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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

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
Histopathology of dentigerous cyst.jpg
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:

Histopathology of a periapical cyst, with metaplastic changes of mucous secreting cells, and ciliated cells.jpg
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

  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

  1. 1.0 1.1 1.2 1.3 1.4 Annie S. Morrison, Kelly Magliocca. Mandible & maxilla - Odontogenic cysts - Periapical (radicular) cyst. Pathology Outlines. Topic Completed: 1 March 2014. Revised: 13 December 2019
  2. 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 Kelly Magliocca, Annie S. Morrison. Mandible & maxilla - Odontogenic cysts - Dentigerous. Pathology Outlines. Topic Completed: 1 October 2013. Revised: 2 December 2019
  3. Leandro Bezerra Borges; Francisco Vagnaldo Fechine; Mário Rogério Lima Mota; Fabrício Bitu Sousa; Ana Paula Negreiros Nunes Alves (2012). "Odontogenic lesions of the jaw: a clinical-pathological study of 461 cases. ". Revista Gaúcha de Odontologia 60 (1). Archived from the original. . 
  4. 4.0 4.1 Tsesis, I; Rosen, E; Dubinsky, L; Buchner, A; Vered, M (2016). "Metaplastic changes in the epithelium of radicular cysts: A series of 711 cases ". Journal of Clinical and Experimental Dentistry: 0–0. doi:10.4317/jced.52846. ISSN 19895488. 
    - "Fig 2- available via license: Creative Commons Attribution 2.5 Generic"
  5. 5.0 5.1 5.2 Annie S. Morrison, Kelly Magliocca. Mandible & maxilla - Odontogenic cysts - Residual cyst. Pathology Outlines. Topic Completed: 1 April 2014. Revised: 13 December 2019

Image sources


Verrucous oral lesions

Author: Mikael Häggström [note 1]

Verrucous hyperplasia.

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

  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

  1. 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


Tonsil

Author: Mikael Häggström [note 1]

Comprehensiveness

On this resource, the following formatting is used for comprehensiveness:

  • Minimal depth
  • (Moderate depth)
  • ((Comprehensive))

Gross processing

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

  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


Image sources


Nasal cavity

  1. REDIRECT Nasal cavity and paranasal sinuses

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:

Cytology

Notes

  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

  1. 1.0 1.1 Steve C Lee, MD, PhD. Salivary Gland Neoplasms. Medscape. Updated: Jan 13, 2021}}
    Diagrams by Mikael Häggström, MD
  2. 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
  3. 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.
  4. 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

Parathyroid glands (white arrow), next to the thyroid gland.

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]

((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]

  See also: General notes on gross processing


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.[6] 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[7] 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

Notes

  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

  1. . Gross Pathology Manual By The University of Chicago Department of Pathology. Updated 2-14-19 NAC.
  2. 2.0 2.1 2.2 2.3 . Gross Pathology Manual By The University of Chicago Department of Pathology. Updated 2-14-19 NAC.
  3. 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.
  4. Monica Dahlgren, Janne Malina, Anna Måsbäck, Otto Ljungberg. Stora utskärningen. KVAST (Swedish Society of Pathology). Retrieved on 2019-09-26.
  5. . THYROID. Royal College of pathologists of Australia. Retrieved on 2019-12-17.
  6. 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. 
  7. "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. 
  8. 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. . 
  9. 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
  10. 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. . 
  11. 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

  1. . 4. 2021. Archived from Sharma Avishesh Singh , Ajay Sahu the original. . 
    - "This is an Open Access article that uses a funding model which does not charge readers or their institutions for access and distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0)"

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]

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.


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  1. 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. 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.
  3. 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.