Surgical Pathology

Sentinel lymph node biopsies (sampling)

" the guard nodes" where metastatic disease will show up first; samples the lymph nodes that drain the neoplasm and surrounding tissue

appropriate procedure for metastatic lesion

"radical procedure"; mastectomy

What is GMS stain used for?

"silver stain"; Fungi

What is Warthin-Starry stain used for?

"silver stain"; bacteria/spirochetes

What is Reticulin stain used for?

"silver stain"; highlights the supporting reticulin network in tissues (supporting collagen); basement membranes (basal lamina)

What is Bielschowsky's stain used for?

"silver stain"; neural tissue

Ziehl-Neelson Stain

Acid Fast Stain--> mycobacterial tissue stains --> TB and leprosy

Congo Red Stain

Amyloid stain--> apple green birfringence with polarization of sample

CD19 and CD20

B-cell markers

What color is associated with immunostains?

Brown

Oligodendrogliomas

Central nervous system glial neoplasms "derived" from or having the characteristics of an oligodendrocyte; 1p and 19q mutations are common in this neoplasm

Prognostic and therapeutic immunostains

ER, PR, CD20, Her2-neu, MIB-1, CD117

If a sentinel lymph node is negative after frozen sectioning, what happens next and why?

For frozen section "negative" lymph nodes, all the lymph node tissue is submitted for permanent sections Occasionally, the additional tissue and/or deeper sections of the tissue (3 levels examined microscopically) will reveal metastatic disease and the patient will undergo a full lymph node dissection at this point

What is the most common fixative used in permanent section diagnosis

Formalin

CK20

GI tract

Class I and II Intermediate filaments

Keratins

CD45

LCA- leukocyte common antigen

appropriate procedure for benign lesion

Lumpectomy

Histological appearance of lymphomas vs. carcinomas

Lymphomas are discohesive Carcinomas are more cohesive

Flow cytometry

Most often used in hematopathology to evaluate for the presence or absence of cell surface antigens to provide an immunophenotype

Fite Stain

Mycobacterial tissue stain for leprosy

What are neurofilaments markers of?

NEURONS

Class V intermediate filaments

Neuroalmins

Class IV Intermediate filaments

Neurofilaments

solution used to cover tissue in cryosectioning

OCT

What are Giemsa stains used for?

Parasites, microorganisms

How are sentinel lymph node biopsies done in order to prevent damage?

Radioactive colloid (protein with a radioactive label) and/or vital dye are injected into and/or around the neoplasm or prior biopsy site The Surgeon uses a "Geiger counter" and visualization of stained tissue to identify and then remove the "sentinel" lymph node or nodes (most commonly 1 to 3 lymph nodes)

Use of Electron Microscopy

Renal biopsies - essentially all renal biopsies Nerve biopsies - many to most biopsies Muscle biopsies - many to most biopsies Virus identification

Electron microscopy

Sections are nanometers in thickness, rather than the microns seen with paraffin embedded tissue; can see organelles

Prussian Blue Stain

Stains iron blue

CD1-CD8

T-cell lymphocyte markers

Complication with sentinel lymph node biopsies (sampling)

Try to make diagnosis of lymph node involvement with minimal disruption of lymphatic drainage to prevent chronic lymphedema that commonly occurs after more aggressive lymph node dissections

When is is appropriate to use frozen sectioning?

Used where the information gained will affect the surgical procedure or immediate therapy, NOT for the convenience of the Surgeon Patient Family

Class III Intermediate filaments

Vimentin, Desmin, Peripherin, GFAP

Her2-neu

a transmembrane growth hormone receptro found in breast and esophageal/gastric malignancies; high grade and have a poor prognosis with an aggressive clinical course

The use of polyclonal Ab as immunostains: where are they obtained from?

animals that have been exposed to the antigen of interest

MIB-1

antibody against Ki-67, a protein expressed in proliferating cells - a "proliferation" marker; indication of a more aggressive malignancy

CK7

breast and pulmonary cancers

Estrogen Receptors (ER) and Progesterone receptors (PR)

breast carcinoma; tend to be lower grade with better prognosis; treated with estrogen inhibition

What color and what "area" of tissue does hematoxylin stain?

dark blue, nucleus

What are desmins markers of?

demonstrates muscle differentiation; will be positive in leiomyomas, leimosarcomas, rhabdomyomas, rhabdomyosarcomas

Disadvantages of frozen sectioning

determining subtleties; can distort the tissue

1p and 19q mutations

diagnostic of oligodendrogliomas

Signs of a malignant spindle cell neoplasm

elongated nucleus; stretched out cytoplasm;

What are keratins markers of?

epithelial cells; will be positive in malignant carcinomas

Pankeratin

epithelial neoplasms (carcinomas)

EMA (epithelial membrane antigen)

expressed in certain glandular tissues and neoplasms

CEA (carcinoembryonic antigen)

fetal glycoprotein; colorectal adenocarcinoma

Auromine O Stain

fluorescent stain of mycobacteria

What is GFAP a marker of?

found in CNS glial cells (astrocytes, oligodendrocytes, ependymal cells); will be positive in glial neoplasms such as astrocytomas, ependmomas, oligodendrogliomas, glioblastomas

p63

found in nuclei of basal epithelial cells of the prostate, myoepithelial cells of the breast, urothelial cells and squamous cells

What is Periodic Acid Schiff Stain (PAS) used for?

fungi, intestine mucins (goblet cells), basement membranes, glycogen; "magenta stain"

hybridomas

fusion of mouse myeloma cells with mouse splenic lymphocytes; produces specific Ab and has longer cell life; able to proliferate (clones)

How are immunostains actually used in a clinical setting?

generally best used in a panel of stains to establish an immunophenotype; H&E is most commonly used for diagnosis

most prominent histochemical stain used in surgical patology

hematoxylin and eosin stain

Pancreatic endocrine hormones

hormone expressed in islet cell neoplasms

Calcitonin

hormone expressed in medullary carcinomas of the thyroid

Parathyroid hormone

hormone expressed in parathyroid neoplasms

Pituitary hormones

hormone expressed in pituitary neoplasms

Thyroglobulin

hormone expressed in thyroid neoplasms

Cytogenetics

involves cell replication with interruption of mitosis and assessment of individual chromosome numbers and structure after Giemsa staining (G banding) Assess for trisomies, monosomies, duplications, deletions and translocations Morphologic changes are assessed Therefore, we don't need to know the specific sequence

The use of polyclonal Ab as immunostains: recognition

less specific; several epitopes of the antigen

CD45 cancers

leukemias and lymphomas

Oil Red O Stain- what type of tissues can this be performed on

lipophilic red dye that dissolves into triglycerides (fat); frozen tissues

Histochemical Stain

may react with a specific cellular component; may precipitate in a certain area

S100

melanocytes

What are vimentins markers of?

mesenchymal cells (fibroblasts, adipocytes, Schwann cells, myocytes, chondrocytes); positive in sarcomas and mesenchymal neoplasms

Vimentin

mesenchymal neoplasms (sarcomas)

The use of monoclonal Ab as immunostains: where are they obtained from? how?

mice splenic lymphocytes; fused with mouse myeloma cells to form a hybrid cell that produces specific Ab

What is an Immunostain?

monoclonal Ab that have a "marker" substance attached that allows microscopic determination as to the presence or absence of these Ab on the slide; sensitive but not specific; primary and secondary Ab used (mouse, anti-mouse)

The use of monoclonal Ab as immunostains: recognition

more specific; recognize only one epitope on the antigen; somewhat LESS sensitive

Gleevac (imatinib)

mutations in CD117 are responsive to Gleevac; tyrosine kinase inhibitor

Neuron Specific Enolase (NSE)

non-specific immunostain

Prostate Specific antigen (PSA)

only made in prostate cells- both benign and prostatic adenocarcinoma

Placental Alkaline Phosphatase (PLAP)

placental tissues and germ cell neoplasms

p504/p63

prostate cocktail; allows us to differentiate between benign prostate glands and high grade PIN and prostatic carcinoma

Immunophenotype

protein expression of a cell; what antigens are present; used for diagnosis

What is the main use or benefit of frozen section diagnosis?

rapid diagnosis of a mass; even while patient is on operating table

What color and what "area" of tissue does eosin stain?

red-pink, cytoplasm

p504S

restricted to prostatic carcinoma and high grade prostatic intraepithelial neoplasia

Intermediate Filament Proteins

series of structural proteins with similar structural and sequence features

K-RAS

site of mutation in colon carcinomas; therapeutic use

CD34

stem cell and blast marker; acute leukemias are CD34 positive

Rituxan

therapeutic: anti-CD20 antibodies used for treatment of B-cell Non-Hodgkins lymphomas; Chronic lymphocytic lymphoma

Herceptin

therapeutic: anti-Her2-neu antibody, can be used as part of the patient's breast carcinoma therapy

Trichrome Stain

three colors: smooth muscle= red; connective tissue (collagen)= blue; neural tissue= pink

TTF-1 (thyroid transcription factor)

thyroid and pulmonary neoplasms

Philadelphia Chromosome

tip of 22 added to 9; drives chronic mylogenous leukemia

CD117

tyrosine kinase protein; mast/stem cell growth factor; proto-oncogene; chronic myelogenous leukemias (CML) and gastrointestinal stromal tumors (GISTs)

What is an immunofluorescent stain?

use MAb that fave a fluorescent tag (fluorochrome) attached; no chemical reaction is needed here--> more difficult and time consuming

FISH (fluorescent) and CISH (chromogenic)

use complimentary nucleic acid probes to detect specific nucleic acid sequences in the tissue/cells being analyzed

In-situ hybridization

used for diagnosis

What are CD markers used for?

useful to immunophenotype hematopoietic neoplasms; used in conjunction with flow cytometry