BCC with squamous cell metaplasia. Only BCC cells are stained with BerEP4. [3]
- Further information: Evaluation of tumors
Reporting
- Aggressiveness pattern, at least if highly aggressive.
- Radicality, mainly into either of the following: edit
- >1 mm (as per Radicality above): "Clear margins" (or: "Clear margins at over __ mm")((or the exact distance thereof)).))
- <1 mm but not continuous with edge: "Close margins at __ mm at (location). [[Locations are mainly the deep edge, or the (superior/inferior/medial/lateral) radial edge.]]." Numbers are generally given at an exactness of 0.1 mm.[10]
- Continuous with margin: "Not radically excised at (location)."
Optionally, subtype of basal-cell carcinoma
Example:
(Skin excision with stratified squamous keratinized epithelium, where the dermis contains) moderately aggressive basal-cell carcinoma, not radically excised at the right margin.[note 4]
|
See also: General notes on reporting
Notes
- ↑ For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
- ↑ The excision example shows a superficial basal cell carcinoma.
- ↑ Desmoplastic tricoepithelioma is particularly similar to basal-cell carcinoma.
- ↑ The direction was known from needle marking.
Main page
References
- ↑ There are many variants for the processing of skin excisions. These examples use aspects from the following sources:
". Ochsner J 5 (2): 22–33. 2003. PMID 22826680. PMC: 3399331. Archived from the original. .
- With a "standard histologic examination" that, in addition to the lesion, only includes one section from each side along the longest diameter of the specimen. - It also shows an example of circular coverage, with equal coverage distance in all four directions. - The entire specimen may be submitted if the risk of malignancy is high.
- ↑ Robert S Bader. Which histologic findings are characteristic of basal cell carcinoma (BCC)?. Medscape. Updated: Feb 21, 2019
- ↑ 3.0 3.1 Sunjaya, Anthony Paulo; Sunjaya, Angela Felicia; Tan, Sukmawati Tansil (2017). "The Use of BEREP4 Immunohistochemistry Staining for Detection of Basal Cell Carcinoma
". Journal of Skin Cancer 2017: 1–10. doi:10.1155/2017/2692604. ISSN 2090-2905.
- ↑ El-Mofty, SK. (2014). "Histopathologic risk factors in oral and oropharyngeal squamous cell carcinoma variants: An update with special reference to HPV-related carcinomas
". Medicina Oral Patología Oral y Cirugia Bucal: e377–e385. doi:10.4317/medoral.20184. ISSN 16986946.
License: CC BY 2.5
- ↑ 5.0 5.1 Webb, David V.; Mentrikoski, Mark J.; Verduin, Lindsey; Brill, Louis B.; Wick, Mark R. (2015). "Basal cell carcinoma vs basaloid squamous cell carcinoma of the skin: an immunohistochemical reappraisal
". Annals of Diagnostic Pathology 19 (2): 70–75. doi:10.1016/j.anndiagpath.2015.01.004. ISSN 10929134.
- ↑ 6.0 6.1 6.2 6.3 6.4 Paolino, Giovanni; Donati, Michele; Didona, Dario; Mercuri, Santo; Cantisani, Carmen (2017). "Histology of Non-Melanoma Skin Cancers: An Update
". Biomedicines 5 (4): 71. doi:10.3390/biomedicines5040071. ISSN 2227-9059.
- ↑ Inskip, Mike; Magee, Jill (2015). "Microcystic adnexal carcinoma of the cheek—a case report with dermatoscopy and dermatopathology
". Dermatology Practical & Conceptual 5 (1). doi:10.5826/dpc.0501a07. ISSN 21609381.
- ↑ Yonan, Yousif; Maly, Connor; DiCaudo, David; Mangold, Aaron; Pittelkow, Mark; Swanson, David (2019). "Dermoscopic Description of Fibroepithelioma of Pinkus with Negative Network
". Dermatology Practical & Conceptual: 246–247. doi:10.5826/dpc.0903a23. ISSN 2160-9381. Creative Commons Attribution License
- ↑ East, Ellen; Fullen, Douglas R.; Arps, David; Patel, Rajiv M.; Palanisamy, Nallasivam; Carskadon, Shannon; Harms, Paul W. (2016). "Morpheaform Basal Cell Carcinomas With Areas of Predominantly Single-Cell Pattern of Infiltration
". The American Journal of Dermatopathology 38 (10): 744–750. doi:10.1097/DAD.0000000000000541. ISSN 0193-1091.
- ↑ 10.0 10.1 David Slater, Paul Barrett. Standards and datasets for reporting cancers - Dataset for histopathological reporting of primary cutaneous basal cell carcinoma. The Royal College of Pathologists. February 2019
Image sources
Actinic keratosis
Authors:
Mikael Häggström; Authors of integrated Creative Commons article[1] [note 1]
Actinic keratosis may present as suspected malignant skin excisions.
Fixation
Generally 10% neutral buffered formalin.
See also: General notes on fixation
Gross processing
Multiple lesions of actinic keratosis on the scalp.
Gross examination
Note:
- Color
- Well-defined or diffuse border
- Size
- Any elevation
Lesions of actinic keratosis are typically ill-marginated, erythematous, scaling, and rough papules or patches. These will typically be found in areas displaying other signs of solar damage, such as atrophy, uneven pigmentation, and telangiectasias.[1]
Tissue selection
Tissue selection from suspected malignant skin lesions, by lesion size:[2][note 2]
<4 mm |
4 - 8 mm |
9 - 15 mm
|
|
|
|
In table above, each top image shows recommended lines for cutting out slices to be submitted for further processing. Bottom image shows which side of the slice that should be put to microtomy. Dashed lines here mean that either side could be used.
Further information: Gross processing of skin excisions
Microscopic evaluation
- Evaluation mainly consists of:
Characteristics
Normal skin (left) and actinic keratosis (right) with the defining characteristic of atypical basal keratinocytes that does not involve the full thickness of the epidermis.
1(a). Actinic keratosis at low magnification, showing discontinuous parakeratosis (as the dysplastic process spares adnexal structures, including sebaceous glands. This specimen also demonstrates dense dermal elastosis). [1]
By definition, actinic keratosis is confined to foci within the epidermis.[1]
it also generally has:[1]
- Aggregates of atypical, pleomorphic keratinocytes which show nuclear atypia, dyskeratosis, and loss of polarity.
- Hyperkeratosis and parakeratosis, the latter overlying the abnormal cells in the epidermis. Due to the sparing of segments of the epithelium overlying adnexal structures, a characteristic pattern of alternating orthokeratosis and parakeratosis, referred to as the “flag-sign,” can often be seen (Figure 1(a)).
- Atypical keratinocytes will not span the full thickness of the epidermis (Figure 1(b)), although those in the basal cell layer will frequently extend into the granular and cornified layers. The exception to this criterion is the Bowenoid variant of actinic keratosis, which resembles cutaneous squamous-cell carcinoma in situ (Bowen's disease) but is less disordered with less nuclear atypia and crowding.
- A more basophilic basal layer than normal, which is generally thought to be a consequence of the close crowding of atypical keratinocytes (Figure 1(b)).
- Some cases will also show basal layer degeneration and the formation of Civatte bodies (Figure 1(c)), the result of a lichenoid infiltrate with irregular acanthosis. This can be distinguished from lichenoid dermatitis by the presence of keratinocyte atypia.
- Dermoepidermal junction irregularities, with small round buds at the basal cell layer that will protrude slightly into the upper papillary dermis (Figure 1(d)).
- There is almost always an associated solar elastosis in the dermis, and a lack thereof can often be sufficient to prompt reconsideration of the diagnosis.
1(b). Early actinic keratosis with keratinocyte dysplasia confined to the lower third of the epidermis.[1]
Civatte body (in a case in lichen planus).
1(d). A more established lesion of actinic keratosis demonstrating nearly full thickness keratinocyte dysplasia and prominent budding of the basal layer into the superficial dermis.[1]
Squamous cell-like skin proliferations: Differential diagnosis
Main differential diagnoses and their characteristics:[3]
Actinic keratosis: Atypical keratinocytes that do not span the full thickness of the epidermis (or, in Bowenoid variant, are less disordered with less nuclear atypia and crowding).
Keratoacanthoma: Symmetrical and circumscribed proliferation of keratinocytes, with central horn plug, with epidermis that extends over the tumor. It can be regarded as a highly differentiated SCC.
Crush artifacts: Needles used to orient the skin sample may create crush artifacts (black arrow) mimicking cellular atypia with mainly hypereosinophilia and nuclear pleomorphism. Image also shows folding artifacts (white arrows).
Adnexal carcinomas: Squamous differentiation, but does not show connection with the epidermis and highlights adnexal features.
Adenosquamous carcinoma: Mixed glandular and squamous differentiation.
Verruca vulgaris: Marked hyperkeratosis and papillomatosis. Rete ridges slope inward at the borders of the lesion.
Verrucous squamous cell carcinoma[note 3]: Exophytic squamous proliferation with marked papillomatosis and low atypia and the presence of koilocyte-like changes. Found in head and neck locations, as well as in the genitalia and sole of the foot.
Inverted follicular keratosis:[note 4]: Sharply circumscribed endophytic verrucous proliferation with prominent squamous features.
Seborrheic keratosis: Acanthosis, absence of atypia, pseudo-horn cysts, in inflamed lesions, mitoses may be present.
Bowenoid papulosis: Atypical keratinocytes and mitoses. Histology similar to Bowen’s disease.
A melanoma may have relatively plentiful eosinophilic cytoplasm, and be seemingly continuous with the squamous epithelium (at left in image), thus resembling a squamous cell carcinoma. However, the nesting of cells at right in the image is more characteristic of a melanoma.
Metastasis: Personal medical history of the patient, nodular proliferation without connection to epidermis, immunohistochemical evaluation. Squamous-cell carcinoma metastasis from lungs to the skin is pictured.
Clinical clues
- Biopsy from sun exposed area (including the face, neck, dorsal hands, and forearms, upper chest, back, and scalp).[1]
- Generally middle-aged or older individuals.[1]
Further workup
Once a diagnosis of actinic keratosis is established, optionally characterize the degree of atypia into either mild, moderate or severe.
Actinic keratosis with moderate atypia, spanning approximately half of stratum spinosum.
Histopathology report
- Objective findings
- A diagnosis of actinic keratosis
- Optionally: The degree of atypia.
- Even absence of evidence of malignancy.
Example for the case in "Further workup":
(Skin excision with squamous stratified epithelium with moderate) atypia in the basal epidermis (, with enlarged and dark cell nuclei as well as slightly disrupted cell arrangements.) No evidence of malignancy.
|
See also: General notes on reporting
Notes
- ↑ For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
- ↑ The excision example shows a superficial basal cell carcinoma.
- ↑ - Buschke–Löwenstein tumor is an alternative name for verrucous squamous cell carcinoma in the ano-genital region.
- Carcinoma cuniculatum is a characteristic form of verrucous squamous cell carcinoma on the sole.
- ↑ Inverted follicular keratosis is generally thought to be a rare variant of seborrheic keratosis, but this position is not universally accepted.
- Karadag, AyseSerap; Ozlu, Emin; Uzuncakmak, TugbaKevser; Akdeniz, Necmettin; Cobanoglu, Bengu; Oman, Berkant (2016). "Inverted follicular keratosis successfully treated with imiquimod
". Indian Dermatology Online Journal 7 (3): 177. doi:10.4103/2229-5178.182354. ISSN 2229-5178.
Main page
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 Initially largely copied from: Yanofsky, Valerie R.; Mercer, Stephen E.; Phelps, Robert G. (2011). "Histopathological Variants of Cutaneous Squamous Cell Carcinoma: A Review
". Journal of Skin Cancer 2011: 1–13. doi:10.1155/2011/210813. ISSN 2090-2905.
-"This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited."
- ↑ There are many variants for the processing of skin excisions. These examples use aspects from the following sources:
". Ochsner J 5 (2): 22–33. 2003. PMID 22826680. PMC: 3399331. Archived from the original. .
- With a "standard histologic examination" that, in addition to the lesion, only includes one section from each side along the longest diameter of the specimen. - It also shows an example of circular coverage, with equal coverage distance in all four directions. - The entire specimen may be submitted if the risk of malignancy is high.
- ↑ Initially copied from: Paolino, Giovanni; Donati, Michele; Didona, Dario; Mercuri, Santo; Cantisani, Carmen (2017). "Histology of Non-Melanoma Skin Cancers: An Update
". Biomedicines 5 (4): 71. doi:10.3390/biomedicines5040071. ISSN 2227-9059.
"This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/)."
Image sources
Squamous-cell carcinoma of the skin
Authors:
Mikael Häggström; Authors of integrated Creative Commons article[1] [note 1]
Squamous-cell carcinoma (SCC) of the skin may present as suspected malignant skin excisions.
Fixation
Generally 10% neutral buffered formalin.
See also: General notes on fixation
Gross processing
Squamous cell carcinoma in situ.
SCC with scaling and ulceration.
If re-excision, see separate section at bottom.
Gross examination
Note:
- Color
- Well-defined or diffuse border
- Size
- Any elevation
Squamous cell carcinoma in situ (essentially synonymous with Bowen’s disease) often presents as an erythematous, well-demarcated, scaly patch or plaque, with a fairly irregular border. They occasionally present as dark skin focalities, especially when found in the genital region and the nails.[1]
Invasive SCC typically has ill-marginated, erythematous, scaling, and rough papules or patches.[1]
Tissue selection
Tissue selection from suspected malignant skin lesions, by lesion size:[2][note 2]
<4 mm |
4 - 8 mm |
9 - 15 mm
|
|
|
|
In table above, each top image shows recommended lines for cutting out slices to be submitted for further processing. Bottom image shows which side of the slice that should be put to microtomy. Dashed lines here mean that either side could be used.
Further information: Gross processing of skin excisions
Microscopic evaluation
Evaluation consists of:
- Determining whether it is a SCC rather than a differential diagnosis.
- Distinguishing a SCC in situ from an invasive SCC
- Radicality, and if radical, determine the least distance to a margin.
Characteristics
Squamous cell carcinoma in situ, showing prominent dyskeratosis and aberrant mitoses at all levels of the epidermis, along with marked parakeratosis. [1]
Main characteristics of squamous-cell carcinoma regardless of location.
- Malignant keratinocytes demonstrating intense mitotic activity, pleomorphism, and greatly enlarged nuclei. They will also show a loss of maturity and polarity, giving the epidermis a disordered or “windblown” appearance.
In situ
In SCC in situ (Bowen’s disease) the epidermis will show:
- Atypia spanning the full thickness of the epidermis, being the main finding.[1]
- Hyperkeratosis and parakeratosis.[1]
- Marked acanthosis with elongation and thickening of the rete ridges. These changes will overly keratinocytic cells which are often highly atypical and may in fact have a more unusual appearance than invasive SCC.
- Typical squamous-cell carcinoma cells are large with abundant eosinophilic cytoplasm and large, often vesicular, nuclei.[3]
- Two types of multinucleated cells may be seen:[1]
- Multinucleated giant cells
- Dyskeratotic cells engulfed in the cytoplasm of keratinocytes.
- Occasionally, cells of the upper epidermis will undergo vacuolization.[1]
There may be a mild to moderate lymphohistiocytic infiltrate detected in the upper dermis.[1]
Atypia spanning the full thickness of the epidermis is enough in this case for the diagnosis of SCC in situ. There is also a lymphohistiocytic infiltrate.
|
In contrast to actinic keratosis, the basal epidermal layer in SCC in situ is frequently spared, and will show little to no visible atypia. Additionally, SCC in situ will almost always involve both the interfollicular and adjacent follicular epithelium and adnexal structures.[1]
Overlap of squamous-cell and basal-cell carcinoma
Basal-cell carcinoma is generally distinguishable by for example relatively less cytoplasm, palisading, cleft formations and absence of horn cyst formation.
edit
Yet, a high prevalence means a relatively high incidence of borderline cases. In such cases, look particularly at the surface and attempt to classify as either of the following:
Basal-cell carcinoma with squamous cell metaplasia or metatypical (squamoid) basal-cell carcinoma. It is basal-cell carcinoma with subepidermal (but no intraepidermal) areas resembling squamous-cell carcinoma.
Basaloid squamous-cell carcinoma, in this case showing a biplastic pattern with basaloid elements associated with both conventional dysplastic squamous surface (arrow heads) and conventional squamous cell carcinoma (arrow).[4]
In unclear cases, the most useful immunohistochemistry marker appears to be MOC-31, which essentially always stains metatypical basal-cell carcinomas but not basaloid squamous-cell carcinomas.[5] UEA-1 appears to be the second most useful marker, staining almost all basaloid squamous-cell carcinomas but only a few metatypical basal-cell carcinomas.[5]
Clinical clues
- Biopsy from sun exposed area (including the face, neck, dorsal hands, and forearms, upper chest, back, and scalp).[1]
- Generally middle-aged or older individuals.[1]
In situ versus invasive
- In situ (Bowen's disease)
- Intact basement membrane.
High magnification, demonstrating an intact basement membrane.[1]
- Invasive SCC
Invasive SCC is defined by dermal infiltration.
Superficially invasive squamous cell carcinoma (SCCSI). These lesions often do not show the marked pleomorphism and atypical nuclei of SCC in situ, but demonstrate early keratinocyte invasion of the dermis.[1]
High magnification demonstrates the pleomorphism of the invading keratinocytes.[1]
Invasive nests with characteristic large celled centers. Ulceration (at left) is common in invasive SCC.
This infiltrate can be somewhat difficult to detect in the early stages of invasion: however, additional indicators such as full thickness epidermal atypia and the involvement of hair follicles can be used to facilitate the diagnosis. Later stages of invasion are characterized by the formation of nests of atypical tumor cells in the dermis, often with a corresponding inflammatory infiltrate.[1]
Radicality
Determine whether the distances between atypical cells are more or less than 1 mm from the deep and radial edges. If less than 1 mm, quantify the distance.[6]
Degree of differentiation
This is applicable to invasive SCC.
edit
Well-differentiated (and yet invasive) SCC, showing prominent keratinization and may form “pearllike” structures where dermal nests of keratinocytes attempt to mature in a layered fashion. Well-differentiated SCC has slightly enlarged, hyperchromatic nuclei with abundant amounts of cytoplasm. Intercellular bridges will frequently be visible.[1]
Moderately differentiated lesions of invasive SCC show much less organization and maturation with significantly less keratin formation.[1]
Poorly differentiated, where attempts at keratinization are often no longer evident. This is a clear-cell squamous cell carcinoma. The dysplastic cells here infiltrate in cords through the dermis. Poorly differentiated SCC has greatly enlarged, pleomorphic nuclei demonstrating a high degree of atypia and frequent mitoses.[1]
Poorly differentiated clear-cell squamous cell carcinoma. For this type of SCC, immunostains will likely be required to classify it unless other areas of the tumor show obvious squamous cell features such as seen here (keratinization in center).
Perineural or vascular invasion
In SCC, look for any perineural invasion,[note 3] and at least a quick glance for any vascular invasion.
Perineural invasion: the arrow indicates a large peripheral nerve that has been surrounded by tumor cells.[1]
Vascular invasion: the arrow indicates a small cluster of atypical squamous cells in a small vessel.[1]
Perineural invasion is defined as tumor in close proximity to nerve and involving at least 33% of its circumference or tumor cells within any of the three layers of the nerve sheath (epineurium, perineurium and endoneurium).[7] First look along the border of the tumor, followed by surrounding tissue, and if still not found, look through the rest of the tumor area as well.[1]
Staging
The AJCC, 8th Ed., does not include any staging system for skin SCC, except for tumors of the vulva.[8]
Optionally: Grading
Multiple variables can be combined to classify a SCC as low or high grade:
Low-Grade SCC[1] |
High-Grade SCC[1]
|
- Well to moderately differentiated: intercellular bridges and keratin pearls
- Tumor cells arranged in solid or sheet-like patterns
- Association with solar damage and precursor actinic keratosis
- Diameter less than 2 cm
- Depth less than 2 mm
|
- Poorly differentiated: clear-cell, sarcomatoid, or single cell features
- Presence of infiltrating individual tumor cells
- Arising de novo or in site of prior injury (ulcer, burn scar, or osteomyleitis)
- Perineural and/or perivascular invasion
- Diameter greater than 2 cm
- Depth greater than 2 mm
|
Further work-up
In vulvar squamous cell carcinoma, generally perform p16 immunohistochemistry, which is considered a surrogate marker for oncogenic HPV infection.[9]
Microscopy report
On this resource, the following formatting is used for comprehensiveness:
- Minimal depth
- (Moderate depth)
- ((Comprehensive))
Components of the report:
- Diagnosis of squamous-cell carcinoma
- Whether it is in situ or invasive. If invasive:
- Degree of differentiation.
- (High or low grade.)
- Even absence of perineural invasion[note 3]
- ((Even absence of or vascular invasion.))
- Radicality, mainly into either of the following: edit
- >1 mm (as per Radicality above): "Clear margins" (or: "Clear margins at over __ mm")((or the exact distance thereof)).))
- <1 mm but not continuous with edge: "Close margins at __ mm at (location). [[Locations are mainly the deep edge, or the (superior/inferior/medial/lateral) radial edge.]]."[6] Numbers are generally given at an exactness of 0.1 mm.
- Continuous with margin: "Not radically excised at (location)."
- Staging is only applicable for the head and neck (lip, ear, face, scalp and neck - see staging at Medscape) and vulva (see staging at cancer.net).
((You may also add a synoptic report (see examples):))
Examples
Squamous cell carcinoma in situ:
((Skin excision with squamous epithelium with))(central parakeratosis. The epidermis is thickened and exhibits disturbed stratification. )All cell layers show atypical epithelial cells with polymorphic and partially hyperchromatic nuclei. The basement membrane is intact. Clear margins. ((There is elastosis and inflammatory cells in the dermis.))
|
Invasive squamous cell carcinoma:
(Skin, right breast, excision:) Invasive keratinizing squamous cell carcinoma, well differentiated, measuring 1.7 cm in greatest dimension. Surgical margins are negative for carcinoma. (Negative for lymphovascular and perineural invasion.) ((Solar elastosis.))
|
((Example synoptic report:))
- Procedure: Skin excision.
- Tumor site: Scalp
- Tumor laterality: Right
- Tumor focality: Unifocal
- Tumor size: 1.6 x 1.4 cm
- Tumor depth of invasion: 0.3 cm
- Histologic type: Squamous cell carcinoma
- Histologic grade: Moderately differentiated
- Specimen margins: Uninvolved by invasive tumor.
- Lymphovascular invasion: Not identified
- Perineural invasion: Not identified
- Regional lymph nodes: No lymph nodes submitted or found.
- Pathologic Stage Classification (pTNM, AJCC 8th Edition):
- Primary Tumor: pT1
- Regional Lymph Nodes: pNX: Regional lymph nodes cannot be assessed
- Additional pathologic findings: Actinic keratosis
Example microscopic description of invasive squamous cell carcinoma:
- Squamous epithelium, with central ulceration, surrounded by hyperkeratosis. In this area in the dermis there are infiltrative nests of epithelioid cells with nuclear pleomorphism and <sparse / moderate / abundant> keratin formation.
See also: General notes on reporting
Re-excisions
Gross processing
edit ((Submit the entire specimen, or)) depending on radicality of previous excision:
- Previously radical (including thin margins): Submit at least one central section across the surgical scar.[10]
- Previously non-radical:
- Visible lesion: Submit the entire scar.[10]
- Lesion not visible: At least one additional radicality slice towards the tips, up to the entire specimen.[11]
Notes
- ↑ For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
- ↑ The excision example shows a superficial basal cell carcinoma.
- ↑ 3.0 3.1 Presence or absence of perineural invasion in squamous-cell carcinoma affects whether adjuvant radiotherapy will be used.
Main page
References
- ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 1.21 1.22 1.23 Yanofsky, Valerie R.; Mercer, Stephen E.; Phelps, Robert G. (2011). "Histopathological Variants of Cutaneous Squamous Cell Carcinoma: A Review
". Journal of Skin Cancer 2011: 1–13. doi:10.1155/2011/210813. ISSN 2090-2905. .
-"This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited."
- ↑ There are many variants for the processing of skin excisions. These examples use aspects from the following sources:
". Ochsner J 5 (2): 22–33. 2003. PMID 22826680. PMC: 3399331. Archived from the original. .
- With a "standard histologic examination" that, in addition to the lesion, only includes one section from each side along the longest diameter of the specimen. - It also shows an example of circular coverage, with equal coverage distance in all four directions. - The entire specimen may be submitted if the risk of malignancy is high.
- ↑ Dr Nicholas Turnbull, A/Prof Patrick Emanual (2014-05-03). Squamous cell carcinoma pathology. DermNetz.
- ↑ El-Mofty, SK. (2014). "Histopathologic risk factors in oral and oropharyngeal squamous cell carcinoma variants: An update with special reference to HPV-related carcinomas
". Medicina Oral Patología Oral y Cirugia Bucal: e377–e385. doi:10.4317/medoral.20184. ISSN 16986946.
License: CC BY 2.5
- ↑ 5.0 5.1 Webb, David V.; Mentrikoski, Mark J.; Verduin, Lindsey; Brill, Louis B.; Wick, Mark R. (2015). "Basal cell carcinoma vs basaloid squamous cell carcinoma of the skin: an immunohistochemical reappraisal
". Annals of Diagnostic Pathology 19 (2): 70–75. doi:10.1016/j.anndiagpath.2015.01.004. ISSN 10929134.
- ↑ 6.0 6.1 1 mm as cutoff for close margin: Brodie M Elliott, Benjamin R Douglass, Daniel McConnell, Blair Johnson, Christopher Harmston (2018-12-14). New Zealand Medical Journal.
- ↑ Strowd, Roy (2021). Neuro-oncology for the clinical neurologist
. Philadelphia, PA: Elsevier. ISBN 978-0-323-69494-0. OCLC 1220993756.
- ↑ Amin, Mahul (2017). AJCC cancer staging manual
(8 ed.). Switzerland: Springer. ISBN 978-3-319-40617-6. OCLC 961218414.
- For access, see the Secrets chapter of Patholines. - Copyright note: The AJCC, 8th Ed. is published by a company in Switzerland, and the tables presented therein are Public Domain because they consist of tabular information without literary or artistic innovation, and therefore do not fulfil the inclusion criterion of the Swiss Copyright Act (CopA) which applies to "literary and artistic intellectual creations with individual character" (see Federal Act on Copyright and Related Rights (Copyright Act, CopA) of 9 October 1992 (Status as of 1 January 2022)). edit
- ↑ Anjelica Hodgson, M.D., Carlos Parra-Herran, M.D.. p16. Pathology Outlines. Last author update: 1 July 2017. Last staff update: 20 July 2022
- ↑ 10.0 10.1 Katarzyna Lundmark. Handläggning av hudprover – provtagningsanvisningar, utskärningsprinciper och snittning (Handling of skin samples - sampling instructions, cutting principles and incision. Swedish Society of Pathology.
- ↑ Pathology Department at NU Hospital Group, Sweden, 2019-2020.
Image sources
Melanoma in situ
Author:
Mikael Häggström [note 1]
Melanoma of the skin generally presents as a dark skin focality and/or a suspected malignant skin excision.
Fixation
Generally 10% neutral buffered formalin.
See also: General notes on fixation
Gross processing
Gross examination
Note:
- Color
- Well-defined or diffuse border
- Size
- Any elevation
Tissue selection
Tissue selection from suspected malignant skin lesions, by lesion size:[1][note 2]
<4 mm |
4 - 8 mm |
9 - 15 mm
|
|
|
|
In table above, each top image shows recommended lines for cutting out slices to be submitted for further processing. Bottom image shows which side of the slice that should be put to microtomy. Dashed lines here mean that either side could be used.
Further information: Gross processing of skin excisions
Microscopic evaluation
Differential diagnoses
Distinguish mainly from dysplastic nevus and invasive melanoma of the skin:
Dysplastic nevus
Comparison of congenital pattern nevus, dysplastic nevus and suspected melanoma edit
Parameter |
Non-atypical congenital pattern |
Low-grade dysplastic nevus |
High-grade dysplastic nevus |
Suspected melanoma in situ
|
Mild dysplasia |
Moderate dysplasia |
Severe dysplasia
|
Macroscopic
|
Lateral circumscription[2]
|
Sharp |
Slightly diminished |
Moderate |
Poor
|
Symmetry[2]
|
Good |
Often broken |
Rare
|
Structural (Low mag.)
|
Delimitation[3]
|
|
Rarely diffuse |
Sometimes diffuse |
Often diffuse
|
Lentiginous proliferation[note 3][3]
|
|
Yes, along with rete pegs |
Yes, along with and focally between rete pegs |
Yes, along with and focally between rete pegs |
Yes partially continuous, multilayered
|
Bridging[3]
|
|
Rarely |
Often
|
Confluent nests[3]
|
|
Rarely |
Sometimes |
Often |
Often widespread
|
Pigment distribution[3]
|
|
Regular |
Irregular
|
Suprabasal presence (less than most superficial third of subcorneal epidermis)
|
Occasionally centrally[2] |
No[3] or rarely[2] |
Occasionally centrally[2] |
Yes, multifocal[3]
|
Pagetoid migration including superficial third of subcorneal epidermis[3]
|
|
No |
No |
Yes, in a maximum of 2 HPF centrally, but not peripherally |
Yes, multifocal and/or in periphery
|
Extended rete pegs
|
Ocassional[2] |
Yes, regular[3] |
Yes, varying[3] |
Yes, often irregular[3] |
Varying, flattened[3]
|
Concentric fibrosis
|
Regressive[2] |
Yes[3] |
Occasional[2]
|
Lamellar fibrosis
|
Rarely[3] |
Often[3] |
Often pronounced[3] |
Occasional[2]
|
Lymphocytic infiltrate[3]
|
|
Mild, perivascular |
Mild or moderate, perivascular |
Varying |
Varying
|
Suprapapillary plate involvement
|
No[2] |
Usually no[2] |
Often[2] |
Yes[2]
|
Cellular (high mag.)
|
Image
|
|
|
|
|
|
Junctional extension[2]
|
Unusual |
Usual |
Extensive
|
Nuclear size[2]
|
Age-related |
Small |
Medium |
Large |
Medium or large. Pleomorphic[4]
|
Nuclear pleomorphism[5]
|
|
Slight |
Prominent
|
Chromatin pattern
|
Uniform[2] |
Condensed[2] |
Partically expanded[2] |
Expanded, coarse in some cells[2] |
Expanded, hyperchromatic, coarse.[2] Usually granular.[5]
|
Nucleoli[2]
|
Age-related |
Small |
Medium |
Large |
Usually[5] large
|
Mitoses[2]
|
Few superficial |
Superficial and deep
|
Histological regression[5][note 4]
|
|
Usually |
Usually not
|
Percentage of atypical melanocytes[3]
|
|
<10% |
About 10 - 50% |
about 50-90% |
Usually> 90%
|
Intradermal melanocytic atypia[3]
|
|
No |
Rarely, in superficial part |
Can be detected in superficial part
|
Intradermal melanocyte maturation[3]
|
|
Yes |
Yes, can be partial |
Yes, can be partial |
Variable
|
In suspected but not certain nevus or melanoma in situ, generally perform immunohistochemistry with SOX10, whereby melanocyte proliferation and nuclear pleomorphism is easier to see.[note 5]
SOX10 immunohistochemistry of a junctional nevus, with atypical melanocytic proliferation, seen mainly in hair follicles.
SOX10 immunohistochemistry of lentigo maligna, showing an increased number of melanocytes along stratum basale, and nuclear pleumorphism.
- Further information: Evaluation of suspected malignancies
Invasive melanoma of the skin
Invasive melanoma of the skin has features melanoma in situ, but also has dermal involvement of atypical melanocytes with cytologic atypia and no maturation.[6]
Further workup
Upon a diagnosis of melanoma in situ, evaluate its margins. Optionally, attempt to determine the histopathologic type and amount of cytoplasmic pigmentation:
- Margins
If melanoma, determine if the distance to any margin is greater or lesser than 2-3 mm.
- 2 mm is used as a cutoff for sharply demarcated, small, superficially spreading or nevoid melanomas.[7]
- 3 mm is used for ill-defined lentigo maligna melanoma in situ.[7]
If lesser, quantify the distance.
If margins are difficult to determine, consider immunohistochemistry with SOX10 to better visualize melanoma nests.[note 5]
- Histopathologic type
Main types of melanoma in situ are:
Type |
Features |
Micrograph
|
Superficial spreading melanoma in situ
|
Melanoma cells with nest formation along the dermo-epidermal junction.
|
|
Lentigo maligna
|
Linear spread of atypical epidermal melanocytes along stratum basale.[8]
|
|
Acral lentiginous melanoma in situ
|
Continuous proliferation of atypical melanocytes at the dermoepidermal junction.[9]
|
|
Report
Most important entries:
- Melanoma area dimensions (width x width)[10]
- Radicality,[10] mainly into either of the following: edit
- >2 or 3 mm (as per Further workup above): "Clear margins" (or: "Clear margins at over __ mm")((or the exact distance thereof)).))
- <2 or 3 mm but not continuous with edge: "Close margins at __ mm at (location). [[Locations are mainly the deep edge, or the (superior/inferior/medial/lateral) radial edge.]]." Numbers are generally given at an exactness of 0.1 mm.
- Continuous with margin: "Not radically excised at (location)."
See also: General notes on reporting
Notes
- ↑ For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
- ↑ The excision example shows a superficial basal cell carcinoma.
- ↑ Lentiginous proliferation is proliferation along the basal layer of the epidermis
- ↑ Histological regression is one or more areas within a tumor in which neoplastic cells have disappeared or decreased in number. In this case, this means complete or partial disappearance from areas of the dermis (and occasionally from the epidermis), which have been replaced by fibrosis, accompanied by melanophages, new blood vessels, and a variable degree of inflammation.
- Ribero, Simone; Gualano, Maria Rosaria; Osella-Abate, Simona; Scaioli, Giacomo; Bert, Fabrizio; Sanlorenzo, Martina; Balagna, Elena; Fierro, Maria Teresa; et al. (2015). "Association of Histologic Regression in Primary Melanoma With Sentinel Lymph Node Status
". JAMA Dermatology 151 (12): 1301. doi:10.1001/jamadermatol.2015.2235. ISSN 2168-6068.
- ↑ 5.0 5.1 SOX10 stains cell nuclei of melanocytes.
- Miettinen, Markku; McCue, Peter A.; Sarlomo-Rikala, Maarit; Biernat, Wojciech; Czapiewski, Piotr; Kopczynski, Janusz; Thompson, Lester D.; Lasota, Jerzy; et al. (2015). "Sox10—A Marker for Not Only Schwannian and Melanocytic Neoplasms But Also Myoepithelial Cell Tumors of Soft Tissue
". The American Journal of Surgical Pathology 39 (6): 826–835. doi:10.1097/PAS.0000000000000398. ISSN 0147-5185.
Main page
References
- ↑ There are many variants for the processing of skin excisions. These examples use aspects from the following sources:
". Ochsner J 5 (2): 22–33. 2003. PMID 22826680. PMC: 3399331. Archived from the original. .
- With a "standard histologic examination" that, in addition to the lesion, only includes one section from each side along the longest diameter of the specimen. - It also shows an example of circular coverage, with equal coverage distance in all four directions. - The entire specimen may be submitted if the risk of malignancy is high.
- ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 2.15 2.16 2.17 2.18 2.19 2.20 2.21 Arumi-Uria, Montserrat; McNutt, N Scott; Finnerty, Bridget (2003). "Grading of Atypia in Nevi: Correlation with Melanoma Risk
". Modern Pathology 16 (8): 764–771. doi:10.1097/01.MP.0000082394.91761.E5. ISSN 0893-3952.
- ↑ 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 3.12 3.13 3.14 3.15 3.16 3.17 3.18 3.19 Katarzyna Lundmark, Britta Krynitz, Ismini Vassilaki, Lena Mölne, Annika Ternesten Bratel. Histopatologisk bedömning och gradering av dysplastiskt nevus samt gränsdragning mot melanom in situ/melanom (Histopathological assessment and grading of dysplastic nevus and distinction from melanoma in situ/melanoma). KVAST (Swedish Society of Pathology). Retrieved on 2019-09-18.
- ↑ Christopher S. Hale. Skin melanocytic tumor - Melanoma - Invasive melanoma. Topic Completed: 1 May 2013. Revised: 17 September 2019
- ↑ 5.0 5.1 5.2 5.3 Husain, Ehab A; Mein, Charles; Pozo, Lucia; Blanes, Alfredo; Diaz-Cano, Salvador J (2011). "Heterogeneous topographic profiles of kinetic and cell cycle regulator microsatellites in atypical (dysplastic) melanocytic nevi
". Modern Pathology 24 (4): 471–486. doi:10.1038/modpathol.2010.143. ISSN 0893-3952.
- ↑ Christopher S. Hale. Skin melanocytic tumor - Melanoma - Invasive melanoma. Pathology Outlines. Topic Completed: 1 May 2013. Revised: 17 September 2019
- ↑ 7.0 7.1 Measurements used to classify a melanoma as radical: Page 406 in: Klaus J. Busam, Richard A Scolyer, Pedram Gerami (2018). Pathology of Melanocytic Tumors
. Elsevier Health Sciences. ISBN 9780323508681.
- ↑ Error on call to Template:cite web: Parameters url and title must be specifiedHon A/Prof Amanda Oakley (2011). . DermNet NZ.
- ↑ Piliang, Melissa Peck (2009). "Acral Lentiginous Melanoma
". Surgical Pathology Clinics 2 (3): 535–541. doi:10.1016/j.path.2009.08.005. ISSN 18759181.
- ↑ 10.0 10.1 . An Example of a Melanoma Pathology Report. Melanoma Foundation. Retrieved on 2019-09-24.
Image sources
Invasive melanoma of the skin
Author:
Mikael Häggström [note 1]
Melanoma of the skin generally presents as a dark skin focality.
Fixation
Generally 10% neutral buffered formalin.
See also: General notes on fixation
Gross processing
Gross examination
Note:
- Color
- Well-defined or diffuse border
- Size
- Any elevation
Tissue selection
Tissue selection from suspected malignant skin lesions, by lesion size:[1][note 2]
<4 mm |
4 - 8 mm |
9 - 15 mm
|
|
|
|
In table above, each top image shows recommended lines for cutting out slices to be submitted for further processing. Bottom image shows which side of the slice that should be put to microtomy. Dashed lines here mean that either side could be used.
Further information: Gross processing of skin excisions
Microscopic evaluation
Differential diagnoses
Dermal nevus
Comparison of dermal nevus and suspected invasive melanoma edit
Parameter |
Non-dysplastic dermal nevus |
Low-grade dysplastic dermal nevus |
High-grade dysplastic dermal nevus |
Suspected invasive melanoma
|
Mild dysplasia |
Moderate dysplasia |
Severe dysplasia
|
Macroscopic
|
Lateral circumscription[3]
|
Sharp |
Slightly diminished |
Moderate |
Poor
|
Symmetry[3]
|
Good |
Often broken |
Rare
|
Structural (Low mag.)
|
Micrograph
|
|
|
|
|
|
Delimitation[4]
|
|
Rarely diffuse |
Sometimes diffuse |
Often diffuse
|
Confluent nests[4]
|
|
Rarely |
Sometimes |
Often |
Often widespread
|
Pigment distribution[4]
|
Regular |
Irregular
|
Concentric fibrosis
|
Regressive (see below table)[3] |
Yes[4] |
Occasional[3]
|
Lamellar fibrosis
|
Rarely[4] |
Often[4] |
Often pronounced[4] |
Occasional[3]
|
Lymphocytic infiltrate[4]
|
|
Mild, perivascular |
Mild or moderate, perivascular |
Varying |
Varying
|
Cellular (high mag.)
|
Micrographs
|
|
|
|
|
|
Nuclear size[3]
|
|
Small |
Medium |
Large |
Medium or large. Pleomorphic[5]
|
Nuclear pleomorphism[6]
|
Slight superficial |
Slight |
Prominent
|
Chromatin pattern
|
Uniform[3] |
Condensed[3] |
Partically expanded[3] |
Expanded, coarse in some cells[3] |
Expanded, hyperchromatic, coarse.[3] Usually granular.[6]
|
Nucleoli[3]
|
|
Small |
Medium |
Large |
Usually[6] large
|
Mitoses[3]
|
Few superficial |
Superficial and deep
|
Histological regression[6] (see below table)
|
|
Usually |
Usually not
|
Percentage of atypical melanocytes[4]
|
|
<10% |
About 10 - 50% |
about 50-90% |
Usually> 90%
|
Histological regression is one or more areas within a tumor in which neoplastic cells have disappeared or decreased in number. In this case, it means complete or partial disappearance of neoplastic cells from areas of the dermis (and occasionally from the epidermis), which have been replaced by fibrosis, accompanied by melanophages, new blood vessels, and a variable degree of inflammation.[7]
In suspected but not certain nevus or melanoma, generally perform immunohistochemistry with SOX10 (which stains cell nuclei of melanocytes), whereby melanocyte proliferation and nuclear pleomorphism is easier to see:[8]
SOX10 showing dermal nevus nests.
Further workup
In case a diagnosis of invasive melanoma of the skin can be made, the following are generally mandatory:
- Margins
- Depth
- Any ulceration
- Histopathologic type.[9]
- Presence of mitoses in the intradermal component.[9]
The following aspects are mandatory in some regions:
- Clark's level (not mandatory in the US)[note 3]
Margins
Determine if the distance to any margin is greater or lesser than 3 mm.[10] If a margin is closer, measure it at an exactness of 0.1 mm.
If margins are difficult to determine, consider immunohistochemistry with SOX10 (staining the nuclei of melanocytes), to better visualize melanoma nests.[11]
Depth and ulceration
For invasive melanoma, measure the depth and whether there is ulceration or not, so as to be able to classify the T stage (following table by AJCC, 8th edition):[12]
T Category
|
Thickness
|
Ulceration status
|
TX: primary tumor thickness cannot be assessed (e.g., diagnosis by curettage) |
Not applicable |
Not applicable
|
T0: no evidence of primary tumor (e.g., unknown primary or completely regressed melanoma) |
Not applicable |
Not applicable
|
Tis (melanoma in situ) |
Not applicable |
Not applicable
|
T1 |
≤1.0 mm |
Unknown or unspecified
|
T1a |
<0.8 mm |
Without ulceration
|
T1b |
<0.8 mm |
With ulceration
|
0.8–1.0 mm |
With or without ulceration
|
T2 |
>1.0–2.0 mm |
Unknown or unspecified
|
T2a |
>1.0–2.0 mm |
Without ulceration
|
T2b |
>1.0–2.0 mm |
With ulceration
|
T3 |
>2.0‐4.0 mm |
Unknown or unspecified
|
T3a |
>2.0–4.0 mm |
Without ulceration
|
T3b |
>2.0–4.0 mm |
With ulceration
|
T4 |
>4.0 mm |
Unknown or unspecified
|
T4a |
>4.0 mm |
Without ulceration
|
T4b |
>4.0 mm |
With ulceration
|
Histopathologic type
If needing to evaluate, the main types of invasive melanoma are:[13]
Type |
Features |
Relative incidence (in comparison to all melanomas)[13] |
Photograph |
Micrograph
|
Superficial spreading melanoma
|
Melanoma cells with nest formation along the dermo-epidermal junction.
|
70%
|
|
|
Nodular melanoma
|
Grows relatively more in depth than in width.
|
15% - 20%
|
|
|
Lentigo maligna melanoma
|
Atypical epidermal melanocytes as well as invasion into the dermis.[14]
|
5% - 10%
|
|
|
Acral lentiginous melanoma
|
Continuous proliferation of atypical melanocytes at the dermoepidermal junction.[15]
|
7% - 10%
|
|
|
Clark's level
If needing to evaluate,[note 3] Clark's levels are:[16]
- Level 1: Melanoma confined to the epidermis (melanoma in situ)
- Level 2: Invasion into the papillary dermis
- Level 3: Invasion to the junction of the papillary and reticular dermis
- Level 4: Invasion into the reticular dermis
- Level 5: Invasion into subcutaneous tissue.
Tumor‐infiltrating Lymphocytes (TILs)
Classify as either of the following:[12]
- Absent TIL infiltrate: no lymphocytes present or, if present, they do not interact with tumor cells.
- Non-brisk TIL infiltrate: focal areas of lymphocytic infiltration in the tumor.
- Brisk TIL infiltrate: TIL infiltration of the entire base of the tumor, or diffuse permeation of the tumor.
Lymph nodes
Cells that stain for melan-A but are nevus-like may be a capsular nevus
If negative on H&E stain, generally use immunohistochemistry for melanoma markers (such as a combination of melan-A and HMB-45) to exclude micrometastasis:
Melanoma micrometastases on melan-A stain.
Other parameters
Optionally, the following parameters can be given:[17]
- histological regression, with complete or partial disappearance from areas of the dermis (and occasionally from the epidermis), which have been replaced by fibrosis, accompanied by melanophages, new blood vessels, and a variable degree of inflammation.[18]
- Further information: Evaluation of tumors
Report
Report when evaluated (as per mandatory vs. optional in Further workup above):
- Melanoma area dimensions (width x width)[19]
- Radicality,[19] mainly into either of the following: edit
- >3 mm : "Clear margins" (or: "Clear margins at over __ mm")((or the exact distance thereof)).))
- <3 mm but not continuous with edge: "Close margins at __ mm at (location). [[Locations are mainly the deep edge, or the (superior/inferior/medial/lateral) radial edge.]]." Numbers are generally given at an exactness of 0.1 mm.
- Continuous with margin: "Not radically excised at (location)."
- Depth or most distant invasion of melanoma cells.[19]
- Ulceration or not, and maximum dimension if present
- Stage as per AJCC
- Clark's level
- Histopathologic type
- Mitotic rate, as amount per mm2
- Significant signs of regression
- Cytoplasmic pigmentation
- Melanoma cell shapes
US example
Skin, mid upper back, excision:
- Malignant melanoma, nodular type, Clark level IV, Breslow thickness 10mm. Surgical margins are negative for melanoma.
See synoptic report.
SYNOPTIC REPORT:
Specimen
Procedure: Excision
Specimen Laterality: Midline
Tumor
Tumor Site: Skin of trunk
Histologic Type: Nodular melanoma
Maximum Tumor (Breslow) Thickness (Millimeters): 10 mm
Macroscopic Satellite Nodule(s): Not identified
Ulceration: Present
Extent of Ulceration (Millimeters): 12 mm
Anatomic (Clark) Level: IV (Melanoma invades reticular dermis)
Mitotic Rate: 18 mitoses / mm2
Microsatellite(s): Not identified
Lymphovascular Invasion: Not identified
Neurotropism: Not identified
Tumor-Infiltrating Lymphocytes: Present, nonbrisk
Tumor Regression: Not identified
Margins
Peripheral Margins: Negative for invasive melanoma
Distance of Invasive Melanoma from Closest Peripheral Margin (Millimeters): 5 mm
Location: 3 o'clock and 9 o'clock
Status of melanoma in situ at peripheral margins: Negative for melanoma in situ
Distance of melanoma in situ from closest peripheral margin (millimeters): Cannot be determined - Ulcerated surface and no in-situ noted in the remaining surface
Location: Lateral
Deep Margin: Negative for invasive melanoma
Distance of Invasive Melanoma from Deep Margin (Millimeters): 2 mm
Status of Melanoma in situ at Deep Margin: Negative for melanoma in situ
Distance of Melanoma in situ from Deep Margin (Millimeters): Cannot be determined (negative for melanoma in situ)
Lymph Nodes
Regional Lymph Nodes: No lymph nodes submitted or found
Pathologic Stage Classification (pTNM, AJCC 8th Edition)
Primary Tumor (pT): pT4b
Regional Lymph Nodes (pN): pNX
|
European example
Sun-damaged skin with central diffusely delimited proliferation of melanocytic cells having polymorphic cell nuclei, distinct nucleoli and uneven light brown pigmentation. An area of pagetoid migration is seen. There is ulceration of a smaller area. The radial margin is over 3.0 mm and the deep margin is 2.0 mm.
- Free margin: Yes
- Margin in mm: 2.0 mm
- Tumor depth: 1.2 mm
- Ulceration: Yes
- Stage: T2b
- Clark's level: IV
- Histopathologic type: Superficial spreading melanoma
- Presence of mitoses: Yes
- Significant signs of regression: No
|
See also: General notes on reporting
Notes
- ↑ For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
- ↑ The excision example shows a superficial basal cell carcinoma.
- ↑ 3.0 3.1 Clark's level is not included in United States AJCC guidelines, but is mandatory for melanomas in Sweden.
-. Breslow Depth and Clark Level. Melanoma Research Alliance. Retrieved on 2020-02-13. - . Bilaga 6. Kvalitetsbilaga för patologi (KVAST-bilaga). Regionala Cancercentrum i Samverkan, guidelines by Swedish Society of Pathology. Retrieved on 2020-02-13.
Main page
References
- ↑ There are many variants for the processing of skin excisions. These examples use aspects from the following sources:
". Ochsner J 5 (2): 22–33. 2003. PMID 22826680. PMC: 3399331. Archived from the original. .
- With a "standard histologic examination" that, in addition to the lesion, only includes one section from each side along the longest diameter of the specimen. - It also shows an example of circular coverage, with equal coverage distance in all four directions. - The entire specimen may be submitted if the risk of malignancy is high.
- ↑ . Melanoma in situ (stage 0). Cancer Research UK. Last reviewed: 27 Jun 2019
- ↑ 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 3.12 Arumi-Uria, Montserrat; McNutt, N Scott; Finnerty, Bridget (2003). "Grading of Atypia in Nevi: Correlation with Melanoma Risk
". Modern Pathology 16 (8): 764–771. doi:10.1097/01.MP.0000082394.91761.E5. ISSN 0893-3952.
- ↑ 4.0 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 Katarzyna Lundmark, Britta Krynitz, Ismini Vassilaki, Lena Mölne, Annika Ternesten Bratel. Histopatologisk bedömning och gradering av dysplastiskt nevus samt gränsdragning mot melanom in situ/melanom (Histopathological assessment and grading of dysplastic nevus and distinction from melanoma in situ/melanoma). KVAST (Swedish Society of Pathology). Retrieved on 2019-09-18.
- ↑ Christopher S. Hale. Skin melanocytic tumor - Melanoma - Invasive melanoma. Topic Completed: 1 May 2013. Revised: 17 September 2019
- ↑ 6.0 6.1 6.2 6.3 Husain, Ehab A; Mein, Charles; Pozo, Lucia; Blanes, Alfredo; Diaz-Cano, Salvador J (2011). "Heterogeneous topographic profiles of kinetic and cell cycle regulator microsatellites in atypical (dysplastic) melanocytic nevi
". Modern Pathology 24 (4): 471–486. doi:10.1038/modpathol.2010.143. ISSN 0893-3952.
- ↑ Ribero, Simone; Gualano, Maria Rosaria; Osella-Abate, Simona; Scaioli, Giacomo; Bert, Fabrizio; Sanlorenzo, Martina; Balagna, Elena; Fierro, Maria Teresa; et al. (2015). "Association of Histologic Regression in Primary Melanoma With Sentinel Lymph Node Status
". JAMA Dermatology 151 (12): 1301. doi:10.1001/jamadermatol.2015.2235. ISSN 2168-6068.
- ↑ Miettinen, Markku; McCue, Peter A.; Sarlomo-Rikala, Maarit; Biernat, Wojciech; Czapiewski, Piotr; Kopczynski, Janusz; Thompson, Lester D.; Lasota, Jerzy; et al. (2015). "Sox10—A Marker for Not Only Schwannian and Melanocytic Neoplasms But Also Myoepithelial Cell Tumors of Soft Tissue
". The American Journal of Surgical Pathology 39 (6): 826–835. doi:10.1097/PAS.0000000000000398. ISSN 0147-5185.
- ↑ 9.0 9.1 - USA: . [https://documents.cap.org/protocols/Skin.Melanoma_4.3.0.2.REL_CAPCP.pdf Protocol for the Examination of Excision Specimens From
Patients With Melanoma of the Skin]. COllege of American Pathologists. Version: 4.3.0.2. Protocol Posting Date: November 2021
-Sweden: . Bilaga 6. Kvalitetsbilaga för patologi (KVAST-bilaga). Regionala Cancercentrum i Samverkan, guidelines by Swedish Society of Pathology. Retrieved on 2020-02-13.
- ↑ Definition of "thin margin": Wolf, Y.; Balicer, R.D.; Amir, A.; Feinmesser, M.; Hauben, D.J. (2001). "The vertical dimension in the surgical treatment of cutaneous malignant melanoma – how deep is deep?
". European Journal of Plastic Surgery 24 (2): 74–77. doi:10.1007/s002380100225. ISSN 0930-343X.
- ↑ Miettinen, Markku; McCue, Peter A.; Sarlomo-Rikala, Maarit; Biernat, Wojciech; Czapiewski, Piotr; Kopczynski, Janusz; Thompson, Lester D.; Lasota, Jerzy; et al. (2015). "Sox10—A Marker for Not Only Schwannian and Melanocytic Neoplasms But Also Myoepithelial Cell Tumors of Soft Tissue
". The American Journal of Surgical Pathology 39 (6): 826–835. doi:10.1097/PAS.0000000000000398. ISSN 0147-5185.
- ↑ 12.0 12.1 Amin, Mahul (2017). AJCC cancer staging manual
(8 ed.). Switzerland: Springer. ISBN 978-3-319-40617-6. OCLC 961218414.
- For access, see the Secrets chapter of Patholines. - Copyright note: The AJCC, 8th Ed. is published by a company in Switzerland, and the tables presented therein are Public Domain because they consist of tabular information without literary or artistic innovation, and therefore do not fulfil the inclusion criterion of the Swiss Copyright Act (CopA) which applies to "literary and artistic intellectual creations with individual character" (see Federal Act on Copyright and Related Rights (Copyright Act, CopA) of 9 October 1992 (Status as of 1 January 2022)). edit
- ↑ 13.0 13.1 [https://books.google.se/books?id=wGclDwAAQBAJ&pg=PA805 Page 805 in: Ferri, Fred (2019). Ferri's clinical advisor 2019 : 5 books in 1
. Philadelphia, PA: Elsevier. ISBN 978-0-323-52957-0. OCLC 1040695302.
- ↑ Michael Xiong; Ahmad Charifa; Chih Shan J. Chen.. Cancer, Lentigo Maligna Melanoma. StatPearls, National Center for Biotechnology Information. Last Update: May 18, 2019.
- ↑ Piliang, Melissa Peck (2009). "Acral Lentiginous Melanoma
". Surgical Pathology Clinics 2 (3): 535–541. doi:10.1016/j.path.2009.08.005. ISSN 18759181.
- ↑ . NCI Dictionary of Cancer Terms. National Cancer Institute. Retrieved on 2020-02-13.
- ↑ Rees, Jonathan; Viros, Amaya; Fridlyand, Jane; Bauer, Juergen; Lasithiotakis, Konstantin; Garbe, Claus; Pinkel, Daniel; Bastian, Boris C (2008). "Improving Melanoma Classification by Integrating Genetic and Morphologic Features
". PLoS Medicine 5 (6): e120. doi:10.1371/journal.pmed.0050120. ISSN 1549-1676.
- ↑ Ribero, Simone; Gualano, Maria Rosaria; Osella-Abate, Simona; Scaioli, Giacomo; Bert, Fabrizio; Sanlorenzo, Martina; Balagna, Elena; Fierro, Maria Teresa; et al. (2015). "Association of Histologic Regression in Primary Melanoma With Sentinel Lymph Node Status
". JAMA Dermatology 151 (12): 1301. doi:10.1001/jamadermatol.2015.2235. ISSN 2168-6068.
- ↑ 19.0 19.1 19.2 . An Example of a Melanoma Pathology Report. Melanoma Foundation. Retrieved on 2019-09-24.
Image sources
Dermatitis
Author:
Mikael Häggström [note 1]
Scope: This article deals with skin conditions where inflammation is the main finding, excluding suspected malignant skin excisions (where inflammation is often a concurrent finding).
Sampling
- For punch biopsies, a size of 4 mm is preferred for most inflammatory dermatoses.[1]
- Panniculitis or cutaneous lymphoproliferative disorders: 6 mm punch biopsy or skin excision.[1]
A superficial or shave biopsy is regarded as insufficient.[1]
Fixation
Generally 10% neutral buffered formalin.
See also: General notes on fixation
Gross processing
Gross pathology processing of skin lesions with benign appearance, by lesion size:[4]
<4 mm |
4 - 8 mm |
9 - 15 mm
|
|
|
|
In table above, each top image shows recommended lines for cutting out slices to be submitted for further processing. Bottom image shows which side of the slice that should be put to microtomy. Dashed lines here mean that either side could be used.
Further information: Gross processing of skin excisions
Staining
3 H&E sections and one section with periodic acid Schiff (PAS)[note 2][1]
- If suspected bacterial and fungal microorganisms, consider Gram stain and Gomori methenamine silver stain.[1]
Microscopic evaluation
One approach is to classify into mainly either of the following, primarily based on depth of involvement:[1]
- Epidermis, papillary dermis, and superficial vascular plexus:
- Vesiculobullous lesions
- Pustular dermatosis
- Non vesicullobullous, non-pustular
- With epidermal changes
- Without epidermal changes. These characteristically have a superficial perivascular inflammatory infiltrate, and can be classified by type of cell infiltrate:[1]
- Lymphocytic (most common)
- Lymphoeosinophilic
- Lymphoplasmacytic
- Mast cell
- Lymphohistiocytic
- Neutrophilic
Continue in corresponding section:
Non vesicullobullous, non-pustular lesions with epidermal changes
Spongiotic dermatitis
It is characterized by epithelial intercellular edema.[1]
|
Characteristics |
Micrograph |
Photograph
|
Acute |
Subacute |
Chronic
|
Generally/Not otherwise specified[note 3]
|
Typical findings:[1]
- Variable degree of epidermal spongiosis and vesicle formation, filled with proteinaceous fluid containing lymphocytes and histiocytes.
- Usually superficial dermal edema with perivascular lymphocytic infiltrate, with exocytosis.
- No acanthosis or parakeratosis.
|
Typical findings:[1]
- Mild to moderate spongiosis and exocytosis of inflammatory cells
- Irregular acanthosis and parakeratosis.
- Superficial dermal perivascular lymphohistiocytic infiltrate
- Swelling of endothelial cells
- Papillary dermal edema are present
|
Typical findings:[1]
- The spongiosis is mild to absent
- Pronounced irregular acanthosis, hyperkeratosis, and parakeratosis
- Minimal dermal inflammation and exocytosis of inflammatory cells are present.
- Possibly fibrosis of papillary dermis
PAS stain is essential to exclude fungal infection.[1]
|
Subacute
|
|
Allergic/contact dermatitis or atopic dermatitis
|
As above. Eosinophils may be present in the dermis and epidermis (eosinophilic spongiosis).[1]
|
|
|
Allergic dermatitis
|
Atopic dermatitis
|
Seborrheic dermatitis
|
Typical findings:[5]
- Focal, usually mild, spongiosis with overlying scale crust, with a few neutrophils
- The crust is often centered on a follicle
- The papillary dermis is generally mildly edematous
- Dilated blood vessels in the superficial vascular plexus
- Mild superficial perivascular infiltrate of lymphocytes, histiocytes and occasional neutrophils. There is some exocytosis of inflammatory cells but not as prominent as in nummular dermatitis
|
Typical findings:[5]
- Psoriasiform hyperplasia, initially slight, with mild spongiosis
- Usually numerous yeast-like organisms in the surface keratin
- Same changes as seen in acute stage.
|
Typical findings:[5]
- More pronounced psoriasiform hyperplasia
- Only minimal spongiosis
- Presence of scaling crusts in a folliculocentric distribution, distinguishes from psoriasis.
|
|
|
In addition to above, an unspecific spongiotic dermatitis can be consistent with nummular dermatitis, dyshidrotic dermatitis, Id reaction, dermatophytosis, miliaria, Gianotti-Crosti syndrome and pityriasis rosea.[1][note 3]
Interface dermatitis
These are sorted into either:[1]
- Interface dermatitis with vacuolar change
- Interface dermatitis with lichenoid inflammation
Interface dermatitis with vacuolar change
Causes of vacuolar interface dermatitis edit
Main conditions[6] |
Characteristics |
Micrograph |
Photograph
|
Generally/Not otherwise specified
|
Typical findings, called "vacuolar interface dermatitis":[6]
- Mild inflammatory cell infiltrate along the dermoepidermal junction (black arrow in image)
- Vacuolization within the basal keratinocytes (white arrow in image)
- Often necrotic, predominantly basal, individual keratinocytes, manifesting as colloid or Civatte bodies
|
|
|
Acute graft-versus-host-disease
|
- Vacuolar alteration of various severity, from focal or diffuse vacuolation of the basal keratinocytes (grade I), to separation at the dermoepidermal junction (grade III)
- Involvement of the hair follicle[6]
- Rarely eosinophils[6]
|
|
|
Allergic drug reaction
|
- Rarely involvement of hair follicles.[6]
- Frequently eosinophils[6]
|
|
|
Lichen sclerosus
|
Hyperkeratosis, atrophic epidermis, sclerosis of dermis and dermal lymphocytes.[7]
|
|
Erythema multiforme
|
|
|
|
|
Lupus erythematosis
|
Typical findings in systemic lupus erythematosus:[8]
- Fibrinoid necrosis at the dermoepidermal junction
- Liquefactive degeneration and atrophy of the epidermis
- Mucin deposition in the reticular dermis
- Edema, small hemorrhages
- Mild and mainly lymphocytic infiltrate in the upper dermis
- Fibrinoid material in the dermis around capillary blood vessels, on collagen and in the interstitium
- In non-bullous cases, perivascular and interstitial neutrophils are sometimes present in the upper dermis, with damage to blood vessels
|
|
|
An interface dermatitis with vacuolar alteration, not otherwise specified, may be caused by viral exanthems, phototoxic dermatitis, acute radiation dermatitis, erythema dyschromicum perstans, lupus erythematosus and dermatomyositis.[1]
Further information: Vacuolar interface dermatitis
Interface dermatitis with lichenoid inflammation
Main conditions[1] |
Characteristics |
Micrograph |
Photograph
|
Generally/Not otherwise specified
|
Typical findings:[1]
- In the papillary dermis: a confluent, band-like, dense inflammation of mainly small lymphocytes and a few histiocytes, along or hugging the dermoepidermal junction.
- Often vacuolar degeneration of basal keratinocytes and apoptotic bodies (colloid or Civatte bodies).
|
|
|
Lichen planus
|
Irregular epidermal hyperplasia with a jagged “sawtooth” appearance, compact hyperkeratosis or orthokeratosis, foci of wedge-shaped hypergranulosis, basilar vacuolar degeneration, slight spongiosis in the spinous layer, and squamatization. The dermal papillae between the elongated rete ridges are frequently dome shaped. Necrotic keratinocytes can be observed in the basal layer of the epidermis and at the dermal-epidermal junction. Eosinophilic remnants of anucleate apoptotic basal cells may also be found in the dermis and are referred to as “colloid or civatte bodies”. Whickham striae are usually seen in the areas of hypergranulosis. Vacuolar degeneration at the basal layer may be noted leading to focal subepidermal clefts (Max Joseph spaces). Squamatization occurs as a result of maturation and flattening of cells in the basal layer. It happens in areas of marked hypergranulosis with prominence of the sawtooth pattern of rete ridges. Wedge-shaped hypergranulosis can occur in the eccrine ducts (acrosyringia) or hair follicles (acrotrichia). In the hypertrophic subtype, the associated hyperkeratosis, parakeratosis, hypergranulosis, papillomatosis, acanthosis, and hyperplasia markedly increased with thicker collagen bundles forming in the dermis. Moreover, the rete ridges are more elongated and rounded as opposed to the typical sawtooth pattern. In atrophic LP, loss of the rete ridges and dermal fibrosis is prominent. In vesiculobullous LP, the disease progression is quicker. Hence, some of the distinctive features such as hyperkeratosis, hypergranulosis, or dense lymphocytic dermal-epidermal infiltrate may not be present. LP lesion may resolve with residual hyperpigmentation caused by a persistent increase in the number of melanophages in the papillary dermis.[9]
|
|
|
Lichenoid drug reaction
|
Can virtually be indistinguishable from cutaneous LP both clinically and histopathologically.
- Typically, lesions have a photodistribution in the absence of oral mucosal involvement.[9]
- Characteristically parakeratosis, a dermal eosinophilic infiltrate, and a perivascular lymphocytic infiltrate affecting the reticular dermis.
- Epidermal changes are less common in lichenoid drug eruptions when compared to classic lichen planus. However, a higher concentration of necrotic keratinocyte and eosinophils in the infiltrate can be helpful in distinguishing lichenoid drug reaction from cutaneous lichen planus. A lengthy interval between the commencement of drug therapy and the onset of lesions does not exclude a diagnosis of lichenoid drug reaction. Resolution of the lesions often occurs within weeks to months after discontinuation of the offending drug.[9]
|
|
|
Lichen nitidus
|
- Localized granulomatous lymphohistiocytic infiltrate in an expanded dermal papilla.
- Thinning of overlying epidermis and downward extension of the rete ridges at the lateral margin of the infiltrate, resulting in a typical "claw clutching a ball" appearance.[10]
|
|
|
Lichen amyloidosus
|
Presence of amyloid, possibly with direct immunofluorescence and Congo red staining.[11]
|
|
Interface dermatitis with lichenoid inflammation, not otherwise specified, can be caused by lichen planus-like keratosis, lichenoid actinic keratosis, lichenoid lupus erythematosus, lichenoid GVHD (chronic GVHD), pigmented purpuric dermatosis, pityriasis rosea, and pityriasis lichenoides chronica.[1] Unusual conditions that can be associated with a lichenoid inflammatory cell infiltrate are HIV dermatitis, syphilis, mycosis fungoides, urticaria pigmentosa, and post-inflammatory hyperpigmentation.[1] In cases of post-inflammatory hyperpigmentation, it is important to exclude potentially harmful mimics such as a regressed melanocytic lesion or lichenoid pigmented actinic keratosis.[1]
Psoriaform dermatitis
Examining multiple deeper levels is recommended if initial cuts do not correlate well with the clinical history.[1]
Psoriaform dermatitis typically displays:[1]
- Regular epidermal hyperplasia, elongation of the rete ridges, hyperkeratosis, and parakeratosis.
- Usually:A superficial perivascular inflammatory infiltrate
- Often: Thinning of epidermal cells overlying the tips of dermal papillae (suprapapillary plates), and dilated, tortuous blood vessels within these papillae
Further histopathologic diagnosis is performed by the following parameters:
Psoriasiform dermatitis[1]
Condition |
Hyperkeratosis |
Parakeratosis |
Acanthosis |
Suprapapillary plate |
Spinous cell layer changes |
Other distinctive feature |
Micrograph
|
Psoriasis
|
Present |
Diffuse |
Regular |
Thin |
Increased mitoses; minimal spongiosis Clubbed rete pegs[12] [13]
|
- Microabscesses
- Thin or absent granular cell layer
|
|
Psoriasiform drug reaction
|
Present |
Focal |
Regular and irregular |
Normal or thick |
Spongiosis; eosinophilic infiltrate |
Basal cell layer with inflammatory cells; Civatte bodies
|
Chronic allergic/contact and atopic dermatitis
|
Present |
Focal; crust may be present |
Irregular |
Normal or thick |
Spongiosis; eosinophilic infiltrate |
|
Fungal infection
|
Compact |
Focal; crust may be present |
Irregular |
Normal or thick |
Occasional neutrophiles; |
|
Lichen simplex chronicus
|
Present |
Focal; thick crust |
Regular or irregular |
Thin or thick |
±minimal inflammatory infiltrate |
Thickened granular cell layer
|
Scabies
|
Present |
Focal or diffuse |
Irregular |
Normal or thick |
Inflammatory infiltrate; eosinophilic spongiosis |
|
Seborrheic dermatitis and HIV dermatitis
|
Present |
Focal |
Irregular |
Normal or thick |
Spongiosis; lymphocytic and neutrophilic infiltrate |
|
Pityriasis rubra pilaris
|
Compact |
Shoulder parakeratosis[note 4]; alternating orthokeratosis and parakeratosis |
Regular or irregular |
Normal or thick |
Spongiosis; lymphocytic infiltrate; rare acantholysis |
|
Pityriasis rosea
|
Present |
Focal |
Irregular |
Normal or thick |
Small foci of spongiosis; lymphocytic infiltrate |
Occasional necrotic keratinocytes of basal layer
|
Syphilis
|
Present |
Focal |
Regular or irregular |
Normal or thick |
Lymphocytes and neutrophils |
Basal layer interface change
|
Pityriasis lichenoides chronica
|
Present |
Caps of parakeratosis |
Irregular |
Normal |
Mild spongiosis, lymphocytic infiltrate; necrotic keratinocytes |
Necrotic keratinocytes of basal layer
|
Mycosis fungoides
|
Present |
Focal |
Regular or irregular |
Normal |
Minimal or no spongiosis; ±Pautrier microabscess |
Atypical lymphoid cells lining the dermo–epidermal junction
|
|
Non vesicullobullous, non-pustular lesions without epidermal changes
Lymphocytic infiltrate
Main conditions[1] |
Characteristics |
Micrograph |
Photograph
|
Urticaria, lymphocyte predominant
|
Perivascular location. Mast cells are relatively sparse, potentially demonstrated with special stains, preferably tryptase stain. Extravasated erythrocytes are present in about 50% of the cases. No vasculitis.[14]
|
Dermal edema [solid arrows in (A,B)] and a sparse superficial predominantly perivascular and interstitial infiltrate of lymphocytes and eosinophils without signs of vasculitis (dashed arrow).[15]
|
|
Fungal skin infection
|
Often visible fungus. Other signs depend on fungus species.[16]
|
|
|
Pigmented purpuric dermatosis
|
- Perivascular infiltrate, but may involve the dermis, further away from blood vessels.[17]
- Sometimes tendency for lichenoid infiltrate[note 5][17]
- Mild vascular damage, mainly endothelial swelling and focal karyorrhectic debris.[17]
- Red blood cell extravasation.[17]
- The epidermis may be normal or may exhibit spongiosis, focal parakeratosis, exocytosis and/or vacuolar change.[17]
|
|
|
Erythema annulare centrifugum
|
- Mild spongiosis, parakeratosis and microvesiculation.
- "Coat-sleeve anomaly": tight lymphohistiocytic infiltrate surrounding superficial vessels
Deep lesions: Sharply demarcated perivascular mononuclear cell infiltrate in middle to deep dermis[18]
|
|
|
Not otherwise specified[note 3]
|
A lesion with superficial lymphocytic infiltrate without additional histopathologic characteristics can be due to for example drug reactions and insect bites.[1][note 3]
|
Lymphoeosinophilic infiltrate
Main conditions[1] |
Characteristics |
Micrograph |
Photograph
|
Urticaria, lymphocyte predominant
|
Perivascular location. Mast cells are relatively sparse, potentially demonstrated with special stains, preferably tryptase stain. Extravasated erythrocytes are present in about 50% of the cases. No vasculitis.[14]
|
Dermal edema (solid arrows) and a sparse superficial predominantly perivascular and interstitial infiltrate of lymphocytes and eosinophils (dashed arrow)
|
|
Prevesicular stage of bullous pemphigoid
|
Image at right shows influx of inflammatory cells including eosinophils and neutrophils in the dermis (solid arrow) and blister cavity (dashed arrows), and deposition of fibrin (asterisks).[19] However, the diagnosis of bullous pemphigoid consist of at least 2 positive results out of 3 criteria:[20]
- Pruritus and/or predominant cutaneous blisters
- Linear IgG and/or C3c deposits (in an n- serrated pattern) by direct immunofluorescence microscopy (DIF)
- Positive epidermal side staining by indirect immunofluorescence microscopy on human salt-split skin (IIF SSS) on a serum sample.
|
|
|
Not otherwise specified[note 3]
|
A lesion with superficial lymphoeosinophilic infiltrate without additional histopathologic characteristics can be due to for example drug reactions and insect bites.[1][note 3]
|
|
|
Lymphoplasmacytic infiltrate
Mastocytosis
Main conditions[1] |
Characteristics |
Micrograph |
Photograph
|
Urticaria pigmentosa
|
Mastocytosis with a clinical picture of darkish spots.
|
|
|
Not otherwise specified[note 3]
|
Includes the rare disease of primary mastocytosis.[1][note 3]
|
|
|
Lymphohistiocytic infiltrate
These include bacterial infections including leprosy, and the sample should therefore be stained with Ziel-Neelsen, acid fast stains, Gomori methenamine silver, PAS, and Fite stains.[1] If negative, an unspecific lymphohistocytic dermatosis may be caused by drug reactions and viral infections.[1][note 3]
Granulomatous inflammation
Further information: Granulomatous skin inflammation
Granulomatous inflammation is defined by the presence of mononuclear leukocytes, specifically histiocytes, appearing as epithelioid cells with round to oval nuclei, often with irregular contours and abundant granular eosinophilic cytoplasm with indistinct cell borders. They may also coalesce to form multinucleated giant cells.[25]
Foreign body: Suture granuloma, with multinucleated giant cells surrounding (grey) suture material.
Neutrophilic infiltrate
No visible pathology
In a referral with a rash or other suspicion of dermatitis, but no visible pathology is seen, generally do a fungal stain, as fungal infections may have no visible pathology on H&E stain.
Notes
- ↑ For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
- ↑ PAS is for evaluation of the epidermal basement membrane, blood vessels, and the presence of fungal organisms
- ↑ 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 In "not otherwise specified" cases, a description of the findings attained so far is generally enough as a diagnosis, but may mention when it can be consistent with a diagnosis that is clinically suspected according to the referral. A more comprehensive approach is to include a comment such as the following:
"Differential diagnosis for this condition include: ____, ____ and ____. Clinical correlation is recommended.
- ↑ Parakeratotic mounds at the edge of follicular ostia.
- ↑ Pigmented purpuric dermatitis of Gougerot and Blum particularly have a tendency for lichenoid infiltrate.
Main page
References
- ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 1.21 1.22 1.23 1.24 1.25 1.26 1.27 1.28 1.29 1.30 1.31 1.32 1.33 1.34 1.35 Alsaad, K O (2005). "My approach to superficial inflammatory dermatoses
". Journal of Clinical Pathology 58 (12): 1233–1241. doi:10.1136/jcp.2005.027151. ISSN 0021-9746.
- ↑ Page 678 in: Chhabra, Seema; Minz, RanjanaWalker; Saikia, Biman (2012). "Immunofluorescence in dermatology
". Indian Journal of Dermatology, Venereology, and Leprology 78 (6): 677. doi:10.4103/0378-6323.102355. ISSN 0378-6323. Archived from the original. .
- ↑ Katarzyna Lundmark, Krynitz, Ismini Vassilaki, Lena Mölne, Annika Ternesten Bratel. Handläggning av hudprover – provtagningsanvisningar, utskärningsprinciper och snittning (Handling of skin samples - Instructions for sampling, cutting and incision. KVAST (Swedish Society of Pathology). Retrieved on 2019-09-09.
- ↑
". Ochsner J 5 (2): 22–33. 2003. PMID 22826680. PMC: 3399331. Archived from the original. .
- With a "standard histologic examination" that, in addition to the lesion, only includes one section from each side along the longest diameter of the specimen. - It also shows an example of circular coverage, with equal coverage distance in all four directions. - The entire specimen may be submitted if the risk of malignancy is high.
- ↑ 5.0 5.1 5.2 Mowafak Hamodat. Skin inflammatory (nontumor) > Spongiotic, psoriasiform and pustular reaction patterns > Seborrheic dermatitis. PathologyOutlines.com. Topic Completed: 1 August 2011. Revised: 26 March 2019
- ↑ 6.0 6.1 6.2 6.3 6.4 6.5 Unless else specified in boxes, reference is: Alsaad, K O (2005). "My approach to superficial inflammatory dermatoses
". Journal of Clinical Pathology 58 (12): 1233–1241. doi:10.1136/jcp.2005.027151. ISSN 0021-9746.
- ↑ Lisa K Pappas-Taffer. Lichen Sclerosus. Medscape. Updated: May 17, 2018
- ↑ Mowafak Hamodat. Skin inflammatory (nontumor) > Lichenoid and interface reaction patterns > Lupus: systemic lupus erythematosus (SLE). PathologyOutlines. Topic Completed: 1 August 2011. Revised: 26 March 2019
- ↑ 9.0 9.1 9.2 Gorouhi, Farzam; Davari, Parastoo; Fazel, Nasim (2014). "Cutaneous and Mucosal Lichen Planus: A Comprehensive Review of Clinical Subtypes, Risk Factors, Diagnosis, and Prognosis
". The Scientific World Journal 2014: 1–22. doi:10.1155/2014/742826. ISSN 2356-6140.
- Attribution 3.0 Unported (CC BY 3.0)
- ↑ "Generalized lichen nitidus
". Pediatr Dermatol 22 (2): 158–60. 2005. doi:10.1111/j.1525-1470.2005.22215.x. PMID 15804308.
- ↑ Shenoi, SD; Balachandran, C; Mehta, VandanaRai; Salim, T (2005). "Lichen amyloidosus: A study of clinical, histopathologic and immunofluorescence findings in 30 cases
". Indian Journal of Dermatology, Venereology and Leprology 71 (3): 166. doi:10.4103/0378-6323.16230. ISSN 0378-6323.
- ↑ "Cytokines and cytokine profiles in human autoimmune diseases and animal models of autoimmunity
". Mediators of Inflammation 2009: 1–20. 2009. doi:10.1155/2009/979258. PMID 19884985.
- ↑ "Diagnosis and classification of psoriasis
". Autoimmunity Reviews 13 (4–5): 490–5. January 2014. doi:10.1016/j.autrev.2014.01.008. PMID 24434359.
- ↑ 14.0 14.1 14.2 14.3 14.4 14.5 14.6 Barzilai, Aviv; Sagi, Lior; Baum, Sharon; Trau, Henri; Schvimer, Michael; Barshack, Iris; Solomon, Michal (2017). "The Histopathology of Urticaria Revisited—Clinical Pathological Study
". The American Journal of Dermatopathology 39 (10): 753–759. doi:10.1097/DAD.0000000000000786. ISSN 0193-1091.
- ↑ Giang, Jenny; Seelen, Marc A. J.; van Doorn, Martijn B. A.; Rissmann, Robert; Prens, Errol P.; Damman, Jeffrey (2018). "Complement Activation in Inflammatory Skin Diseases
". Frontiers in Immunology 9. doi:10.3389/fimmu.2018.00639. ISSN 1664-3224.
- ↑ Guarner, J.; Brandt, M. E. (2011). "Histopathologic Diagnosis of Fungal Infections in the 21st Century
". Clinical Microbiology Reviews 24 (2): 247–280. doi:10.1128/CMR.00053-10. ISSN 0893-8512.
- ↑ 17.0 17.1 17.2 17.3 17.4 Stephen Lyle. Pigmented purpuric dermatoses. Dermpedia.org. Retrieved on 2019-11-05.
- ↑ 18.0 18.1 . Histology of erythema annulare centrifugum. DermNet NZ. Retrieved on 2019-11-05.
- ↑ Giang, Jenny; Seelen, Marc A. J.; van Doorn, Martijn B. A.; Rissmann, Robert; Prens, Errol P.; Damman, Jeffrey (2018). "Complement Activation in Inflammatory Skin Diseases
". Frontiers in Immunology 9. doi:10.3389/fimmu.2018.00639. ISSN 1664-3224.
- ↑ "Assessment of diagnostic strategy for early recognition of bullous and nonbullous variants of pemphigoid.
". JAMA Dermatol 155 (2): 158–165. December 2018. doi:10.1001/jamadermatol.2018.4390. PMID 30624575.
- ↑ Celiker, Hande; Toker, Ebru; Ergun, Tulin; Cinel, Leyla (2017). "An unusual presentation of ocular rosacea
". Arquivos Brasileiros de Oftalmologia 80 (6). doi:10.5935/0004-2749.20170097. ISSN 0004-2749.
- ↑ Assoc Prof Patrick Emanuel (2013). Syphilis pathology. Dermnet NZ.
- ↑ 23.0 23.1 Wilson, Thomas C.; Legler, Allison; Madison, Kathi C.; Fairley, Janet A.; Swick, Brian L. (2012). "Erythema Migrans
". The American Journal of Dermatopathology 34 (8): 834–837. doi:10.1097/DAD.0b013e31825879be. ISSN 0193-1091.
- ↑ Soyer, H. Peter; Jakob, Lena; Metzler, Gisela; Chen, Ko-Ming; Garbe, Claus (2011). "Non-AIDS Associated Kaposi's Sarcoma: Clinical Features and Treatment Outcome
". PLoS ONE 6 (4): e18397. doi:10.1371/journal.pone.0018397. ISSN 1932-6203.
- ↑ Shah, Kabeer K.; Pritt, Bobbi S.; Alexander, Mariam P. (2017). "Histopathologic review of granulomatous inflammation
". Journal of Clinical Tuberculosis and Other Mycobacterial Diseases 7: 1–12. doi:10.1016/j.jctube.2017.02.001. ISSN 24055794.
- ↑ 26.0 26.1 26.2 Antiga, Emiliano; Caproni, Marzia (2015). "The diagnosis and treatment of dermatitis herpetiformis
". Clinical, Cosmetic and Investigational Dermatology: 257. doi:10.2147/CCID.S69127. ISSN 1178-7015.
- ↑ Huma A. Mirza; Amani Gharbi; William Gossman.. Dermatitis Herpetiformis. StatPearls at National Center for Biotechnology Information. Last Update: July 11, 2019.
- ↑ Saleem, Maryam; Iftikhar, Hassaan (2019). "Linear IgA Disease: A Rare Complication of Vancomycin
". Cureus. doi:10.7759/cureus.4848. ISSN 2168-8184.
- ↑ Casarin Costa, Jose Ricardo; Virgens, Anangelica Rodrigues; de Oliveira Mestre, Luisa; Dias, Natasha Favoretto; Samorano, Luciana Paula; Valente, Neusa Yuriko Sakai; Festa Neto, Cyro (2017). "Sweet Syndrome: Clinical Features, Histopathology, and Associations of 83 Cases
". Journal of Cutaneous Medicine and Surgery 21 (3): 211–216. doi:10.1177/1203475417690719. ISSN 1203-4754.
- ↑ Giang, Jenny; Seelen, Marc A. J.; van Doorn, Martijn B. A.; Rissmann, Robert; Prens, Errol P.; Damman, Jeffrey (2018). "Complement Activation in Inflammatory Skin Diseases
". Frontiers in Immunology 9. doi:10.3389/fimmu.2018.00639. ISSN 1664-3224.
- "Figures - available via license: CC BY 4.0"
Image sources
Benign non-inflammatory skin conditions
Author:
Mikael Häggström [note 1]
These are aberrations that do not display signs of suspected malignant excisions or dermatitis. These may present as skin cysts.
Fixation
Generally 10% neutral buffered formalin.
See also: General notes on fixation
Gross processing
Gross pathology processing of skin lesions with benign appearance, by lesion size:[1]
<4 mm |
4 - 8 mm |
9 - 15 mm
|
|
|
|
In table above, each top image shows recommended lines for cutting out slices to be submitted for further processing. Bottom image shows which side of the slice that should be put to microtomy. Dashed lines here mean that either side could be used.
Further information: Gross processing of skin excisions
Microscopic evaluation
The primary objective is to determine the location, and then the most likely cell type of the aberration:
Epidermis
Ulceration: On the outer ear, consider chondrodermatitis nodularis chronica helicis (pictured): With the ulceration surrounded by acanthosis and parakeratosis.
Dermis
Elastosis is the buildup of elastin in tissues (actinic or "solar" elastosis pictured).
Sebaceous hyperplasia: Increased volume of multiple, mature sebaceous lobules attached central dilated ducts in the upper dermis.[2]
Edematous granulation tissue, low magnification
Edematous granulation tissue, high magnification, with connective tissue, inflammatory cells and blood vessels.
Keloid: Wide bands of collagen with large, brightly eosinophilic, glassy fibers, parallel to fibroblasts and myofibroblasts.
Hypertrophic scar: Replacement of the papillary and reticular dermis by scar tissue with prominent vertically oriented blood vessels.[3]
Fatty tissue
Notes
- ↑ For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
Main page
References
- ↑
". Ochsner J 5 (2): 22–33. 2003. PMID 22826680. PMC: 3399331. Archived from the original. .
- With a "standard histologic examination" that, in addition to the lesion, only includes one section from each side along the longest diameter of the specimen. - It also shows an example of circular coverage, with equal coverage distance in all four directions. - The entire specimen may be submitted if the risk of malignancy is high.
- ↑ Sato, Toshitsugu; Tanaka, Masaru (2014). "Linear sebaceous hyperplasia on the chest
". Dermatology Practical & Conceptual. doi:10.5826/dpc.0401a16. ISSN 21609381.
- ↑ Rabello, FB; Souza, CD; Farina Jr, JA (2014). "Update on hypertrophic scar treatment
". Clinics 69 (8): 565–573. doi:10.6061/clinics/2014(08)11. ISSN 18075932.
Image sources
Keloid
Author:
Mikael Häggström [note 1]
Gross processing
Gross pathology processing of skin lesions with benign appearance, by lesion size:[1]
<4 mm |
4 - 8 mm |
9 - 15 mm
|
|
|
|
In table above, each top image shows recommended lines for cutting out slices to be submitted for further processing. Bottom image shows which side of the slice that should be put to microtomy. Dashed lines here mean that either side could be used.
Further information: Gross processing of skin excisions
Microscopic evaluation
A keloid is characterized by wide bands of collagen with large, brightly eosinophilic, glassy fibers, parallel to fibroblasts and myofibroblasts.
- Keloid versus hypertrophic scar - Typical findings
|
Keloid |
Hypertrophic scar
|
|
|
|
Flattening of the overlying epidermis
|
No |
Yes
|
Scarring of the papillary dermis
|
No |
Yes
|
Collagen
|
Thick hyalinized bundles |
Whorl-like or nodular arrangements
|
Vertically oriented blood vessels
|
Yes |
No
|
Prominent disarray of fibrous fascicles/nodules
|
Yes |
No
|
Tongue-like advancing edge underneath normal-appearing epidermis and papillary dermis
|
Yes |
No
|
Horizontal cellular fibrous band in the upper reticular dermis
|
Yes |
No
|
Prominent fascia-like fibrous band
|
Yes |
No
|
Reporting
Example report:
Skin, left earlobe, excision: - Keloid
|
Notes
- ↑ For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
Main page
References
- ↑
". Ochsner J 5 (2): 22–33. 2003. PMID 22826680. PMC: 3399331. Archived from the original. .
- With a "standard histologic examination" that, in addition to the lesion, only includes one section from each side along the longest diameter of the specimen. - It also shows an example of circular coverage, with equal coverage distance in all four directions. - The entire specimen may be submitted if the risk of malignancy is high.
Image sources
Hypertrophic scar
Author:
Mikael Häggström [note 1]
Gross processing
Gross pathology processing of skin lesions with benign appearance, by lesion size:[1]
<4 mm |
4 - 8 mm |
9 - 15 mm
|
|
|
|
In table above, each top image shows recommended lines for cutting out slices to be submitted for further processing. Bottom image shows which side of the slice that should be put to microtomy. Dashed lines here mean that either side could be used.
Further information: Gross processing of skin excisions
Microscopic evaluation
A hypertrophic scar is characterized by replacement of the papillary and reticular dermis by scar tissue with prominent vertically oriented blood vessels. [2]
- Keloid versus hypertrophic scar - Typical findings
|
Keloid |
Hypertrophic scar
|
|
|
|
Flattening of the overlying epidermis
|
No |
Yes
|
Scarring of the papillary dermis
|
No |
Yes
|
Collagen
|
Thick hyalinized bundles |
Whorl-like or nodular arrangements
|
Vertically oriented blood vessels
|
Yes |
No
|
Prominent disarray of fibrous fascicles/nodules
|
Yes |
No
|
Tongue-like advancing edge underneath normal-appearing epidermis and papillary dermis
|
Yes |
No
|
Horizontal cellular fibrous band in the upper reticular dermis
|
Yes |
No
|
Prominent fascia-like fibrous band
|
Yes |
No
|
Notes
- ↑ For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
Main page
References
- ↑
". Ochsner J 5 (2): 22–33. 2003. PMID 22826680. PMC: 3399331. Archived from the original. .
- With a "standard histologic examination" that, in addition to the lesion, only includes one section from each side along the longest diameter of the specimen. - It also shows an example of circular coverage, with equal coverage distance in all four directions. - The entire specimen may be submitted if the risk of malignancy is high.
- ↑ Rabello, FB; Souza, CD; Farina Jr, JA (2014). "Update on hypertrophic scar treatment
". Clinics 69 (8): 565–573. doi:10.6061/clinics/2014(08)11. ISSN 18075932.
Image sources
Arteries
Author:
Mikael Häggström [note 1]
Presentations
Gross processing
A minimal gross processing of arteries includes a longitudinal dissection and inspection of tunica intima.
Consecutive cross-sections allows for a detection and estimation of atherosclerotic stenosis.
Plaque at different degrees of atherosclerotic stenosis.
Microscopic examination
- Confirm that it is actually an artery (may be a vein, and a neuron may look grossly like a small artery).
- Look for atherosclerosis and thrombosis.
- Classify atherosclerosis as mild, moderate or severe.
- If cross-sections were made, estimate the maximum percentage of occlusion for each artery.
Histopathology of pre-atherosclerotic intimal lesions: Intimal thickening (A) consists mainly of smooth muscle cells in a proteoglycan-rich matrix. Intimal xanthoma (B) displays intimal thickening with isolated foam cells (arrows).[1]
A progressive atherosclerotic lesion: Pathological intima thickening (A) has some extracellular lipid (EL) present deep in the lesion without true necrosis.[1]
Progressive lesion: A fibrous cap atheroma has a well-formed necrotic core (NC) containing lipids with an overlying thick fibrous cap (FC).[1]
Progressive lesion: Fibrocalcific plaques are heavily calcified lesions with or without a necrotic core.[1]
Histopathology of plaque components in atherosclerosis: (A) Intraplaque neovasculature (arrows); (B) intraplaque hemorrhage; (C) large areas of calcification seen as purple morula; (D) lumen thrombus (arrowhead); stained with hematoxylin and eosin (H&E); (E) macrophage infiltration; stained with CD68 antibodies.[1]
Cross-sections collapse more or less after cutting, and estimations of the maximum percentage of stenosis should be made as imagined on an expanded blood vessel, as: 1-(lumen area)/(atherosclerosis area). In this case, there is 45-50% stenosis.
Evaluate for giant cell arteritis at least upon request. It is characterized by a granulomatous inflammation of arteries with discontinuous and fragmented internal elastic lamina. [2]
Microscopy report
- Classify any atherosclerosis as mild, moderate or severe.
- If cross-sections were made, state the maximum percentage of stenosis for each artery.
Example:
Sections of the three main coronary arteries reveal << mild / moderate / severe>> atherosclerosis, with approximately __%, __% and __% stenosis of the left anterior descending, left circumflex coronary artery and right coronary artery, respectively.
|
Notes
- ↑ For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
Main page
References
Image sources
Thrombus
Author:
Mikael Häggström [note 1]
Composition of a fresh thrombus.
Microscopic evaluation
An organizing thrombus. [1]
Look for presence of fibroblasts or myofibroblasts, conferring a diagnosis of an organizing thrombus.
Reporting
Example:
Right profunda femoris artery clot, excision: Organizing thrombus.
|
Notes
- ↑ For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
Main page
References
- ↑ Picture from:Pantanowitz, Liron; Duke, Wayne H (2008). "Intravascular lesions of the hand
". Diagnostic Pathology 3 (1): 24. doi:10.1186/1746-1596-3-24. ISSN 1746-1596.
- "Figure- available via license: Creative Commons Attribution 2.0 Generic"
Image sources
Aneurysm
Author:
Mikael Häggström [note 1]
Cross-section of an arterial aneurysm, showing most of the area consisting of organized mural thrombus (tan-brown area).
Gross processing
- Describe the shape (generally either fusiform or saccular).
- Measure the length and diameter
Make several cross-sections and look for any dissection in the wall.
Gross report
On this resource, the following formatting is used for comprehensiveness:
- Minimal depth
- (Moderate depth)
- ((Comprehensive))
(( A. Labeled -left upper extremity aneurysm. The specimen is received in formalin and consists of a segment of)) fusiformly dilated vessel measuring 11.5 cm in length and the diameter is 6.5 (x 6.5 cm). Upon sectioning, <<most \ (( __ %))>> of the area is occupied by tan-yellow to tan-red non-homogenous surface, consistent with an organized mural thrombus. (No visible wall dissection.)
|
Notes
- ↑ For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
Main page
References
Image sources
Soft tissues
Tophus/gout
Author:
Mikael Häggström [note 1]
Preparation
A tophus specimen should be sent dry to the pathology department, and not be put in formalin.[note 2]
Gross processing
Preferably make a touch prep for polarized light microscopy. At least if urate crystals are not initially detected, take sections to be put in 100% alcohol and tell the histology lab to prepare it as per gout protocol.[note 2] With characteristic crystals on a touch prep, sections may possibly be submitted in formalin.[note 2]
Microscopy evaluation
On a touch prep, look for needle-shaped crystals of urate. On polarized light, these will have negative birefriengence.
Light microscopy of a touch preparation of a gout tophus, showing needle-shaped crystals
Uric acid crystals in polarized light, showing negative birefringence, with yellow color when aligned parallel to the axis of the red compensator, and blue when aligned perpendicularly to it.[1]
In contrast, pseudogout, also called calcium pyrophosphate dihydrate (CPPD) crystal deposition disease) displays rhombus-shaped or parallelogram-shaped crystals with negative birefringence.
To look for crystals in a regular light microscope, look without condenser (right image) if possible, wherein crystal outlines are more clear than with condenser (left image). CPPD crystals are depicted.
Notes
- ↑ For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
- ↑ 2.0 2.1 2.2 Formalin dissolves the crystals.
Main page
References
Image sources
Peripheral nerve sheath tumor
- REDIRECT Soft tissue tumor
Lipomatous tumor
Author:
Mikael Häggström [note 1]
Fixation
Generally 10% neutral buffered formalin.
See also: General notes on fixation
Comprehensiveness
On this resource, the following formatting is used for comprehensiveness:
- Minimal depth
- (Moderate depth)
- ((Comprehensive))
Gross processing
- Perform consecutive slicing of the entire specimen.
- Look for signs of liposarcoma: Mainly by firm volumes.[1] Color varies from yellow to white (and firm) depending on the proportion of adipocytic, fibrous and/or myxoid content.[2] Areas of fat necrosis are common in larger lesions. Rarely, infiltrative growth is seen.[2]
- Submit slices from any suspicious parts, or at least one representative slice from the specimen.[3] (A more comprehensive practice is to submit 1 section per centimeter, and 2 sections per cassette.[4])
Cross-section of lipoma. Homogenous texture.
Liposarcoma: Tumor section reveals brownish-yellowish areas, hemorrhagic and calcific zones.
Gross report
- Color
- Even absence of hemorrhage or necrosis.
Example:
Mass ((weighing 121 grams)) and measuring 10 x 6,5 x 3,5 cm. ((The surgical margin is intact.)) Cut sections show homogenous yellow color, with no hemorrhage or necrosis. ((The specimen is serially sectioned, and representative sections are submitted for microscopic examination in __ cassettes.))
|
See also: General notes on gross processing
Microscopic evaluation
Lipoma: lobules of mature white adipose tissue divided by delicate and inconspicuous fibrous septa containing thin-walled capillary-sized vessels. Still, look close at the fibrous septa:
An atypical lipomatous tumor (also termed well-differentiated liposarcoma), lipoma-like subtype. At low magnification, the majority of the tumor essentially has the look of benign mature adipocytes (except for mildly increased variation in lipid droplet sizes), but high magnification of a fibrous band shows spindle cells with enlarged, hyperchromatic nuclei. Another clue for liposarcoma is a higher variability of lipid droplet sizes.
Fibrolipoma is a lipoma with focal areas of large amounts of fibrous tissue. A sclerotic lipoma is one step further: a predominantly fibrous lesion with focal areas of fat.[5] If unsure of degree of fibrosis: Simply report as lipoma.
Angiolipoma is a lipoma with abundant capillaries, with hyaline or fibrin (pictured) thrombi.[6]
Main features of liposarcoma:[7] - Spindle cells with enlarged, hyperchromatic nuclei. - Apparently univacuolated adipocytes (may look normal). - Lipoblasts, but is neither necessary nor sufficient for diagnosis.
Myxoid liposarcoma: Hypercellular solid sheets of cells lying back to back, with round cells or primitive cytomorphology.[8]
A pedunculated lipomatous skin tumor may be a pedunculated lipofibroma:
Pedunculated lipofibroma, gross pathology
Histopathology, showing thin rim of epidermis, and dermal lipocytes without capsule.
For atypical cases and as a non-subspecialist in soft tissue pathology, generally seek expert opinion, including further workup.
Microscopy/Histopathology report
For lipomas: (Absence of signs of malignancy.)
(Chest wall, left lateral, excision:)
- Lipoma.
- (Negative for malignancy)
((Microscopic description: Tissue composed of univacuolar fat cells and delicate and inconspicuous fibrous septa.))
|
See also: General notes on reporting
Notes
- ↑ For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
Main page
References
Image sources
Hernia sac
Author:
Mikael Häggström [note 1]
Gross pathology of a hernia sac.
Comprehensiveness
On this resource, the following formatting is used for comprehensiveness:
- Minimal depth
- (Moderate depth)
- ((Comprehensive))
Fixation
Generally 10% neutral buffered formalin.
Gross processing
A gross inspection is almost always enough, and tissue generally does not need to be submitted except in unique circumstances.[1] ((Still you may submit 1 cassette of one or more representative sections for an inguinal hernia sac in a patient aged up to 16 years of age, or in case of hernia sacs from other regions than inguinal.))
- Gross report
((A. Labeled - ___. The specimen is received in formalin and consists of)) __ fragment(s) of pink-tan fibromembranous tissue, measuring ___ cm in greatest dimension and ___ cm in greatest thickness. The surfaces are smooth. There are no sections submitted for microscopic examination. (Representative sections are submitted for microscopic examination in __ cassettes.)
|
Microscopic report
Mesothelial lining of a hernia sac.
In case of a gross only examination, the microscopic report may still be given as a formality:
Right inguinal region, herniorrhaphy: Hernia sac, gross examination only.
|
When microscopy slides of the case are available, you may screen the sample at low magnification to rule out obvious pathology:
Umbilical hernia sac, hernia repair: Connective tissue lined by mesothelium, consistent with hernia sac.
|
Notes
- ↑ For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
Main page
References
Image sources
Oral
Jaw cysts
Author:
Mikael Häggström [note 1]
Cystic changes in the jaw bones or around teeth:
Microscopic examination
Attempt to characterize the lining of the cyst. Look for important signs:
Signs
Cholesterol clefts: Indicates of a periapical (radicular) cyst[1] or an inflamed dentigerous cyst[2].
Any keratinization of the lining.
Any signs of malignancy. Further information: Evaluation of suspected malignancies
Diagnoses
Relative incidence of odontogenic cysts. [3]
All the following are odontogenic cyst, and in case of inability to specify further, may be simply diagnosed as such:
Cyst type |
Lining epithelium |
Other characteristics |
Image
|
Periapical (radicular) cyst
|
Stratified squamous epithelium of variable thickness, except when originating in a maxillary sinus where there is respiratory epithelium (pseudostratified ciliated columnar epithelium).[1]
|
- A fibrous capsule of varying thickness, with chronic inflammatory cells, wherein a plasma cells may be abundant.[1]
They sometimes have the following features:[1]
- Cholesterol clefts in the cyst lining.
|
Histopathology of a periapical cyst, with metaplastic changes of mucous secreting cells (B), and ciliated cells (C). [4]
|
Non-inflamed dentigerous cyst
|
- 2 - 4 layers of cuboidal epithelium, devoid of superficial keratinization.[2]
- Sometimes partially a thin, fragmented layer of eosinophilic columnar cells or low cuboidal epithelium[2]
|
Typically:[2]
- Fibrous to fibromyxoid connective tissue
- No rete ridges, flat interface
They occasionally have:
- Dystrophic calcifications
|
|
Inflamed dentigerous cyst
|
Hyperplastic non-keratinized epithelium[2]
|
Typically:[2]
- Fibrous connective tissue
- Chronic inflammatory cells
Sometimes:[2]
- Elongated interconnecting rete ridges
- Cholesterol clefts, possibly cholesterol granuloma
They occasionally have:[2]
- Dystrophic calcifications
|
|
Residual cyst
|
Stratified squamous epithelium:[5]
- May demonstrate exocytosis, spongiosis, and/or hyperplasia
- May be discontinuous in part and range in thickness from 1 to 50 cell layers, but usually 6 - 20 cell layers
In early cysts, the epithelial lining tend to be proliferative and arcading, with an intense inflammation.
Established cysts tend to rather have fairly regular lining with a higher degree of differentiation, resembling a simple stratified squamous epithelium
|
Cyst lumen may demonstrate fluid and cellular debris.[5]
|
|
All types above can occasionally have scattered mucous or ciliated cells, as well as Rushton bodies, which are amorphic, eosinophilic, linear to crescent-shaped bodies in the cyst epithelium.[4][1][2][5]
Report
- Type of lining
- Other visible features
- At least the most probable type of cyst.
- Even absence of signs of malignancy
Example:
Parts of a cyst, lined by stratified squamous epithelium, with foci of mucous cells and ciliated cells. The underlying fibrous capsule contains cholesterol clefts and inflammation. No signs of malignancy. - Benign odontogenic cyst of periapical type.
|
See also: General notes on reporting
Notes
- ↑ For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
Main page
References
Image sources
Verrucous oral lesions
Author:
Mikael Häggström [note 1]
Verrucous oral lesions have hypergranulosis and/or hyperkeratosis as the most conspicuous finding.
Microscopic evaluation
Look for signs of koilocyte-like changes, which may indicate verrucous squamous cell carcinoma, and which typically only has low atypia:[1]
Verrucous squamous cell carcinoma (images are from penis).
If uncertain, perform immunohistochemistry for Ki67 and p53.
Notes
- ↑ For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
Main page
References
Image sources
Tonsil
Author:
Mikael Häggström [note 1]
Comprehensiveness
On this resource, the following formatting is used for comprehensiveness:
- Minimal depth
- (Moderate depth)
- ((Comprehensive))
Gross processing
Gross pathology of a hypertrophic tonsil.
First look at the requisition form ((and in the medical records)) for the following suspicions:
- Suspected infection: Confirm that a sample has been taken for microbiology. If not, take a sample from within the specimen when you gross it.
- Possible lymphoma: Make a touch prep and take sample(s) for flow cytometry. If you have bilateral tonsils, and they look grossly similar, you may combine a small sample of each tonsil into one container for flow cytometry.
- Suspected tumor: Ink the external surfaces before sectioning. Otherwise inking is not needed. Further information: Tumor
Inspect the tonsils for any significant gross focal changes. A representative section of the grossly most abnormal part from each tonsil is generally enough.
- Example gross report
((A. Labeled - ___. The specimen is received in formalin and consists of)) one rubbery, ovoid, pink-tan tonsil(s) measuring ____. The mucosal surfaces are unremarkable. On sectioning, the tissue is tan-white and homogenous, with no gross lesions. (Representative sections are submitted for microscopic examination in __ cassettes.)
|
Notes
- ↑ For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
Main page
References
Image sources
Salivary glands
Author:
Mikael Häggström, M.D. [note 1]
The major salivary glands are the parotid, submandibular, and sublingual glands.
Evaluation
Look for the most common tumors:
Relative incidence of parotid tumors.[1]
Relative incidence of submandibular tumors.[1]
Pleomorphic adenoma (also called benign mixed tumor), H&E stain.[2]
Cytology
Pleomorphic adenoma (Pap stain). It can usually be diagnosed by its typical fibrillary stroma (mesenchyme). Stromal cell nuclei are small. Myoepithelial cells are usually the predominant cell type, and can have various shapes but are usually more elongated than epithelial cells. Epithelial cells may have prominent nucleoli.[3]
Warthin's tumor, with typical cellular features (and relatively uncommon binucleated cells).[4] Pap stain. For a diagnosis, you should see sheets of oncocytes and a mixed population of lymphocytes.[5]
Reporting=
Example report:
Right parotid mass, biopsy: – Pleomorphic adenoma.
|
Notes
- ↑ For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
Main page
References
- ↑ 1.0 1.1 Steve C Lee, MD, PhD. Salivary Gland Neoplasms. Medscape. Updated: Jan 13, 2021}}
Diagrams by Mikael Häggström, MD
- ↑ Image by Mikael Häggström, MD. Reference for description: Bin Xu, M.D., Ph.D.. Pleomorphic adenoma. Pathology Outlines. Last author update: 30 July 2021. Last staff update: 6 February 2023
- ↑ Image by Mikael Häggström, MD. Reference for description: Bin Xu, M.D., Ph.D.. Pleomorphic adenoma. Last author update: 30 July 2021. Last staff update: 5 August 2021
- ↑ Image by Mikael Häggström, MD. References for entries:
- Köybaşioğlu FF, Önal B, Han Ü, Adabağ A, Şahpaz A (2020). "Cytomorphological findings in diagnosis of Warthin tumor
". Turk J Med Sci 50 (1): 148-154. doi:10.3906/sag-1901-215. PMID 31769640. PMC: 7080357. Archived from the original. . Binucleation: - Dr.S. Malliga (2006-10-18). A correlative cytological and histopathological study on lesions of salivary gland. - Chan MKM, McGuire LJ: Cytodiagnosis of Lesions Presenting as Salivary Gland Swellings: A Report of Seven Cases. Diagn Cytopathol 8: 439-443, 1992b.
- ↑ Adriana Handra-Luca, M.D., Ph.D., Jen-Fan Hang, M.D.. Warthin tumor. Pathology Outlines. Last author update: 1 September 2012. Last staff update: 28 June 2022
Image sources
Thyroid
Fixation
Generally 10% neutral buffered formalin. Fix all thyroids at least overnight to avoid artifactual nuclear atypia.[1]
See also: General notes on fixation
Removal during autopsy
Sharply dissect the thyroid from the cartilage, starting at the posterior end of each lobe & working forward. Do not cut the isthmus. Try to find parathyroids.
Gross processing of thyroidectomy
- Weigh.[2] Up to 30 g versus over 30 g grams is an accepted cutoff between normal and increased weight of the thyroid gland.[3]
- Measure each lobe and isthmus in 3 dimensions, respectively.[2]
- Ink outer surface,[2] at least if malignancy is suspected.[4]
Hemithyroidecomy (lobe + isthmus) or lobectomy, including completion thyroidectomies: Use separate colors over the cut surface and the outer “capsular” or "peripheral" surface.
None of the outer “capsular” surface should be inked like the cut surface.
Intact total thyroidectomy: Separate colors for each lobe and the isthmus.
If no appreciable isthmus, Separate colors for each lobe.
((In addition, use different ink colors on the anterior versus posterior “capsular” or "peripheral" surface.))
Serially section the specimen at 3-4mm intervals,[5] such as follows:[2]
Hemithyroidecomy (lobe + isthmus) or lobectomy: Include isthmic orange margins in your transverse sections.
Intact total thyroidectomy: Transverse lobe sections and sagittal isthmus sections
Short/inconspicious isthmus: The isthmus can be included in the transverse sections.
See also: General notes on gross processing
Thyroiditis, defined by a significant inflammatory infiltrate, usually lymphocytic.
Thyroid hyperplasia: Variable sized dilated follicles with flattened to hyperplastic epithelium. May form nodules, but without any significant capsule. Architecture resembles normal thyroid, but may be somewhat hypercellular.[6]
Thyroid follicular adenoma, being architecturally and cytologically different from surrounding gland, and being completely enveloped by thin fibrous capsule (if not being encapsulated, mainly consider thyroid carcinoma if atypical cells, otherwise nodular hyperplasia with dominant nodule, the latter especially if there are hyperplastic changes elsewhere in gland).[7] Hyperfunctioning follicular adenoma typically shows follicles with papillary infoldings and bubbly, pale colloid with peripheral scalloping (a). Non-hyperfunctioning adenomas with papillary hyperplasia usually show a more predominantly papillary pattern without vacuolated cytoplasm and scalloping colloid (b).[8]
NIFTP (noninvasive follicular thyroid neoplasm with papillary-like nuclear features): [9]
Hürthle cell adenoma, typically consisting of cells with large size, distinct cell borders, deeply eosinophilic and granular cytoplasm, large nucleus with prominent nucleolus, and complete loss of cell polarity.[10]
Relative incidences of malignant thyroid tumors.
Papillary thyroid carcinoma
A papillary thyroid carcinoma is characterized by:
Pseudonuclear inclusions (representing cytoplasmic invaginations)
Also, it typically has nuclei with:[11]
- Enlargement, elongation, overlapping
- Chromatin with clearing, margination, glassy / ground glass texture
- Nuclear membrane with irregular contour
Other thyroid tumors
Follicular thyroid carcinoma, resembling follicular cells, and typically do not display the nuclear features of papillary thyroid carcinoma mentioned above. Distinction from adenoma requires invasion of adjacent thyroid parenchyma, capsule (complete penetration) and/or blood vessels (in or beyond the capsule).[12]
Reporting
For cancers, generally include a synoptic report, such as per College of American Pathologists (CAP) protocols at cap.org/protocols-and-guidelines.
See also: General notes on reporting
Thyroid cytology
Author:
Mikael Häggström [note 1]
Adequacy
A minimum number of 6 clusters with 10 cells each has been arbitrary established to assume adequacy for a definitive diagnosis.[13] The presence of characteristic cells may still confer a definitive diagnosis, but otherwise, the report will simply state inadequate number of cells.
Risk stratification
Papillary thyroid carcinoma, with typical features shown. Pap stain.
Look at least for the following imaged features, and classify findings as per the Bethesda system:
Bethesda system
Category
|
Description[14]
|
Example report
|
I
|
Non diagnostic/unsatisfactory
|
|
II
|
Benign (colloid and follicular cells)
|
Thyroid aspiration, right upper pole:
- Negative for malignant cells.
- Clusters of benign follicular epithelial cells and colloid. Findings are consistent with a benign hyperplastic nodule. (Bethesda category II)
|
III
|
Atypia of undetermined significance (AUS) or follicular lesion of undetermined significance (FLUS) (follicular or lymphoid cells with atypical features)
|
Thyroid aspiration, right mid pole:
- Clusters of atypical follicular cells of undetermined significance (Bethesda category III).
|
IV
|
Follicular nodule/suspicious follicular nodule (cell crowding, micro follicles, dispersed isolated cells, scant colloid)
|
|
V
|
Suspicious for malignancy
|
|
VI
|
Malignant
|
|
Relative incidences of histopathologic diagnoses of solitary thyroid nodules that have undergone fine needle aspiration.[15]
Cytology of benign follicular epithelial cells (Bethesda category II), Pap stain, showing cells with significant nuclear pleomorphism but otherwise insignificant features.
Look for microfollicles, which are flat groups of follicular cells, each having less than 15 follicular cells arranged in a circle that is at least two thirds complete.[16][image 1] They indicate a follicular neoplasm.
Thyroid spherules, on the other hand, are benign features. A spherule may mimic a microfollicle, but has a more smooth, round, ball-like contour, and even spacing of the follicular cell nuclei.[17]
Relative incidences of malignant thyroid tumors.
Cytopathology suspicious for Hürthle cell neoplasm (Bethesda category IV), Pap stain. However, it cannot distinguish Hürthle cell adenoma from Hürthle cell carcinoma, which requires histopathologic sections to see transcapsular or vascular invasion. Hürthle cell hyperplasia (as seen in Hashimoto's thyroiditis) may show moderate variation in nuclear sizes and prominent nucleoli, but further findings favoring Hürthle cell neoplasm include a large number of Hürthle cells, and discohesiveness.[18]
Notes
- ↑ For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
Main page
References
- ↑ . Gross Pathology Manual By The University of Chicago Department of Pathology. Updated 2-14-19 NAC.
- ↑ 2.0 2.1 2.2 2.3 . Gross Pathology Manual By The University of Chicago Department of Pathology. Updated 2-14-19 NAC.
- ↑ Shamim, A; Monira, K; Manowara, B; Sabiha, M; Alim, A; Nurunnabi, ASM (1970). "Weight of the Human Thyroid Gland A Postmortem Study
". Bangladesh Journal of Medical Science 9 (1): 44–48. doi:10.3329/bjms.v9i1.5230. ISSN 2076-0299.
- In turn citing: Langer P. Discussion about the limit between normal thyroid and goiter: mini review. Endocrine regulations. 1999 March; 33(1): 39-45.
- ↑ Monica Dahlgren, Janne Malina, Anna Måsbäck, Otto Ljungberg. Stora utskärningen. KVAST (Swedish Society of Pathology). Retrieved on 2019-09-26.
- ↑ . THYROID. Royal College of pathologists of Australia. Retrieved on 2019-12-17.
- ↑ Swati Satturwar, M.D., F. Zahra Aly, M.D., Ph.D.. Thyroid & parathyroid - Hyperplasia / goiter - Multinodular goiter. PathologyOutlines. Last author update: 11 June 2021. Last staff update: 18 November 2021
- ↑ Sheren Younes, M.D.. Thyroid & parathyroid Benign thyroid neoplasms. Follicular adenoma.. Pathology Outlines. Last author update: 1 November 2014. Last staff update: 8 March 2022
- ↑ Cameselle-Teijeiro JM, Eloy C, Sobrinho-Simões M (2020). "Pitfalls in Challenging Thyroid Tumors: Emphasis on Differential Diagnosis and Ancillary Biomarkers.
". Endocr Pathol 31 (3): 197-217. doi:10.1007/s12022-020-09638-x. PMID 32632840. PMC: 7395918. Archived from the original. .
"This article is licensed under a Creative Commons Attribution 4.0 International License"
- ↑ Image by Mikael Häggström, MD. Reference for findings: Rachel Jug, M.B.B.Ch., B.A.O., David Poller, M.D., Xiaoyin "Sara" Jiang, M.D.. NIFTP. Pathology Outlines. Last author update: 10 May 2018
- ↑ Shuanzeng (Sam) Wei, M.D., Ph.D.. Thyroid & parathyroid - Other thyroid carcinoma - Main- Oncocytic (Hürthle cell) tumors. Pathology Outlines. Last author update: 1 October 2017. Last staff update: 21 July 2021
- ↑ Bin Xu, M.D., Ph.D.. Thyroid & parathyroid - Papillary thyroid carcinoma - Papillary thyroid carcinoma overview. Pathology Outlines. Topic Completed: 8 January 2020. Minor changes: 28 May 2021
- ↑ Shuanzeng (Sam) Wei, M.D., Ph.D.. Thyroid & parathyroid - Other thyroid carcinoma - Follicular. Pathology Outlines. Last author update: 1 August 2017. Last staff update: 24 May 2022
- ↑ Michael, Claire W.; Pang, Yijun; Pu, Robert T.; Hasteh, Farnaz; Griffith, Kent A. (2007). "Cellular adequacy for thyroid aspirates prepared by ThinPrep: How many cells are needed?
". Diagnostic Cytopathology 35 (12): 792–797. doi:10.1002/dc.20768. ISSN 87551039.
- ↑ "The bethesda system for reporting thyroid cytopathology: interpretation and guidelines in surgical treatment
". Indian Journal of Otolaryngology and Head and Neck Surgery 64 (4): 305–311. December 2012. doi:10.1007/s12070-011-0289-4. PMID 24294568.
- ↑ Diagram by Mikael Häggström, MD. Source data: Arul P, Masilamani S (2015). "A correlative study of solitary thyroid nodules using the bethesda system for reporting thyroid cytopathology.
". J Cancer Res Ther 11 (3): 617-22. doi:10.4103/0973-1482.157302. PMID 26458591. Archived from the original. .
- ↑ Ayana Suzuki, C.T., Andrey Bychkov, M.D., Ph.D.. Thyroid & parathyroid - Follicular neoplasm. Last author update: 21 April 2022. Last staff update: 12 May 2022
- ↑ Costigan DC, Shaar M, Frates MC, Alexander EK, Barletta JA, Cibas ES (2020). "Defining thyroid spherules: A benign cytomorphologic feature that mimics microfollicles.
". Cancer Cytopathol 128 (3): 171-176. doi:10.1002/cncy.22219. PMID 31856389. Archived from the original. .
- ↑ Image by Mikael Häggström, MD. References for findings:
- Ayana Suzuki, C.T., Andrey Bychkov, M.D., Ph.D.. Hürthle cell neoplasm. Pathology Outlines. Last author update: 7 May 2020. Last staff update: 12 May 2022 - Shawky M, Sakr M (2016). "Hurthle Cell Lesion: Controversies, Challenges, and Debates.
". Indian J Surg 78 (1): 41-8. doi:10.1007/s12262-015-1381-x. PMID 27186039. PMC: 4848220. Archived from the original. .
Image sources
Lungs
Author:
Mikael Häggström [note 1]
Basic microscopic screening
- For screening of lung autopsies, see Lung autopsy
Mainly look for carcinoma. Further information: Lung tumor
If granulomas are seen, generally stain for acid-fast bacteria and fungi.
Common findings
Active searching for them is not mandatory.
Emphysema (enlarged alveoli). Reporting is optional in mild cases in the elderly.
Respiratory epithelial shedding in a small bronchus. If present, look for vascular leakage, mucus hypersecretion and/or widespread airway narrowing, together indicating asthma.[1]
Other pertinent findings
hyaline membranes, suggesting diffuse alveolar damage.
Pulmonary aspergillosis, seen as acutely branching septated hyphae.[2]
Pulmonary mucormycosis, seen as non-septated and broad-branching, and sometimes branching at right angles (black arrow).[3]
For fungi not conforming to the two main forms above, a general pathologist may attempt to get input by readily available expertise locally, but if it cannot be readily speciated, then it's generally acceptable to simply report as fungi present.
Notes
- ↑ For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
Main page
References
Image sources
Lung tumor
Gross processing
As per presentation above.
Microscopic evaluation
Lung cancers by relative incidence.
Medical imaging provides a major clue as to whether a lung tumor is benign or malignant, where lesions smaller than 2 cm are likely to be benign, whereas lesions larger than 2 cm are malignant (that is, lung cancer) in 85% of cases.[1]
Benign tumors
Subsequently distribution of benign tumors and lung cancers, respectively, are as follows:[1]
Minute pulmonary meningothelial-like nodules (MPMNs) are interstitial nodular proliferations of small oval or spindle-shape cells in nests, [2] and do not need reporting. [image 1]
Benign lung tumors:
- Hamartomas - 76%
- Benign fibrous mesothelioma/solitary fibrous tumor (SFT) - 12.3%
- Inflammatory pseudotumor (IPT) - 5.4%
- Lipoma - 1.5%
- Leiomyoma - 1.5%
- Other - 3.3%
Lung cancers
Large cell carcinoma of the lung: neoplastic cells with abundant pale eosinophilic cytoplasm.
Small-cell carcinoma, with typical findings.[4]
TTF-1 needs to have nuclear staining on immunohistochemistry to count as positive. Cytoplasmic staining is disregarded for diagnostic purposes. [5]
Whereas large cell carcinoma is more often histologically distinct, adenocarcinoma and SCC may look alike. In such cases, an immunohistochemistry panel of TTF1, CK5/6, and p63 can be used to distinguish the two.[6][7]
Further workup
edit For primary lung non-small cell carcinoma (NSCLC) stages IB - IV (such as being more than 3 cm in size), generally perform full next generation sequencing panel (DNA and RNA) with PDL-1 immunostaining. For an advanced stage NSCLC that is not a candidate for biopsy or re-biopsy, a viable alternative is “liquid biopsy” on peripheral blood for circulating tumor DNA.[8]
Notes
Main page
References
- ↑ 1.0 1.1 Alain C. Borczuk (2008). "Benign Tumors and Tumorlike Conditions of the Lung
". Archives of Pathology & Laboratory Medicine 132 (7). Archived from the original. .
- ↑ Kuroki, Masaomi; Nakata, Hiroshi; Masuda, Toshifumi; Hashiguchi, Norihisa; Tamura, Shozo; Nabeshima, Kazuki; Matsuzaki, Yasunori; Onitsuka, Toshio (2002). "Minute Pulmonary Meningothelial-like Nodules: High-Resolution Computed Tomography and Pathologic Correlations
". Journal of Thoracic Imaging 17 (3): 227–229. doi:10.1097/00005382-200207000-00008. ISSN 0883-5993.
- ↑ Dr Nicholas Turnbull, A/Prof Patrick Emanual (2014-05-03). Squamous cell carcinoma pathology. DermNetz.
- ↑ Image by Mikael Häggström, MD. Source for findings: Caroline I.M. Underwood, M.D., Carolyn Glass, M.D., Ph.D.. Lung - Small cell carcinoma. Pathology Outlines. Last author update: 20 September 2022}}
- ↑ Image by Mikael Häggström, MD. Source for significance: Bejarano PA, Mousavi F (2003). "Incidence and significance of cytoplasmic thyroid transcription factor-1 immunoreactivity.
". Arch Pathol Lab Med 127 (2): 193-5. doi:10.5858/2003-127-193-IASOCT. PMID 12562233. Archived from the original. .
- ↑ Inamura K (2018). "Update on Immunohistochemistry for the Diagnosis of Lung Cancer.
". Cancers (Basel) 10 (3). doi:10.3390/cancers10030072. PMID 29538329. PMC: 5876647. Archived from the original. .
- ↑ Affandi KA, Tizen NMS, Mustangin M, Zin RRMRM (2018). "p40 Immunohistochemistry Is an Excellent Marker in Primary Lung Squamous Cell Carcinoma.
". J Pathol Transl Med 52 (5): 283-289. doi:10.4132/jptm.2018.08.14. PMID 30235512. PMC: 6166010. Archived from the original. .
- ↑ . National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology (NCCN Guidelines) - Non-Small Cell Lung Cancer. Version 3.2024. Section: Principles of molecular and biomarker analysis (2024-03-12).
Image sources
Lung wedge resection and lobectomy
Author:
Mikael Häggström [note 1]
Comprehensiveness
On this resource, the following formatting is used for comprehensiveness:
- Minimal depth
- (Moderate depth)
- ((Comprehensive))
- Other legend
<< Decision needed between alternatives separated by / signs >>
{{Common findings / In case of findings}}
[[Comments]]
Link to another page
Intraoperative consultation
Perform:
- Tumor microscopy on frozen sectioning if there is intermediate risk of cancer (if frozen section does not show cancer, the surgeon may not need to perform lymph node dissection)
- Margin assessment: A gross distance from tumor to the parenchymal is generally sufficient, unless a suspected malignancy is close enough to confer a significant risk of extension to the margin, in which case the closest parenchymal margin should be frozen en face[note 2]. For lobectomies, generally perform frozen section on the bronchial and vascular margin en face[note 2].
Grossing
Surgical margin sampling of a lobectomy for intraoperative consultation.
Perform the following:[1]
- Measure the specimen in 3 dimensions.
- (Weigh lobectomies.).
- Describe pleural surface, including color, and any presence of granularity, adhesions, retraction, or tumor.
- Palpate for any tumors.
- Ink the surgical margin and cut it away just below any sutures or staples. If the margin is substantially stapled (and their removal would be either too tissue-damaging or otherwise inconvenient), ink and use another section of the tissue underneath it for frozen sectioning.
- In intraoperative consultations use a section that is presumably closest to a tumor for frozen sectioning, with the tissue en face[note 2], for radicality. This is generally enough to report intraoperatively to the surgeon, unless otherwise requested.
- ((Sample the entire surgical margin for standard processing.))
- Cut open the bronchi of the specimen with a pair of scissors, as far as they can fit within the lumina. Attempt to cut so as to be able to take a section that includes both any tumor and nearest bronchus. Palpate for tumors intermittently. Describe the cut surface, including color and consistency, and any focal lesions.
- Turn the specimen to the side with least cuts so far, and serially section it. Palpate for tumors intermittently.
Initial measurements when triaging fresh lobectomies
- Size of lobe in 3 dimenstions
- Size of tumor (in 3 dimensions)
- (Weight)
- Distance from tumor to closest
parenchymal, bronchial and vascular margins
|
- Measure tumor size as a maximum diameter (or 3 dimensions)
- Determine location: Which lobe if applicable, and if it is peripheral, central or hilar.
- Margin length to pleura and hilum/surgical margin.
- Any involvement of major bronchi or blood vessels.
- Describe any lymph nodes, including location, range of sizes and appearance of cut surface.
Tissue selection
Vascular (inked yellow), bronchial (inked blue) and parenchymal (inked black) margins of a lobectomy, showing staple line of bronchial margin being removed with scissors to allow for tissue selection.
- 1 from bronchial and vascular margins, en face[note 2], if present, ((differentially inked))
- 1 from nearest parenchymal margin, en face
- Sections of any tumor
- Any other focal change
- 1 from random non-neoplastic lung tissue
Gross report
((A. Labeled - ___. The specimen is received fresh for intraoperative consultation and consists of)) of a right upper lobe of lung which measures __ x __ x __ cm (and weighs __ g). The specimen includes a bronchial stump measuring __ cm in length and __ cm in diameter, which grossly appears unremarkable. The pleural surface is mottled tan-pink {{and slightly puckered on the __ aspect}}. There is a staple line representing the parenchymal margin measuring __ cm in length. The stapled margin is inked black. (On opening the bronchial tree, the mucosa is tan and smooth and the lumens are patent. The blood vessels are opened to reveal no blood clot or tumor.) {{Cut section show an irregular, gray-tan, rubbery firm mass measuring __ x __ x __ cm. The tumor is located __ cm from the bronchial and vascular margin and __ cm from the nearest surgical margin. The tumor abuts smaller bronchi and vessels.}} The remaining parenchyma is pink and spongy. (No lymph nodes are identified in the peribronchial region.) (Representative sections are submitted for microscopic examination in __ cassettes.)
|
Squamous cell carcinoma involving a subsegmental bronchus with distal chronic obstructive pneumonia. The tumor is seen as a rounded nodule, approximately 2 cm in diameter, proximal to a more irregular focus of chronic obstructive pneumonia with fibrosis.
See also: General notes on gross processing
Microscopic evaluation
Look mainly for carcinoma. Further information: Lung tumor
Microscopy report
Lung synoptic reports contain information (number and station) on all lymph nodes received per accession. For example, if Parts A-D are mediastinal nodes (8 in total) and Part E is a lobectomy containing 2 additional peribronchial nodes, the synoptic report for Part E should document all 10 nodes, for example:
A. Lymph node, station 1:
Negative for carcinoma. (0/1, 2 etc)
B. Lymph node, station 2:
Negative for carcinoma. (0/1, 2 etc)
C. Lobectomy, RLL:
Adenocarcinoma
- Size:
- Histologic type
- Margins
See also: General notes on reporting
Notes
- ↑ For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
- ↑ 2.0 2.1 2.2 2.3 En face means that the section is tangential to the region of interest (such as a lesion) of a specimen. Further information: Gross_processing#Cutting
Main page
References
Image sources
Lymph nodes
Author:
Mikael Häggström [note 1]
Comprehensiveness
On this resource, the following formatting is used for comprehensiveness:
- Minimal depth
- (Moderate depth)
- ((Comprehensive))
Gross processing
If suspected lymphoma, before putting tissue in formalin, ensure that tissue is preserved in appropriate media for any special tests (usually flow cytometry). Further information: Lymphoma
In samples with tumors, slice through all included fat while palpating and looking for lymph nodes, and submit all that are found.
For lymph nodes taken for potential breast cancer metastasis, find out and report the procurement time and the time when put in formalin.[note 2]
Gross procedure
- Measure the dimensions. For a lymph node with minimal surrounding fatty tissue, measure the greatest dimension (or 3 dimensions). For specimens with substantial amount of fatty tissue, measure the specimen in 3 dimensions, and measure the greatest dimension seen for individual lymph nodes therein after serial sectioning.
- Find as many lymph nodes as you can in a specimen. Good locations to start include the presumed lymphatic drainage directions from a tumor, as well as when following the lymphatic directions from the vascular margins of a specimen. Serially section fatty tissue into slices that are thin enough to be palpated for small ovoid resistances. If you still have trouble finding enough lymph nodes, put fatty tissue in a vinegar and acetic acid solution made for the purpose of turning lymph nodes pale/white as well as making them more firm for palpation. Colon tumors are sometimes tattooed during endoscopy, and in such cases the tatoo ink often stains lymph nodes as well.
Gross pathology of a mesenteric lymph node.
Lymph node in partially inked mesorectal fat after a night in acetic acid.
- Section lymph nodes if needed. Lymph nodes less than 5 mm may be submitted whole, while larger lymph nodes may be sectioned at 2-3 mm intervals.[1]
- Generally do not submit multiple sectioned lymph nodes in the same cassette, to allow exact counting of the number of involved lymph nodes on microscopy. If you will nevertheless submit multiple bisected lymph nodes in the same cassette, ink each lymph node differently.
Making a "touch prep": Press a glass slide against the cut surface of the lymph node, apply cytologic fixative solution immediately and stain with H&E.
- If suspected lymphoma, such as an enlarged lymph node without any adjacent tumor or another almost certain cause, make a touch prep. Also, take a small fresh sample for flow cytometry:
- For flow cytometry, aim for a tissue size of approximately 5 mm3. Put it in specific flow cytometry preservative medium (such as RPMI), and ensure it gets to the flow cytometry lab. If it is after normal hours and there is no one to ask to find such medium, you can put the specimen in normal sterile saline (enough to cover the tissue) in a fridge (2-8°C) until the next morning.[2] If you receive multiple lymph nodes for flow cytometry, still only sample one (unless the referral asks for separate flow cytometry studies, or there is a given history of one lymph node having high uptake and another having low uptake on PET scanning).
Definition of an enlarged lymph node
- By size, where lymphadenopathy in adults is often defined as a short axis of one or more lymph nodes is greater than 10mm.[3][4] However, there is regional variation as detailed in this table:
Upper limit of lymph node sizes in adults
Generally |
10 mm[3][4]
|
Inguinal |
10[5] – 20 mm[6]
|
Pelvis |
10 mm for ovoid lymph nodes, 8 mm for rounded[5]
|
Neck
|
Generally (non-retropharyngeal) |
10 mm[5][7]
|
Jugulodigastric lymph nodes |
11mm[5] or 15 mm[7]
|
Retropharyngeal |
8 mm[7]
- Lateral retropharyngeal: 5 mm[5]
|
Mediastinum
|
Mediastinum, generally |
10 mm[5]
|
Superior mediastinum and high paratracheal |
7mm[8]
|
Low paratracheal and subcarinal |
11 mm[8]
|
Upper abdominal
|
Retrocrural space |
6 mm[9]
|
Paracardiac |
8 mm[9]
|
Gastrohepatic ligament |
8 mm[9]
|
Upper paraaortic region |
9 mm[9]
|
Portacaval space |
10 mm[9]
|
Porta hepatis |
7 mm[9]
|
Lower paraaortic region |
11 mm[9]
|
Lymphadenopathy of the axillary lymph nodes can be defined as solid nodes measuring more than 15 mm without fatty hilum.[10] Axillary lymph nodes may be normal up to 30 mm if consisting largely of fat.[10]
In children, a short axis of 8 mm can be used.[11] However, inguinal lymph nodes of up to 15 mm and cervical lymph nodes of up to 20 mm are generally normal in children up to age 8–12.[12]
Lymphadenopathy of more than 1.5 cm - 2 cm increases the risk of cancer or granulomatous disease as the cause rather than only inflammation or infection.[13]
Urgency
The processing of lymph nodes is preferably rushed when the H&E stain will determine whether immunohistochemistry will be performed, especially when a lymph node is submitted together with a separate specimen that may be solved without immunostains. This rushing allows you to have the immunostained slides by a similar time as the rest of the case.[14] Examples of cases that are preferably rushed for such reasons include those that may be stained by CK AE1/AE3 in order to visualize otherwise occult lymph node involvement if you don't see any involvement on the H&E stain, mainly in cases when one or more sentinel lymph nodes are submitted together with any of the following:
Rushing is not necessary for non-sentinel lymph nodes.
Gross report
- Individual lymph node, example
((A. Labeled - ___. The specimen is received in formalin and consists of)) __ fragment(s) of soft pink-tan tissue, measuring __ cm in greatest dimension (or __ x __ x __(. (Representative sections are submitted for microscopic examination in __ cassettes.)
|
- Multiple lymph nodes
((A. Labeled - ___. The specimen is received fresh and consists of)) 2 irregular fragments of yellow-tan fatty and fibrous soft tissue measuring __ and ___ cm in greatest dimension. Within the adipose tissue are multiple tan-brown lymph nodes measuring up to __ cm in greatest dimension. The cut surfaces display no gross lesions. The lymph nodes are entirely submitted for microscopic examination (in 10 cassettes). KEY TO SECTIONS:
- A1–A3– one lymph node, serially section
- A4-A5– one lymph node, serially sectioned
- A6– one lymph node, bisected
- A7– one lymph node, bisected
- A8– two lymph nodes, each bisected, differentially inked
- A9– one lymph node, bisected
- A10– multiple lymph nodes.
|
- Additional information
- If potential breast cancer metastasis: The specimen was procured at __ AM/PM on (date), 2020. The specimen was placed in formalin at __ AM/PM on (date), 2020.
- If lymphoma workup: A touch prep is made, and a minor part of the specimen is submitted for flow cytometry. The remainder of the specimen is submitted for microscopic examination in one cassette.
Microscopic examination
Defining a lymph node
For counting lymph nodes, each should have a discernible capsule around lymphoid cells. Also count larger free-standing lymphoid aggregates. However, the definition of what constitutes a lymph node is largely subjective.[15] Also strive to keep a consistency with the gross description. In addition, any cancer involvement is in itself a relative indication of being a lymph node.
General screening
Look for:
- Whatever pathology is indicated by the referral, or findings in other submitted specimens.
- Enlargement, as preferably measured during grossing, but can possibly be made on the microscopy slide. If present, see separate section below.
Metastases: generally first look around the edges with intermediate magnification, and low mag in the middle, since cancer metastases usually occur at edges (as in this case). For suspected urothelial cancers, however, look closely throughout the node, as they have a tendency to show up anywhere in lymph nodes.
Granulomas (non-necrotizing granuloma pictured). If seen generally perform staining for acid-fast bacilli, and GMS stain for fungi.
Microscopy of enlarged lymph nodes
Look at any other slides for the same case first, in order to find any pathology that may be reflected in in the lymph nodes as well, mainly cancer metastasis or reactive lymph nodes from inflammation.
Look primarily at the overall architecture, with main findings being:
Dilated sinuses. The most cellular expansion is sinus histiocytosis (pictured). If it appears as such, look for a signet ring appearance, which may be a signet ring carcinoma or melanoma. If unsure, use immunostains for CD68, cytokeratin, S100 and mucin.[16]
- Paracortical hyperplasia: Paracortical hyperplasia of a reactive lymph node shows expansion of paracortical areas by a mixed infiltrate, often having a mottled appearance, and it usually has a concomitant reactive follicular hyperplasia.[17] A T-cell lymphoma should be suspected if there is obliteration or marked diminution of the B-cell cortical region, or highly irregular or hyperchromatic nuclei.[17]
- Unspecific hyperplasia: An unspecific pattern of lymph node enlargement, without atypical cells, in the lymphatic drainage direction from an inflamed area, may simply be diagnosed as "benign reactive lymph node".
Workup of cancerous lymph nodes
If cancer is detected in a lymph node:
- Attempt to specify a specific cancer diagnosis'. If the patient has a known carcinoma or sarcoma etc, it is generally enough to confirm that it is consistent with a metastasis thereof.
- Measure the size of involvement.
- Look for extranodal extension.
Reporting
A non-involved lymph node in a patient with cancer can be reported for example as:
Sentinel lymph node #1, left axilla, (excision): One benign lymph node((, negative for malignancy (0/1))).
|
Cancerous lymph nodes with patients with known consistent cancer primary can be reported as metastatic,, such as:
Sentinel lymph node #2, left axilla, (excision): Macrometastatic carcinoma involving one of one (1/1) lymph node. Metastatic carcinoma measures 0.4 cm in greatest dimension. (Negative for extranodal extension).
|
Notes
- ↑ For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
- ↑ The duration that a specimen has been without formalin affects mainly the reliability of estreogen and progesteron receptor testing:
- Pekmezci, Melike; Szpaderska, Anna; Osipo, Clodia; Erşahin, Çağatay (2012). "The Effect of Cold Ischemia Time and/or Formalin Fixation on Estrogen Receptor, Progesterone Receptor, and Human Epidermal Growth Factor Receptor-2 Results in Breast Carcinoma
". Pathology Research International 2012: 1–7. doi:10.1155/2012/947041. ISSN 2090-8091.
Main page
References
- ↑ . Protocol for the Examination of Biopsy Specimens From Patients With Melanoma of the Skin. College of American Pathologists. Version: Melanoma Biopsy 4.1.0.0 Protocol Posting Date: August 2019
- ↑ . Specimen Information and Requirements for Flow Cytometry Testing. Lifelabs. Doc #8218 Ver: 7.0 Current Issued: 13-Apr-2018
- ↑ 3.0 3.1 Ganeshalingam, Skandadas; Koh, Dow-Mu (2009). "Nodal staging
". Cancer Imaging 9 (1): 104–111. doi:10.1102/1470-7330.2009.0017. ISSN 1470-7330. PMID 20080453.
- ↑ 4.0 4.1 Schmidt Júnior, Aurelino Fernandes; Rodrigues, Olavo Ribeiro; Matheus, Roberto Storte; Kim, Jorge Du Ub; Jatene, Fábio Biscegli (2007). "Distribuição, tamanho e número dos linfonodos mediastinais: definições por meio de estudo anatômico
". Jornal Brasileiro de Pneumologia 33 (2): 134–140. doi:10.1590/S1806-37132007000200006. ISSN 1806-3713. PMID 17724531.
- ↑ 5.0 5.1 5.2 5.3 5.4 5.5 "Current concepts in lymph node imaging
". Journal of Nuclear Medicine 45 (9): 1509–18. September 2004. PMID 15347718.
- ↑ . Assessment of lymphadenopathy. BMJ Best Practice. Retrieved on 2017-03-04. Last updated: Last updated: Feb 16, 2017
- ↑ 7.0 7.1 7.2 Page 432 in: Luca Saba (2016). Image Principles, Neck, and the Brain
. CRC Press. ISBN 9781482216202.
- ↑ 8.0 8.1 Sharma, Amita; Fidias, Panos; Hayman, L. Anne; Loomis, Susanne L.; Taber, Katherine H.; Aquino, Suzanne L. (2004). "Patterns of Lymphadenopathy in Thoracic Malignancies
". RadioGraphics 24 (2): 419–434. doi:10.1148/rg.242035075. ISSN 0271-5333. PMID 15026591. Archived from the original. .
- ↑ 9.0 9.1 9.2 9.3 9.4 9.5 9.6 Dorfman, R E; Alpern, M B; Gross, B H; Sandler, M A (1991). "Upper abdominal lymph nodes: criteria for normal size determined with CT.
". Radiology 180 (2): 319–322. doi:10.1148/radiology.180.2.2068292. ISSN 0033-8419. PMID 2068292.
- ↑ 10.0 10.1 Page 559 in: Wolfgang Dähnert (2011). Radiology Review Manual
. Lippincott Williams & Wilkins. ISBN 9781609139438.
- ↑ Page 942 in: Richard M. Gore, Marc S. Levine (2010). High Yield Imaging Gastrointestinal HIGH YIELD in Radiology
. Elsevier Health Sciences. ISBN 9781455711444.
- ↑ Laurence Knott. Generalised Lymphadenopathy. Patient UK. Retrieved on 2017-03-04. Last checked: 24 March 2014
- ↑ "Lymphadenopathy and malignancy
". American Family Physician 66 (11): 2103–10. December 2002. PMID 12484692.
- ↑ Chandler IP, Oommen R, Lawson CW (2003). "Invasive lobular carcinoma and cytokeratin immunohistochemistry: an audit.
". J Clin Pathol 56 (3): 240. doi:10.1136/jcp.56.3.240. PMID 12610108. PMC: 1769908. Archived from the original. .
- ↑ Parkash V, Bifulco C, Feinn R, Concato J, Jain D (2010). "To count and how to count, that is the question: interobserver and intraobserver variability among pathologists in lymph node counting.
". Am J Clin Pathol 134 (1): 42-9. doi:10.1309/AJCPO92DZMUCGEUF. PMID 20551265. Archived from the original. .
- ↑ Egan, Caoimhe; Jaffe, Elaine S. (2018). "Non-neoplastic histiocytic and dendritic cell disorders in lymph nodes
". Seminars in Diagnostic Pathology 35 (1): 20–33. doi:10.1053/j.semdp.2017.11.002. ISSN 07402570.
- ↑ 17.0 17.1 Weiss, Lawrence M; O'Malley, Dennis (2013). "Benign lymphadenopathies
". Modern Pathology 26 (S1): S88–S96. doi:10.1038/modpathol.2012.176. ISSN 0893-3952.
Image sources
Liver
Author:
Mikael Häggström [note 1]
Comprehensiveness
On this resource, the following formatting is used for comprehensiveness:
- Minimal depth
- (Moderate depth)
- ((Comprehensive))
Tissue sampling
Fixation
Generally 10% neutral buffered formalin.
Non–formalin-fixed tissue may be needed for tests such as microbiological analysis or copper quantification studies.[1]
Gross processing in autopsy
- ((Measure the distance from the liver edge to the right costal margin.))
- Inspect the color and texture of the surfaces, including external and cut surfaces. Potential pathologies:
Diffuse areas of pallor in cirrhosis, see Cirrhosis
Pale macronodules of cirrhosis, see Cirrhosis
Nutmeg texture of congestive hepatopathy
- Look for any focal change in the liver volume, mainly any tumor. If found: Further information: Liver tumor
- Determine liver weight. The standard reference range for men is 970–1,860 g (2.14–4.10 lb)[2] and for women 600–1,770 g (1.32–3.90 lb).[3]
- Make consecutive liver slices, such as in the sagittal or coronal plane.
Gross report in autopsy
- ((Distance from the liver edge to the right costal margin.))
- Weight. If abnormally low or high, preferably include the reference range.
- Color and texture of cut surfaces
- Any focal change
Example:
Minimal |
More comprehensive |
Normal ranges
|
The liver weighs ___g.
|
The liver is << of normal size / {{enlarged}}, at ___g.
|
[[Men: 970-1860 g.[2] Women 600-1770g.[3].]]
|
The liver surface is <<smooth ((and glistening)) {{/deformed by small and large nodules}}((, and is <<light tan / dark brown>> in color)). << Normal/ {{/ firm}} consistency. Cut surface[note 2] is normal / << (shows normal homogeneous brown parenchyma) / {{Yellowish color, indicating steatosis}} / {{dark nutmeg similar paths, indicating congestion}}. (No focal changes.)((The liver edge is _cm below the right costal margin.))
Microscopic evaluation
Pathologies can be topographically classified by liver zones. P: portal tract. V: central vein.
A general screening includes (with further information in sections below):
- Looking at the referral/requisition form (and looking at the medical records) for particular conditions to look for or evaluate. (Perform a severity grading of previously known liver diseases.)
- Commonly, this includes to quantify any cirrhosis, at least if the patient had alcohol abuse.
- Steatosis is also common.
- Signs of acute liver failure.
- Signs of malignancy. If a tumor is found: Further information: Liver tumor
- Signs of congestive hepatopathy (indicating heart failure).
- Signs of inflammation at least around the portal triads.
Cirrhosis
Steatohepatitis with mild fibrosis (van Gieson's stain).[1]
Histopathology of steatohepatitis with moderate fibrosis (van Gieson's stain).[1]
Further information: Cirrhosis
Steatosis
At least classify steatosis by severity:
Steatosis grading: a: none. b: mild. c: moderate. d: severe.
Note the presence of microvesicular steatosis, as it is usually more harmful. It shows foamy hepatocytes (two annotated by arrows), as opposed to the more common macrovesicular steatosis (insert).
Note any particular pattern of the steatosis, mainly centrilobular (pictured) or periportal.
Signs of acute liver failure
Lobular disarray and associated lymphocytic inflammation, acidophil acidophil body formation (arrow) and bilirubinostasis, suggesting acute hepatitis.[1]
Shock liver, showing its hallmark[4] pathologic finding centrilobular necrosis but viable periportal hepatocytes. The necrotic hepatocytes are seen as slightly more eosinophilic (red) and discohesive.
Massive hepatic necrosis: Liver cell dropout, residual hepatocytes and intact portal tract pattern.[5]
Congestive hepatopathy
Histopathology of congestive hepatopathy, with sinusoidal dilation in zone 3. As the severity of the lesion increases, the sinusoids around the central vein become distended with extravasated red cells and there is adjacent hepatocyte plate atrophy. [6]
- Acute hepatic congestion shows dilated sinusoidal capillaries predominantly in zone 3 of the hepatic acinus.[7]
- Typical findings of chronic hepatic congestion are atrophy of hepatocytes in zone 3, perisinusoidal edema, thrombosis and hemorrhage. Chronic congestion typically displays perivenous and perisinusoidal fibrosis, with fibrous septa that bridge central hepatic veins. In contrast, other causes of distortion and cirrhosis typically have fibrous septa predominantly between portal triads. However, nonalcoholic steatohepatitis also may show perisinusoidal fibrosis in early stages; in later stages, the fibrosis tends to be in the portal triad. Cirrhosis develops in the final stages of congestive hepatopathy. Regenerating hepatocytes tend to grow in a sleevelike pattern along portal tracts, resulting in a nodular liver with preserved portal triads and obliterated or fibrosed hepatic veins, a pattern called "reverse lobulation". This pattern can also be seen in venous obstruction due to Budd-Chiari syndrome.[8]
Hemosiderin
Look for Kupffer cells with significant hemosiderin deposition (shown next to a hepatocyte with lipofuscin pigment.
Iron stain can highlight the hemosiderin (blue stain) in unclear cases.
Hepatocyte lipofuscin alone is of no real pathologic importance and does not warrant a mention in the report.[9]
Report
- Presence of any liver disease
- (Quantification of its severity.)
- ((Even absence of hepatitis, malignancy, congestive hepatopathy and/or steatosis.))
Notes
- ↑ For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
- ↑ "Cut surface shows..." may alternatively be expressed as "On sectioning, the parenchyma is..."
Main page
References
- ↑ 1.0 1.1 1.2 1.3 Boyd, Alexander; Cain, Owen; Chauhan, Abhishek; Webb, Gwilym James (2020). "Medical liver biopsy: background, indications, procedure and histopathology
". Frontline Gastroenterology 11 (1): 40–47. doi:10.1136/flgastro-2018-101139. ISSN 2041-4137.
- "This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license"
- ↑ 2.0 2.1 Standard reference range: Molina, D. Kimberley; DiMaio, Vincent J.M. (2012). "Normal Organ Weights in Men
". The American Journal of Forensic Medicine and Pathology 33 (4): 368–372. doi:10.1097/PAF.0b013e31823d29ad. ISSN 0195-7910.
- ↑ 3.0 3.1 Standard reference range: Molina, D. Kimberley; DiMaio, Vincent J. M. (2015). "Normal Organ Weights in Women
". The American Journal of Forensic Medicine and Pathology 36 (3): 182–187. doi:10.1097/PAF.0000000000000175. ISSN 0195-7910.
- ↑ Ciobanu AO, Gherasim L (2018). "Ischemic Hepatitis - Intercorrelated Pathology.
". Maedica (Bucur) 13 (1): 5-11. PMID 29868133. PMC: 5972787. Archived from the original. .
- ↑ Xue, Ran; Zhu, Yueke; Liu, Hui; Meng, Qinghua (2019). "The clinical parameters for the diagnosis of hepatitis B virus related acute-on-chronic liver failure with sepsis
". Scientific Reports 9 (1). doi:10.1038/s41598-019-38866-3. ISSN 2045-2322.
-"This article is licensed under a Creative Commons Attribution 4.0 International License"
- ↑ Shah, Shailja C.; Sass, David A. (2015). "“Cardiac Hepatopathy”: A Review of Liver Dysfunction in Heart Failure
". Liver Research - Open Journal 1 (1): 1–10. doi:10.17140/LROJ-1-101. ISSN 23794038.
-"This is an open access article distributed under the Creative Commons Attribution 4.0 International License (CC BY 4.0),"
- ↑ . Acute Hepatic Congestion. Pathway Medicine. Retrieved on 2020-03-06.
- ↑ Wells, Michael L.; Fenstad, Eric R.; Poterucha, Joseph T.; Hough, David M.; Young, Phillip M.; Araoz, Philip A.; Ehman, Richard L.; Venkatesh, Sudhakar K. (2016). "Imaging Findings of Congestive Hepatopathy
". RadioGraphics 36 (4): 1024–1037. doi:10.1148/rg.2016150207. ISSN 0271-5333.
- ↑ . The Internet Pathology Laboratory for Medical Education. The University of Utah Eccles Health Sciences Library. Retrieved on 2020-12-18.
Image sources
Liver tumor
Author:
Mikael Häggström [note 1]
Tissue sampling
- Liver biopsy
- Autopsy: Further information: Autopsy
Gross examination
Note the following:[1]
- Whether the tumor is sell demarcated from surrounding tissue
- Whether there is visible infiltration or invasion into surrounding tissue
- Any necrosis or bleeding
Microscopic evaluation
A bile duct hamartoma is also very common. [2] This image shows typical features: [3] - Small to medium sized, irregularly shaped bile ducts lined by bland cuboidal epithelium (may also be flattened). - Prominent intervening collagenous stroma. - Bile ducts containing eosinophilic debris (may also contain inspissated bile)
Liver tumor types by relative incidence in adults in the United States.[4]
Hepatocellular adenoma (inflammatory type pictured) may have minor atypia.[5]
Further information: Evaluation of suspected malignancies
Notes
- ↑ For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
Main page
References
- ↑ . General oncology. Amboss. Retrieved on 2020-01-29.
- ↑ Yang, Xiao-Yu; Zhang, Hai-Bo; Wu, Bin; Li, Ai-Jun; Fu, Xiao-Hui (2017). "Surgery is the preferred treatment for bile duct hamartomas
". Molecular and Clinical Oncology 7 (4): 649–653. doi:10.3892/mco.2017.1354. ISSN 2049-9450.
- ↑ Upasana Joneja, M.D.. Liver & intrahepatic bile ducts - Developmental anomalies / cysts - Von Meyenburg complex. Pathology Outlines. Topic Completed: 23 November 2020. Minor changes: 23 November 2020
- ↑ Table 37.2 in: Sternberg, Stephen (2012). Sternberg's diagnostic surgical pathology
. Place of publication not identified: LWW. ISBN 978-1-4511-5289-0. OCLC 953861627.
- ↑ Figure 7 from Bioulac-Sage, Paulette; Sempoux, Christine; Possenti, Laurent; Frulio, Nora; Laumonier, Hervé; Laurent, Christophe; Chiche, Laurence; Frédéric Blanc, Jean; et al. (2013). "Pathological Diagnosis of Hepatocellular Cellular Adenoma according to the Clinical Context
". International Journal of Hepatology 2013: 1–13. doi:10.1155/2013/253261. ISSN 2090-3448.
- Attribution 3.0 Unported (CC BY 3.0) license
Image sources
Adrenals
Author:
Mikael Häggström [note 1]
Comprehensiveness
On this resource, the following formatting is used for comprehensiveness:
- Minimal depth
- (Moderate depth)
- ((Comprehensive))
Main targets
Autopsy
Autopsy processing
In autopsy:
- Make a couple of cuts through the adrenal glands, such as transversal ones, and look mainly for adrenal tumors.
- ((Remove the adrenals, trim them from excessive adherent fat, and weight them. Their combined weight in an adult human ranges from 7 to 10 grams.[1]))
Adrenal cortical necrosis. Hemorrhage, fibrin thrombi and short postmortem interval indicate ante-mortem necrosis, otherwise it can be regarded as a postmortem change.[2]
Adrenal venous congestion in circulatory failure.
Autopsy report
Normal status can be described as either:
- Adrenal glands are normal bilaterally.
- (Adrenal glands are ordinarily configured and with no definable focal changes on cut surfaces.)
- ((The adrenals are normal in size, shape and consistency, with a weight of __ grams on the right and __ grams on the left. The cortices are orange with <normal / increased / decreased thickness>. The medullae are <grey / autolyzed>.))
Notes
- ↑ For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
Main page
References
- ↑ O'Hare, A. Munro Neville, Michael J. (1982). The Human Adrenal Cortex Pathology and Biology – An Integrated Approach
. Springer London. pp. Chapter 4: Structure of the adult cortex. ISBN 9781447113171.
- ↑ Page 120 in: Rutty, Guy (2001). Essentials of autopsy practice
. London New York: Springer. ISBN 978-1-85233-541-0. OCLC 44769560.
Image sources
Adrenal tumors
Incidences and prognoses of adrenal tumors. [1]
Adenoma versus carcinoma
The most common adrenal tumors are adrenocortical adenomas and carcinomas. These are most commonly distinguished by the Weiss system,[2] as follows:[3]
Characteristic[3] |
Score
|
High nuclear grade (enlarged, oval to lobated, with coarsely granular to hyperchromatic chromatin and easily discernible, prominent nucleoli)[4] |
1
|
More mitoses than 5/50 high power fields |
1
|
Atypical mitoses |
1
|
Eosinophilic cytoplasm in >75% of tumor cells |
1
|
Diffuse architecture of >33% of tumor |
1
|
Necrosis |
1
|
Venous invasion |
1
|
Sinusoidal invasion (no smooth muscle in wall) |
1
|
Capsular invasion |
1
|
Total score indicates:[3]
- 0-2: Adrenocortical adenoma
- 3: Undetermined
- 4-9: Adrenocortical carcinoma
Gross pathology of adrenocortical adenoma.
Zona fasciculata versus adrenocortical adenoma. An adrenocortical adenoma typically has mild changes in comparison, including larger cells with larger and more pleomorphic nuclei with more coarse chromatin. H&E stain. [image 1]
Adrenocortical adenoma with focal high grade nuclear atypia.[5]
Adrenocortical adenoma with focal necrosis[5]
Gross pathology of adrenocortical carcinoma. They are generally large, with a tan-yellow cut surface, and often have areas of hemorrhage and necrosis.
Histopathology of adrenocortical carcinoma, with marked mitotic activity.
Other adrenal tumors
Reporting
For cancers, generally include a synoptic report, such as per College of American Pathologists (CAP) protocols at cap.org/protocols-and-guidelines.
Kidney with tumor
{{Renal tumor - entire article}
Urinary tract stone
Author:
Mikael Häggström [note 1]
When sent to the pathology department, these are generally sent for stone analysis to determine the chemical composition.
Gross processing
Abide by local practices for what container to use and where to leave stone specimens. Generally submit the entire specimen, or as much as you can conveniently fit in the container.
Example report:
The specimen is received dry and consists of __ irregular fragment(s) of {{tan}} calculus measuring up to __ cm in maximum dimension. The entire specimen is submitted for spectrographic analysis.
|
Notes
- ↑ For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
Main page
References
- ↑ Data and references for pie chart are located at file description page in Wikimedia Commons.
- ↑ Wang, Cuiping; Sun, Yang; Wu, Huanwen; Zhao, Dachun; Chen, Jie (2014). "Distinguishing adrenal cortical carcinomas and adenomas: a study of clinicopathological features and biomarkers
". Histopathology 64 (4): 567–576. doi:10.1111/his.12283. ISSN 03090167.
- ↑ 3.0 3.1 3.2 Aye, Than Than; Myint, Phone; Myint, Kyar Nyo Soe (2015). "Adrenocortical Oncocytoma Presenting with Gynaecomastia
". Journal of the ASEAN Federation of Endocrine Societies 30 (1): 27–30. doi:10.15605/jafes.030.01.08. ISSN 08571074.
- ↑ Tito Fojo. Adrenocortical Cancer. Retrieved on 2020-07-02.
- ↑ 5.0 5.1 Gupta S, Melendez J, Khanna A (2010). "Deoxycorticosterone producing tumor as a cause of resistant hypertension.
". Case Rep Med 2010: 372719. doi:10.1155/2010/372719. PMID 20671982. PMC: 2909735. Archived from the original. .
- "This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited."
Image sources
Pancreas
Author:
Mikael Häggström [note 1]
Comprehensiveness
On this resource, the following formatting is used for comprehensiveness:
- Minimal depth
- (Moderate depth)
- ((Comprehensive))
Upper limits of pancreas weight[1][notes 1]
Patient age |
Men |
Women
|
<20 years |
115g |
80g
|
21-30 years |
115g |
125g
|
31-40 years |
155g |
140g
|
41-50 years |
155g |
110g
|
51-60 years |
175g |
125g
|
>60 years |
160g |
110g
|
Overall |
160g |
120g
|
In autopsy
Inspect the pancreas regarding color and consistency. ((Separate it and measure its dimensions.))
Cut it in consecutive short axis slices.[notes 2] Note the appearance of the parenchyma (and the size of the duct).
Microscopic examination
Look for pancreatic intraepithelial neoplasia and pancreatic tumors.
Pancreatic lipomatosis is a common finding. This case shows moderate to severe lipomatosis, with mainly interlobular but also scattered intralobular fatty infiltration. Reporting is optional in at least mild to moderate cases.
Stages of pancreatic intraepithelial neoplasia.[2]
Notes
- ↑ Upper limit is calculated as mean plus 2 standard deviations.
- ↑ The pancreas may also be cut in the longitudinal plane.
- ↑ For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
Main page
References
Image sources
Pancreatic tumor
Microscopic evaluation
If a biopsy has been processed both for histology and cytology, make sure that their results are not contradictory.
Stages of pancreatic intraepithelial neoplasia.[1]
Relative incidences of various pancreatic neoplasm.[2]
Cancer type |
Relative incidence[3] |
Microscopy findings[3] |
Micrograph
|
Pancreatic ductal adenocarcinoma (PDAC)
|
90% |
Glands and desmoplasia |
|
Pancreatic acinar cell carcinoma (ACC)
|
1% to 2%
|
Granular appearance |
|
Solid pseudopapillary tumor
|
|
Discohesive tumor nests surrounded by thin fibrous bands. |
Low and high magnification[4]
|
Adenosquamous carcinoma
|
1% to 4%[5] |
epithelial cells. |
|
Pancreatic neuroendocrine tumor
|
5%
|
Multiple nests of tumor cells |
Gastrinoma
|
Pre-cancer below for comparison:
|
Precancer: Intraductal papillary mucinous neoplasm (IPMN)
|
3%
|
Mucinous epithelial cells.[6] Growth within the pancreatic ducts.[7] |
|
Types of intraductal papillary mucinous neoplasm (IPMN)
Staging
edit
Stage pancreatic cancers as follows:[8]
Tumor (T) |
Criteria
|
TX |
The primary tumor cannot be evaluated.
|
T0 |
No evidence of cancer was found in the pancreas.
|
Tis |
Carcinoma in situ. This includes:
- High-grade pancreatic intraepithelial neoplasia (PanIn-3)
- Intraductal papillary mucinous neoplasm with high-grade dysplasia
- Intraductal tubulopapillary neoplasm with high-grade dysplasia
- Mucinous cystic neoplasm with high-grade dysplasia.
|
T1 |
The tumor is in the pancreas only, and is ≤2 cm in greatest dimension
|
- T1a |
Tumor ≤0.5 cm in greatest dimension
|
- T1b |
Tumor >0.5 cm and <1 cm in greatest dimension
|
- T1c |
Tumor 1–2 cm in greatest dimension
|
T2 |
The tumor is in the pancreas only, and it is >2 cm and ≤4 cm in greatest dimension
|
T3 |
Tumor >4 cm in greatest dimension
|
T4 |
Tumor involves celiac axis, superior mesenteric artery, and/or common hepatic artery, regardless of size
|
Node (N) |
Criteria
|
NX |
The regional lymph nodes cannot be evaluated.
|
N0 |
Cancer was not found in the regional lymph nodes.
|
N1 |
Metastasis in 1 to 3 regional lymph nodes.
|
N2 |
Metastasis in 4 or more regional lymph nodes.
|
Metastasis (M) |
Criteria
|
M0 |
No distant metastasis
|
M1 |
Distant metastasis, including distant lymph nodes. Pancreatic cancer most commonly spreads to the liver, the peritoneum, and the lungs.
|
Cornea
Author:
Mikael Häggström [note 1]
Comprehensiveness
On this resource, the following formatting is used for comprehensiveness:
- Minimal depth
- (Moderate depth)
- ((Comprehensive))
Gross processing
- Inspect
- Measure
- Serially section in 3-4 mm wide slices.
Example gross report:
(Labeled: ___. The specimen is received in formalin and consists of an) << opaque / translucent>> corneal disc measuring __ cm in diameter and __ cm in thickness. The specimen is serially sectioned and entirely submitted for microscopic examination in one cassette.
|
Microscopic examination
Corneal subepithelial acute inflammation, seen as the presence of neutrophils, as well as chronic inflammation, seen as plasma cells and lymphocytes. There is an associated neovascularization. Bowman's membrane is disrupted. The findings are non-specific.
Look for integrity of Bowman's and Descemet's membranes.
For corneal opacities, look for the most common causes, which generally manifest as:[9]
- Inflammation and edema
- Traumatic injury
Reporting
Example:
(Right eye cornea, excision: Cornea with) patchy acute and chronic inflammation, nonspecific, with disrupted Bowman's membrane and associated neovascularization.
|
Notes
- ↑ For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
Main page
References
- ↑ Hackeng WM, Hruban RH, Offerhaus GJ, Brosens LA (2016). "Surgical and molecular pathology of pancreatic neoplasms.
". Diagn Pathol 11 (1): 47. doi:10.1186/s13000-016-0497-z. PMID 27267993. PMC: 4897815. Archived from the original. .
- "This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/)" - Image title and optimization: Mikael Häggström, M.D.
- ↑ Diagram by Mikael Häggström, M.D.
Source data: Wang Y, Miller FH, Chen ZE, Merrick L, Mortele KJ, Hoff FL (2011). "Diffusion-weighted MR imaging of solid and cystic lesions of the pancreas.
". Radiographics 31 (3): E47-64. doi:10.1148/rg.313105174. PMID 21721197. Archived from the original. .
- ↑ 3.0 3.1 Unless otherwise specified in boxes, reference is: "Therapeutic Implications of Molecular Subtyping for Pancreatic Cancer
". Oncology 31 (3): 159–66, 168. March 2017. PMID 28299752. Archived from the original. .
- ↑ Image by Mikael Häggström, MD.
Reference for features: Pooja Navale, M.D., Omid Savari, M.D., Joseph F. Tomashefski, Jr., M.D., Monika Vyas, M.D.. Solid pseudopapillary neoplasm. Last author update: 4 March 2022
- ↑ "Adenosquamous carcinoma of the pancreas: a case report
". Cases Journal 3 (1): 41. February 2010. doi:10.1186/1757-1626-3-41. PMID 20205828.
- ↑ Diana Agostini-Vulaj. Pancreas – Exocrine tumors / carcinomas – Intraductal papillary mucinous neoplasm (IPMN). Pathology Outlines. Topic Completed: 1 July 2018. Revised: 9 March 2020
- ↑ "Pathologic Evaluation and Reporting of Intraductal Papillary Mucinous Neoplasms of the Pancreas and Other Tumoral Intraepithelial Neoplasms of Pancreatobiliary Tract: Recommendations of Verona Consensus Meeting
". Annals of Surgery 263 (1): 162–77. January 2016. doi:10.1097/SLA.0000000000001173. PMID 25775066.
- ↑ Amin, Mahul (2017). AJCC cancer staging manual
(8 ed.). Switzerland: Springer. ISBN 978-3-319-40617-6. OCLC 961218414.
- For access, see the Secrets chapter of Patholines. - Copyright note: The AJCC, 8th Ed. is published by a company in Switzerland, and the tables presented therein are Public Domain because they consist of tabular information without literary or artistic innovation, and therefore do not fulfil the inclusion criterion of the Swiss Copyright Act (CopA) which applies to "literary and artistic intellectual creations with individual character" (see Federal Act on Copyright and Related Rights (Copyright Act, CopA) of 9 October 1992 (Status as of 1 January 2022)). edit
- ↑ Michael Woods (2018). Corneal Opacity. Winchester Hospital, MA.
Image sources
Nasal cavity
- REDIRECT Nasal cavity and paranasal sinuses
Parathyroid glands
Author:
Mikael Häggström [note 1]
Presentations
Intraoperative consultation
Necessary components are:
- Weight of the parathyroid gland or fragment thereof. Generally, there should not be any subjective description of "enlarged" or similar.[note 2]
- Presence of parathyroid tissue upon frozen section. In particular, exclude sampling from the thyroid. It is not necessary to specify any particular parathyroid pathology on intraoperative consultation (which in case of hyperparathyroidism relies on imaging and intraoperative parathyroid hormone levels rather than the histopathology)[1].
Autopsy
Optionally for a comprehensive autopsy, or where there is suspicion of parathyroid pathology, an effort is made to find the parathyroid glands, and inspect them for general or focal hyper-/neoplasia.
Microscopic evaluation
The main conditions to look for and distinguish are:
- Parathyroid hyperplasia: Typically involves all 4 glands with diffuse enlargement.[2]
- Parathyroid adenoma: Typically nodular growth with compressed rim of normal tissue.[2]
Either is indicated by a decreased amount of intra-gland adipose tissue, and increased weight. A weight of 35-160 mg is above average but not in itself "enlarged" in the absence of other findings.[note 2]
Histology of the parathyroid glands
Parathyroid chief cell hyperplasia: An increase in the parenchymal cell mass,as a result of the proliferation of chief cells, oncocytes, and transitional oncocytes in multiple parathyroid glands.[3]
Parathyroid adenoma, with chief cells and eosinophilic follicles
Parathyroid adenoma, fine needle aspiration
Microscopy report
Example for an intraoperative consultation:
A. Left inferior parathyroid, excision: 24 mg of parathyroid tissue.
C. Right superior parathyroid, excision: 14 mg of parathyroid tissue.
|
Whenever possible, make a single report for multiple fragments from the same location. Example of final report, including additional fragments from the same locations:
A,B. Left inferior parathyroid gland, excision: Hypercellular parathyroid gland (121 mg aggregate weight), consistent with parathyroid hyperplasia.
C,D. Right superior parathyroid gland, excision: Parathyroid gland (94 mg aggregate weight) without significant histopathologic changes.
E. Left superior parathyroid gland, excision: Hypercellular parathyroid gland (142 mg aggregate weight), consistent with parathyroid hyperplasia.
F. Right inferior parathyroid gland, excision: Hypercellular parathyroid gland (85 mg aggregate weight), consistent with parathyroid hyperplasia.
|
Normal example in autopsy:
Sections show <<1, 2, 3, 4>> parathyroid glands with no focal changes or signs of hyperplasia.
|
Urinary bladder
Author:
Mikael Häggström [note 1]
Urinary bladder biopsy
Usually performed as a transuretral resection of the bladder (TURB).
Gross reporting of transurethral resections
- Generally submit all material. (It may be sufficient to submit representative sections that include the muscular layer, if grossly identified. Yet, many departments require submission of the entire specimen regardless, so if unsure, that is the safe choice.)
- If transported or processed together with other cases, put the samples in thin-mesh cassettes or tissue bags to limit contamination.[note 3]
Example report:
Container A. Labeled "bladder tumor". The specimen is received in formalin and consists of multiple fragments of tan-gray, friable soft tissue measuring about __ x __ x __ cm in aggregate. The specimen is entirely submitted for microscopic examination in __ cassettes.
|
Microscopy
Mainly look for urothelial carcinoma (also called transitional cell carcinoma), which constitutes 95% of bladder cancers.[4]
Low grade urothelial carcinoma: Urothelium is thickened but only slightly atypical and has maintained polarity.
In contrast, an inverted urothelial papilloma has smooth surface with minimal to absent exophytic component, is well circumscribed with smooth base, and has no obvious infiltration and no/minimal cytologic atypia.[5]
Other possibilities:
Radiation cystitis with atypical stromal cells (“radiation fibroblasts”), edema and inflammation. Check whether the patient has received radiation before making the diagnosis.
Edema (clear spaces of both the lamina propria and cytoplasm of multiple urothelial cells), which is non-specific.
Notes
- ↑ 1.0 1.1 For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
- ↑ 2.0 2.1 The average weight of each parathyroid gland is about 30 mg in men and 35 mg in women,A but with a great variability: 90% of normal parathyroid glands weight less than 100g, and 96% less than 160g.B Thus, by weight alone, a pathologists generally can't tell whether a parathyroid is enlarged, or whether it is of its normal weight, such as being one of the 4% that are normally over 160g.
- A. Johnson, S J (1 April 2005). "Best Practice No 183: Examination of parathyroid gland specimens
". Journal of Clinical Pathology 58 (4): 338–342. doi:10.1136/jcp.2002.002550. PMID 15790694. - B. Yao, Kathy; Singer, Frederick R.; Roth, Sanford I.; Sassoon, Aaron; Ye, Cynthia; Giuliano, Armando E. (2004). "Weight of Normal Parathyroid Glands in Patients with Parathyroid Adenomas
". The Journal of Clinical Endocrinology & Metabolism 89 (7): 3208–3213. doi:10.1210/jc.2003-031184. ISSN 0021-972X.
- ↑ Urothelial carcinoma is a promiscuous contaminant of other tissues.
- Carll T, Fuja C, Antic T, Lastra R, Pytel P (2022). "Tissue Contamination During Transportation of Formalin-Fixed, Paraffin-Embedded Blocks.
". Am J Clin Pathol 158 (1): 96-104. doi:10.1093/ajcp/aqac014. PMID 35195717. Archived from the original. .
Main page
References
- ↑ Naik AH, Wani MA, Wani KA, Laway BA, Malik AA, Shah ZA (2018). "Intraoperative Parathyroid Hormone Monitoring in Guiding Adequate Parathyroidectomy.
". Indian J Endocrinol Metab 22 (3): 410-416. doi:10.4103/ijem.IJEM_678_17. PMID 30090736. PMC: 6063190. Archived from the original. .
- ↑ 2.0 2.1 Diana Murro Lin. Thyroid & parathyroid - Parathyroid nonmalignant - Parathyroid adenoma. Pathology Outlines. Topic Completed: 27 October 2020. Minor changes: 2 June 2021.
- ↑ Piciucchi, Sara; Barone, Domenico; Gavelli, Giampaolo; Dubini, Alessandra; Oboldi, Devil; Matteuci, Federica (2012). "Primary Hyperparathyroidism: Imaging to Pathology
". Journal of Clinical Imaging Science 2: 59. doi:10.4103/2156-7514.102053. ISSN 2156-7514.
- This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
- ↑ . Types of Bladder Cancer: TCC & Other Variants. CTCA.
- ↑ Monika Roychowdhury. Bladder, ureter & renal pelvis - Urothelial neoplasms - noninvasive - Inverted urothelial papilloma. Pathology Outlines. Topic Completed: 1 December 2014. Minor changes: 3 December 2020
Image sources
Urine cytology
Author:
Mikael Häggström [note 1]
Clinical information
It is not necessary to look through more than readily available reports from previous urine cytologies.
Evaluation
Mainly look for:
Reactive urothelial changes, Pap stain, showing urothelial cells with enlarged nuclei but a nucleus-cytoplasm ratio of less than 0.5. There are bacteria, as well as an inflammatory response of neutrophils, providing a cause for the changes. Can be reported as "Benign urothelial cells, neutrophils and bacteria".
High-grade urothelial carcinoma. Cytologic diagnosis of high-grade urothelial carcinoma requires > 10 cells with high N/C ratio, irregular chromatin pattern and hyperchromatic nuclei (Pap stain).[1]
Distinguish urothelial carcinoma from decoy cells, which are virally infected epithelial cells (Pap stain).
Also report the presence of red blood cells (here seen compared to benign urothelial cells, Pap stain).
The Paris System for reporting urine cytology, version 2.0. [2]
The N/C ratios apply to the finding of any cells meeting the criteria, and not the average among atypical cells (in the majority of obviously positive cases, N/C/ratio averages 0.5).[2] When there are obvious features of malignancy, there is no need to hunt for cells that fulfil all criteria to make such diagnosis.[2]
Nuclear/cytoplasmic ratios.
Fibrovascular cores weakly indicate a urothelial neoplasm, but can be present in all Paris System categories.
Notes
- ↑ For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
Main page
References
Image sources
Digit
Author:
Mikael Häggström [note 1]
For an amputated toe or finger:
Comprehensiveness
On this resource, the following formatting is used for comprehensiveness:
- Minimal depth
- (Moderate depth)
- ((Comprehensive))
- Other legend
<< Decision needed between alternatives separated by / signs >>
{{Common findings / In case of findings}}
[[Comments]]
Link to another page
Intitial processing
- Measure length and average diameter
- Determine the anatomic location of the cut (proximal to the distal phalanx, middle phalanx, metatarsal phalangeal joint etc).
- Look at soft tissue margins whether they look viable or necrotic.
- Look at the skin surface. For any lesion such as ulcerated or necrotic one, measure the distance to the nearest soft tissue margin.
- Ink the surgical margins differently for soft tissue and bony margin(, including if the bony margin is a joint surface ("cartilaginous margin").)
Amputated finger after longitudinal split.
- Split the digit longitudinally, either in the midline or at the closest margin between any ulcer and the soft tissue margin.
- Let the tissue fix in formalin and then use a relatively strong decalcifying agent, usually at least 5-6 hours.
Tissue selection
Sections for microscopy are taken as follows:
For amputations disarticulated at the joint:
- Perpendicular sections of the articular cartilage and adjacent bone. State which bone in key of sections.
For amputations resected by cutting across bone:
- Ink the bone at the proximal margin, submit perpendicular section of bony margin.
Gangrene and/or suspected osteomyelitis:
- Submit cross sections of each bone with associated ulcer and/or gangrene if appropriate, generally sagittal/longitudinal. Attempt to include the longitudinal distance from potential osteomyelitis to the proximal bony/cartilaginous margin.
- Skin and soft tissues at proximal margin.
- If margin is close to gangrene: perpendicular sections
- If far, submit en face[note 2]
- If you receive a separate thin or discoid bone slice, it is generally an additional bone margin. Preferably, have this decalcified and processed promptly, so that it may be used to make a preliminary report as to whether it is involved even before the main specimen is processed.
Contiguous longitudinal sections from a finger with suspected osteomyelitis.
Finger with en face soft tissue margins because of no proximity to gangrene.
At least if osteomyelitis is suspected, ink all proximal (and/)or distal cut surfaces (differentially) of each slice, so that the pieces can be oriented, and the distance between osteomyelitis and the surgical margin can be estimated. The exception is where pieces can most definitely be anatomically oriented, such as the presence of a nail distally.
Gross report
Example:
(A. Labeled - ___. The specimen is received in formalin and consists of an amputated toe/finger.) The digit measures ___ cm in length and ___ cm in average diameter. The digit is resected ___ [[location]]. {{The proximal ___ cm of the specimen is not covered by skin and soft tissue.}} The skin and soft tissue margins appear <viable / necrotic>. The skin surface of the digit appears ___ {{and displays an (ulcerated/necrotic/gangrenous) lesion, cm from the cutaneous margin}}. The nail is <color/thickened/absent/necrotic>. The soft tissue surgical margin is inked blue [[for example]], and the <<bony surgical / cartilaginous>> margin of the ___ [[specific bone involved]] is inked green [[for example]]. On cut sections, the bone subjacent to the ulcer shows no gross abnormalities. Representative sections are submitted for microscopic examination in ___ cassettes following decalcification. Key to sections:
- Longitudinal section through distal phalanx
- Longitudinal section through proximal phalanx, including <<bony surgical / cartilaginous>> margin
- Skin and soft tissues at proximal margin, submitted en face
|
Microscopic examination
Mainly, detect the presence of:
- Microscopic report
Example:
(A. Left third toe, amputation:) Toe with ulcer, gangrene and osteomyelitis. Osteomyelitis involves the distal phalanx, middle phalanx and proximal phalanx. Osteomyelitis is 2.0 cm from the proximal articular surface of the proximal phalanx. (The skin and soft tissue at the surgical margin appear viable.)
|
Bone
Grossing
To submit slides for microscopy, generally gross as follows:
- Split the bone in the plane of interest for microscopy slides.
- Fix the bone in formalin.
- Perform decalcification of the specimen. First, generally take at least a small piece to be kept separately in formalin, in case the main specimen becomes necrotic, so that you have at least one more chance to decalcify it more lightly. If the order and/or history is suspicious for metastasis, try to sample a part of the specimen that is soft enough to not need decalcification (to avoid the risk that decalcification will impair later immunohistochemistry or other testing).
- Take the sections of interest.
Microscopic evaluation
Look for any of the following:
Metastasis
Highly suspicious prostate adenocarcinoma metastasis can be confirmed with NKX1, TTF1 and CDX2.
Notes
- ↑ For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
- ↑ En face means that the section is tangential to the region of interest (such as a lesion) of a specimen. Further information: Gross_processing#Cutting
Main page
References
Image sources
Pituitary
Author:
Mikael Häggström [note 1]
Microscopic evaluation
- Look for cellular expansions, which in the anterior pituitary confers a loss of normal cellular heterogeneity.
- If present, distinguish it as hyperplasia or neoplasia. If uncertain, by using reticulin immunohistochemistry, hyperplasia will show a preserved reticulin meshwork, whereas pituitary adenomas have disruption of it.[1]
- For adenomas, unless otherwise indicated by the medical history, will generally by definition be of the silent type. Basophilic or acidophilic staining may give a clue about the subtype, but immunohistochemistry is generally required.
Normal cellular heterogeneity of the anterior pituitary. Nuclear pleomorphism, like the large nucleus of the chromophobe, is a normal finding in this location.
Incidences of silent pituitary adenomas.[2]
A silent gonadotroph pituitary adenoma which is in this case is eosinophilic (contrary to normal, basophilic, gonadotroph cells).[3]
Microscopy report
In normal autopsy:
Adenohypophysis and neurohypophysis with no focal changes.
|
Notes
- ↑ For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
Main page
References
- ↑ Al-Brahim, N Y Y; Asa, S L (2006). "My approach to pathology of the pituitary gland
". Journal of Clinical Pathology 59 (12): 1245–1253. doi:10.1136/jcp.2005.031187. ISSN 0021-9746.
- ↑ Drummond, Juliana; Roncaroli, Federico; Grossman, Ashley B; Korbonits, Márta (2019). "Clinical and Pathological Aspects of Silent Pituitary Adenomas
". The Journal of Clinical Endocrinology & Metabolism 104 (7): 2473–2489. doi:10.1210/jc.2018-00688. ISSN 0021-972X.
- "This article has been published under the terms of the Creative Commons Attribution License (CC BY; https://creativecommons.org/licenses/by/4.0/)"
- ↑ Gaballa, Salem; Lindsay, Jane; AlJaf, Avan; Hlaing, Kyaw M; Patel, Kashyap (2020). "Acute Unilateral Oculomotor Nerve Palsy as the Initial Presenting Sign of Nonfunctioning Apoplectic Gonadotroph Adenoma
". Cureus. doi:10.7759/cureus.8819. ISSN 2168-8184.
- "This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 4.0"
Image sources
Clinical pathology
Author:
Mikael Häggström, M.D. [note 1]
Memorization-worthy:[note 2] For the most likely types of cases and/or questions that you may be responsible for, know where to find local policies and procedures, and have a good idea of whom to ask for further advice. Make sure you have access and/or contact details for whenever and wherever you are likely to need them.
Blood bank
Author:
Mikael Häggström [note 1]
If you expect to get questions regarding blood products, get a copy of the local cutoffs for approving transfusions of red blood cells, platelets and plasma, and keep it so that you can quickly look it up when needed.
Always consider if a blood product should be given as per a local precaution protocol (usually including regular check-ups of the patient).
Specific questions or requests
- Generalized dosage in adults:
- Plasma: Generally 10-15 ml/kg, and results in approximately 25-30% plasma volume replacement. Detailed calculation
- Cryoprecipitate: 1 unit for every 7-10kg of body weight. 10 units generally replaces 100-150 mg/dl. Detailed calculation
Notes
- ↑ 1.0 1.1 For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
- ↑ Further information on what is memorization-worthy or not: Learning pathology
Main page
References
Image sources
Blood compatibility testing
Author:
Mikael Häggström [note 1]
Blood typing
ABO antigens and antibodies
Upon direct testing by adding antibodies against A, B and/or Rh to patient blood, agglutination means that the patient has the antigen tested. Upon indirect testing by adding A or B antigen to patient plasma, agglutination means absence of the antigen in the patient (and thus the patient produces antibodies against it).
Identification of non-ABO antibodies
In the antibody screening procedure, an individual's plasma is added to a panel of two or three sets of red blood cells which have been chosen to express most clinically significant blood group antigens. Agglutination of the screening cells by the plasma, with or without the addition of anti-human globulin, indicates that an unexpected blood group antibody is present. If this occurs, further testing using more cells (usually 10–11) is necessary to identify the antibody. By examining the antigen profiles of the red blood cells the person's plasma reacts with, it is possible to determine the antibody's identity as follows:
The image above shows the interpretation of an antibody panel used to detect antibodies towards the most relevant blood group antigens. Each row represents "reference" or "control" red blood cells of donors which have known antigen compositions and are ABO group O. A + means that the antigen is present on the reference red blood cells, and 0 means it is absent; nt means "not tested". The "result" column to the right displays reactivity when mixing reference red blood cells with plasma from the patient in 3 different phases: room temperature, 37°C and AHG (with anti-human globulin, by the indirect antiglobulin test).[1]
- Step 1; Annotated in blue: starting to exclude antigens without reaction in all 3 phases; looking at the first reference cell row with no reaction (0 in column at right, in this case cell donor 2), and excluding (here marked by X) each present antigen where the other pair is either practically non-existent (such as for D) or 0 (presence is homozygous, in this case homozygous c).
When both pairs are + (heterozygous cases), they are both excluded (here marked by X), except for C/c, E/e, Duffy, Kidd and MNS antigens (where antibodies of the patient may still react towards blood cells with homozygous antigen expression, because homozygous expression results in a higher dosage of the antigen).[2] Thus, in this case, E/e is not excluded in this row, while K/k is, as well as Jsb (regardless of what Jsa would have shown).[note 2]
- Step 2: Annotated in brown: Going to the next reference cell row with a negative reaction (in this case cell donor 4), and repeating for each antigen type that is not already excluded.
- Step 3: Annotated in purple. Repeating the same for each reference cell row with negative reaction.
- Step 4: Discounting antigens that were absent in all or almost all reactive cases (here marked with \). These are often antigens with low prevalence, and while there is a possibility of such antibodies being produced, they are generally not the type that is responsible for the reactivity at hand.
- Step 5: Comparing the remaining possible antigens for a most likely culprit (in this case Fya), and selectively ruling out significant differential antigens, such as with the shown additional donor cell type that is known to not contain Fya but contains C and Jka.
In this case, the antibody panel shows that anti-Fya antibodies are present. This indicates that donor blood typed to be negative for the Fya antigen must be used. Still, if a subsequent cross-matching shows reactivity, additional testing should be done against previously discounted antigens (in this case potentially E, K, Kpa and/or Lua).[1]
Hemagglutination inhibition[2]
Neutralizing substance |
Antigen cancelled
|
- Hydatid cyst fluid
- Pigeon eggs
|
P1
|
Saliva |
H, Lea
|
Breast milk |
I
|
Guinea pig urine |
Sda
|
Hemagglutination inhibition substances sound like they came from a witch brew!
When multiple antibodies are present, or when an antibody is directed against a high-frequency antigen, the normal antibody panel procedure may not provide a conclusive identification. In these cases, hemagglutination inhibition can be used, wherein a neutralizing substance cancels out a specific antigen.[2] Alternatively, the plasma may be incubated with cells of known antigen profiles in order to remove a specific antibody (a process termed adsorption); or the cells can be treated with enzymes such as ficain or papain which inhibit the reactivity of some blood group antibodies and enhance others (see table below).
Clinical implication
The following is a simplified classification for the main anti-erythrocyte antibodies, using mneumonics for the main involved antigen groups:
- Anti-A/B antibodies: These will cause immediate hemolytic transfusion reaction if the red blood cells do not have compatible antigens, even if there is no previous exposure to the antigens. Therefore, blood transfusions must always be ABO compatible.
- "Kickers"-class antibodies: Antibodies against Kidd, Kell, Rh, S and Duffy group antigens. These have a significant risk of causing hemolytic transfusion reactions when present, and therefore, patients with kickers-class antibodies should receive blood that is negative for the antigen, except for very critical situations where there is no time to find compatible blood.[3] Kickers-class antibodies generally need a previous exposure to the antigen to form, with transfusion reactions being possible upon subsequent transfusions.[2] Some patients first test positive and later test negative for a kickers-class antibody, but such patients must still be transfused with antigen-negative blood regardless.[4] They are generally of the IgG subtype, and are generally most active at 37°C.
- "Limply"-class antibodies: Antibodies against Lutheran, Ii, M/N, P1, Lewis group antigens. These almost never cause clinically significant transfusion reactions (but anti-Ii antibodies are usually the type that causes cold agglutinin disease,[5] a form of autoimmune hemolytic anemia).[2] Hence, there is generally no need to find blood that is negative for the antigen for a limply-class positive patient. These antibodies are generally naturally occurring, that is, they don't require a previous exposure to the antigen to form. They are generally of the IgM class, and are generally not reactive at body temperature, but rather most active at room temperature and below.[6]
Following is a comparison of clinically relevant characteristics of antibodies against the main human blood group systems:[2]
|
ABO |
Rh |
Kell |
Duffy |
Kidd |
Lutheran |
MNS |
Lewis |
P |
Ii
|
Most common in immediate hemolytic transfusion reactions
|
A |
|
Yes |
Fya |
Jka |
|
|
|
|
|
Most common in delayed hemolytic transfusion reactions
|
|
E,D,C |
|
|
Jka |
|
|
|
|
|
Most common in hemolytic disease of the newborn
|
Yes |
D,C |
Yes |
|
|
|
|
|
|
|
Commonly produce intravascular hemolysis
|
Yes |
|
|
|
Yes |
|
|
|
Yes |
|
Reactive at room temperature
|
Yes |
|
|
|
|
|
M,N |
Lea, Leb |
P1 |
|
Nearly always clinically insignificant
|
|
|
|
|
|
Yes |
M,N |
Yes |
P1 |
|
Naturally occurring
|
Yes |
|
|
|
|
Yes |
M,N |
Yes |
Yes |
Yes
|
Enhanced by ficain[7] and papain[8]
|
Yes |
Yes |
|
|
Yes |
|
|
Yes |
P1 |
Yes
|
Destroyed by ficain[7] and papain[8]
|
|
|
|
Fya, Fyb |
|
Yes |
Yes |
|
|
|
Displaying dosage Further information: Blood compatibility testing
|
|
Cc, Ee |
|
Yes |
Yes |
|
Yes |
|
|
|
Notes
- ↑ For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
- ↑ Besides from C/c, E/e, Duffy, Kidd and MNS, clinically significant dosage effects is rare but not impossible for other antigens, which thus may still be considered if subsequent cross-matching is reactive.
Main page
References
- ↑ 1.0 1.1 Justin R. Rhees, M.S., MLS(ASCP)CM, SBBCM. Introduction to Antibody Identification. University of Utah, Medical Laboratory Sciences.
- ↑ 2.0 2.1 2.2 2.3 2.4 2.5 Mais, Daniel (2014). Quick compendium of clinical pathology
. United States: American Society for Clinical Pathology Press. ISBN 978-0-89189-615-9. OCLC 895712380.
- ↑ Pamela P. Goodell, Lynne Uhl, Monique Mohammed, Amy A. Powers (2010). "Risk of Hemolytic Transfusion Reactions Following Emergency-Release RBC Transfusion
". American Journal of Clinical Pathology 134 (2). doi:10.1309/AJCP9OFJN7FLTXDB.
- ↑ Uhl, L (11 Jan 2021). Pretransfusion testing for red blood cell transfusion. UpToDate.
- ↑ "Autoimmune hemolytic anemia: current knowledge and perspectives
". Immunity & Ageing 17 (1): 38. November 2020. doi:10.1186/s12979-020-00208-7. PMID 33292368.
- ↑ Ferdowsi S, Mohammadi S, Ahmadnezhad M, Herfat F, Rezvani A, Eshghi P (2022). "Anti-M antibody and ABO blood grouping discrepancy: a report of three cases with review of literature.
". Hematol Transfus Cell Ther 44 (2): 288-290. doi:10.1016/j.htct.2020.09.150. PMID 33358685. PMC: 9123591. Archived from the original. .
- ↑ 7.0 7.1 Hill, Ben C.; Hanna, Courtney A.; Adamski, Jill; Pham, Huy P.; Marques, Marisa B.; Williams, Lance A. (2017). "Ficin-Treated Red Cells Help Identify Clinically Significant Alloantibodies Masked as Reactions of Undetermined Specificity in Gel Microtubes
". Laboratory Medicine 48 (1): 24–28. doi:10.1093/labmed/lmw062. ISSN 0007-5027. PMID 28007780.
- ↑ 8.0 8.1 Eric Ching. Questions and Answers on Proteolytic Enzymes Used in Blood Group Serology. Canadian Society for Transfusion Medicine.
Image sources
Kleihauer–Betke test
Author:
Mikael Häggström [note 1]
The Kleihauer–Betke test stains fetal red blood cells (cells containing HbF) dark reddish-pink, while adult red blood cells will be white to light pink.
Collection
EDTA-containing-tube.
Criteria for fetal cells
KB stain with green marks at cells counted as fetal (HbF) cells, and red marks at incompletely colored cells at top and a too small cell at right.
To count, a fetal blood cell should be:
- Stained more than approximately half of what is seen in control.
- Not be nucleated or too big (white blood cell are generally also stained).
- Not be too small.
Semi-quantification
This is done for Rh-positive mothers to estimate the severity of a suspected feto-maternal hemorrhage, which can be suspected by various clinical findings (including neonatal anemia, stillbirth, intrauterine growth restriction, hydrops fetalis, decreased or absent fetal movements, non-reassuring fetal heart rate tracing, sinusoidal fetal tracing, and fetal tachyarrythmias, placenta previa with bleeding, and placental abruption)[1].
10HPFs (in 40x) are scanned, and fetal RBCs are counted (cells per 10 HPFs, not average per HPF), and classified as:
- 0 - Negative
- 1 - Rare
- 2-5 - Few
- 6-10 - Moderate
- >10 - Abundant
Quantification
This is done for Rh-negative mothers to estimate the number of Rho(D) immune globulin vials to administer.
2000 cells are counted, in order to give a percentage calculated as:
- Fetal RBCs (given in%) = (Fetal RBC count) / (Total cell count) *100
Alternatively, an acceptable estimation of at least 2000 cells can be done by using a micrograph (or a microscopy grid) to estimate the mean number of cells in a certain area, and using the same mean to estimate the number of cells in equally sized areas:
1. Count cells (both adult and fetal) until reaching 100 cells (including each cell in square by square if using a microscopy grid). Take note of how large micrograph area (or how many grid squares) were counted (here designated as x amount), and how many fetal RBCs were counted.
2. Pick another random location (you may randomize again if it is of a significantly different cell density, but do not let your decision be influenced by the number of fetal RBCs in the area or near its edge). Count the total number of cells in the same area size (or same x number of squares), and how many of them are fetal RBCs.
3. Pick another location again, and count the number of cells in the same area size, and how many of them are fetal RBCs.
- If a count of 200-300 cells only shows 0 or 1 fetal RBC, there only needs to be 1 vial of 300 micrograms Rho(D) immune globulin, and the rest of the steps in this section can be skipped.
Standard deviation |
Count cells in following number of areas
|
Up to 6 |
3
|
7 |
4
|
8 |
5
|
9 |
6-7
|
10 |
8
|
11 |
10
|
12 |
12
|
- Calculate how much the count for the second and third areas deviated from 100, and take the average thereof, which will be used as standard deviation.[note 2] If the standard deviation is higher than 12, count a total of 2000 cells regardless of areas and calculate as per formula above, and the rest of the steps can be skipped.
- Use the table at right to estimate how many areas in total you need to count in order to have a mean number of cells per area with an acceptable confidence interval.
4. After having counted the needed number of areas, calculate the average of the number of cells per area (or per x number of squares), and assume that number for the rest of the counting.
5. Divide 2000 by the number of cells per area, and round that up to know the number of areas you need to perform the next step on in order to presumably have a total of 2000 cells (including previously counted areas).
6. In those additional areas, only count the number of fetal cells per area (or x number of squares), and add that to the fetal cells from previous areas.
Fetal RBCs (given in%) = (Fetal RBC count) / (Presumable total cell count) *100
Example:
100 cells are counted, and their area is marked with a rectangle.
A new location is randomly chosen, and inside the same rectangular area, 94 cells are counted. This is a deviation 6 cells compared to the first count.
A third area of the same size yields a count of 108 cells, deviating 8 from 100. The standard deviation used[note 2] is therefore the mean of 6 and 8, which is 7. As per the table, one more area needs to be counted.
The third area yields 110 cells. The average number of cells per area is now calculated as the mean of 100, 94, 108 and 110, which is 103.
With an average of 103 cells per area, the number of areas needed to presumably include at least 2000 cells in our case is another 16.
The sum of all fetal RBCs in all areas in this example is 45. The presumable total cell count is 103 * 20 = 2060. Thus:
- Fetal RBCs (given in%) = 45 / 2060 * 100 = 2.2%
Calculation of number of vials
Assuming that a vial of 300 micrograms of Rho(D) immune globulin will protect against 30 mL of fetal blood, the number of vials needed to compensate for the fetal-maternal transfusion is calculated as following, rounded up,[2] or rounded to the closest full number and then adding 1.[3]
Number of vials = Fetal RBCs in% * 1.7
For example, with 2.2% fetal RBCs, the number of vials would be 4[2] or 5[3].
Notes
- ↑ For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
- ↑ 2.0 2.1 Technically, the standard deviation would be calculated as the average deviation from the mean of all areas, but the simplified calculation used in this resource can be regarded to be close enough for practical purposes.
Main page
References
Image sources
Peripheral blood smear
Author:
Mikael Häggström [note 1]
Look at and comment separately on white blood cells, red blood cells and platelets. You generally don't need to aim for a perfect report, because for most purposes, a peripheral smear is a relatively simple screening test, and clinicians may opt to perform for example flow cytometry and/or a bone marrow biopsy if they want a better evaluation.
Comprehensiveness
On this resource, the following formatting is used for comprehensiveness:
- Minimal depth
- (Moderate depth)
- ((Comprehensive))
- Other legend
<< Decision needed between alternatives separated by / signs >>
{{Common findings / In case of findings}}
[[Comments]]
Link to another page
Oil immersion microscopy
This is preferred for light microscopy of peripheral blood smears in order to achieve a very high magnification. First use low or medium power to center on suspicious cells, or where red or white blood cells are best appreciated. Put a drop of immersion oil on the location and switch to the immersion objective. Then, whenever there's oil on a slide, always think twice before switching between objectives so as to avoid getting oil on any of your dry objectives (which is a bit tedious to clean off).
Red blood cells
Automated values
When available, automatic quantification of mean corpuscular volume (MCV) and red blood cell (RBC) distribution width (RDW), usually as part of CBC panel, generally decides whether you will call the sample "normocytic" versus "microcytic"/"macrocytic" and/or "anisocytotic", even if it is not clearly visible in the microscope. If automated values are not available, compare RBC sizes to lymphocyte nuclei, which should normally be the same size. If mean corpuscular hemoglobin (MCH) and mean corpuscular hemoglobin concentration (MCHC) are normal, but you still see multiple RBCs with central pallor greater than 50% of the diameter, you can report it as "Increased central pallor", and you may add "indicating iron deficiency" if it is compatible with the clinical history.
Automated values can be graded as follows:[1]
Interpretation
|
Mild
|
Moderate
|
Marked
|
Microcytosis |
MCV : 70 - 79 |
MCV : 60 - 69 |
MCV <60
|
Macrocytosis |
MCV : 100 - 115 |
MCV : 115 - 125 |
MCV >125
|
Hypochromasia |
MCH : 23 - 26 |
MCH : 21 - 23 |
MCH <20
|
Anisocytosis |
RDW: 14.5[2] or 16[1] - 18 |
RDW : 18 - 22[1] or 26[2] |
RDW > 22[1] or 26[2]
|
Morphologic findings
Look for poikilocytosis (red blood cells of abnormal shapes). These are counted as a percentage of visible red blood cells:[1]
|
Image
|
Rare/Occasional
|
Moderate amount of
|
Many/Abundant
|
Polychromasia
|
|
3 - 5% |
5 - 25% |
>25%
|
Spherocytes
|
|
1 - 5% |
5 - 25% |
>25%
|
Schistocytes
|
|
up to 2% |
2 - 25% |
>25%
|
Target cells (codocytes)
|
|
up to 3% |
3 - 25% |
>25%
|
Tear drop cells
|
|
up to 2% |
2 - 25% |
>25%
|
Burr cells (echinocytes)
|
|
1 - 3% |
3 - 10% |
>10%
|
Sickle cells (drepanocytes)
|
|
3 - 5% |
5 - 25% |
>25%
|
Elliptocytes
|
|
1 - 5% |
5 - 25% |
>25%
|
Basophilic stipplings
|
|
up to 2% |
2 - 25% |
>25%
|
Howell Jolly bodies
|
|
up to 1% |
2 - 3 % |
>3%
|
- Burr cells versus spur cells
Burr cells are distinguished from spur cells by having more equally distributed and rounded projections. They are usually artifactual. However, they may also be caused by renal insufficiency, so if this is present, a report may include "Occasional/Multiple echinocytes, consistent with renal insufficiency".
- Intraerythrocytic findings
When seeing what appears to a platelet overlying a red blood cells (as pictured), confirm that there is a halo.
Otherwise, make sure it is not babesia (pictured) or malaria (images below).
Malaria, showing appearance at different intraerythrocytic blood stages.
If malaria is suspected, also make a thick blood film.
Platelets
If CBC is performed, use count to determine whether platelets are "normal in number" or whether there is "thrombocytopenia" or "thrombocytosis". If no CBC, count platelets within a high power oil immersed field, which should normally be 8 to 20.
Large platelets are those with a diameter greater than 4 microns. Giant platelets are those with a diameter greater than 7 microns (larger than a normal red blood cell).[3] Example report:
Numerous large and giant platelets(, suggesting an increased platelet turnover)(( such as in immune thrombocytopenic purpura. They may also be present in myeloproliferative neoplasms, myelodysplasia, and some congenital thrombocytopenia syndromes, including Bernard-Soulier syndrome and MYH9-related disorders.[3]))
|
In thrombocytopenia from automatic counting, look in particular for:
- Clumping of platelets (which can cause a falsely low automatic platelet count). If present, check with the lab if it was sent in EDTA (which may cause artefactual clumping) and ask to have a blood sample sent in sodium citrate instead. Also, look for satellitosis (platelets attached around white blood cells).
- Schistocytes among red blood cells.
White blood cells
Look for:
Blast cells, generally having large nucleus, immature chromatin, a prominent nucleolus, scant cytoplasm and few or no cytoplasmic granules. This example has an Auer rod (to the left of the nucleus). Further information: Suspected blasts on peripheral blood smear
Hypersegmented neutrophils. This is abnormal when more than half of neutrophils have at least 4 segments, or more than 5% of neutrophils have more than 5 segments.[4]
In patients with known chronic lymphocytic leukemia, estimate the percentage of prolymphocytes, which are medium-sized lymphocytes with prominent nucleoli.[5] A percentage of less than 5% can be reported as such.
When smudge cells constitute more than 10% of white blood cells, or in patients with CLL, a separate smear with a drop of serum albumin to every four or five drops of blood should be made to stabilize cell membranes.[6] A semi-quantification of different cell lines should then be made on the albumin slide, whereas white and red blood cell morphology should still be made on the original slide, since it is altered by albumin.
Report
Example report:
Normochromic normocytic red blood cells. Red blood cells show <normal morphology / anisopoikilocytosis with occasional ___>. [[If thrombocytopenia, also add "Schistocytes are not significantly increased" if applicable.]]
{{Leukocytosis with neutrophilia / lymphocytosis.}} White blood cells show no left shift or blasts.
Platelets show no evidence of clumping, and show normal granularity.
(Causes of the above findings include ___.)
|
Notes
- ↑ For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
Main page
References
Image sources
Platelet aggregation study
Author:
Mikael Häggström [note 1]
On for example optical densitometry, a first and second wave of platelet aggregation is seen, in this case for an ADP-initiated aggregation. [1]
In a platelet aggregation study, the aggregation process is started by different agonists (ADP, epinephrine etc.) and the aggregation pattern can usually conform into any of the following patterns:
Platelet aggregation function by disorders and agonists
|
ADP |
Epinephrine |
Collagen |
Ristocetin
|
P2Y receptor defect[2] (including Clopidogrel)
|
Decreased |
Normal |
Normal |
Normal
|
Adrenergic receptor defect[2]
|
Normal |
Decreased |
Normal |
Normal
|
Collagen receptor defect[2]
|
Normal |
Normal |
Decreased or absent |
Normal
|
- Von Willebrand disease[3]
- Bernard–Soulier syndrome[2]
|
Normal |
Normal |
Normal |
Decreased or absent
|
- Glanzmann's thrombasthenia[2]
- Afibrinogenemia
|
Decreased |
Decreased |
Decreased |
Normal or decreased
|
Storage pool deficiency[3]
|
Absent second wave |
Partial
|
Aspirin or aspirin-like disorder
|
Absent second wave |
Absent |
Normal
|
Further reading
Notes
- ↑ For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
Main page
References
- ↑ Jiang, L.; Xu, C.; Yu, S.; Liu, P.; Luo, D.; Zhou, Q.; Gao, C.; Hu, H. (2013). "A critical role of thrombin/PAR-1 in ADP-induced platelet secretion and the second wave of aggregation
". Journal of Thrombosis and Haemostasis 11 (5): 930–940. doi:10.1111/jth.12168. ISSN 15387933. PMID 23406164.
- ↑ 2.0 2.1 2.2 2.3 2.4 Borhany, Munira; Pahore, Zaen; ul Qadr, Zeeshan; Rehan, Muhammad; Naz, Arshi; Khan, Asif; Ansari, Saqib; Farzana, Tasneem; et al. (2010). "Bleeding disorders in the tribe: result of consanguineous in breeding
". Orphanet Journal of Rare Diseases 5 (1). doi:10.1186/1750-1172-5-23. ISSN 1750-1172.
- ↑ 3.0 3.1 . Why Perform Platelet Aggregation?. Helena Biosciences. 2015
Image sources
Bone marrow
Author:
Mikael Häggström [note 1]
Bone marrow aspirate showing normal "trilineage hematopoiesis": - Myelomonocytic cells: an eosinophil myelocyte marked - Erythroid cells: an orthochromatic erythroblast marked - Megakaryocytic cells.
Autopsy
Using pliers or similar tool, squeeze some bone marrow from a rib.
Microscopic evaluation
- Confirm trilineage hematopoiesis (see image).
- Look for apparent cellular atypia or decrease of cellular diversity.
Report
Example in a normal case:
Bone marrow from rib (or other location if applicable): Trilineage hematopoiesis. There is no evidence of malignancy.
|
Bone marrow biopsy
Gross processing
- Ensure that the biopsy is properly fixed (generally at least 2 hours).
- Measure length and diameter of each fragment.
- If the biopsy is received in a zinc-containing fixative, rinse it for about 2 minutes, such as placing the cassette in a container under running water (and block any sink enough so that the cassette won't float away).
Histopathology of bone marrow with insufficient decalcification, wherein the bony trabeculae may get pushed by the microtome blade and plow away the cells of interest as displayed. To compensate, thicker sections may be taken, also making evaluation harder.
- Put in decalcifying solution, preferably using a type that is optimal for performing subsequent immunohistochemistry. Generally decalcify the specimen for about 15 minutes initially, and palpate the specimen to check whether it is still firm. If it is, decalcify another 5-10 minutes and check again. Rather have it a little bit too soft than a little bit too firm. Be careful to follow grossing guidelines for bone marrows, since even a small aberration in the processing is likely to be noticed as creating artifacts.
- Gross report example
The specimen is received in AZF solution and consists of __ core needle bone marrow biopsy fragment(s) measuring __ cm in length and 0.2 cm in diameter. The specimen is entirely submitted for microscopic examination in one cassette following decalcification.
|
Microscopic evaluation
Evaluate the following:
- Bone marrow aspirate
Find a location where bone marrow cells can be seen individually, preferably with minimal peripheral blood among them. Sometimes it is between trabeculae and sometimes it is in the surrounding area. Perform a differential count by counting 500 cells[1] and dividing the numbers by 5 to get their percentages. Don't count cells that don't have a cytoplasm or nucleus. If you receive several slides, count about the same number of cells from each slide, but don't count cells from slides where the cell types are more indistinct.
- Myeloid/erythroid ratio, usually defined as the ratio between the number of neutrophil granulocytes and precursors versus the number of erythroblasts. Depending on source, the lower limit of the normal range for this ratio bone marrow aspirate smears in adults is 1 to 2, and the upper limit is 5 to 8.[2] In histologic sections, the normal range is 1.5 – 3.0.[2] Some hematologists also include eosinophils, basophils and monocytes, as well as their precursors, in the myeloid number, but this has only a minor effect on the M:E ratio in normal individuals.[2] Still, if you are to calculate the value for a senior, check their preference first.
In a bone marrow count, nucleated red blood cells count into the total percentage of cells (but does not count into percentage of white blood cells in peripheral blood).
- Bone marrow biopsy, H&E stain
- Adequacy: There should preferably be 5 intertrabecular spaces.
- Cellularity: This is a rather rough estimation of the area of hematopoietic cells divided by the area of all intertrabecular matter, which otherwise mainly consists of fat cells and a small interstitial space. Areas of bone, hemorrhage or artifacts are not counted. In patients 20-80 years, the percentage should be about 100 minus age, such as 40% in a 60 year old patient.
- Thrombopoiesis: There are normally about 3 megakaryocytes per 40x field.
- Look for any granuloma or cancer metastasis
- Bone marrow biopsy, other stains
Generally including:
Ring sideroblast, defined by five or more perinuclear iron granules that encompass at least 1/3 of the nuclear circumference. [3]
- Iron stain: Look at approximately 100 cells and semi-quantify the presence of any ring sideroblasts.
- Reticulin to grade the amount of fibrosis.
- CD3 and CD20 to highlight T and B cells, respectively.
Microscopic report
Example template:
On this resource, the following formatting is used for comprehensiveness:
- Minimal depth
- (Moderate depth)
- ((Comprehensive))
- Other legend
<< Decision needed between alternatives separated by / signs >>
{{Common findings / In case of findings}}
[[Comments]]
Link to another page
SOURCE:
- Bone marrow aspirate and biopsy
CLINICAL INFORMATION:
- {{Lymphocytosis / Pancytopenia / Anemia etc }}
DIAGNOSIS: PERIPHERAL BLOOD:
- {{Lymphocytosis / Pancytopenia / Anemia etc }}
BONE MARROW, {{POSTERIOR ILIAC CREST,}} ASPIRATE AND BIOPSY:
- {{Chronic/Acute lymphocytic/myeloid leukemia.}}
- See description and comment.
GROSS DESCRIPTION:
- [[As per gross report above.]]
MICROSCOPIC DESCRIPTION:
PERIPHERAL SMEAR:
- WBC:__ x103/ul
- RBC:__ x106/ul
- HGB:__ g/dl
- HCT:__ %
- MCV:__ fl
- MCHC:__ g/dl
- RDW-CV:__ %
- PLT:__ x103/ul
- RETIC:__ %
|
DIFFERENTIAL(%):
- NEUTR/BANDS:_
- LYMPHS:_
- MONOS:_
- EOS:_
- BASOS:_
- BLASTS:_
- MYELOS:_
- METAS:_
- NRBCS/100WBCS:_
- PLASMA CELLS:_
|
MORPHOLOGY:
- Red Blood Cells: No significant abnormality.
- White Blood Cells: No significant abnormality.
- Platelets: No significant abnormality.
BONE MARROW ASPIRATE:
- Left / RIGHT / UNDESIGNATED SITE
CELLULARITY ESTIMATE: Adequate. / Hypocellular and hemodilute. / Hypercellular. /
Too few cells for morphologic evaluation.
MARROW DIFFERENTIAL
- Erythroblasts: __%
- Blasts: __%
- Neutrophils/precursors: __%
- Eosinophils: __%
- Basophils: __%
- Lymphocytes: __%
- Monocytes: __%
- Plasma Cells: __%
- M:E ratio: __:__
ERYTHROPOIESIS: Maturing.
GRANULOPOIESIS: Maturing.
MEGAKARYOCYTES: Present.
LYMPHOCYTES: Mature.
PLASMA CELLS: Rare without atypia.
BONE MARROW TOUCH PREPARATION:
_
BONE MARROW BIOPSY:
- Left / RIGHT / UNDESIGNATED SITE
SPECIMEN ADEQUACY:
- Satisfactory. / Limited. / Unsatisfactory.
CELLULARITY:_
- _%: Normocellular / Hypercellular / Hypocellular for age. / Variable ( _ %- _ %, overall _ %) / Cannot assess cellularity due to small biopsy. {{With aspirative artifact.}}
Decalcified bone marrow biopsy demonstrates ____________________
BM Erythropoiesis
_
BM Cellularity
_
BM Megakaryocytes
_
BM Myelopoiesis
_
BONE MARROW IRON STAIN:
Storage iron _/4 on aspirate smear with / without ring sideroblasts.
SPECIAL STAINS:
- Reticulin Stain: ___ reticulin fibrosis (_+/3+)
FLOW CYTOMETRY:
- No immunophenotypic evidence for abnormal myeloid maturation, an increase in blasts, or a lymphoproliferative disorder (see attached report).
COMMENT:
- {{Cytogenetic study and next generation sequencing panel for myeloid neoplasm are pending.}}
- All stains have functional controls.
|
Forensic pathology
Author:
Mikael Häggström [note 1]
Estimation of time of death
An estimation of the time of death is made by postmortem changes of the body. A very approximate rule of thumb for estimating the postmortem interval is as follows:[4]
- Warm and flaccid: less than 3 hours
- Warm and stiff: 3 to 8 hours
- Cold and stiff: 8 to 36 hours
- Cold and flaccid: More than 36 hours.
Notes
- ↑ 1.0 1.1 For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
Main page
References
- ↑ Abdulrahman AA, Patel KH, Yang T, Koch DD, Sivers SM, Smith GH (2018). "Is a 500-Cell Count Necessary for Bone Marrow Differentials?: A Proposed Analytical Method for Validating a Lower Cutoff.
". Am J Clin Pathol 150 (1): 84-91. doi:10.1093/ajcp/aqy034. PMID 29757362. Archived from the original. .
- ↑ 2.0 2.1 2.2 BJ. Bain (2017-02-19). Chapter 5: Pathology of the marrow. Basicmedical Key.
- ↑ Salama M, Teruya-Feldstein J, Kremyankaya M. Atlas of Diagnostic Hematology. Philadelphia, PA: Elsevier; 2021.
- ↑ Senior, T (2018). Forensic ecogenomics : the application of microbial ecology analyses in forensic contexts
. London, United Kingdom San Diego, CA: Academic Press. ISBN 978-0-12-809360-3. OCLC 1023028365.
Image sources
- ↑ Image(s) by: Mikael Häggström et al. - using source images from multiple authors (full list is located at image page in Wikimedia Commons.
Attribution 4.0 International license
Career choice
Author:
Mikael Häggström [note 1]
Subspecialization
The most useful goal is arguably to become a subspecialist in a particular field within pathology, for which you can be a go-to person when other pathologists need help, and at the same time maintaining basic skills in handling general pathology, at least for the most common conditions where you are expected to practice. In either case, it is important to be able to extend beyond your comfort zone when needed, and at least try to solve cases that fall outside the official subspecialties of the pathologists at hand, even if you may need to search for someone to consult you for the case.
Judge subspecialties primarily by their presumed everyday work, and how well it fits with your personal strengths and weaknesses. As much as possible, base your evaluation on real life exposure to the practice, and put only minimal weight on how interesting the theoretical literature thereof is.
To some degree, consider whether you will want to live and work in (or commute to) a larger city (with more demand to dedicate yourself to a narrow-scoped subspecialty), or a relatively smaller town (with an increased demand for broader or otherwise generally needed subspecialties, mainly surgical pathology and cytopathology but mostly also hematopathology).
Notes
- ↑ For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
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References
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Teaching pathology
Strive to always begin with the real life situation in which the point you want to teach is relevant for improving the management of a patient. If you can't think of a situation where something would relevant, generally don't teach it. Also, present them with all pertinent information that you can readily look up or ask from fellow trainees.
If possible, teach by giving students tasks from real cases and present to you what they would do. Until you know a student better, assume that the person is uneducated enough to need to ask or look up how to do something, but at the same time smart enough to only study what is needed to perform the task, so a greater responsibility means a greater need to study.
When making MCQs, keep the presentation brief, with only little irrelevant and/or misleading information. Everyday pathology work offers enough practice in finding the relevant information among medical records, lab results etc.
Only expect memorization to what is memorization-worthy (see the Learning pathology chapter). Memorized does not mean teach-worthy; just because you've memorized something yourself doesn't automatically mean it's worthy of memorization for others.
Notes
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