Fall - ATech ALL SETS
Mucous acini
secrete mucus
Give example of simple cuboidal
secretory cells (ie glands, kidney tubules, terminal bronchials of lungs & ducts of reproductive tract)
Scabrous
shaggy
What are "matted" nodes?
positive LN that have coalesced (ie collection of LN that have capsular extension of tumor from 1 node to another)
Basic dyes
positive charge on dye ion
Lactate dehydrogenase (LDH) - melanoma
prognostic factor for decreased survival in melanoma (does not effect T staging)
Counterstains or cytoplasmics stains
progressive (ie once desired intensity reached, rxn is stopped)
Mordant-dyes
progressive but most often need regressive staining (ie overstained then differentiated until desired element is left stained).
Keratinocytes
prolif from base, move upward & keratinize to form non-living protective (waterproof) keratin layer
Lymphoma
prolif that arise as discrete tissue masses (within LN, spleen or extranodal tissues)
collagen and elastin (dermis)
provide strength and elasticity in skin
What are perithyroidal tissues include?
sizable blood vessels & small peripheral nerves that are continuous with pretracheal fascia
What is the primary detail the government is concerned about on DC?
proximate cause of death
What sinuses are often resected with larynx, but are technically part of hypopharynx?
pyriform sinuses (small pouches that extend inferiorly from intersection of aryepiglottic folds, glossoepiglottic folds & pharyngeal wall)
Flow cytometry
rapidly/quantitatively measure presence of membrane Ag or DNA content of tumor cells
pacinian corpuscle
receptors for deep pressure & vibration
Metaplasia
reversible change of 1 differentiated cell type replaced by another cell type
Annular
ring-shaped
Confluent
running together
Give example of stratified cuboidal
salivary glands & most especially parotid glands
Excrescence
outgrowth from a surface
Serrated
saw-like notches
Purpuric
patches of purple discoloration from extravasation of blood into the skin and mucous membranes
Homeostasis
physiological state of regulation, maintaining internal environment
What is a predictor in more aggressive pattern of spread in papillary & follicular carcinomas?
vascular spread
Glottis location (structures)
ventricle --> ~1cm below true vocal cord (anterior commissure & true vocal cord)
Pustules
vesicles filled with pus (ie impetigo) -macroscopic lesion
How does epiglottis attach to the thyroid cartilage?
via thyroepiglottic ligament
Squash Prep Procedure
w/ scalpel place small amt diagnostic tissue @ top of slide --> flip another slide on top and gently pull apart (don't squish!) --> FIX)
Verrucoid
wart-like
Eroding
wearing away
When should you bisect eyelid specimen
when eyelid ellipse = <10mm (bisect perpendicular to long axis - thru tumor center)
When should you cut a cruciate configuration for eyelid specimen?
when eyelid ellipse = >10mm (3-4mm central portion & 2 tips - bisected) <- 5 submissions
Chatter
when something is LOOSE in cryostat, or needs to be serviced
Peltier plate
where you freeze chucks (btwn -50F & -70F)
Touch Prep Procedure
with paper towel, dab dry a section of tissue - use forceps, touch & lift 3x on clean slide --> fix or air dry
Subglottis location
~1cm below true vocal cord --> cricoid cartilage
How much does sublingual gland weigh?
~3 grams
Most COMMON fixative
½ 95% EtOH and ½ 10% formalin
Viscid
sticky, tenacious
Lesion
structural abnormality produced by disease or injury
Anatomic Pathology
study of structural changes caused by disease
How many samples to take from encapsulated nodules to reduce sampling error?
submit entirely
Mordant
substances/metals that act as link btwn dye & tissue
Mordant
substances/metals that act as link btwn dye & tissue → mordant and dye combine to form "lake" that is basic in action (ie positive charge on dye binds to negative charges)
Papillary/superficial plexus
supplies dermal papillae & epidermis w/ superficial dermis
What are the 3 anatomical regions of the larynx?
supraglottis, glottis & subglottis
Suicide
taking of one's own life
Columnar
taller than wide; nucleus close to base of cell (ie small intestine, microvilli)
What does salivary secretory unit consist of?
terminal branched tubulo-acinar structure composed of either serous or mucous secretory cells, or both.
Invasive
the ability to break through barriers
Immediate cause of death
the disease, injury, or complication that directly precedes death
How does structure of thyroid cartilage contribute to carcinoma spread?
the lack of internal perichondrium allows easier spread of carcinoma at level of anterior commissure
Circulating Tumor Cells
these can be captured/isolated using 3D flow cells coated with Ab specific for tumor cells of interest
Basement Membrane
thin film of non-cellular tissue on which epithelium rests
Membranous
thin, transparent, pliable lining or covering
Letulle
thoracic, cervical, abdominal, and pelvic organs removed as 1 organ block (ie "en masse" removal) and then dissected into organ blocks
meissner's corpuscle
touch receptors (light touch/soft fleeting movement)
Give example of pseudostratified columnar, ciliated
trachea
Fungating
tumor crawling along a surface
Residual Tumor (R) - melanoma
tumor remaining in patient after therapy RX: cannot assess presence of residual tumor R0: No residual tumor R1: Microscopic residual tumor R2: Macroscopic residual tumor
Widely invasive follicular carcinomas consist of ....
tumors with grossly apparent invasion of thyroid and/or soft tissue (ie extrathyroidal invasion)
Contiguous
two structures touching along a boundary or point
Septicemia
uncontained infxn systemically effecting the blood (aka blood poisoning)
Homogeneous
uniform in structure or composition
Accidental
unintentional death
How should you take margins of complex specimen
use common sense
Shattering
from block being TOO COLD, or tissues having higher H2O content (edematous/bloody tissues & brain biopsies)
Stripe on section
from nicks on blade (from calcification/staples/sutures) OR from tissue stuck under the blade (must be wiped off)
Anasarca
full body edema
Tinea capitis
fungal infxn in head (most often seen in children)
Tinea corporis
fungal infxn of body (ie in skin = ring worm)
Tinea pedis
fungal infxn of feet
Tinea cruris
fungal infxn of genital tract
Tinea unguium
fungal infxn of nail/nail bed
Cachaxea
metabolic change where patient loses weight to skin & bones because tumor takes all nutrients
Sabulous
gritty
Fungating
growing along a surface
Exophytic
growing out of a surface in tree-like fashion
Indurated
hardened when it is normally soft
Myxoid
mucoid, mucus-like
arrector pili muscle
muscle attached to base of hair follicle (pulls hair in upright position during cold and fright)
what is sebum?
natural conditioner all over body but mostly in hair and face, decrease in activity with age
Pathogenesis
natural history in development of disease
Acidic dyes
negative charge on dye ion
Leukemia
neoplasms w/ widespread involvement of bone marrow & often periph blood
Micrometastasis - melanoma
nodal metastasis diagnosed after pathologic exam of sentinel LN biopsy or lymphadenectomy (in pts w/out clinical or radiological metastasis evidence)
Cortex
nodules present with germinal centers where B cells mature into plasma cells after activation
Translucent
not clear but light passes through
Firm
not yielding easily under pressure
Weigerf hematoxylin
nuclear stain in nonroutine techniques - resists decolonization in acidic staining solutions
Focal
occurring in a particular area
Satellitosis - melanoma
occurs w/in 2cm of primary tumor
Mucinous
of, relating to, resembling, or containing mucin
Pedunculated
on a stalk
Granular
on a surface, sand-like, finely roughened
What does spread of carcinoma in larynx depend on?
on wall-defined barriers of larynx (thryoid cartilage & cricothyroid membrane)
What is a subtotal laryngectomy?
only portions of larynx resected (hemilaryngectomy, supraglottic laryngectomy)
Exudative
oozing of fluids
Fetid
having a disagreeable odor
Pigmented
having a visible color
Dermatophytoses
having dermatophytes (ie fungus spores) residing in skin
Fenestrated
having openings
Palpebral
having to do with the eyelid
Why is Identifying tumor origin important?
helps guide further sectioning of specimen to determine path of tumor spread
Cavity
hollow space within a structure
Give example of stratified squamous, non-keratinized
oral cavity, pharynx, vocal folds in larynx, vagina/anus
When should you submit a section of anterior commissure?
in cancers that involve the vocal cords
Modified neck dissection, type I
includes all classic radical neck dissection, except spinal accessory nerve
Modified neck dissection, type II
includes all classical radical neck dissection, except spinal accessory nerve & internal jugular vein
Hypertrophy
increase in SIZE of cells/tissue --> response to stimulus
Hyperplasia
increased NUMBER of cells --> response to stimulus
Lymph-vascular Invasion (LVI) - melanoma
indicates if microscopic lymph-vascular invastion seen & includes lymphatic, vascular or lymph-vascular invasion
How should you ink a complex specimen?
ink margins differentially
Endothelium
inner lining of blood vessels (simple squamous epithelium) Function = diffusion
Dictation for punch biopsies:
".. is a __cm in diameter circular (or punch biopsy of) tan skin, excised to a death of 0.3 cm. The skin surface (or epidermis) displays a 0.3 cm tan shiny papule, less tan 0.1 cm from the margin. The margin is marked in blue, the specimen is bisected and entirely submitted as A1."
What is important to remember in steps for sampling LN?
"Pick your nodes" - *Orient & Regionalize LN according* to tumor location -*Dissect colon & radial dissections LAST* - cannot reorient the specimen once cut
Macroscopic Residual Tumor - SCC
"R" useful to indicate known/assumed status of completeness of surgical excision
****Biopsy Standard Dictation****
"Received in formalin labeled (patient's name) and (specimen-labeled tissue type or site) is/are 4 tan-pink soft tissues, ranging from ___x___x___cm to ___x___x___cm, submitted in toto as A1"
Memorize this dictation:
"Received in formalin, labeled "patient's name" & "specimen label on container" are/is ## tan-pink soft tissues, ranging from ___x___x___cm to ___x___x___cm, submitted in toto as A1"
What is "chattering" and what causes it? How can it be resolved?
"Venetian blind" effect on face of block. Due to loose parts on cryostat. Ensure everything is tightened and/or have machine serviced.
Autopsy Tech: Rokitansky
"in situ" dissection combined with removal of organ blocks (term used erroneously when PathMD actually referring to Ghon & Letulle)
Rokitansky
"in situ" dissection combined with removal of organ blocks (term used erroneously when pathologists are actually referring to Ghon & Letulle)
Skin Ellipse Oriented Dictation
"is a ___x___cm tan skin ellipse, excised to a depth of ___cm. A long suture designates the superior end, a short suture designates the medial edge. The medial edge is marked blue, the lateral edge is marked green. The skin surface displays a ___x___cm gray-red centrally ulcerated lesion, ___cm from the lateral margin, ___cm from the medial margin. Sectioning shows only superficial involvement of the lesion. The entire tissue is submitted as follows: -A1: superior end (tip) -A2-4: sequential sections from superior to inferior -A5: inferior end (tip)"
Proximate cause of death
"legal cause of death" -the disease or injury which initiated the chain of events leading to death
Incidence of Disease
# of cases per year, How often that disease occurs
Prevalence of Disease
# of persons that has the disease at any given moment
What type of specimen are tonsils typically?
'Gross-only' (Not submitted for microscopic exam)
Meissner corpuscles
(Nerves- dermis) Papillary dermal touch receptors concentrated in hands and feet (light, soft, fleeting touch). Rapid response.
Merkel cell neurites
(Nerves- intraepidermal) In epidermis-contain neuro-endocrine typre membrane-bound vesicles in cytoplasm. Make synaptic junctions with myelinated sensory nerve ending in upper dermis. Slow response.
Pacinian corpuscles
(Nerves- subcutis) Found deep in subcutis, for deep pressure and vibration, numerous in palm and soles of feet.
Apocrine glands
(Skin adnexae) Glands of groin and axilla; produce odor
Eccrine glands
(Skin adnexae) Produce sweat for cooling the body
Fibrous tissue septae
(Subcutis) Strengthens the adipose tissue and ties subcutis to both dermis and underlying structures such as fascias.
Adipose tissue
(Subcutis) Triglyceride (fat) store; provides insulation and structural padding.
Nails
(Unguis) (Skin adnexae) Keratin plates; strengthen tips of fingers and toes
Glomus bodies
(dermis vessels) -Arteriovenous (AV) shunts, diverts blood from skin to conserve heat -found mainly in hands, feet, ears
Cutaneous plexus
(dermis vessels) Supplies deep dermis and subcutis
papillary/superficial plexus
(dermis vessels) Supplies dermal papillae, epidermis & superficial dermis
Arrector pili muscles
(pilosebaceous units) (Skin adnexae) Hair follicle associated smooth muscle bundles, function to pull hair erect in cold or fright
Hair follicles
(pilosebaceous units) (Skin adnexae) Produce hair
Sebaceous glands
(pilosebaceous units) (Skin adnexae) Sebum (oil) producing holocrine glands
External Exam
***TAKE A LOT OF NOTES!*** *Head to foot in methodical manner* 1. *Match name* & MRN to chart and body tag 2. *Measure & Weigh* body 3. Describe: -*Back/dorsal surface* (scars, tattoos) -*Hair* (baldness patterns, color length) -*Eyes* (color of sclera, irides & pupil - include asymmetry to denote brain injury) -*Mouth* (dentition: complete, edentulous, primary -child-, 2ndary -adult-) -*Face* (piercings, tattoos, scars) -*Ears* (setting/symmetry) -*Chest* (symmetry, nipples, any masses) -*Abdomen* (protuberant, flucuent or taught) -*Extremities* (symmetry, missing digits - scars, tattoos) -*Genitalia* (normal/abnormal for stated gender)
Basic Block Repair
**FIRST REMOVE BLADE** 1. Plastering (when OCT has retracted from tissue) - add drop of OCT on chuck face, then press on flat freezing surface (ie cryostat stage or freezing apparatus) and try again 2. Remove a staple - Use forceps or hemostat to rotate staple out, add more OCT and press with over chuck freezing block 3. Remove a suture - Use only a hemostat, but same as staple 4. The Gouge - see above
Fixation technique to find LN
*1/2 formalin + 1/2 dissect-aid* for a couple hours (especially for colon or breast)
Squamous Cell Carcinoma (SCC)
*2nd most common skin cancer - caused by UV radiation* 1. Grade: malignant, few metastasize, Px depends on stage at resection 2. Found on sun-exposed skin, mostly head & neck of elderly 3. Lesion: *overlying scale/crusting*; flat plaque, small ulcer or slightly elevated keratotic plaque (ulcerating, papillomatous & subcutaneous variants) 4. Microscopic: *Keratinous pearls, whirled foci*, *nests of tumor cells* (aggregates of atypical epith cells invading dermis), variable mitotic activity 5. Risk factors: -UV light, HPV, X-rays, PUVA therapy (for psoriasis), Immunosuppression 6. Pathogenesis: DNA damage induced by exposure to UV light
Y-shaped incision
*Acromion process -> Xiphoid process -> Pubic Symphasis* (sometimes U-shaped in ppl w/ large breasts) (Circumvent Umbilicus) -Use gauze to pull tissue while you cut -Keep knife parallel to & close to bone
Before you cut in autopsy, what should you do?
*Check name, MRN & birth date!!!!*
Lymphadenopathy
*Chronic, abnormal enlargement of LN*, usually associated with disease but not necessarily w/ malignancy
Large elliptical, irregular or circular skins, *Oriented*
*Done as re-excision or wide excision* 1. Measure L x W, & D of excision 2. Describe how its oriented & inked (ink different margins in different colors) 3. Describe lesion or previous biopsy site & distance from closest edge 4. Describe cut surface of lesion 5. Cut margins (either clockwise perpendicular or enface circumferentially) 6. Block area of lesion/biopsy site, cross section sequentially & submit in a designated fashion
Large elliptical, irregular or circular skins, *Unoriented*
*Done as re-excision or wide excision* 1. Measure L x W, & D of excision 2. Describe lesion or previous biopsy site & distance from closest edge 3. Describe cut surface of lesion 4. Ink margin in 1 color 5. Cut margins (either clockwise perpendicular or enface circumferentially) 6. Block area of lesion/biopsy site, cross section & submit sequentially 7. Dictation: like other skin ellipses but with change: "the entire lesion is submitted sequentially from 12 to 6 o'clock"
What are age-related changes in LNs?
*Fat Replacement*: -as aging occurs, LN increasingly replaced by fat (particularly in axillary, cubital & popliteal regions) *Germinal Center* -common in infants/kids -decreases in young adults -often absent in elderly
What test is useless and waste of money if used for Hodgkins Lymphoma?
*Flow cytometry* (it will not work) (so if clinical history says hodgkins, do not order!!!)
Keratinocytes (epidermis)
*Form Stratum corneum* Cells proliferate from base, migrate upward and keratinize to *form non-living protective, abrasion-resistant waterproof keratin layer*
Sialadenitis
*Gland inflammation* - From trauma, infxn, or autoimmune (Sjogren's syndrome)
Histologic Grades of SCC
*Grade 1: well-differentiated tumors* (squamous epith frequently shows recognizable/abundant keratinization) *Grade 2: moderately-differentiated tumors* (more structural disorganization where squamous epith derivation is less obvious) *Grade 3: poorly differentiated tumors* (difficult to establish squamous differentiation) *Grade 4: undifferentiated tumors*
Describe what is located on each "cube" surface of maxilla specimen
*Inferior* - hard palate *Superior* - floor of orbit *Medial* - nasal wall (turbinates) *Lateral* - bony & soft tissue surfaces of face *Posterior* - musculature & bony processes of pterygoid complex
What should be included when reporting surgical margins?
*Info regarding distance* of invasive carcinoma, carcinoma in situ, or high-grade dysplasia *from the margin*
Lymphedema/edema
*Localized collection of interstitial fluid* -occurs when LN cannot drain from area of body (ie woman with breast cancer, axillary dissection -> LN blocked and arm can swell)
What special stains should you use when punch biopsy is looking for fungus?
*Looking for Dermatophytes* 1. GMS (gomori methenamine silver) 2. PAS (periodic acid-schiff) can save a day or two in Dx
Precursor B-cell Neoplasms
*Neoplasms of immature B cells* Example: B-cell acute lymphoblastic leukemia/lymphoma (B-ALL) (With T-ALL, Most common cancers in children)
Precursor T cell Neoplasms
*Neoplasms of immature T cells* Example: T cell acute lymphoblastic leukemia/lymphoma (T-ALL) (With B-ALL, Most common cancer in children)
Peripheral B-cell Neoplasms
*Neoplasms of mature B cells* Example: Chronic lymphocytic leukemia (CLL) (CLL most common leukemia of adults)
Peripheral T cell neoplasms
*Neoplasms of mature T cells & NK cells* Example: Mycosis Fungoides/Sezary Syndrome
Pediatric Autopsies
*Perinatal pathologist preferred to do autopsy* 1. External exam (especially fetuses & newborns) search for malformations (ie cleft palate, choanal atresia or stenosis/atresia of anus & vagina. Face, ears & hand changes due to Down's, renal agenesis or gargoylism) 2. Placenta, fetal membranes, and umbilical cord must be studied 3. Brain removal - horizontal cut from behind one ear to the other, combined w/ midline cut, running caudally from 1st cut. (Most suitable for preterm infants) 4. Demo pneumothorax by opening whole chest cavity under water (not for permanent record) 5. For organ removal, use any technique mentioned 6. Use en masse for rare malformations (ie anomalous pulmonary venous connections) 7. Min Requirement for peds autopsy = take histologic sections from lungs, liver, kidney, thymus, costochondral junction of a rib, & brain. -Add placenta, fetal membranes & umbilical cord for fetuses and newborns.
What is RPMI?
*Roswell Park Memorial Institute medium* (used for for flow cytometry & cytogenetics)
Most common type of cancer for metastasis via hematogenous spread
*Sarcomas* (soft tissue, CT, mesenchymal tissue) -less common than lymphogenous spread but MORE malignant
Lymphadenitis
*Secondary inflammation of LN* (occur when lymphatic system is transporting bacteria, *after severe infection or injury* - ie radiation treatment)
Lymphangitis
*Secondary inflammation of lymph vessels* (occur when lymphatic system is transporting bacteria, *after severe infection or injury* - ie radiation treatment)
Radioactive Specimens
*Used in sentinel node mapping procedures, also breast & prostate specimens* (Ask radiation safety officer if have ??) 1. Written procedures s/b developed in conjuction w/ institution's radiation safety officer 2. Safety officer responsible for training for staff
Hematogenous spread occurs via
*Venous tracts* (because veins are more abundant & have thinner walls so there is less resistance for tumor invasion)
Dysplasia
*disordered growth* (often seen in epithelial) -loss of uniformity & architectural orientation -considerable pleomorphism -large hyperchromatic nuclei -high nuclear:cytoplasmic ratio
Autopsy Report
*evidentiary document based on expert medical opinion* -considered medical expert opinion & evidence -evidentiary document that forms basis of opinions (criminal trial, deposition, wrongful death suit, med malpractice civil suit, admin hearing, workman's comp hearing)
Basal Cell Carcinoma
*most common malignant skin tumor - AND most common cancer in humans!* 1. Grade: low, does NOT metastasize, locally destructive 2. Found on sun-exposed skin *DDx = dermatofibroma* 3. Lesion: flesh colored to pearly, raised papules & nodule w/ depressed center, prominent telagiectatic vessels, thickened plaques, can ulcerate (rodent ulcer) 4. Microscopic: *invasive nest or cords of basophilic cells* resembling basal keratinocytes, *nuclear palisading at edges of nest*, peri-tumoral mucin production 5. Pathogenesis: mutations lead to unbridled Hedgehog signaling
Coagulative necrosis
*most common* 1. *predominate protein denaturation* w/ framework preservation (ie hypoxic death in all tissues except brain) 2. undergoes autolysis or heterolysis (lysosomal digestion via other WBC) *(infarct)*
Histologic examination
*most important method of dx* Required: -complete clinical data -good tissue preservation -adequate specimen sampling
Malignant Melanoma
*most malignant of all skin tumors* 1. Originate from melanocytes 2. Mutations that increase RAS prolif pathways are strongly associated 3. Dx = ABCDE 4. Radial growth 1st, then vertical growth (often can metastasize) 5. Microscopic: large cells w/ expanded, irregular nuclei containing peripherally clumped chromatin & prominent eosinophilic nucleoli) 6. Dx @ younger age = more aggressive 7. Treatment: surgical excision, metastasis = chemo & radiation, vaccine (new), 5 year survival depending on stage
Steps of Touch Prep
- Dab section dry - dab section 3x on slide -Fix or air dry
Consequences of delayed fixation?
- Dessication of tissue. - Loss of nuclear detail, leakage of fluids from cytoplasm -artifacts
Methyl Green-Pyronin Y
- differentiates between DNA & RNA (id plasma cell/immunoblast tissue). → methyl green bound by highly polymerized DNA while RNA binds pyronin. DNA = green/blue-green RNA = red Goblet cells = mint green Background = pale pink to colorless Immunoblast & plasma cell cytoplasm = intense red Nuclei = green/blue-green
Methyl Green-Pyronin Y
- differentiates between DNA & RNA - IDs plasma cell/immunoblast tissue (methyl green bound by highly polymerized DNA while RNA binds pyronin) DNA = green/blue-green RNA = red Goblet cells = mint green Background = pale pink to colorless Immunoblast & plasma cell cytoplasm = intense red Nuclei = green/blue-green
Why should you still sample normal tissue?
- histologic eval may reveal things not visible by gross dissection - may give insight on origin of lesion - documents surgically removed structures
May-Grunwald Giemsa Stain
- permits differentiation of cells present in hematopoietic, also shows microorg. → Nuclei = Blue Leuk cytoplasm = Shades of pink, gray or blue depending on cell type Bacteria = blue
May-Grunwald Giemsa Stain
- permits differentiation of cells present in hematopoietic, also shows microorganisms Nuclei = Blue Leuk cytoplasm = Shades of pink, gray or blue depending on cell type Bacteria = blue
Feulgen Reaction
- shows DNA → mild HYDROLYSIS via HCl (removes purine bases, leaves sugars & phosphates of DNA intact) DNA = reddish purple Cytoplasm = light green
Feulgen Reaction
- shows DNA → mild HYDROLYSIS via HCl...removes purine bases, leaves sugars & phosphates of DNA intact. DNA = reddish purple Cytoplasm = light green
Ideal brush for frozen sections?
- stiff bristles and wide gripping surface -angled tip
What is most common thyroid carcinoma?
-"Classic" papillary carcinoma
What is important to remember for LN from axillary dissections?
-"apical" region may be designated by a stitch - must indicate if any nodes found -indicate in slide key node has been sectioned & entirely submitted or single section submitted (A3, single node, bisected)
Microscopic features of melanoma
-"the great imitator" -atypical large cells, many w/ nucleoli -pigment variable -expresses S100 protein
Types of viral skin infxns
-*Chronic: does not go away* (ie warts - verruca vulgaris & HPV-can lead to cancer) -*Acute: self-limited* (goes away on own w/out treatment) (ie maculopapular rash -measles, vesicular -VZV chicken pox, shingles)
What are important variants to document in papillary carcinoma?
-*Follicular variant*: encapsulated/well-demarcated, infiltrative -*Tall cell variant* (more aggressive) -*Cribriform-morular variant* -*Diffuse sclerosing variant* (requires more aggressive initial surgical management)
What is melanoma?
-*Malignancy of melanocytes* -most common in light-skinned populations (especially w/ increased sun exposure) -Predesposition via DNS (dysplastic nevus syndrome)
How do you orient an eye?
-*Optic nerve = posterior* -*Cornea, Iris & Pupil = anterior* -Posterior ciliary vessel = medial -*Inferior Oblique = PosteroLateral*
Autopsy Tech: Virchow
-*Organs removed 1 by 1* -Used most widely 1st: expose cranial cavity and spinal cord 2nd: remove thoracic, cervical & abdominal cavity organs (in that order!)
Types of neck dissections
-*Radial* -*Modified* -internal jugular &/or sternocleidomastoid muscle spared -*Selective* - (supraomohyoid, posterolateral, lateral, central) -*Superselective* - surgeon specified -*Extended radical* - surgeon specified
Maxillectomy tumor types
-*SCC* (oral cavity, maxillary inferior aspect) -*Adenocarcinoma* (glands, inside nasal cavities) -*Lymphoma* (nests of LN tissue all over nasal cavity)
How should you remove the chest plate? What should you look for?
-*Use stryker saw or rongeurs* (big pliers) -Cover edges of rib w/ towel to prevent stick injuries -Remember your anatomy! *Note what looks abnormal* (Characteristics of pleural surfaces - visceral, parietal - and of pericardium -thickened? Denotes pathology) -*Note evidence of previous surgeries* - very important!
What should you submit for multi-nodular goiters?
-1 to 2 sections from periphery of nodule -Up to 5 nodules per lobe
Cryostat temperature
-20 F
What is the procedure for fixing an enucleation?
-24-48 hours -Rinse -Place in EtOH *DO NOT PUNCTURE*
What fixatives in lymphoma protocol are timed? how long?
-AZF/B5 -2 hours (make sure section is thin!)
Advantage of Sentinel LN procedure
-Ability for surgeon to resect only 1 or several selected LN -Permits a more comprehensive pathologic exam for occult tumor
ALL clinical features
-Abrupt, stormy onset -Symptoms related to depressed marrow fuction -Bone pain & tenderness -Generalized lymphadenopathy, splenomegaly, hepatomegaly & testicular enlargement -CNS manifestations
What criteria would qualify for a tonsil gland gross exam?
-Age: under 3 or over 10 -Gross abnormality -Size: >3cm -Asymmetry...lymphoma? -MD requested based on clinical hx (ie chronic middle ear infxns)
How do you orient tissues to cut them?
-Align VERTICALLY if several tissues knife goes thru all tissues at once -Pointy side DOWN to catch leading edge -Fat FAR from blade
Where should you ink a larynx specimen?
-Anterior aspect (only 1 color if thyroid not present) -Posterior aspect (along cricoid cartilage - all colors should meet laterally)
What is a disadvantage for fixing enucleation with Formalin?
-Anterior chamber & vitreous cavity Contraction (result in artifactual detachment of retina) -tissue shrinkage
Acute disease
-Arise rapidly -Distinct symptoms -Resolves fairly rapidly with treatment (ie otitis media - ear infxn)
Chronic disease
-Arises slowly -Ambiguous signs/symptoms -Persists for long time -Generally not prevented by vaccine or cured by medicine (ie arthritis - inflammation of joints)
What should you do in dictation if both tonsils are symmetrical?
-Average the weight and measurement -Submit 1 section of each
Fixatives to use for LN, spleen & BM? And why are they done?
-B3/B5 (mercuric fixatives) -AZF (acetic acid zinc formalin) *To INCREASE nuclear detail!!*
What is the superior mucosal margin consist of?
-Base of tongue (anterior) -Pyriform sinuses/posterior hypopharynx (lateral) -Cricoid mucosa (posterior)
Acrochordons
-Benign -Fibroepithelial polyps (aka Skin Tags) -Seen in heavier ppl, pregnancies & those with diabetes -located in skin folds
After cutting margins of maxillectomy, what do you do?
-Bisect specimen thru tumor center -Describe cut surface of tumor (tumor relationship to adjacent structures)
What causes anthracotic LN?
-Coal dust, smoke or pollution -Associated with silica exposure
What is anthracosis?
-Collection of carbon in LN & lungs (seen in smokers & city dwellers of high pollution) -Incidental findings, not pathogenic
ALL prognosis
-Complete remission in 95% children -80%ish children cured -40%ish adults cured Better px = hyperploidy, trisomy of chrom 4, 7, 10 & (12;21) translocation
What is the structure of thyroid gland?
-Composed of right & left lobe connected with isthmus -Some have pyramidal lobe extending cephalad anterior to thyroid cartilage
What make up the structural base for the vocal cords
-Conus elasticus -Quadrangular membrane
Medulla
-Core/Middle of LN -Mostly processes T cells
What is regarded a "close" margin?
-Cut points are 5mm (general) and 2mm (glottis larynx) -Success also found 3-7mm (general), 1mm (glottis)
What are sterile fresh tissue (in RPMI) used for?
-Cytogenetics -Microbial cultures -Flow cytometry
Subcapsulary sinus
-Deep to capsule -Lined by epithelium
Snap-frozen fresh tissue used for?
-Detailed IHC -Enzyme histochem
What is the purpose of a frozen procedure? (3)
-Determine margins of known lesion -Dx on unexpected finding -Eval of "indeterminate" diagnoses on previously biopsied sections.
What is simple goiter?
-Diffuse, non-toxic, colloid goiter -Usually >40gm -Eventually converts to multi-nodular
What happens to salivary glands as we age?
-Diminishing CT & myoepithelial cells surrounding glands -leads to less salivation and dry mouth
Important questions to ask when processing glottic cancers
-Does tumor involve 1 or both vocal cords & what is length of cord involvement? -Is anterior commissure involved? & does tumor extend anteriorly into thyroid cartilage? -HOw far inferiorly below free edge of true vocal cords does tumor extend? -Does tumor extend superiorly into ventricle, false cord, or epiglottis base? -Does cancer involved paraglottic space?
Compound exocrine glands consist of
-Ductal portions -Acinar portions (serous, mucinus or mixed) surround sac-like portion of compound gland
Principles regarding lymphoid neoplasms
-Dx requires histologic exam of LN/involved tissue -Ag receptor gene rearrangement precedes transformation (vs normal polyclonal) -Most are B cell origin -Tend to disrupt normal immune regulatory mechanisms -Neoplastic B/T cells circulate widely but land where normal counterparts are located -HL spreads in orderly fashion
What can happen if LN are place in dry gauze or empty specimen container? What can be used to prevent this?
-Edges of specimen dries out -Produces prominent dessication artifact at edge of node -Use RPMI medium
What are the 2 techniques for margin section?
-En face/shave (ink side down) -Perpendicular cut (cut side down)
Give etiology, pathogenesis, pathophysiology and lesion of an example. (ie Sunburn)
-Etiology: excessive exposure to sun rays -Pathogenesis: excessive absorption of UV radiation injuring the skin -Pathophysiology: Expressed by dilation of blood vessels, increased blood flow as rxn to injury -Lesion: Hot, painful skin (depending on severity). Can also be vesicle (bullae) formation
How does margin status relate to tumors?
-Eval of the relationship of tumor to inked edge of tissue represents determination of margin status -may determine patient outcome
Name some general medical problems associated with formaldehyde exposure?
-Eye, nasal, respiratory irritation (varies with each individual). Those prone to hypersensitivity rxn or IgE rxns (atopic) are more prone to have these reactions. -Long term exposure have decreased lung capacity
Who discovered formaldehyde? How was it first used?
-Ferdinand Blum (in 19th century). -First used as antiseptic
Pre-epiglottic space
-Filled with adipose & CT -Lymphatics & blood vessels present, but No LN!!!
Inking for small skin biopsy
-For >0.5cm largest diameter, ink dermis before sectioning & bisect specimen -trisect shave specimens >1.0cm
Epithelial tumors
-From epidermis, hair follicles, sebaceous & sweat glands -*Seborrheic keratosis* = most common benign -*Acrochordons* (skin tags) -*Actinic Keratosis* (precancerous, but benign) - use liquid nitrogen spray to burn off
What are Air-dried touch preps used for?
-Giemsa -Enzyme cytochemistry -Immunofluorescence for terminal transferase
What does a classic lymphoma look like? And what should you perform?
-Glistening, shimmering, homogeneous cut surface -Perform lymphoma protocol
A sharp/fresh blade is important for what two things?
-Good diagnostic section -Contamination (ability to track pt hx if accidentally cut)
What is formaldehyde classified as? By whom?
-Group 1 carcinogen (same at asbestos & benzene) by WHO, who regulates the IARC. -Occupation carcinogen by EPA & OSHA, thus giving them ability to regulate it - require posted warnings & monitor air quality
What are B5-fixed specimens used for?
-H&E -Basic IHC
What are formalin fixed, paraffin embedded specimens used for?
-H&E -Basic IHC
What are 2 most common thyroid resections might you receive in lab?
-Hemithyroidectomy (1 lobe + 1/2 isthmus) -Total thyroidectomy (entire thyroid)
How should ITCs be examined?
-Histologic exam -IHC -Flow cytometry -PCR
What are some artifacts that can occur in frozen sections?
-Ice crystals = freeze too slow or overly watery tissue (brain/edema/bloody) -Stripe = nicked blade or tissue clumped under blade -Overfreezing = shattering -Underfreezing = fatty tissue, LN, breast, skin - too soft to cut...smears and ruins section -Floaters = dirty stain line -Air Bubbles = OCT not properly applied or air trapped under cover slips -Falls off Slide = section too THICK -Dry tissue = -Discontinuous wheel motion = variable thickness & difficult tissues rip -can also make block pop off
Why is it important to submit adequate number of sections for salivary glands?
-If tumor foci missed, benign masses can malignantly transform -Tumors are mophologically diverse
What methods used to detect occult tumor in LN?
-Immunohistochemistry (IHC) -Polymerase Chain Reaction (PCR)
Physiology of Goiter (Nodular hyperplasia)?
-Impaired thyroid hormone synthesis -Increased TSH & decreased T3/T4 -Causes follicular hypertrophy/hyperplasia
What causes the blue halo effect? How is this solved?
-Incomplete drying/too much heat on processor -Solved by completely dehydrating & use paraffin just above melting point
Why USE touch preps?
-Increased nuclear detail & cytoplasmic components
How to sample margins of layrnx?
-Inferior mucosal = shave. unless tumor <1cm from margin, then perpendicular -Lateral R&L = perpendicular, on edge in separate cassettes -Anterior soft tissue (R&L) = perpendicular Superior margin -vallecula = perpendicular -lateral (aryepiglottic fold & piriform sinus) = oblique, lay face down -posterior (cricoid cartilage) = R&L sections perpendicular
What is multi-nodular goiter?
-Irregular enlargement of thyroid gland due to repeated episodes of hyperplasia & involution (degeneration) of simple goiter (eye bulging, exophthalmos, not present)
What are some questions to ask/describe after cutting sections of LN?
-Is nodal architecture preserved? -Is node grossly nodular or diffuse? -Any focal lesions present? -Capsule intact? -Appearance of perinodal tissues?
Important questions to ask when processing supraglottic cancers
-Is tumor above/below the hyoid? -Does tumor involve false cord, epiglottis, aryepiglottic folds, &/or arytenoids? -Does inferior edge of tumor involve anterior commissure &/or roof of ventricle? -If aryepiglottic fold involved, how far down pyriform sinus does tumor extend? -HOw far does cancer extend superiorly toward base of tongue? -Does cancer involve pre-epiglottic space? -Does tumor invade cartilaginous framework?
Important to know about staging a tumor
-Know *usual drainage routes of lymph* when dealing with certain LN to determine likely sites of metastasis
CLL & SLL morphology
-LN diffusely effaced w/ small lymphocytes -round, slightly irregular nuclei -clusters of mitotically active cells (prolif centers) -smudge cells present
What are age spots called? Made of?
-Lentigo senilis -made of melanocytes in basal layer/flat brown spots
Describe how to separate levels of radical neck dissection
-Level I: dissect off submandibular salivary gland & triangle of soft tissues anterior to SCM muscle -Levels II-IV: divide SCM muscle into 3rds (find LNs) -Level V: remove triangle of fatty CT posterior to SCM muscle
What happens if you delay fixation?
-Loss of Nuclear Detail -Cytoplasm fluid leakage
What is appearance of delayed fixation?
-Loss of chromatin in nuclei -Cell shrinkage -Cytoplasm disruption -Artifact spaces around cells
Medicolegal autopsies
-Makes evidentiary document that forms opinion for criminal trial, deposition, wrongful death/malpractice suits, or workmans comp. -All autopsies can be considered this
Before touching specimen, also check for:
-Matching information -Special studies -Information to indicate the appropriate procedure.
Where are germinal centers most commonly located?
-Mesenteric LN (colon) -Cervical LN (neck)
Give an example of simple squamous
-Mesothelium (1 cell layer) in body cavities -Endothelium in blood vessels
Goiter physiology
-Non-toxic, typically hypothyroidism, low T3/T4 & increased TSH -Causes follicular hypertrophy & hyperplasia w/ minimal colloid -Advanced stages = follicular atrophy w/ massive colloid storage
What causes overprocessing/excessive dehydration? How is this solved?
-Occurs with thick & thin sections are processed at same time. -Solved by having processing schedules depending on size of tissue (biopsies only take 3 hrs - do in last part of day, while bigger specimens take 12 hrs - do overnight, set up before leaving).
Follicular carcinoma variants
-Oncocytic variant
Dermal Connective Tissue Tumors
-Originate from fibroblasts or blood vessels -Benign/low grade malignant 1. Dermatofibroma = benign 2. Kaposi's Sarcoma = malignant
Meissner corpuscles
-Papillary dermal touch receptors (hands & feet) -Detect light touch, soft fleeting movement
What is done during surgical procedure for parathyroid adenoma?
-Parathyroid is removed & blood PTH levels are monitored to make sure entire problematic gland is removed (PTH levels drop once all removed) -Done with Frozen Section
Symptoms of laryngeal tumors
-Persistant hoarseness -Dysphagia (painful swallowing) -Pain in pharynx/larynx -Hemoptysis (expectorating blood)
Steps of Squash prep
-Place small amount of tissue at top of slide -Flip another slide on top, and gently pull apart -Fix immediately
What is the "poke method" for fixing LN? When would it be used?
-Poke a hole into the LN to allow formalin to get in -For tiny LN you will submit w/out cutting (in toto)
What is perineural invasion in primary cancer typically associated with?
-Poor local disease control -Poor regional control -Metastasis to regional LN -Decrease in disease-specific survival & overall survival
Test Results
-Positive: abnormal condition present -Negative: normal state/disease is absent -True Positive: test = pos & patient DOES have disease -False Positive: test = pos & patient doesNOT have disease -True Negative: test = neg & patient doesNOT have disease -False Negative: test = neg & patient DOES have disease -Normal Range: established range for quantitative results that have numerical values (ie reference range)
Paraglottic space
-Potential space deep to ventricles & saccules -Filled with adipose & CT -Lymphatics & blood vessels present, but No LN!!!
3 important landmards of larynx
-Pre-epiglottic space -Para-glottic space -Anterior commissure
What should you do on a thyroid gland if included with larynx resection?
-Process last (after taking other sections) -Remove & gross separately -Look for parathyroids!!!
What technique should you use for cornea & conjunctiva of intraepithelial neoplasia?
-Process scrapings as wet-fixed smears -Fix rapidly 95% EtOH - NO air dry -Detect microorganisms with Gram, Giemsa, PAS & Papanicolaou stains
What is of less prognostic significance in thyroid cancer?
-Regional LN spread -Tumor deposits <2mm greatest dimension -Micrometastasis, isolated tumor cells & psammoma bodies
Before you touch the specimen, check:
-Requisition -Container -Cassette -Cap -Special Studies -Patient History
What structures are included in radical neck dissection?
-SCM muscle -Int. Jugular vein -Spinal accessory nerve (CN XI) -LN level I-V
What does a radical neck dissection include?
-SCM muscle -internal jugular vein -spinal accessory nerve -LN from levels I-V
What is the ideal section to be submitted for frozen procedure?
-Section most representative of tissue -Cannot be normal or necrotic
Where does lymph fluid drain from?
-Skin -GI tract -Resp tract -Any major organ in contact w/ outside env
Things to include in capsule description
-Smooth vs roughened -Intact vs disrupted -Any evidence of tumor extension
Dif-Quik procedure
-Solution 1 (fixative) = *formaldehyde/methanol/h2o* (10sec) -Solution 2 (nuclear detail stain) = *blue/azure dye* (5 dips) -Solution 3 = *xanthene dye*- mostly eosin (5 dips) -Dip in h2o & air dry -> (coverslip here at LLU) *OR* -Dip in xylene & coverslip (elsewhere)
Varigated
integrated different colors and streaks
Basement Membrane (dermo-epidermal junction)
-Specialized structure produced by epidermis & dermis in combo -Ties epidermis to dermis
Sublayers of Epidermis
-Stratum Corneum -Stratum Lucidum -Stratum Granulosum -Stratum Spinosum -Stratum Basale
What are some site-specific carcinomas in the larynx?
-Supraglottic SCC -Glottic SCC -Subglottic SCC -Transglottic carcinoma
What are the anatomic regions of larynx?
-Supraglottis -Glottis -Subglottis -Paraglottic space
What can you use to ink specimens? Which is most efficient?
-Tattoo inks -Silver nitrate sticks -India ink -Commercially prepared inks for tissues (MOST EFFICIENT)
Curettage
-Thin shavings/scrapings of skin (usually in many pieces) -Dx only, margins indeterminate (must do additional excision)
What are 2 ways a PathMD might want you to do a Frozen Section on an eyelid resection?
-Thin strips for margins (on edge) -Inked & cross-sectioned (embedded linearly on edge)
Adipose tissue
-Triglyceride storage -Provides insulation & structural padding
Method for Lymphogenous spread
-Tumor cells shed from primary tumor, enter & travel via lymphatics. -Cancer cells are filtered & trapped by LN (2ndary site for tumor growth)
Why is follicular variant of papillary carcinoma important to document
-Unencapsulated have propensity for metastasis (like papillary carcinoma) -Encapsulated variants less likely to metastsize (like follicular adenoma/carcinoma)
IHC stains
-Use unlabeled Ab to specific tissue Ag followed by treatment with enzyme-labeled Ab. -Perform on fresh-frozen, formalin-fixed, paraffin-embedded tissues
Why would you use a celloidin bag technique?
-Useful for retrieval of tissue fragments & cellular material suspended in fluid -Fix with 10% formalin before & after filtering -Submit for routine paraffin processing/sectioning
Minor Salivary Glands
-Von Ebner's glands -Palate, base & lateral border of tongue -Lip, cheek & apex of tongue
What should you do in dictation if tonsils are asymmetrical?
-Weigh & measure separately (Use weight to say which is which in cassette) -Perhaps put 2 sections of heavier tonsil in 1 cassette
Important questions to ask when processing subglottic cancers
-What is superior extent of tumor? Does it involve true vocal cord? -What is inferior extent of tumor? How close is tumor to inferior margin? -What is max depth of invasion? Does carcinoma penetrate conus elasticus & extend into paraglottic space?
Important questions to ask when processing salivary gland
-What procedure performed & what structures present? For parotids, which lobes removed? -Is a neoplasm present? -What are type, size & degree of differentiation of tumor? -Does tumor infiltrate small or large nerves? -DOes tumor involve any margins? -If LN are present, how many are present & how many invovled by tumor? -DOes non-neoplastic portion of salivary gland show any pathology?
Important questions to ask when processing maxillectomy
-What procedure performed & what structures/organs present? -Is a neoplasm present? -Probable site of tumor origin? What surface does tumor arise? -What is size of tumor & what is the greatest depth of tumor invasion? -Histologic type & grade of tumor? In situ component? -Does tumor extend into bone? Does tumor extend beyond bony confines of maxillary sinus, involving adjacent compartments/structures? -Does tumor involve margins? -Does tumor involve regional LN? Include # of LN examined and involved
Important questions to ask when processing larynx specimen, in general
-What procedure performed & what structures/organs present? -What is exact location of tumor? Probable site of tumor origin & what compartments/structures are involved by direct extension? -Does tumor cross midline of larynx? -Tumors size, grade, type & growth pattern (exophytic/endophytic)? Depth of deepest tumor? -Is there perineural and/or vascular invasion? -Any soft tissue/mucosal margins involved?
What should you include when submitting sections from a MEN syndrome thyroid?
-You should regionalize sections (indicate regions the sections are from in cassette key)
Who would undergo prophylactic removal in MEN syndrome? What organ?
-Young people positive for RET proto onco gene -Thyroid gland
CT provides
-a noninvasive way to see anatomy -give ability to rapidly acquire 2D scans (then computer turns them into 3D)
Dyskeratosis
-abnormal, premature keratinization w/in cells below the stratum granulosum -microscopic lesion
Which categories of salivary gland carcinomas DO require grading?
-adenoids cystic carcinoma -mucoepidermoid carcinoma (most common histologic type seen in larynx) -adenocarcinoma, nos
What is Squamous cell carcinoma (SCC)
-affect head & neck of elderly -quick growing, flesh-colored to red nodules -overlying scale/crusting -usually asymptomatic unless perineural invasion present -Ulcerating, papillomatous & subcutaneous variants -caused by UV radiation -capable of metastasis *2nd most common skin cancer*
Nevus flammeus
-aggregate of small blood vessels -congenital disorder (ie port wine mask)
Tonsil Actinomyces
-anaerobic & microaerophilic bacteria (Mouth normal microbiota) -Micro: filimentous, branching gpr - may look like hyphe Aka Tonsil stone
High-risk Histological Features of SCC
-anatomic site (ear or hair-bearing lip) -high grade (poor differentiation) -tumor thickness -perineural invasion -lymph-vascular invasion
Thyroid cartilage
-anterior & extends posteriorly -No perichondrium so tumors can easily extend thru (anterior aspect of larynx)
ANterior commissure
-anterior dense ligamentous attachment of true vocal cords to thyroid cartilage (which lacks internal perichondrium)
How should you orient larynx specimen?
-anteriosuperior = epiglottis (flap points anterior) -anterioinferior = thryoid cartilage (projects posterior)
Langerhans cells
-antigen presenting cells (ie histocytes)
How should you approach complex specimens?
-approach as cube -orient using structures -describe structures involved & uninvolved 3D measure: -overall -ancillary structures -lesion to margin
Secondary Follicle
-arise from primary follicle via Ag stimulation of B cells (Ab production) -contains pale-staining germinal center (polarized towards site of Ag entry) -contains B cells, follicular dendritic cells (CD21 & CD25) & macrophages
Histologic appearance of SCC
-atypical epith cells invade dermis -*keratin pearl formation/keratinization* -variable mitotic activity
Melanocytes
-basally located -produce melanin pigment & pass to keratinocytes -provide UV light protection
Cytologic interpretation
-based on changes in appearance of individual cells -false-pos uncommon, but false-negs occur due to sampling errors -must be confirmed via biopsy before treatment!
Describe subglottis region
-begins 1 cm below free edge of vocal cords & extends inferiorly to trachea
Palatine tonsils
-bilateral on posterior oropharynx just behind uvula (Can cause swallowing/breathing troubles if swollen)
Mucoceles
-blockage or rupture of salivary gland duct -most common inflammatory lesion in salivary glands -typically self-limited
What should you also describe after tumor?
-bone involvement -other structures involved (cassette key)
Stratum basale (aka basal cells)
-bottom most layer (dermal-epidermal junction) -prolif continuously (mitotically active) -renew other layers of epidermis -single layer of cuboidal/low columnar cells -interspersed melanocytes
Nodal goiter
-calcified areas -colloidal areas
Arytenoid Cartilages
-can't be seen easily
Sinuses
-carry lymph from afferent end to efferent lymphatics
Crust
-coagulated plasma or blood to cover skin defect (ie scabs, healing wounds)
Superficial Spreading Melanoma
-confluent atypical cell nests at junction -prominent radial growth before & during vertical phase -less than 3cm in diameter
Stratum granulosum
-contains building blocks of keratinisation -where keratinisation begins -granlulosa cells -btwn spinosum & corneum or lucidum (palms & feet)
What are external landmark to help with orientation of eye?
-cornea (anterior 1/6th of globe) -posterior ciliary arteries -nasal vessel is prominant (IDs nasal aspect) -measure distance btwn limbus & optic nerve (IDs nasal aspect) -insertions of extraocular muscles
How should you open a larynx specimen?
-cut vertically up posterior aspect (of trachea, thru cricoid cartilage) -push open superior horns of thyroid cartilage -keep open with small wooden stick
How to avoid tangential section of a round nodule
-decapitate & cut like a pie instead of like bread
Atrophy
-decrease in SIZE of cells/tissues -occurs after disuse/decreased nutrient supply -causes decrease in metabolic activity of cells
Anterior commissure location (structures)
-deep to ventricle -*ligamentus attachments from vocal cords to thyroid cartilage*
LN embryology
-derived from mesoderm -lymphatic development follows that of cardiovascular system
What should you include in your dictation of matted nodes?
-describe -measure -% specimen involved
Grading
-determined by cytologic appearance -behavior & differentiation are related -more poorly differentiated = more aggressive tumor
Staging
-determined by surgical exploration/imaging -based on size, local/regional LN spread, distant metastases (TNM) -*greater clinical value than grading*
Keratinocytes
-develop at bottom (alive) of epidermis & rise to top (dead)
Acanthosis
-diffuse epidermal hyperplasia -microscopic lesion
What should you note in salivary glands sent for sialoliths?
-dilated ducts -parenchyma necrosis/edema -character, color, size of sialoliths, degree of obstruction
Ulceration
-discontinuity of skin showing complete loss of the epidermis revealing dermis or subcutis -microscopic lesion
Erosion
-discontinuity of the skin showing incomplete loss of the epidermis -microscopic lesion
Immediate cause of death
-disorder that immediately preceded the death
things to do after dissection
-dispose of sharps & biohazards in appropriate container -store specimen in container w/ enough formalin (no leaking) and biohazard label affixed -wash down cutting area (disinfect if known viral hep/HIV/TB)
How should you submit cataracts?
-document color, diameter & thickness of lens nucleus ????
What is the developmental embryology of salivary glands?
-ectodermal structures -arise from solid epithelial buds of oral mucosa
How to make dictation more concise?
-eliminate a lot of descriptions of normal anatomy -don't describe mechanics of dissection
How should you cut margins for maxillectomies?
-en face (soft tissue/gingival margins) -perpendicular (soft tissue margins)
Papillary Carcinoma
-encapsulated -solid (papillary) & cystic components
***Reactive LN***
-enlarged or normal size -painful when compressed -soft on palpation -tan/pink hemogenous -sometimes granular & bulging cut surface
Ulcer
-epidermis defect with evidence of rxn (ie tularemia ulcer - can use maggots to treat)
What are the most important mucosal landmarks to ID larynx?
-epiglottis -aryepiglottic folds -false vocal cords -ventricles -true vocal cords -subglottis (-base of tongue w/ overlying mucosa)
WHat is the cartilaginous framework of larynx?
-epiglottis cartilage -thyroid cartilage -cricoid cartilage
What does cutting vertically to open a larynx accomplish?
-exposes the mucosal surface w/out disrupting anatomical structures located along anterior & internal walls
CLL & SLL clinical features
-fatigue, weight loss, anorexia -generalized lymphadenopathy & hepatosplenomegaly -lymphocytosis (CLL) -immune abnormalities -autoAb against RBC & platelets
Macule
-flat, pigmented lesion -less than 5mm (0.5cm) -macroscopic lesion
Vesicle
-fluid-filled elevated bubble-like lesions -less than 5mm (ie herpes) -macroscopic lesion
When is sampling lymph nodes especially important?
-for neoplasm resections where critical staging info may depend on number & location of LN involved by metastatic tumor
Epidermolysis bullosa
-formation of blister upon any minor trauma (ie wearing clothes) -several congenital skin disorders together -3 major forms/16 subtypes
Vacuolization
-formation of vacuoles w/in or adjacent to cells -often refers to basal cell-membrane zone area -microscopic lesion
Trachea characteristics
-formed by C-shaped cartilaginous rings (most inferior margin of larynx) -ciliated pseudostratified columnar epithelium
Thyroid cartilage
-forms the anterior & lateral walls of the larynx
Pseudomyxoma Peritonei
-from ovarian & appendiceal cancers -mucinus, bubble-like growths that extend & envelope abdominal organs -seen in omentum (caking), gets integrated & firm -> get bubble-like growths
Albinism
-generalized hypopigmentation (no pigment) -caused by inborn errors of metabolism -pale skin, never tan, white hair, red eyes -congenital disorder
Grossly describe a positive LN
-gray white, firm -staging increases when tumor makes LN start to coalesce (matted LN)
Why is fixation important in a maxillectomy specimen?
-helps strip mucosal margins from underlying bone -minimizes tissue fragmentation & distortion if bone saw needed -needs to be fixed before you can demineralize/decalc
Types of subtotal laryngectomies
-hemilaryngectomy -supraglottic laryngectomy -glossectomy (ORIENTATION = IMPORTANT)
Manner of death
-homicide -suicide -accidental -natural -therapeutic misadventure -unknown
Hyperthyroidism
-hypermetabolic state -caused by elevated free T3/T4 via hyperactivity of thyroid Commonly caused by Graves disease
Papillomatosis
-hyperplasia of dermal papillae -causes surface elevation -microscopic lesion
Hypergranulosis
-hyperplasia of the stratum granulosum -microscopic lesion (often due to intense rubbing)
Fat necrosis
-in adipose tissue -Lipase activity -> release of FA from trigly -> complex with Ca++ to form soaps -Fat saponification (Grossly white, chalky areas (fat) & vague cell outlines/Ca++ deposition)
Glomus body
-in dermis of fingertips & other periph sites prone to cold -control blood flow
What should you include with your external description of an eye?
-include abnormal features -Inspect outer surface (for melanoma specimens) -Inspect optic nerve (for retinoblastoma) -Take photos of anything abnormal -Transillumination
What happens to a LN in infection? What is it called?
-increases in size as it fights off foreign Ag -called "Reactive LN"
Cricoid cartilage
-inferior & anterior to thyroid cartilage (posterior aspect of larynx)
Describe glottis region
-inferior to the supraglottis region -composed of true vocal cords (w/ anterior & posterior attachments) & anterior/posterior commissures
Exocytosis
-inflam cells infiltrate the epidermis -microscopic lesion
Tonsilitis
-inflammed tonsils (Exudate over surface) -2ndary to strep infxn
Spongiosis
-intercellular edema of the epidermis -microscopic lesion
merkel cell
-intra-epidermal touch receptors & contain neuroendocine-type membrane-bound vesicles in their cytoplasm -associate with free nerve endings
Hydropic swelling (ballooning)
-intracellular edema of keratinocytes -microscopic lesion (ie seen in viral infxns)
Nodular Melanoma
-invasive tumor (very little radial growth) -poorer prognosis
Ocular Melanoma
-iris has spot -capillaries in sclera engorged
Wheal
-itchy, elevated lesion with variable blanching & erythema -result of dermal edema -macroscopic lesion
Scales
-keratin layers that cover skin in flakes/sheets & easily scraped away (ie dandruff) -macroscopic lesion
Parakeratosis
-keratinization w/ retained nuclei in stratum corneum -microscopic lesion (on mucus membranes, parakeratosis = normal)
Bullae
-larger fluid-filled vesicles -greater than 5mm (ie 2ndary to burns)
What are the important sections to take in complex specimen?
-lesion to closest margin -lesion to soft tissue -cross section of lesion -margins -uninvolved (paranchyma)
Nevi
-lesions -normal skin elements arranged in abnormal manner
What size of papillary carcinoma lesions are associated with excellent prognosis? Worse prognosis?
-less than 1 cm -greater than 4 cm
Paraglottic space
-less well-defined area made of loose CT -lies btwn thyroid cartilage & 2 membranes that form structural base for the vocal folds, the conus elasticus & quadrangular membrane
Lentiginous
-linear pattern of melanocyte prolif -w/in epidermal basal cell layer -microscopic lesion
What should you include when documenting tumor?
-location (supraglottic, glottic, subglottic) -measure tumor & depth of invasion -describe: endophytic/exophytic, max depth of invasion, relationship to other structures & midline (include measurement!)
Subcutaneous (subcutis)
-lower layer -contains adipose, blood vessels, lymphatics & nerves
What is clinically seen in lymphangitis & lymphadenitis?
-lymph vessels visible as red streaks in skin -LNs painfully enlarged -Occurs post radiation treatment, but also occurs in other disease processes (ie cat scratch scratch fever, necrotizing faciitis)
Lymphoma
-lymphoid neoplasms arise as discrete masses usually in LN -can get in other 2ndary lymphoid tissue (ie peyer's patches)
Leukemia
-lymphoid neoplasms which have wide-spread involvement of bone marrow & blood
Plasma Cell Neoplasms
-lymphoid tumor -typically arise in bone marrow (not LN) & composed of terminally differentiated B cells
Capsule
-made of collagen
Stratum spinosum
-majority of epidermis -multilayered/round nuclei/promenent nuleoli & cytoplasm -desmosomes form strong contacts btwn adjacent keratinocytes -2nd to bottom layer
Melanocytes
-makes dark pigment -responsible for skin color -provides UV protection -within stratum basale (bottom layer) of epidermis
How should you proceed if you see tracheostomy site?
-mark different color than anterior margin -inspect by cutting thru this site to see if involved by tumor -anular (circular) section
What doe you look for in a tonsil specimen?
-masses or yellow granules of actinomyces -lymphoma! (Tan homogenous nodules)
Humoral Immunity
-mediated by *B lymphocytes* via *Ab production* -effective against *extracellular* microbes
Cell-mediated immunity
-mediated by *T lymphocytes* -effective against *cell-associated microbes* (ie phagocytosed microbes & microbes in cytoplasm of cells) -activates: macrophages, NK cells, Ag-specific cytotoxic T cells & release of certain cytokines in response to certain Ag
Melanocytic nevi
-melanocytes arranged in abnormal order -congenital disorder
B3/B5 fixatives
-mercuric fixatives -*must be timed!!* (overfix = brittle/hard tissue) -no more than 2 hours -can ruin IHC, must mark sections fixed with B3/B5 -disposal via hazmat -alot of labor involved
Sentinel Lymph Node ID Rationale - melanoma
-metastatic involvement of sentinel node increases likelihood that more distant nodes also contain metastatic disease -negative sentinel nodes mean other nodes less likely to contain metastasis -Patients w/ 1 node have higher survival rates than patients with 2 or more nodes
Lymphogenous spread
-metastatic spread via Lymphatics: *solid cell growths* (w/in lymph vessels & from minute cellular emboli) can *break free & pass to regional LN via lymph vessels* -most typical w/ *carcinomas*
Dermis
-middle layer (papillary & reticular layers) -contains CT, blood vessels, nerves, hair follicles, adnexal glands (ie sebaceous & sweat glands), collagen & elastic fibers (important for skin tone/strength) <- tougher in males
What can happen if you submit too few sections of salivary gland?
-missing focal areas of malignant transformation in pre-existing adenoma -provides incomplete representation of overall microscopic appearace of morphologically diverse neoplasms
Lip, cheek & apex of tongue type of acini
-mixed: both serous & mucous acini
ALL morphology
-morrow is hypercellular / lots of high mitotic activity lymphoblasts -tumor cells = scant basophilic cytoplasm w/ slightly larger nuclei, stippled chromatin, inconspicuous nucleoli
Diffuse Large B-cell Lymphoma (DLBCL)
-most common form of NHL
Follicular Lymphoma
-most common indolent NHL -associated w/ BCL2 translocations
Fungus Skin Infxns
-most commonly found in dead surface layers (ie upper cornium & lecudium), hair & nails (ie Tinea pedis, unguium, corporis, cruris, capitis)
What are Anaplastic (undifferentiated) carcinomas?
-most extreme tumor progression & have high-grade malignancy -spindled, pleomorphic, squmoid or rhabdoid morphology
What does multi-nodular goiter grossly look like?
-multilobulated, asymmetrically enlarged -cut surface = brown gelatinous colloid, focal hemorrhage, fibrosis, calcification & cystic change
Pleomorphic adenoma (in a salivary gland)
-multiple components w/in adenoma -benign mass can have malignant transformation
Follicular Lymphoma prognosis
-not curable -survival 7-9 years
Fibrinoid necrosis
-often associated inflam & thrombosis -*pattern from Ag-Ab complex deposition in blood vessels* -Microscopically = bright pink amophous material (protein deposition) in arterial walls
Stratum Lucidum
-only in palms & soles of feet -consists of 5 layers of dead keratinocytes -just below corneum
What do photos help with in complex specimen?
-orientation -tumor & involvement
Epidermis
-outer layer -made of keratinocytes & scattered melanocytes
Describe a typical palatine tonsil
-oval-shaped nodules of tissue -lateral surface covered by thick, fibrous capsule w/ adherent soft tissues -medial surface covered by tan, glistening mucosa (somewhat cerebriform)
Describe an unremarkable (normal) LN
-ovoid, with a tan-pink homogeneous cut surface -3mm - 1cm (any bigger may indicate pathology)
Follicular Lymphoma clinical features
-painless, generalized lymphadenopathy
What is the fat pad of the body called and where is it located?
-panniculus adipose -subcutaneous layer of the skin
Pyriform sinuses
-part of hypopharynx (commonly resected with larynx) -pouches extending inferior from intersection of aryepiglottic folds, glossoepiglottic folds & pharyngeal wall
When should you submit tonsils & adenoids?
-patient age is greater than 10 or less than 3 -tonsils/adenoids are grossly abnormal -size greater than 3cm -size disparity btwn the 2 -histo eval is requested by MD or indicated in patient's clinical history
Pattern for Lymphogenous spread
-pattern involves the natural route of lymph flow (surgeons will map the tumor using this flow)
What is supraglottic laryngectomy?
-performed for tumors of supraglottic larynx -supraglottis removed with horizontal incision thru ventricles (process like total, be sure to sample any new margins properly)
Chronic Lymphocytic Leukemia (CLL) & Small Lymphocytic Lymphoma (SLL)
-peripheral B cell Neoplasms -most common adult leukemia -SLL & CLL morphologically, phenotypically & genotypically indishtinguishable -chromosomal translocations RARE -Origin is post-germinal center memory B cell
How should you approach neck dissection?
-photos (for orientation & levels) -overall 3D measurement -Structures included & their measurements -Divide into levels (verify!)
Describe Supraglottis region
-portion of larynx superior to the ventricles -composed of epiglottis, arytenoids, aryepiglottic folds & false cords
What are the boundaries of the pre-epiglottic space?
-posterior = epiglottis -inferior = thryoepiglottic ligament -anterior = thyrohyoid membrane
Adenoids
-posterior to soft palate -infxn can be problematic as they are directly near eustachian tube & basilar plate
What are anatomic landmarks of larynx that if invaded by cancer suggest it can escape from larynx?
-pre-epiglottic space -paraglottic space -anterior commissure -cricothyroid membrane
Acute Lymphoblastic Leukemia/Lymphoma (B-ALL or T-ALL)
-precursor B or T cell lymphocytes -most common childhood cancers -Most have chromosomal changes -Complementary mutations (not just 1) needed to cause ALL
Type of acini in Palate, base & lateral border of tongue
-predominately mucous acini
Sublingual gland
-predominately mucous acini -some serous acini
Submandibular/Submaxillary Glands
-predominately serous acini -some mucous acini
Dx for minimal extrathyroidal extension
-presence of carcinoma extending into perithyroidal tissues -infliltration of skeletal muscle & around sizable vascular structures and nerves
Microsatellitosis - melanoma
-presence of tumor nests greater than 0.05mm in diameter (in reticular dermis, panniculus or vessels beneath principle invasive tumor) -but separated from it by at least 0.3mm of normal tissue
Folliculitis
-primary skin infxn -caused by staph & typically limited to hair follicles
Impetigo
-primary skin infxn -superficial infxn caused by staphylococcus or streptococcus -superficial pustules rupture leaving golden-colored crusts
Mucous acini
-produce acidic/neutral sialomucins -well rounded basalar nuclei -arranged around empty lumen (1st step in digestion)
Why is sampling LN important?
-provides staging for MD (based on # and location)
Arytenoid cartilages
-pyramidal shape -rest along upper border of cricoid cartilage
Describe the maxillary sinus
-pyramidal shaped & surrounded by craniaofacial bones -superior = orbital floor -medial wall = lateral nasal wall -lateral/anterial walls = facial tissues -posterior wall = musculature & pterygoid bony processes -inferior = hard palate
Acral Lentiginous
-rare -on volar aspects of feet & hands -also on inguinal & mucosal locations
Merkel cell carcinoma (aka neuroendocrine carcinoma)
-rare skin cancer -Lesion: flesh-colored or blue-red nodule, often on face/head/neck -develops in older people
What does uninvolved thyroid tissue look like?
-red, glistening
Post-analytical Phase
-results reporting/archiving -sample archiving (body fluids, tissues, blocks & slides) -billing
Primary Follicle
-round aggregates of small, dark-staining lymphocytes w/in cortex -Absent immune stimulation (B cells) -near capsule -w/in network of follicular dendritic cell processes -no germinal center present
What does "its a big node" mean?
-said by surgeons -when you get a node with no info -look at patient history or talk to MD
Minimal PPE
-scrubs -waterproof shoe coverings -surgical gown - gloves - cap -mask -eye protection -waterproof apron
Necrotizing fasciitis
-secondary skin infxn -commonly caused by strep pyogenes
Serous acini cells
-secrete fluid isotonic w/ plasma (serous fluid)
Serous acini
-secrete serous fluid -PAS positive -intracytoplasmic granules basally located at intercellular capillaries
How should you find the LN in neck dissection?
-separated into levels (label & submit accordingly to level) -look for nodes in fatty CT
Onycholysis
-separation of nail plate from nail bed -macroscopic lesion
Von Ebner's Glands
-serous acini only -on the tongue
Parotid gland
-serous acini only -small LN near or w/in gland (intraparenchymal LN)
Cricoid cartilage
-shaped like signet ring -forms posterior wall of larynx
Fissure
-sharp edge defect of epidermis extending to deep layers of skin (ie fungal disease/athlete's foot)
Why USE squash preps?
-shows COHESIVE nature of tissue (Lymphoma dissociate into SINGLE cells - epithelials are clumpy) -CT & brain tumors show fibrillarity of cytoplasm (ie thin strands in background)
Nodule
-similar to papule, but lager -greater than 5mm (ie moles & sebaceous cysts)
What are factual descriptions ?
-size (particularly important!) -weight -color -shape -consistency -specific lesions
What structures should you submit sections of in a neck dissection?
-submandibular gland -internal jugular vein margins & cross section of involved area (in 1 cassette) -SCM muscle margins & involved area
What is included in radical neck dissection, Level I?
-submandibular gland -triangle of soft tissue anterior to SCM muscle
Excoriation
-superficial skin defect caused by scratching -macroscopic lesion
Stratum Corneum
-superficial/upper most layer -composed of dead keratinocytes (loss of nuclei & cytoplasm) -flattened & interconnected
What is glossectomy?
-surgical removal of tongue & surrounding tissues -take margin sections from anterior, lateral & posterior (perpendicular) -tumor most likely on lateral aspect -take at least 3 sections of tumor ORIENTATION = VERY IMPORTANT
Myoepithelial cells
-surround acini -mediate acinar contraction
Mechanism (or mode) of death
-systemic or biologic abnormality which preceded
Describe a typical adenoid
-tend to be flat & frequently fragmented -mucosal surfaces are disrupted by deep longitudinal clefts that extend into underlying lymphoid tissue
How do insertions of extraocular muscles help orientation of eye?
-tendon of superior oblique = posterior/temporal to superior rectus insertion & superior to optic nerve -inferior oblique muscle = temporal to optic nerve & posterior ciliary vessel
Pre-analytical Phase
-test ordered/tissue removed -sample collection/packaging -sample transport (outpatient or inpatient)
Why use histologic grading for salivary gland carcinomas?
-they are independent behavior predictor -plays a role in optimizing therapy -positive correlation btwn histologic grade & clinical stage
Lichenification
-thickened, rough skin, usually result of repeated rubbing -macroscopic lesion
Hyperkeratosis
-thickening of the stratum corneum -microscopic lesion (associated with qualitative abnormality of keratin)
Autopsy Tech: Letulle
-thoracic, cervical, abdominal & pelvic organs removed as 1 organ block, then dissected into organ blocks -"en masse" removal -Adv: fast, available under 30 min -Dis: requires more experience, awkward to handle
Autopsy Tech: Ghon
-thoracic, cervical, abdominal & urogenital organs removed as organ blocks -"en bloc" removal -widely used
What are some other structures that may be part of larynx resection?
-thyroid gland -trachea
What are the 2 common operative thyroid procedures?
-total thryoidectomy: entire thyroid removed -hemithyroidectomy: only 1 lobe & isthmus margin removed
What other structures should you note if seen?
-tracheostomy site (anteroinferior aspect trachea) -thyroid gland (process separately) -radical neck dissections (remove bilaterally)
Pre-epiglottic space
-triangular space anterior to base of epiglottis -Filled w/ fatty CT -posterior = epiglottis -inferiorly = thryoepiglottic ligament -anteriorly = thyrohyoid membrane -superiorly = hyoepiglottic ligament
Hematogenous spread
-tumors spread via *blood vessel* -typical in *sarcomas*
Liposuction
-typically "gross only" -examine thoroughly
How should you process palatine tonsils and adenoids?
-typically receive both -compare size, shape, consistency -measure & weigh separately -bivalve along long axis of each -inspect cut surfaces for masses, abscess, or other lesions
What does uninvolved mucosa look like on laryngectomy?
-typically tan, glistening & smooth
Lentigo Maligna Melanoma
-usually on face -slow progression from radial to vertical -up to 6cm in diameter -look like "ink stains"
What is dx criterion for follicular carcinoma? What is prognosis for this dx?
-vascular invasion associates with poor outcome -number of foci associates with outcome
Analytical Phase
-verify patient info -Clinical lab: accessioning, specimen processed via instruments/exam, results automated/entered upon interpretation of results -Anatomic Lab (cytology vs surgical pathology): specimen processed, special studies, pathologist interpretation
What is hemilaryngectomy?
-voice-preserving -Rt/Lt thyroid cartilage, true vocal cord, false cord & ventricle removed in continuity (all 1 side) (be sure to sample any margins properly)
What is supraglottic laryngectomy?
-voice-preserving -above ventricle, only get upper half of larynx
What is a hemilaryngectomy?
-voice-preserving procedure -includes either Rt or Lt thyroid cartilage, false & true cords, and ventricle (all in continuity-- ie 1 side of larynx)
Parotid gland characteristics
-weight = 14-28 g -stensen's duct -broad main lobe & smaller deep lobe (facial nerve btwn lobes) -contains *interparanchymal LN*
Follicular Carcinoma
-well demarcated -solid w/ hemorrhagic areas
Wharthon's Tumor
-well demarcated mass surrounded by unremarkable, tawny, lobulated salivary gland parenchyma -In *parotid gland* (almost exclusively) -More common in males, age 50-70
Direct seeding
-when tumor goes *directly into serous membrane* of body cavity -very common in *ovarian cancer*
Secondary Lymphoid Organs
-where Ag is localized & exposed to mature lymphocytes -initiates adaptive immune response Includes: -Spleen -LN -Tonsils -Appendix -Peyer's patches
Primary Lymphoid Organs
-where immature lymphocytes develop (differentiation, prolif & maturation of stem cells into immuno competent cells) Includes: -Thymus -Bone Marrow
-Posttreatment prefix (before TNM) -Retreatment prefix -Autopsy prefix
-ycTNM or ypTNM -rTNM (does not change original staging) -aTNM (only postmortem)
right ventricle walls thickness
0.5 cm
Histologic grades for laryngeal carcinomas
1 - well differentiated 2 - moderately differentiated 3 - poorly differentiated 4 - cannot be assessed
Histologic grades for salivary gland carcinomas
1 - well differentiated (low grade) 2 - moderately differentiated (intermediate grade) 3 - poorly differentiated (high grade) 4 - cannot be assessed
Regressive hematoxylin stains
1) Delafield (oxidation occurs naturally w/ light & air, Doesn't readily evaporate) 2) Ehrlich (gives sharp nuclear stain)
Progressive Hematoxylin Stains
1) Harris (consistent nuclear staining), 2) Mayer (doesn't form surface sheen, 2-3 month shelf life, slower staining, difficult to overstain, crisp nuclear stain), 3) Gill (goblet cells only stained by GILL, no surface sheen)
Ways to differentiate a progressive stain
1)Basic/cationic dyes → by weak acids & Acidic/anionic dyes → by alkalines 2)Excessive use of mordant (ie regressive iron hematoxylin methods) 3)Oxidize the dye
3 safety concerns with formaldehyde
1)Carcinogen (WHO group 1) 2)General medical problems - eye irritation, tears, odor sensations, hypersensitivity rxn: dermititis & skin sensitization with chronic exposure 3)Acute harmful effect - pulmonary edema & death (large amounts)
Ways to reduce path lab errors when specimen receiving
1)Check patient history 2)Anatomic sites must match container AND req
Characteristics of well-fixed, well-processed section
1)Crisp nuclear membrane & various chromatin patterns 2)Cytoplasm stains well with eosin 3)No artifactual spaces btwn cells 4)No cell shrinkage
How can you fix delayed fixation?
1)Fix IMMEDIATELY 2)Cut tissues thin enough or cut open specimens to fix 3)Fix with correct volume of fixative (15-20x that of tissue)
How can you fix incomplete fixation?
1)Fix at least 8-12hrs up to 48hrs-week 2)Fix with correct volume of fixative (15-20x that of tissue) 3)Change formalin solutions frequently
H&E staining procedure for Frozen Section
1)Fix ½ 95% EtOH and ½ 10% formalin (3-10 dips) 2)H2O (3 dips) 3)Hematoxylin (15-30 sec/dips) 4)H20 (3 dips) 5)Bluing/ammonia (3-10 dips) 6)H20 (3 dips) 7)Eosin (15 dips) 8)95%EtOH 2x (10 dips each) 9)100%EtOH 2x (10 dips each) 10)Xylene 2x (10 dips each or until streak gone) 11)Wipe back, mounting media & cover slip
Main discrepancies in clinical setting
1)Labeling error 2)Anatomic sites missing 3)Incomplete clinical info on req 4)Multiple specimen designations not indicated 5)Improper prep of specimen before sending to lab
Types of labeling discrepancies
1)No patient label on specimen nor req 2)Mismatch of label on specimen vs req 3)Both specimen and req have incorrect patient label
Problems & Solutions of Processing
1)Overprocessing/excessive dehydration occurs when thick & thin sections processed at same time. S:Cut sections as thin as possible - 3mm 2)Blue halo effect (nuclear smudginess) from incomplete drying prior to clearing/too much heat on processor S:completely dehydrate & heat to just above mp for paraffin
Types of ID Error in clinical setting
1)Preanalytical - before specimen gets to lab 2)Analytical - during specimen processing at lab 3)Postanalytical - after results complete, delivery of results
Factors Affecting Dye Binding
1)Solution pH determines tissue and dye charge 2)Increased temp increases rate of stain 3)Increased stain w/ increased conc. Of dye 4)Added salts changes stain ability (compete for binding sites) 5)Fixative changes amino group & therefore eosin binding
Rules of fixation
1)fixation denatures macromolecules - kills cells, prevents autolysis & microbial attack, firms tissue & changes tissue's receptivity to stains/histochemical procedures 2)Different fixatives = different morphological patterns 3)Fixation = chemical rxn (not instant) 4)Fixative must be present for rxn to occur
Advantage to using formaldehyde as fixative
1)less cell shrinkage & tissue distortion 2)cheap 3)stable 4)usable with almost any tissue 5)less overfixation
How many sections should you typically submit for tonsils & adenoids? When does this change?
1-2 sections (representative); different when diffusely enlarged or structurally abnormal
How many sections from eye?
1-2 sections from P-O section & 1 optic nerve margin
Inking Specimens
1. "If you Think it, ink it" (but consider reasons before using time/resources to ink) 2. Dry specimens before inking! (Why? to prevent running) 3. Meticulously apply ink to surface 4. Dry ink BEFORE cutting 5. Cut from tissue to ink (avoid dragging ink thru tissue) 6. Apply a mordant (many fixatives don't require anymore)
Signs & Symptoms of melanoma
1. "Mole" with irregular borders &/or blotchy coloration in shades of red, white, blue & black 2. Perhaps with recent change, enlargement, irritation, ulceration or bleeding
Important info to include in dictation for sentinel LN (& most LN dissections)
1. # of LN in a resection 2. size range 3. Ask if sections s/b cut longitudinal or transverse 4. Cut into 2-3mm sections 5. Describe cut surface 6. Capsule/extracapsular involvement 7. Standard 3 levels per block
Things to include in lesion description
1. % volume occupied by lesion (multinodular goiter) 2. location of nodule (solitary lesion) 3. diffuse vs solitary 4. cystic, solid or combo 5. encapsulated? 6. extracapsular extension? 7. distance of lesion from capsule & margin (hemi) 8. size of lesion in 3D
What results in excessive physiologic stress or injury?
1. *Adaptation* - REVERSIBLE changes in size, #, phenotype, metabolic activity, or function of cells 2. *Reversible injury* - pathologic cell changes that can be restored to normal if stimulus removed -> NOT permanent 3. *Irreversible injury* - stressors exceed capacity of cell to adapt (beyond point of no return) -> permanent
Punch Biopsies
1. *Check Clinical History!* - if for T-cell lymphoma, must put 1/2 into zeus transport media! 2. Dx only, not excisional 3. Measure diameter & depth 4. Meticulously ink resection margins (not on epidermis) 5. Bisect (if >0.5cm 6. Cut surface down btwn 2 sponges 7. Write "cut surface down" on side of cassette 8. Dictation: "is a ___cm in diameter punch biopsy of tan skin, excised to depth of ___cm. The skin surface displays ___cm tan shiny papule, less than ___cm from the margin. The margin is marked in blue, the specimen is bisected and entirely submitted as A1"
How should you remove the bowel?
1. *Clamp duodenum at Ligament of Trietz* (suspensory muscle of duodenum) 2. Keeping tension on bowel, *cut along length of bowel* (at cecum, release entire intestines with blunt dissection) 3. *Hand at rectum* (hear sound-undo rectum from pelvic wall) & *milk back the contents* 4. *Clamp rectum BEFORE cutting at distal end* 5. Place entire bowel in pan for later examination
Ways metastasis Occurs
1. *Direct seeding*: -when tumor goes directly into serous membrane of body cavity (very common in ovarian cancer) 2. *Lymphogenous spread*: -metastatic spread via LN, solid cell growths that permeate lymph vessels & from minute cellular emboli (can break free & pass to regional LN) -most typical w/ carcinomas 3. *Hematogenous spread*: -tumors spread via blood vessels -typical in sarcomas
Molecular/Cytogenetic Dx
1. *Dx of Malignancy* - PCR or FISH used to differentiate neoplastic & reactive proliferations 2. *Px of Malignancy* - genetic alterations associated with poor Px 3. *Residual disease detection*- detect small numbers of malignant cells (assess therapy efficacy or tumor recurrence) 4. *Dx of hereditary predispositions* - detected via mutational analysis of genes (ie BRCA-1 & 2)
Name some paraneoplastic syndroms
1. *Endocrinopathies* - (cushing syndrome, hypercalcemia) 2. *Neuropathic syndromes* - (polymyopathy, periph neuropathies, neural degen., myasthenic syndromes) 3. *Skin disorders* - (acanthosis nigricans) 4. *Skeletal/joint abnormalities* - (hypertrophic osteoarthritis) 5. *Hypercoagulability* - (migratory thrombophlebitis, disseminated intravascular coagulation, nonbacterial thrombotic endocarditis)
Spongiosis
intercellular edema of epidermis
Chart review
1. *Entire chart must be thoroughly reviewed* 2. *Make extensive notes* as to incidences & conditions around time of death (especially if surgery involved) 3. *Make DDx* (PAD = provisional anatomic dx -> gives MD idea of immediate gross findings of autopsy, must be submitted w/in 24 hrs of autopsy) 4.***CHECK NAME ON CHART MATCHES NAME ON WRISTBAND/FOOT TAG BEFORE YOU CUT***
What sampling approaches are used in lab dx of cancer?
1. *Excision or biopsy* 2. *Needle aspiration* - (for breast, thyroid & LN) 3. *Cytologic smears* - (ie pap smears for uterine, cervix & tumors of stomach, bronchus, endometrium & urinary bladder)
What hazards do radioactive bodies present?
1. *External exposure* - primary concern if body unopened 2. *Radioactive contamination*
LN functions
1. *Filter lymph* - prevent spread of microorganisms & toxins that enter interstitial fluids 2. *Destroy bacteria, toxins & particulate matter* - thru phagocytic action of macrophages 3. *Produce Antibodies* - thru activity of B cells
Biopsy Rules
1. *Handle carefully!* DO NOT CRUSH! 2. *Use disposable pipette* instead of forceps for gentler transfer (new one for each body location) 3. *# of pieces on cassette* & in dictation 4. *Fix immediately* 5. Orient *(mucosal bx) mucosal side up* 6. *Wrap in filter paper/btwn sponges* so histology can easily find specimen (Only use sponge in well-fixed specimens!) 7. *Always wrap Core bx!* 8. *TRICK: 100mL eosin* in last OH to help histologist see specimen 9. *Process bx separately*
Habits of Grossing Station
1. *Keep clean!* -free of blood, tissues, xtra containers, cluttered papers 2. *NEVER have more than 1 case on board at at time!!!!* 3. Keep *only necessary instruments on board* 4. *Use wet paper towel*/formalin neutralizer pads *as dissection base* (change with every case) 5. *Know where sharps are located* (autopsy, have 1 spot for sharps, ie at the head) 6. NEVER leave sharps in body while working 7. Be aware where others are cutting if multiple hands inside body
Ways to estimate time of death
1. *Livor mortis* - pink erythema of skin surfaces 2. *Rigor mortis* - muscle rigidity 3. *Algor mortis* - postmortem cooling 4. *Stomach contents state of digestion* 5. Autolysis 6. Putrification 7. Mummification 8. Adipocere 9. Entomologic Evidence 10. Chemical evidence
What is a critical determinant of neoplasm that effects both benign & malignant tumors?
1. *Location* - (ie benign GI tract tumor causes obstruction/bleeding) 2. *Hormonal effects* - (tumors in endocrine glands can start producing hormones, may cause paraneoplastic syndromes)
What is subcutaneous layer composed of?
1. *Loose CT* 2. *Fat* (adipose) (ie panniculus adipose - fat pad of body) 3. *Muscle* 4. *Nerve receptors* (Pacinian corpuscle - deep pressure/vibration) (where cellulite comes from!)
Manner of death
1. *Natural* - caused exclusively by disease 2. *Accident* - caused by not intentional trauma 3. *Suicide* - intentional, unnatural death via one's self 4. *Homicide* - intentional, unnatural death via another person (intent to cause harm)
Anatomic Orientation
1. *Orient BEFORE cutting!* 2. *Strong knowledge of anatomy* necessary (recognition & interpret unique anatomic landmarks) 3. *Think of Specimen as a cube*: -Superior/Inferior -Medial/Lateral -Anterior/Posterior -Superficial/Deep
Steps for sampling a LN
1. *Orient specimen & designate levels of regional LN* (for radial neck dissection) - ie relation of LN to tumor 2. If node *grossly positive, take 1 section* 3. *LN > 0.5cm* in greatest dimension s/b *sectioned & entirely submitted* if no evidence of tumor involvement.
Steps to grossing thyroid
1. *Orient specimen* 2. *Weigh & measure* 3. *Describe shape, contours & symmetry* 4. *Note extrathyroidal tissues* (parathyroids/LN & anterior aspect 4 skeletal muscle) 5. *Palpate specimen* (consistency & find lesions) 6. *Ink surfaces* 7. *Shave isthmus margin* (hemi) 8. *Serially section* & 9. *Lay out individual slices* to maintain orientation 10. *Inspect & describe cut surfaces* 11. *Submit sections*: normal parenchyma, LN, parathyroids, tumor-parenchyma interface & tumor-capsule interface (submit entire tumor capsule if encapsulated) 12. *Touch prep* & OH fix for Diff-Quik/H&E staining
Types of Tumor Markers
1. *PSA* (prostate-specific Ag) - elevated in malignant or benign prostate neoplasms/hypertrophy/inflamm 2. *CEA* - elevated in cancer of colon, pancreas, stomach & breast...also in non-neoplastic conditions (alcoholic cirrhosis & hepatitis) 3. *AFP* - elevated in liver & testicular germ cell tumors...also in non-neoplastic conditions (cirrhosis & hepatitis) 4. *CA-125* - ovarian cancer 5. *CA-19-9* - colon & pancreatic cancer 6. *CA-15-3* - breast cancer
5 categories of lymphoma via WHO
1. *Precursor B cell neoplasms* (immature B cells) 2. *Peripheral B cell neoplasms* (mature B cells) 3. *Precursor T cell neoplasms* (immature T cells) 4. *Peripheral T cell/NK cell neoplasms* (mature T&NK cells) 5. *HL* (neoplasms of Reed-Sternberg cells)
Salivary Gland grossing steps
1. *Weigh & 3D measure* 2. *Orient if indicated* by MD for malignancy - if so, ink (especially nerve margins) 3. *Section thinly* 4. *Sialolith present?* -Picture & describe 5. *Tumor?* -3D measure -Describe cut surface (including demarcation) -Location (how close to duct/margin/edge), -Intraparenchymal LN -Other structure involvement (nerves, 6. *Submit 1 section per cm of tumor* OR *submit entire tumor if done in <5 cassettes*
Dissection of Organs
1. *Weigh solid* organs (not stomach, gall bladder, urinary bladder) 2. *Measurements* of organs for notes (all organs) 3. *Note abnormalities* 4. *Take Appropriate sections* 5. *Photos!!!*
Actinic Keratosis (AK)
1. *benign* squamous cell carcinoma in-situ but can develop into invasive SCC (freeze off so doesn't happen) 2. Lesion: small erythematous keratotic lesion on sun-damaged skin. Scaly, white to yellow-brown, can have urticaria or tenderness. *cutaneous horns* from alot of keratin production 3. Grading: Keratin-intraepithelial neoplasm, grade I-III 4. Microscopic: -hyperkeratosis w/intermittent parakeratotic nuclei, 2 -keratinocyte atypia along basal layer, -budding of basal layer keratinocytes but NO invasion -perivascular inflamm 5. Receive: curettage or shave/excisional bx
What is dermis composed of?
1. *blood vessels* 2. *meissner's corpuscle* - touch receptors (light touch/soft fleeting movement) 3. *pacinian corpuscle* - receptors for deep pressure & vibration 4. *free nerve endings* - sense pain, temp change & itchiness (ie urticaria) 5. *nerve fibers* - forward info to the nervous system 6. *sebaceous glands* - oil glands (saculated organs that secrete sebum...ie sebaceous cysts) 7. *hair follicles* - mostly produce hair 8. *arrector pili muscle* - muscle attached to base of hair follicle (pulls hair in upright position during cold and fright)
X-ray purpose in autopsy
1. *locate bullets, broken bones & foreign bodies* 2. For children, document old/new fractures or any bone injury
Seborrheic Keratosis (SK)
1. *most common benign epithelial tumor* 2. Pigmented Lesions: tan-brown to black papules, solitary or multiple, smooth to verrucoid (wart-like exophytic with furrowed surface). 1mm-several cm 3. DDx = SK vs melanoma (up to pathMD) 4. Microscopic: *benign squamoid & basaloid prolif w/ acanthosis* (diffuse epidermal hyperplasia), *papillomatosis* (surface elevation via hyperplasia & enlargement of dermal papillae), *keratin-filled horn cysts*, *hyperkeratosis* (thickening of keratin layer-stratum corneum) 5. Receive: shave or excisional bx
What should you remember for thyroid frozen section?
1. *take THIN sections* (demonstrates tumor-margin & tumor-capsule relationships) 2. *touch prep* - whether wanted or not (select lesion tissue -> dry surface -> touch to labeled dry, clean slide -> EtOH -> Dif-Quik or H&E
Prognosis factors for Merkel cell carcinoma
1. *tumor thickness* 2. *mitotic rate* = >10 per high-power field correlates with poor prognosis 3. *tumor-infiltrating lymphocytes* (same guidelines as melanoma) 4. *nodular patterned* tumor growth = better survival 5. *Infiltration pattern* = w/out well-circumscribed interface w/ strands infiltrating thru dermal collagen
Operator dependent errors
1. Accessioning (wrong pt entered into computer) 2. Set up (wrong cassette with wrong case) 3. Grossing (wrong tissue in wrong cassette)
Subcutis
1. Adipose tissue 2. Fibrous tissue septae
Stains for narrow-spectrum fungi (cryptococcus)
1. Alcian blue 2. Mayer's 3. Southgate's mucicarmine 4. Ziehl-Neelson (ZN)
4 groups of fixatives
1. Aldehydes - act by cross-linking proteins, particularly lysine residues (ie formaldehyde) 2. Oxidizing agents - probably cross-link proteins, precise mechanism unknown (ie potassium permanganate) 3. OHs - protein denaturing agents (ie methanol) 4. Form insoluble metallic precipitates (ie mercuric chloride)
What should sections demonstrate?
1. All lesion components 2. Tumor interface (& surrounding capsule, if present) 3. Tumor relationship to thryoid capsule & extrathyroidal soft tissues 4. Parathyroids presence
Storing a Specimen (ie post analytical)
1. All parts received are stored in individual containers 2. Be sure of adequate formalin covering specimen 3. For regionalized LN, wrap levels individually & labeled before returning to container 4. If oriented, maintain tags for later orientation
Margin Sampling
1. Always simply specimens margins, even if thought to be benign 2. Perpendicular sections show relationship of lesion to margin 3. Shaved (parallel) sections best when margin appears widely free of tumor or cylindrical structures
How to measure eyeball?
1. Anterior-Posterior 2. Medial-Lateral 3. Superior-Inferior 4. Measure any attachments
Inking Specimen Guidelines
1. Apply ink before sectioning specimen 2. Don't use excessive ink 3. Dry specimen surface before application 4. Allow ink to dry before sectioning
Opening & Sectioning Specimen
1. Before cutting, What special studies needed?? 2. Tissue type & pathology dictates how/where specimen opened 3. Palpate for pathology 4. Open specimen (don't cut entirely thru) 5. Maintain lesion & relationship to surrounding structures 6. Inspect & Dissect the ENTIRE specimen (satellite lesions)
Dermatofibroma
1. Benign 2. Lesion: firm, tan-brown, occasionally tender papule, can be several cm 3. Microscopic: spindle-shaped fibroblasts in well-defined, middermal, nonencapsulated mass. Sometimes extends into subcutaneous fat. Most w/ overlying epidermal hyperplasia
Describe epithelial cysts & their surgical dissection
1. Benign 2. Most common cutaneous cyst received 3. Microscopic: stratified squamous lining w/ variably thick granular layer & loose, laminated keratin 4. Margins not important, but still ink! 5. Sections = 1 6. Describe as skin ellipse -> surface lesion -> description of cut surface DICTATION - Measure, describe contents *"___x___cm cyst containing a gray-white fetid, keratinaceous material"*
Normal LN Structure
1. Capsule 2. Cortex 3. Medulla 4. Primary Follicle (nodule) 5. Secondary Follicle 6. Sinuses 7. Afferent Vessels 8. Efferent Vessels
What are the safety concerns regarding formaldehyde?
1. Carcinogenicity 2. General medical problems 3. Acute harmful effects
Death timeline
1. Cessation of respiration 2. Cessation of circulation
BEFORE TOUCHING SPECIMEN what are the 4 things?
1. Check Req - For NAME, REASON for FS (ie pre-OP dx), and required SPECIAL STUDIES 2. Check Container 3. Check Cap 4. Check Cassette ***ALSO, before starting, write down tissue BEGINNING MEASUREMENTS!!!***
Pigmented lesions: oriented ellipse (excisional bx)
1. Check orientation & ink, indicating margins 2. Measure skin (length x width, excised to depth___) 3. measure & describe lesion 4. measure distance from lesion to closest margin 5. Serially section (describe cut surface, measure thickness/distance from deep margin) 6. Submit sections: (tips in different cassettes, indicate orientation in slide key, submit sections per orientation)
Ways to reduce path lab errors when specimen receiving
1. Check patient history 2. Anatomic sites must match container AND req
Things to remember when photographing specimen
1. Clean background 2. Orient specimen (proper ID tag/include scale) 3. Use cable - reduces camera vibration 4. Check focus/exposure settings 5. Check lighting/avoid shadows
Dermis
1. Collagen & elastin - strength & elasticity 2. Vessels -*Papillary/superficial plexus* -*Cutaneous Plexus* -*Glomus bodies*
What is Moh's Surgery?
1. Complex concurrent FS/surgery (while patient open) 2. Tissue sparing (performed on areas difficult to do large resections) 3. Tissue mapped then cut by FS - horizontal to epidermis, bottom to top 4. Additional tissue resected at any positive margin 5. Continues until no evidence of positivity
Characteristics of well-fixed, well-processed section
1. Crisp nuclear membrane & various chromatin patterns 2. Cytoplasm stains well with eosin 3. No artifact spaces btwn cells 4. No cell shrinkage
Touch prep procedure
1. Dab section of tissue dry 2. Use forceps to touch & lift 3x on clean slide 3. Either fix or air dry (depending on studies)
Mycosis Fungoides (Cutaneous T-Cell Lymphoma)
1. Dermal tumors, but cells come from elsewhere (blood) 2. *1/2 specimen put in Zeus fixative!!!!!* 3. Lesion: macules/papules that progress to nodules & lacerating masses (scaly, red-brown patches, scaling plaques) 4. Microscopic: **Sezary-Lutzner Cell present!** (CD4+ cell w/ hyperconvoluted nucleus), T lymphocyte infiltrates skin
Differentiation of Mesoderm
1. Dermis (deep layer of skin) 2. Bone 3. Smooth & Skeletal Muscle 4. Blood vessels 5. Pleura/Peritoneum/Pericardium 6. Urogenital system
Disposal of Hazards
1. Dispose of sharps immediately in proper container 2. Materials soiled w/ biohazardous stuff s/b disposed in proper biohazard bags 3. Immediately store specimens properly following dissection (adequate formalin) 4. Specimen containers wiped clean & securely closed 5. Stored for min of 3 weeks or until signed out 6. Review CAP checklist
Techniques for Cutting Fat
1. Dissect off any unnecessary fat from tissues a. Fat Gouge Trick (if r b. otating block does not put fat behind more "cut-able" tissue) *remove blade first!* i. Use DULL spatula to dig out unwanted portion while chuck in machine ii. Add OCT and freeze - continue sectioning 2. Orient tissue so fat hits blade LAST 3. Start with clean stage & very cold block 4. Sharp blade, swift turn of wheel w/ NO hesitation 5. Try thicker section
Techniques for Cutting Fat
1. Dissect off any unnecessary fat from tissues a. Fat Gouge Trick (if rotating block does not put fat behind more "cut-able" tissue) *remove blade first!* i. Use DULL spatula to dig out unwanted portion while chuck in machine ii. Add OCT and freeze - continue sectioning 2. Orient tissue so fat hits blade LAST 3. Start with clean stage & very cold block 4. Sharp blade, swift turn of wheel w/ NO hesitation 5. Try thicker section
Lip Wedges
1. Done on lips 2. Wedge-shaped skin w/ 2-3 margins 3. Ink = 1st color = 1st margin/2nd color = 2nd margin 4. Enface - Ink side down in cassette 5. If oriented = submit margins in 2 different cassettes If not oriented = submit margins in same cassette 6. Serially section & submit 1-2 sections in another cassette
Ways to solve discrepancies:
1. Double-check system 2. Check clinical history to requisition 3. Make proper collection containers accessible for staff (ie prefilled formalin containers in ER) -Communicate errors to clinical staff in all scenarios
What should you do when submitting 2 LN in 1 cassette?
1. Dry both LNs 2. Ink *only 1* of LN or ink 2nd in different color 3. Bisect both LN - cut NON-inked 1st!!!!! 4. Indicate in slide key: contains 2 LN, each bisected, 1 inked
What are avoidable FS limitations?
1. Drying artifacts - loss of nuclear definition, FIX IMMEDIATELY!!! 2. Sampling error (unforgivable!) -DO NOT CHOOSE WRONG PART OF TISSUE!! Be meticulous... 3. Fat - hard to freeze (low enough temp to freeze will shatter other important tissue) 4. Inferior quality of section - is this from technician or taught technique ie training/performance inconsistencies? 5. Incorrect Embedding
What can PET/CT do for cancer/metastasis?
1. Dx a problem 2. Predicts likely outcome of different treatments & helps pinpoint best one 3. Monitors patient progress
Scalp punch biopsy
1. Dx inflam conditions 2. Use parallel sectioning - bisect ~1mm above subcutis layer 3. Ink/embed cut surfaces facing blade 4. Serially section 5. Stain every other slide (unstained for fungal stains)
Why skin specimens?
1. Dx tumors 2. Ensure complete tumor excision 3. ID nature of inflam disease
Possible precursors to melanoma
1. Dysplastic nevus 2. Congenital nevus 3. Xeroderma pigmentosum 4. Any nevus w/ junctional activity
3 primitive embryologic tissues every cell is derived
1. Ectoderm 2. Mesoderm 3. Endoderm
Biopsies types
1. Endoscopic - thru mouth or rectum (for hersh braun disease & J biopsies - put sponge on top to reduce curling) 2. Core - Thyroid, LN, breasts 3. Needle - Liver, lung, prostate (very delicate -place linearly in filter paper) 4. Suction - done endoscopically (for polyps or hersh braun) 5. Wedge - Lungs or wedge of skin (each done differently) 6. Incisional - Dx only (benign or malignant, no margins) 7. Excisional - Dx & clear margins 8. Shave - Dx only, or MD fairly certain its benign
3 Layers of Skin
1. Epidermis 2. Dermis 3. Subcutaneous
Differentiation of Ectoderm
1. Epidermis/adnexae 2. Brain & nerves (CNS/PNS) 3. Sensory epithelium (ears, eyes & nose) 4. Glands (subcutaneous, mammary, pituitary) 5. Teeth enamel
Neoplasms of the skin
1. Epithelial cell tumors 2. Pigmentary cell (melanocytes) tumors 3. Dermal CT tumors 4. Blood-borne immigrant cell tumors
Adult Autopsy - in order
1. External descriptions, body weight and length 2. Y-shaped incision & removal of abdomen for microbio studies (if indicated). 3. Collect abdominal effusions/exudates; 4. Hernia search 5. Incision of anterior abdominal musculature and breasts 6. Pneumothorax search 7. Lower ribs cut to collect pleural fluid 8. Chest plate removed 9. Thymic fat pad removed 10. Incision of pericardial sac & fluid collection 11. Blood removal (if indicated) for microbio, serologic, biochem, toxicology studies 12. Ligatures to ID carotid, subclavian and femoral arteries (at some places for embalmer convenience) 13. Then use various techniques for organ removal -En masse -Ghon (organ blocks) to preserve vascular supplies -Virchow when vascular not needed 14. CNS, PNS, muscles, bones, joints exposed at end of autopsy
Fixation Techniques
1. Fatty Breast Tissues (not bx!) -Use commercially prepped Pen-Fix -Use 1/2 37% formaldehyde & 1/2 100%EtOH (2-4/6hrs) 2. LN (colon & axillary) -When specimen arrives -> open, cut thru fat & fix in 1/2 formalin & 1/2 Dissect-Aide 3. Bone -Fix in 1/2 formalin & 1/2 decalcification solution
Nucleic Acid Stains
1. Feulgen Reaction 2. Methyl Green-Pyronin Y
What step should you add after fixing eyeball if contains excessive calcium deposits or bone formation?
1. Fix 2. Decalcify with NaCitrate/Formic acid for 24-72 hours 3. Wash overnight 4. Place in EtOH 60% (do not over decalcify)
How can you remedy delayed fixation?
1. Fix IMMEDIATELY 2. Cut open specimens when possible 3. Fix with correct volume of fixative (15-20x that of tissue) 4. Sort cassettes by specimen thickness for appropriate processing schedule
How can you remedy incomplete fixation?
1. Fix at least 8-12 hrs (some say 48 hrs-1 week) 2. Fix with correct volume of fixative (15-20x that of tissue) 3. Change formalin solutions frequently
H&E staining procedure for Frozen Section
1. Fix ½ 95% EtOH and ½ 10% formalin (3-10 dips) 2. H2O (3 dips) 3. Hematoxylin (15-30 sec/dips) 4. H20 (3 dips) 5. Bluing/ammonia (3-10 dips) 6. H20 (3 dips) 7. Eosin (15 dips) 8. 95%EtOH 2x (10 dips each) 9. 100%EtOH 2x (10 dips each) 10. Xylene 2x (10 dips each or until streak gone) 11. Wipe back, mounting media & cover slip
Rules of fixation
1. Fixation denatures macromolecules - kills cells, prevents autolysis & microbial attack, firms tissue & changes tissue's receptivity to stains/histochemical procedures 2. Different fixatives = different morphological patterns 3. Fixation = chemical rxn (not instant) 4. Fixative must be present for rxn to occur (open up specimens)
Steps of Staining Process (10)
1. Fixative (1/2 NBF, 1/2 ETOH) - 3-10 dips. 2. Water- 3 dips 3. Hematoxylin - 15-30 seconds 4. Water- 1 or 2 sets, 3 dips each 5. Ammonia/Bluing Agent - 3-10 dips 6. Water - 3 dips 7. Eosin - 15 seconds or dips 8. 4 Runs ETOH (2) 95%, (2) 100%. 10 Dips each. 9. Xylene (2) - At least 10 dips in each, until slide runs clear
Type of studies & transport medium for fresh tissue
1. Flow cytometry 2. Cytogenetics 3. Studies requiring cell cultures (Use RPMI (roswell park memorial institute) medium (short term storage) for 1-3) 4. PCR-based techniques (look for DNA/RNA alterations) (Can be snap frozen in liquid nitrogen for long term storage)
How to use synoptic reporting
1. Fully integrated in anatomic pathology lab info service, so don't have to go into separate program for sign-out activities 2. During accessioning, worksheets attached to case & then dictated to create final dx 3. Sign-out PathMD does final review & data elements are captured/stored on relational database, final report generated QA routinely performed electronically w/in framework of module
Differentiation of Endoderm
1. GI system 2. Internal linings (mucosa) of GI & resp tract 3. Liver 4. Pancreas 5. Parenchyma of thyroid, parathyroid 6. Tonsils, thymus 7. Epithelial lining of urinary bladder, uretha & parts of ear
Most common stains for fungal/AFB
1. GMS (gomori methenamine silver) 2. PAS (periodic acid-schiff)
How to retrieve from stage?
1. Gently touch slide to tissue on the stage. Tissue will come up to slide by static/cohesive attraction. 2. Avoid stretching or folding...keep steady hand.
2 broad categories of Lymphoma
1. Hodgkin Lymphoma (HL) 2. Non-hodgkin Lymphoma
Steps of a maxillectomy
1. ID specimen anatomic boundaries & locate tumor within maxillary sinus 2. Ink mucosal & soft tissue margins 3. Sample all margins (soft tissue, bone, mucosa (shave), skin) 4. Section specimen along a plane to best demo tumor relationship to adjacent structures/compartments (determine tumor size & extent of spread) 5. Submit tumor sections that demo relationship to adjacent structures/compartments
How to approach complex specimen
1. ID various components of specimen 2. Think of each component as geometric shape (bone=cylinder, epithelium=square sheet, soft tissue=cube) 3. Approach each component separately 4. Look for relationships btwn lesions & each component
HOw should you approach complex specimens?
1. ID various components of specimen 2. Think of each component as geometric shape 3. Approach each component separately 4. Document relationship btwn any lesion & each component of specimen
How to clean up a formalin spill?
1. Increase humidity in lab 2. PPE (including wet mask) 3. Wet paper towel boundary 4. Absorb from center & discard in bag (neutralize) 5. Neutralize spill area & wash with soapy water
How do you sample mucosal margins?
1. Inferior - shave (if tumor far) & perpendicular (if tumor close) 2. Superior - perpendicular sections of each mucosal margin (tongue base, pyriform sinus, cricoid mucosa)
Reasons to keep cryostat door shut?
1. Keep at proper temp 2. Keep humidity OUT 3. Keep electrostaticity OUT - fix with dryer sheets
Specializations
1. Keratinized: cells contain keratin for tough, impermeable barrier (ie found in skin) 2. Ciliated: apical plasma membrane extensions made of microtubules (ie beat rhythmically to move mucus/stuff thru a duct)
Important things to remember about LN
1. LN larger than 5mm should be serially sectioned at 2-3mm intervals 2. Do not submit sections from more than one LN in same cassette
Scrape Prep Procedure
1. Label 2 slides/prep EtOH fix 2. Bisect LN 3. Dry cut surface 4. Scrape cut surface w/ new scalpel blade 5. Wipe blade on slide 6. Turn other slide upside down onto 1st slide & scrape apart 7. Immediately fix in EtOH
Discrepancies in clinical setting
1. Labeling error 2. Anatomic sites missing 3. Incomplete clinical info on req 4. Multiple specimen designations not indicated 5. Improper prep of specimen before sending to lab
4 types of melanoma
1. Lentigo Maligna Melanoma 2. Superficial Spreading Melanoma 3. Nodular Melanoma 4. Acral Lentiginous Melanoma
What are things to do to minimize crushing small tissues?
1. Lift small specimens with end of wooden applicator, filtered directly on tissue bag or use pipette 2. Quickly place in fixative 3. Mark fragments so they are easily found by histotech
Cancer Cachexia characteristics
1. Loss of appetite = Loss of body fat & lean mass (Profound weakness) 2. Metabolic changes -reduced production/storage of fat & increases FA mobilization -increased muscle catabolism
What tissues for touch preps
1. Lung tumors 2. Thyroid 3. LNs (sentinel nodes) 4. FS procedure on breast margins
How does lymph flow thru LN?
1. Lymph flows into subcapsulary sinus via afferent vessels carrying WBCs, dendritic cells & Ag-processing macrophages 2. Via cortical sinuses, headed to cortex & then to medulla (lined by macrophages) 3. Lymph flows out thru efferent vessels w/in hilum
Kaposi Sarcoma
1. Malignant 2.Pathogenecity: caused by herpes virus (HHV-8) 3. Lesion: blood vessels and perivasicular CT cells, hemorrhagic nodules, multiple/confluent 4. Often seen in AIDS patients
Steps in parathyroid dissection
1. Measure & *weigh* 2. Describe gross appearance (shape & color) 3. Bisect & describe cut surface 4. Frozen section or Touch prep (OH-fixed/H&E) 5. Sample other tissue that may be part of specimen
Skin Ellipse Oriented
1. Measure L x W, & D of excision 2. Describe lesion, distance from closest margin 3. Describe cut surface & distance from deepest resection 4. 2 Ink colors (lateral margin = 1st color/medial margin = 2nd color) 5. Tips in separate cassettes, designated 6. Serially section & sequentially submit (~2-3 pieces per cassette), designate (ie superior to inferior)
Skin Ellipse Unoriented
1. Measure L x W, & D of excision 2. Describe lesion, distance from closest margin 3. Describe cut surface & distance from deepest resection 4. Ink 1 color 5. Tips in 1 cassette 6. Serially section & sequentially submit (~2-3 pieces per cassette)
How to process eyelid resection for frozen section
1. Measured Quickly 2. Submitted "in toto" (no cutting) 3. Embed *"on edge"*
Nerves
1. Meissner corpuslces 2. Merkel Cell neurites 3. Free nerve endings
Congenital Disorders
1. Melanocytic nevi 2. Nevus flammeus 3. Albinism 4. Epidermolysis bullosa
Types of Tissue
1. Muscle 2. Nervous 3. Connective 4. Epithelial
Points to remember when decalcifying sections
1. Must be fixed before decalc. 2. Do at Room temp 3. Don't decalc longer than necessary (brittle/hard) 4. Wash in water for at least 24 hours after decalc 5. Decalc volume = 10-15x that of tissue
Adnexae
1. Nails 2. Pilosebacous Units -Hair follicles -Sebaceous glands -Arrector pili muscles 3. Eccrine glands 4. Apocrine glands
2 types of cell death
1. Necrosis - Irreversible cell damage, inflammatory response (more common) 2. Apoptosis - Programmed cell death, minimal inflammatory response. Normal function - embryogenesis
Most Common types of labeling discrepancies
1. No patient label on specimen nor req 2. Mismatch of label on specimen vs req 3. Both specimen and req have incorrect patient label
Causes of incomplete fixation?
1. Not fixed long enough 2. Inadequate amount of fixative 3. Section too thick 4. Formalin solution depleted
Nucleus
1. Nuclear membrane (separate nucleus contents to that of cytoplasm) 2. Nuclear pores (allow communication btwn nucleus and cytoplasm) 3. Nucleolus (produces most ribosomal RNA) 4. Chromatin (heterochromatin/euchromatic - genetically active DNA)
Methods to detect tumors in sentinel LN
1. Numerous H&E sections 2. Laser microdissection 3. PCR (single tumor cell)
Steps to processing larynx specimen
1. Orient 2. Measure & Describe 3. Ink soft tissue/mucosal margins 4. Cut posterior aspect to open 5. Photos 6. Fix specimen (few hours to overnight) 7. Sample margins 8. Describe & measure tumor 9. Sample anatomic landmarks (pre-epiglottic space, glottic region, anterior commissure)
Steps to grossing a total thyroidectomy
1. Orient 2. Weigh & Measure 3. Look for Parathyroids & include in dictation ("parathyroids not grossly appreciated") 4. Describe capsule & lesion 5. Ink lobes differentially - anterior/posterior 6. Ink isthmus black 7. Serially section the lobes from Superior to Inferior & lay out on paper towel OR 7. "C" section 8. Inspect & palpate for 4 things 9. PHOTO of Lesions 10. Submit in proper order *Make sure to do a TOUCH PREP*
Steps to grossing hemithryoidectomy
1. Orient 2. Weigh & Measure 3. Look for Parathyroids & include in dictation 4. Describe capsule & lesion 5. Ink lobes differentially - anterior/posterior 6. Ink isthmus black 7. *Shave (en face) isthmus margin* 8. Serially section the lobes from Superior to Inferior & lay out on paper towel OR 8. "C" section 9. Inspect & palpate for 4 things 10. PHOTO of Lesions 11. Submit in proper order *Make sure to do a TOUCH PREP*
Fundamentals of Specimen Dissection
1. Orient - use anatomic landmarks 2. Measure - size most important to document in gross dictation (overall size/distance from surgical margin) 3. Ink - marks resection margin 4. Sample - include lesion sections, normal tissue & margins 5. Assess Margins - perpendicular section for good margin eval
Total Laryngectomy steps
1. Orient specimen 2. Describe specimen 3. Ink soft tissues & mucosal margins 4 Cut thru posterior midline, crack open & keep open w/ wooden stick 5. Photos of opened larynx 6. Sample mucosal margins (inferior & superior) 7. Sample soft tissue margins (anterior & posterior) 8. Describe & submit sections of tumors (keep supraglottis, glottis & subglottis in mind) 9. Describe & submit section from both sides to include false cords, ventricles & true cords 9. Describe & submit sections of pyriform sinuses, epiglottis, aryepiglottic folds, anterior commissure, supglottis, thyroid cartilage, cricoid cartilage & hyoid bone 10. Sample pre-epiglottic & paraglottic spaces and anterior commissure 12. Document any other organs resected (thyroid gland/radical neck dissection)
Steps to processing maxillectomy
1. Orient specimen 2. Measure 3D 3. Describe anatomic boundaries (eye, skin, nasal choana, teeth) 4. Ink external margins of soft tissue 5. W/out sectioning, look into maxillary sinus & try to ID tumor (document size, location, walls involved, tumor origin?) 6. Sample margins of soft tissue, bone, mucosa & skin (number & type depend on nature/extent of resection) 7. Photo each margin section 8. Bisect specimen along plane thru tumor epicenter to demo tumor-adjacent structure relationship (avoid teeth unless necessary to include) 9. Describe tumor appearance & growth characteristics (exophytic/endophytic/erosive/infiltrative) 10. Measure tumor (include deepest invasion) 11. Submit tumor to show tumor-surrounding mucosa relationship (if tumor extends into other structures, include sections from those as well) 12. Regional LN are typically submitted separately
Steps to Radical Neck Dissection
1. Orient specimen 2. Measure 3D 3. Open the vein & sample any lesions 4. Separate off each level, ID all LN & submit each node 5. Examine submandibular gland & submit a section 6. Section muscle & submit a section if any lesions present
Steps to grossing an eye
1. Orient specimen 2. Measure anteroposterior, horizontal & vertical dimensions (mm) 3. Measure cornea & length of optic nerve 4. External description - transillumination 5. PHOTOS 6. Sectioning 7. Submit P-O section only, lesion (if present) & optic nerve margin
Problems Processing:
1. Overprocessing/excessive dehydration -Leads to very brittle & hard to cut -dessication 2. Blue halo effect (nuclear smudginess) -Leads to mushy tissue, underfixed, causes big holes
How to sample a margin
1. Parallel section - ie a shave specimen (adv = large surface area of margin can be evaluated with single section) (Dis = does not effectively demo relationship btwn margin & edge of tumor) 2. Perpendicular section - taken at right angle to edge of specimen (adv = can be used to demo relationship of tumor edge to margin)
Death opinions, 3 errors made:
1. PathMD holds onto 1 interesting finding, but ignores other equaling compelling evidence pointing to another explanation 2. Failure to see distinctions btwn degrees of opinion & probability 3. Failure to see the unspoken underlying assumptions
Info to include on specimen req
1. Patient ID - full name, identifying #, DOB 2. Type of specimen - date of collection, site of specimen, type of procedure 3. Clinical history - pertinent clinical history, ddx, operative findings 4. Additional Notations - special requests, biohazard alerts, name/phone # of MD to contact
Sequence of dictation
1. Patient name, type of specimen, what structures present 2. move from one component to next in methodical progression 3. overall to specific 4. abnormal to normal 5. relavent to ancillary (may choose to dictate after specimen has been fully examined to give less chaotic dictation)
Fixation
1. Place specimen in adequate formalin immediately after opening container upon receipt 2. Specimens to *fix before exam* (have muscles that can curl): -*Esophagectomies* -*Gastrectomies* -*Laryngectomies* 3. Cut THIN sections (no more than 3mm thick!) 4. Remember: Sections fix faster/better than full organ
Phases where discrepancies can occur:
1. Preanalytical - before specimen gets to lab 2. Analytical - during specimen processing at lab 3. Postanalytical - after results complete, delivery of results
What are the WHO categories of lymphoid neoplasms.
1. Precursor B-cell Neoplasms 2. Peripheral B-cell Neoplasms 3. Precursor T-cell Neoplasms 4. Peripheral T-cell & NK-cell Neoplasms 5. Hodgkin Lymphoma
Vertical growth of melanoma
1. Presence of nests w/in papillary dermis 2. Cytologically distinct from nests in intraepidermal
Infectious diseases of skin
1. Primary - occurs in normal skin 2. Secondary - occurs in already diseased skin 3. Systemic - spreads thru blood/lymphatics, more common in immunocompromised (ie skin abscesses post transplant)
What 4 things to inspect & palpate for in total/hemithyroidectomy?
1. Primary lesions and satellite nodules 2. Symmetry (for total thyroidectomy) 3. Capsular extension of any lesion 4. Characteristics of any lesion
What does synoptic reporting do?
1. Provides uniform/standardized data elements thru checklists so pathMDs can avoid free-text components 2. Generates consistent/standardized reports to optimized path reporting standards w/ QA & QC (ie accurate/consistant dx & staging info for MDs to base treatment & survival predictions) 3. Gives clear/consistent path dx info, reduces re-review slides & time signing out 4. Improves assessment of quality of care studies, marketing & research activities 5. Cancer registry can use template to pull out common data elements from complete path report *Overall, Uniformity of data capture lends itself to subsequent ease of data viewing/extraction with rapid production of standardized, high-quality data*
Growth phases of melanoma
1. Radial 2. Vertical
How do you reduce radiation exposure?
1. Reduce time 2. Increase distance 3. Use proper shields
Characteristics of melanoma Regression
1. Replacement of tumor cells by lymphocytic inflamm 2. Epidermis attenuation (less virulent) 3. Nonlaminated dermal fibrosis w/ inflamm cells, melanophagocytosis & telangiectsia
6 things to check before dictating specimen
1. Req 2. Cap 3. Cassette 4. Container 5. Special Procedures 6. Clinical history
Things to check before processing a specimen?
1. Req 2. Container 3. Cap 4. Cassette 5. Clinical history 6. Special tests
What are the ways to retrieve a FS tissue after cut?
1. Retrieving from stage 2. Retrieving from block
What is the order of submission for Thyroid?
1. Right Lobe (Superior -> Mid -> Inferior) 2. Left Lobe (Superior -> Mid -> Inferior) 3. Isthmus (Hemi: en face & Total: isthmus->Rt, isthmus->Lt) *Submit all sections with lesion*
Case Contamination
1. Rinse forceps following every specimen 2. Visually check forceps to insure tissue not stuck on tip 3. TRICK: have water container near to rinse instruments
How to improved IHC staining
1. Sample representative of area to study 2. Stabilize tissue w/ appropriate method 3. Do not overfix tissue
How should you use sensitive/specific tests?
1. Screen with highly SENSITIVE test 2. Confirm Positives with highly SPECIFIC (ie 1st pap smear (sensitive) -> 2nd biopsy (specific) tells difference btwn inflammatory & cancerous tissue) (ie 1st CA125 blood test (sensitive) -> 2nd workup w/ tumor markers/radiology (specific) as blood test could be indicating benign conditions)
What should be minimal PPE?
1. Scrubs 2. Eye protection 3. Gloves 4. Plastic gown to cover scrubs/exposed skin 5. Shoe coverings
Advantage of IMRT?
1. Sculpt out tumor w/out affecting healthy tissue 2. Radiates only tumor, not everywhere 3. Lowers morbidity associated with radiation treatment 4. Fewer treatments needed
How to retrieve from block?
1. Section cut is not fully detached, but small amt of medium is attached at top. 2. Wheel turned in opposite direction - brings section back to face of block. 3. Section retrieved by placing slide over tissue on face of block
Autoflourescent fungi
1. Seen in H&E stains under UV light 2. good for candida, aspergillus, coccidoides 3. Good for FS
Why use squash preps?
1. Shows tissue's cohesive nature (lymphoma dissociate into single cells -> epithelials are clumpy) 2. CT & brain tumors show fibrillarity of cytoplasm (thin strands in background)
Main reasons to receive a salivary gland
1. Sialoliths 2. Tumor - could possibly be lymphoma in the intraparenchymal LN
Stratification
1. Simple: single cell layer 2. Stratified: more than one cell layer - only 1 layer touching basal lamina (can withstand large amts of stress) 3. Pseudostratified: single cell layer, but position of nuclei give stratified look (common with columnar cells)
What is the appearance of incomplete fixation?
1. Smudgy nuclei 2. Tissue morphology not well maintained
Factors Affecting Dye Binding
1. Solution pH determines tissue and dye charge 2. Increased temp = increased stain rate 3. Increased dye concentration = increases stain rate 4. Added salts changes stain ability (compete for binding sites) 5. Amino group changed by Fixative & therefore eosin binding
Name the 4 step approach for diagnosing/prognosing tissues?
1. Specimen orientation - anatomical orientation & pertinent clinical history thru a req 2. Dissecting the specimen - clean cutting station, handle tissues carefully, margin inking, opening/sectioning specimen, fix specimen, specimen storage 3. Gross Description - represents permanent record of specimen's macroscopic features 4. Specimen Sampling - ie selective sampling (makes sure diagnostic tissue is studied and does not waste resources of lab/people)
Categorical vocabulary
1. Specimen type 2. Histological type 3. Extent of tumor
Causes of delayed fixation?
1. Specimens obtained long after blood supply gone 2. Specimen not cut open for fixation 3. Section too thick 4. Inadequate fixative volume
WHO classification of SCC
1. Spindle-cell SCC 2. Acantholytic SCC 3. Verrucous SCC 4. SCC w/ horn formation 5. Lymphoepithelial SCC
Epithelium by Shape
1. Squamous 2. Cuboidal 3. Columnar 4. Transitional
Epidermis Layers
1. Stratum Basale 2. Stratum Spinosum 3. Stratum Granulosum 4. Stratum Lucidum 5. Stratum Corneum
How should you section an eye?
1. Submit distal 3mm portion of optic nerve 2. No focal lesions after external exam? -open eye in horizontal plane parallel to center of optic nerve & macula (Pupil-Optic nerve section) 3. Stop to examine intraocular components w/ dissecting microscope 4. Place cut surface of globe on flat surface 5. Cut eye parallel to initial section
Shave Biopsies
1. Superficial excision (thin/1 piece) 2. For Dx, but can be full excision 3. Measure 2D 4. Describe lesions & measure distance from edge 5. Ink deep surface 6. Bisect if >0.3-0.4cm 7. Put 2 halves btwn 2 sponges to keep from curling 8. Write "on edge" on side of cassette 9. Dictation: "is a ___x___cm thin gray skin with an ill-defined brown-black macule, measuring ___x___cm, ___cm from the closest margin. The specimen is inked, bisected and entirely submitted as A1"
WHO - malignant melanocytic neoplasms of skin
1. Superficial spreading melanoma 2. Nodular melanoma 3. Lentigo maligna melanoma 4. Acral lentiginous melanoma 5. Mucosal-lentiginous melanoma 6. Desmoplastic/neurotrophic melanoma 7. Melanoma from blue nevus 8. Melanoma from giant congenital nevus 9. Melanoma of childhood 10. Nevoid melanoma 11. Persistent melanoma 12. Melanoma, NOC (not otherwise classified)
What procedures should be followed for bodies with high levels of radioactivity?
1. Supervision by Radiation Safety Officer 2. Monitoring of personnel external exposure (hand/body) 3. Disposable tools, secured area access, time limits, proper PPE
4 components of synoptic reporting
1. Synoptic reporting dictionarys & sub-dictionaries 2. Specimen data entry & text generation 3. Results interface (HL-7 interface) 4. Data search & management reporting
Normal thyroid activity
1. TSH stimulates thyroid release of T3/T4 2. T4 -> T3 3. T3 binds to thyroid receptors to stimulate global basal metabolic rate (increased protein synthesis & carb/lipid catabolism)
How to orient maxillectomy
1. Teeth (anterior-posterior) 2. Nasal structures (medial) 3. Eye/Orbital Structures (superior, often medial)
DC: Hints
1. Think pathophysiology (for chain of events leading to death) 2. Can lump a series of inter-related events 3. Two independent processes can be present that caused death (ie 2 drugs caused death)
What are the 4 main limitations of Frozen sections?
1. Time 2. Limited special stains and studies 3. Lack of consultation 4. FS Artifacts
What are actual FS limitations?
1. Time 2. Limited special stains/studies - can't diagnose if you don't have right test avail. 3. Lack of Consultation - can't diagnose if you don't know 4. Freezing artifacts = stromal & nuclear ice crystals/compression artifacts/nuclear chromatin changes
What are REASONS to do FS?
1. To find margins 2. Eval of Lymph Nodes 3. Dx of unexpected findings 4. Dx on mass previously biopsied (that was inadequate or indeterminate) ***NO NORMAL OR NECROTIC TISSUE***ALSO NOT FOR CURIOSITY!!!
Methods of Cytologic Slide Prep
1. Touch prep 2. Crush prep 3. Frozen Section
**KNOW WELL**: What is included in Lymphoma protocol (work up)?
1. Touch prep - OH fixed *and* air-dried 2. Squash prep 3. Flow cytometry (RPMI) 4. Cytogenetics (RPMI) 5. Acetic Zinc Formalin (AZF) or B3/B5 (thin slice) 6. One piece s/b frozen for molecular studies (store at -70)
What should you do for extranodal specimens of lymphoma?
1. Touch prep or frozen section to determine lymphoma 2. Yes? submit for appropriate special studies 3. Routinely process the rest as you would other specimens
How do you clean the cryostat brushes?
1. Touch soap & H2O and dry 2. Dip in 100% EtOH and dry 3. Dip in Xylene and dry 4. Cool a few seconds on cold surface
What factors contribute to risk of radioactive contamination?
1. Type/activity of radiation 2. Body opened or unopened 3. Days since admin of radioactive material 4. Time persons spend in vicinity of body
How does sentinel lymphadenectomy work?
1. Under general/local anesthesia - Inject intradermally radioactive tracer at site of previous biopsy scar and see where dye goes. 2. Sentinel node(s) are sent for frozen section or touch prep while primary tumor removed (based on knowledge of how lymph flows)
Squash Prep Procedure
1. Use scalpel to place small amt diagnostic tissue @ top of slide 2. Flip another slide on top and gently pull apart (don't squish!) 3. FIX
Wedge Biopsies
1. Usually on lip, ear & labia 2. Wedge-shaped skin w/ 2-3 margins 3. Ink = 1st color = 1st margin/2nd color = 2nd margin 4. Enface - Ink side down in cassette 5. If oriented = submit margins in 2 different cassettes If not oriented = submit margins in same cassette 6. Serially section & submit 1-2 sections in another cassette
Reasons tissue would fall off slide
1. Very dry tissue (either by nature or by desiccation, ie didn't fix right away) 2. More perimeter than area of tissue...ie lots of edges allows for turbulence of staining to jostle tissue off 3. Ammonia bluing reagent = too concentrated 4. Fix using 100% instead of 95% EtOH 5. Section is placed on top of embedding medium already on slide - be careful not to overlap tissue on embedding medium of nearby section
How should you process tonsils?
1. Weigh & measure INDIVIDUALLY 2. Describe mucosa & cut surfaces (Exudate on mucosa or granules in crypts)
Steps to processing salivary glands
1. Weigh & measure specimen 2. Describe external surface!!! 3. Orient & distinguish superficial/deep lobes 4. ID any nerves with specimen (to submit) 5. Ink 6. Palpate for tumor 7. Section gland (3mm intervals) 8. Measure & describe tumor/cut surface (well demarcated, encapsulated, infilitrative, solid/cystic, areas of cartilaginous differentiation, how close tumor to margins, multinodular) 9. Submit enough sections showing relationship of tumor to inked soft tissue margin, tumor to uninvolved gland, tumor to identifiable nerves 10. Examine/describe/submit remaining gland (including LN in parotid)
Epithelial Cyst (aka Wen)
1. Well-circumscribed, firm, Filled with fetid (stinky) gramous sebaceous material 2. Take out material before submitting 3. Only need to submit capsule of cyst 4. Treat like skin elipse
What should the sections for histology try to demonstrate?
1. all components of lesion (solid & cystic areas) 2. tumor-capsule-parenchyma interface 3. tumor relationship to thyroid capsule/extrathyroidal tissues 4. presence of parathyroids, LN, & normal parenchyma
What should you consider when sampling a tumor?
1. be sure to sample all areas of tumor that look different 2. large cyst sections s/b taken from areas of thickened or complex-looking walls 3. lesion s/b extensively or entirely submitted when concern for malignant transformation within benign lesion or premalignant process 4. peripheral sections of tumor usually more informative than sections from center
Autopsy benefits
1. can confirm/disprove clinical dx 2. reassure family that pt medical care was appropriate 3. increases medical knowledge & research opportunities
Why is the periphery the best place to obtain section of tumor?
1. central zone is frequently necrotic 2. periphery demos interface with tumor and adjacent tissues
Liquifactive necrosis
1. common in *bacterial infxns* (abcesses) & brain 2. necrotic area = soft & filled w/ fluid 3. *predominate autolysis or heterolysis* *(pus)*
Purpose of Pathology
1. discover etiology 2. understand pathogenesis 3. explain pathophysiology 4. describe lesion
Punch biopsy
1. embed so sections are obtained perpendicular to plane of epidermis 2. read clinical history carefully - might require special stains!
Instructions for Case Histories
1. fill out the "COD" & "contributing causes" as you would if signing out the DC 2. The "manner of death" line is included to help in IDing cases for which you would not normally be signing out unless you worked for the coroner/ME.
Melanoma ulceration features
1. full-thickness epidermal defect 2. evidence of reactive changes 3. thinning, effacement, or reactive hyperplasia of surrounding epidermis in absence of trauma/recent surgery 4. invasion thru epidermis (vs nonulcerated lift overlying epidermis) -Lower survival rate if tumor ulcerated -Increased ulceration in increased thickness -Ulceration may be present in situ, but does not effect staging
Direct immunofluoresence
1. improves dx of fungi 2. performed on formalin-fixed paraffin-embedded Adv: IF rids need for cultures, microorganism deactivated by formalin (does not effect fungi), & final ID possible w/in hours after H&E/GMS stains examined
Pigmented lesions: unoriented ellipse (excisional bx)
1. ink margin 2. measure skin ellipse (length x width, excised to depth___) 3. measure & describe lesion 4. measure distance from lesion to closest margin 5. Serially section (describe cut surface, measure thickness/distance from deep margin) 6. Submit sections: (tips in 1 cassette, CS in additional cassettes - no more than 2-3 sections per cassette)
Pigmented lesions: Shave
1. ink margin 2. measure/describe specimen & lesion 3. measure distance from lesion to closest margin 4. bisect 5. lay flat between 2 sponges 6. write "on edge" on side of cassette
Elliptical Cutaneous Specimens
1. ink resection margins (including deep) 2. note orientation in gross dictation 3. 1st remove small tips and place in separate cassettes (if orientation provided) or same cassette (if no orientation) 4. embed cut surface of tip down 5. single slices layed flat in cassette from rest of specimen
Berslow's Depths
1. less than 1mm = 85-90% 5 year survival 2. greater than 1mm = <50% 5 year survival
Why would you submit a normal LN?
1. microscopic alterations could provide insight into origin of primary lesion 2. document the structure was surgically removed
Gangrenous necrosis
1. no pattern 2. coagulative necrosis applied to ischemic limb 3. superimposed bact infxn gives liquid pattern (ie wet gangrene)
Virchow
1. organs removed 1 by 1. 2. In order: cranial cavity -> spinal cord (from the back) -> thoracic organs -> cervical organs -> abdominal organs
Lymph Node Sampling
1. orient specimen, designate various regional lymph node levels & submit soft tissues before LN dissection 2. look for LN in fresh specimen (often preferred) as fixed tissue can make finding smaller LN difficult when surrounded by hard tissue 3. LN bigger than 5mm s/b sectioned to ease fixation 4. Never submit multiple sections from more than 1 LN in single cassette.
Issues to address in Melanoma surgical report
1. procedure performed/structures present 2. histologic type of tumor 3. growth phase 4. deepest level tumor penetration 5. max tumor thickness 6. any margins involved by tumor? 7. tumor ulcerated? 8. mitotic figures? 9. precursor lesions? 10. evidence of lesion regression? 11. host inflam response? 12. evidence of vascular/neural invasion
How to process Moh's
1. process horizontal sections 2. try to provide anatomic localization of involved margins based on MD info
Goals of gross description?
1. serves as descriptive report so reader can mentally reconstruct specimen 2. serves as slide index for pathMD to correlate slide to precise location on specimen (ie what cut from which part of lesion) for diagnostic/research purposes 3. accounts for distribution of tissue (ie what parts went into which cassettes)
What technique to Dx skin (cutaneous) tumor, but don't typically determine margins?
1. shave biopsy 2. punch biopsy 3. curettage
Round cutaneous specimens
1. tangentially shave (all around) & embed separate cassettes (if oriented) 2. serial slicing of remaining central tissue
Caseous necrosis
1. tuberculous lesions 2. soft, friable, "cheesy" material 3. microscopically amorphous eosinophilic material w/ cell debris *(granuloma)*
For dissection, what are 3 fundamental questions to ask yourself?
1. what structures are present? 2. what is the nature of the pathologic process? 3. how extensive is that process?
left ventricle walls thickness
1.0 cm
mitral valve width
10 cm
Microtome Angle
10 degree
Microtome Angle
10 degrees
What is the ideal/set angle setting on the microtome?
10 degrees
Ideal TRIM thickness
10 micrometers
How many LN are typically included with *radical or modified radical* neck dissection?
10 or more
How many LN are typically seen in a radical/modified radical neck dissection?
10 or more
Trim thickness
10 um
Fixation for enucleation?
10% Neutral Buffered Formalin OR Gluteraldehyde
What is most common fixative for ocular tissue
10% Neutral buffered formalin (except for electron microscopy - causes tissue shrinkage)
pancreas
100 gms - 23 cm
uterus (after gestation)
110 gms
tricuspid valve width
12 cm
Female brain
1275 gms
testes
13 gms
Kidney
130 - 160 gms
thymus (in first 25 years of life)
14 - 25 gms
Weight of parotid gland
14-28 grams
spleen
140 - 160 gms
male brain
1400 gms
liver
1650 gms
What is the rule concerning formalin volume?
1:15-20 ratio, but in larger or fatty specimens may need more or less
# of slides made
2 slides per block
prostate (under 50)
20 gms
The Entire frozen procedure from receipt to diagnosis must be completed in how many minutes?
20 minutes
How do you fix brain tissue?
20% formalin for 2 weeks (do not cut open prior to fixing), then rinse for at least 1 hour before brain cutting.
Chuck size uses
20mm - brain & cord biopsy 40mm - bone
How long to fix enucleated globe (eyeball)?
24-48 hours (then h2o rinse, 16 hours & EtOH 60% for grossing)
female heart
250 gms
How should you measure a tumor of a maxillectomy?
2D measurements & note if seen externally
In a sentinel node with no gross pathology, how many sections per block?
3
ovary
3 gms
How many levels in histology s/b taken for LN?
3 levels on each block ("face in" inbtwn each level taken)
Epidermolysis Bullosa:
3 major forms of this condition and 16 subtypes, several congenital skin disorders together. You have a formation of skin blisters with any rubbing or trauma including wearing clothing. Can be fatal in children because of infection.
What is the optimal thickness of tissue sections in a cassette?
3 mm
Common fixative for Electron Microscopy
3% gluteraldehyde
thyroid
35 gms
uterus (before gestation)
35 gms
What is the weight of thyroid gland?
35 grams (increases 50% in women during secretory phase of menstrual cycle)
male heart
350 gms
How should you measure a maxillectomy?
3D measurement: -superior/inferior -anterior/posterior -medial/lateral
Size of section you cut
3mm (no larger than a nickel) - must fit diagnostically on slide
prostate (over 50)
40 gms
lung
400 gms each
Each turn of the wheel advances the microtome how far?
5 micrometers
Ideal SECTION thickness
5 micrometers
Section thickness
5 um (thicker for brain or difficult tissues: fat/bloody)
adrenal gland
6 gms
How many LN are typically seen in a selective neck dissection specimen?
6 or more
How many LN are typically included with *selective* neck dissection?
6 or more LN
How many minutes should a PA perform their portion of the frozen section procedure within?
7 minutes
How much does submandibular gland weigh
7-8 grams
aortic valve width
7.5 cm
parathyroid
75 - 150 mgs
pulmonic valve width
8.5 cm
Most often used fixatives are (2):
95% ETOH, Formalin
Dx of malignant melanomas
A = Asymmetry B = Borders (irregular) C = Color (variegated) D = Diameter (increasing) E = Evolution (change over time)
Incision:
A clean linear cut, with smooth, clean edges.
Anaplasia
A lack of differentiation
Lentiginous
A linear pattern of melanocyte proliferation within the epidermal basal cell layer
Metaplasia
A reversible change in which one differentiated cell type either epithelial or mesenchymal is replaced by another cell type
Crust:
A skin defect covered with coagulated plasma/blood will be seen on healing wounds. Looks like a scab
Elliptical
A symmetrical oval
Basement Membrane
A thin film of non-cellular tissue on which the epithelium rests
Fistula:
A tract of communication from organ to organ or organ to skin. Often happens in rectum to anus. Usually caused by infection.
MALIGNANT MELANOCYTIC LESIONS MELANOMA (malignant melanoma)
A. General: • *malignancy of melanocytes* most common in light skinned populations, especially those with increased sun exposure. Women have better tumor survival rates than men. A predisposition for development of melanoma may be inherited through DNS (dysplastic nevus syndrome). B. Risk factors for developing melanoma: Generally: • *"WASPs" are at greater risk than non-WASPS* (White, Affluent people who are Sun sensitive and/or have Precursor moles). (Note: normal number of nevi is approximately 20, total body) C. Location: • skin usually, generally *in sun-exposed regions*. Melanoma can also occur in deep soft tissues (clear cell sarcoma, melanoma of soft parts), in the retina (eye grounds appear black, no "red reflex"), esophagus and ano-rectal region. D. S/S: *a "mole" with irregular borders and/or "blotchy" coloration in shades of red,* *white, blue, and black,* *perhaps with recent change; enlargement, irritation, ulceration or bleeding*. E. *Growth phases: RADIAL and VERTICAL*. Radial spread (laterally) usually occurs first, before the lesion invades (vertical phase) ... exception is nodular melanoma (which has virtually no radial phase). F. Four types: 1. LENTIGO MALIGNA MELANOMA: usually on face. Slow progression from radial to vertical phase (years). May get large, up to 6 cm in greatest diameter. They look like "ink stains." 2. SUPERFICIAL SPREADING MELANOMA: Confluent atypical cell nests at junction; prominent radial growth pattern before and during vertical phase (therefore these tumors, like lentigo maligna, can get rather large, but still are usually less than 3 cm in diameter). 3. NODULAR MELANOMA: by definition an invasive tumor (very little radial growth). Therefore a poorer prognosis. 4. ACRAL LENTIGINOUS MELANOMA: a rare variety (1% of melanomas) arising on the volar aspects of feet (92%) and hands (8%). Sometimes subungual in location. Melanomas that occur in mucosal locations are lumped into this category (vagina, esophagus, etc). G. Although 80% or more arise "de novo", possible precursors of melanoma include: 1. Dysplastic nevus 2. Congenital nevus 3. Xeroderma pigmentosum 4. Any nevus with junctional activity H. Microscopic features: • "the great imitator"; *atypical large cells, many with nucleoli. Pigment variable* (stains: Fontana Masson, others). Tumor expresses S100 protein (stained through special immunohisto- chemical techniques). Melanoma-specific antibodies have been developed, but some are not truely "specific." I. Prognosis: (usually depends on "vertical phase"): 1. Clark's levels (see diagram below): I - in situ (no vertical growth): 100% cure if totally excised. II - invasion into papillary dermis: local excision only, good prognosis. III - invasive tumor filling papillary dermis to form a "line" at beginning of reticular dermis (uninvolved). Course is difficult to predict ("thick 3s and thin 3s). Need to correlate with Breslow's tumor depth (below). IV - invasive tumor in reticular dermis. Corresponds to lesion depth of greater than 0.75 mm. V - invasive tumor in subcutaneous tissue (fat). Less than 10%, 5 year survival. 2. Breslow's depths: Invasion depth measured from granular layer: • less than 1.0 mm ... 85-90% 5-year survival • more than 1.0 mm ... < 50% survival.
Mycosis Fungoides:
AKA T-Cell lymphoma. Fix in Zeus fixative for immuno-staining. Skin macules and papules that progress to nodules and ulcerating masses.
Transitional
AKA urothelium, bladder
How will a tumor spread if 1st located laterally?
into bones, cheek & possibly parotid gland
Glomus bodies
AV shunts, divert blood from skin to conserve heat (hands, feet & ears)
Fistula
Abnormal communication between organs (Caused by infxn - diverticulitis)
Dyskeratosis
Abnormal, premature keratinization within cells below the stratum granulosum
Excoriated
Abrasive surface
AZF fixative
Acetic acid Zinc Formalin -no mercury, can dispose w/out hazmat -greater flexibility in fix times -decreases decalcification time in BM -eliminates alot of labor (as needed with B3/B5)
What is saliva formed by?
Acinar cells
Coagulation necrosis
Acute and flat
How will a tumor spread if 1st located on roof of sinus?
into orbital cavity, ethmoid sinuses & cribriform plate
Bluing agent is typically made how?
Adding 3 drops Ammonium hydroxide to entire jar of distilled water.
Of salivary gland carcinomas that do require grading, which one is based on growth pattern?
Adenoids cystic carcinoma High grade based on % of solid growth (>30%)
Subcutis
Adipose, blood vessels, lymphatics, nerves
Adv/disadv using H&E for fungal infxn dx
Adv: -eval host response (Splendore-hoeppli phenomenon) -detects other microorganisms -confirm presence of naturally pigmented fungi -demo's nuclei of yeast-like cells Disadv: -difficult to distinguish poorly stained fungi from tissue components -sparse fungi easily overlooked -morphologic features not evident or misleading
What are adv & disadv to using gluteraldehyde fixation with enucleation?
Adv: Causes LESS shrinkage (Used for light & electron microscopy) Disad: Tissue become very brittle & affect staining (PAS false pos)
Adv/Disadv for GMS
Adv: gives better contrast & stains degenerated/nonviable fungi Disadv: Mask natural color of pigmented fungi & do not show inflamm response to fungal invasion
Adv/disadv for PAS:
Adv: shows fungi morphology better than GMS & stains degenerated fungi Disadv: can have false positive
Adv/Disadv to Letulle
Advantage = fast, available to undertaker <30 min w/out rushing dissection. Disadvantage = requires more experience, organ mass is awkward to handle
Advantages and Disadvantages of Virchow
Advantages: Fast and easy to do, disadvantage you can lose relationships between organs or organ and pathology
Cutaneous melanoma prognosis
Affected by primary anatomic site and "vertical phase"
If no sections are required for submittal, what should you do?
After completing gross description, place specimen in formalin to store for at least 2 weeks
Fixation:
After opening the specimen upon receipt, the specimen should be pinned or placed in container (most often in esophagetomies, gastrectomies, laryngectomies). Take measurements in fresh state! Many specimens do specimens fresh. Fresh or thick dont take sections thicker than 3mm or 0.3 cm in thickness!
Process of staging a tumor
After removal of organ of involvement: -LN are systematically removed -examined in usual order of lymph drainage received from organ involved
Langerhan Cells
Ag-presenting cell thru-out epidermis
Grossly describe adenoids
Aggregate of granular fragmented tan-pink soft tissues
Storing a specimen
All parts received are stored in the individual containers (consider ALL parts legal evidence from req to specimen), make sure there is adequate formalin coverage on the specimen, when doing a regionalized lymph node dissections, levels should be wrapped individually and labeled before returning to the container
WHere should you open the larynx specimen?
Along posterior aspect
How do you measure total thryoidectomy?
Always do the same way! Measure 3D 1. Right lobe 2. Left lobe 3. Isthmus 4. Pyramidal (if present)
What should you remember for lymphatic drainage of breast?
Always examine *lateral aspect* of breast tissue for nodes (ie axillary tail) (3D measure packet of adipose tissue & dictate "within which are # LN ranging from smallest to largest")
What does parathyroid regulate?
Amount of calcium in body (low blood Ca++ = more PTH secreted) (high blood Ca++ = less PTH secreted)
Prognostic factor - melanoma
Amount of pattern of disease in sentinel node
Medicolegal autopsies
An autopsy that is performed under the provisions of the medical examines office of that state
Neoplasm
An uncontrolled growth of new cells, and can be benign or malignant
How do you orient a radical neck dissection?
Aneriosuperior = submandibular gland Medial = int. jugular vein overlaying SCM muscle
Which is more aggressive form of follicular carcinoma, capsular invasion or angioinvasive?
Angioinvasive
What is an important parameter for papillary and follicular carcinomas?
Angiolymphatic invasion
Why are margins important?
Answers the question: does the tumor extend to that edge so that it affects adjacent structures?
Level VI
Anterior (central) Compartment -LN = Pre/paratracheal, precricoid & perithyroid nodes (including LN in recurrent laryngeal nerve) -Sup. Boundary = hyoid -Inf. boundary = suprasternal notch -Lat boundaries = common carotids -Post boudary = prevertebral fascia
What structures make up boundaries of pre-epiglottic space?
Anterior - thyroid cartilage & thyrohyoid membrane Posterior - epiglottis & thyroepiglottic ligament Base - hyoepiglottic ligament
Location of Thyroid in body
Anterior to trachea under cricoid cartilage
What is location of thyroid gland?
Anterior to upper trachea & inferior to cricoid cartilage
How to orient maxilla in maxillectomy
Anterior/Lateral = teeth & cheek skin (if present) Medial = nasal choana (ie lateral wall of nasal sinus) Superior = eye (if present)
How do you orient larynx specimen?
Anteriosuperior = epiglottis Anterioinferior = thyroid cartilage
How do you orient a radical neck dissection?
Anterosuperior = Level 1 (submandibular gland) Posteromedial = Internal jugular vein Posterolateral = SCM
Langerhans cells (epidermis)
Antigen presenting cells throughout epidermis and upper dermis.
What is the surgical criteria for removing a LN in sentinel lymphadenectomy?
Any node that picks up blue dye (these are mapped as most likely metastasis)
What does an en face margin show?
Any positive part makes it positive
What are nodes called in the region of an apical stitch?
Apical nodes
Ciliated Cells
Apical plasma membrane extension composed of micro tubules, capable of beating rhythmically to move mucus or other substances through a duct.
Lentigo
Area of skin with hyperplasia of melanocytes
What does a grossly positive LN look like?
Areas (or entire LN) of ill-defined gray, white & firm tumor
Acute Disease
Arises rapidly, accompanied by distinctive symptoms, lasts a short time
What is an example of chronic disease?
Arthritis
When tumor sits over anterior commissure (above false cords) what is the most likely site for tumor extension?
Arytenoid cartilage
Microscopic Examination
Assessment of magnified images of small structures. The study of cellular morphology.
Gross Examination
Assessment of tissue specimens either surgical or autopsy with the unaided eye
How long to fix tissues in formaldehyde?
At least 8-12 hours (others say 48hrs - 1 week)
How long to fix tissues in formaldehyde?
At least 8-12 hours, sometimes 48hrs - week
What should you document/describe in cataract specimen?
BCDE 1. Bisection at center - note any papillary items 2. Color & opacity 3. Diameter & thickness 4. Embedding (ie on edge)
What duct is associated with sublingual gland
Bartholin's duct - empties into floor of mouth on both sides of tongue frenulum
What is the most common pathology seen for eyelid excisions?
Basal Cell Carcinoma
Which carcinoma accounts for the majority of all malignant epithelial tumors of eyelids?
Basal Cell Carcinoma
Merkel Cells
Basally located sensory neuroendocrine cells
T classification of melanoma
Based on: -thickness of primary tumor -presence/absence of ulceration -mitotic rate -anatomic level of invasion
Why would you fix a larynx specimen?
Because it will cut down on tissues curling when put into a cassette due to muscle
Why are elliptical specimens taken?
Because the wound lies parallel to skin tension lines (easy closure)
When should you take photos of maxillectomy?
Before & after bisecting
Chronic Disease
Begins slowly, signs and symptoms are difficult to interpret, persists for a long time, unable to be prevented by a vaccine or cured by medication
What is an anthracotic LN?
Benign collection of carbon typically seen in lungs, trachea & intrapulmonary LN (common!) w/ lung
Pigmented lesions:
Benign. Patch of skin where melanocytes show hyperactivity shown to UV stimulation. Become darker when exposed to sun
Pigmented Lesions
Benign: 1. *Freckles* - patch of skin with melanocytes hyperactivity to UV radiation, darken with sun exposure 2. *Lentigos* - hyperplasia of melanocytes, don't darken with sun exposure 3. *Nevi* - developmentally abnormal skin (RAS pathway) -Dermal nevus (in dermis) -Junctional nevus (at dermoepidermal junction) -Compound nevus (junctional & dermal) 4. *Dysplastic nevus* - precursor to malignant melanoma -larger than non-dysplastic nevi (>5mm) -flat macules to slightly raised plaques w/ varied pigmentation & irregular borders -Occur in both sun-exposed & protected skin
Kidney
Bilateral kidneys, aorta, bilateral ureters, urinary bladder also includes prostate
Green color
Bile or bile pigments
What is an example of a highly specific test?
Biopsy
What color ink should you never use on skins?
Black! Because of melanoma.
What is the preferential route of spread for follicular carcinoma?
Blood vessels
What happens if you have too much PTH?
Bones keep releasing Ca++ into blood & leads to osteoporosis (brittle bones)
Well demarcated
Boundary between normal and abnormal is easily seen
What tissue for squash prep?
Brain
Which tissues used for SQUASH PREPS?
Brain (or other gooey tissue)
What type of tissue is used on squash prep slides? What does it show?
Brain, "gooey" tissue. -shows cohesive nature of tissues
What are/where do most mislabels for pathology happen?
Breast, skin and colon biopsies/during analytical phase in the pathology lab
Boundaries of paraglottic space?
Btwn thyroid cartilage & vocal cords base membranes (conus elasticus/quadrangular membrane)
What is exophytic?
Bulging out of tissue into polyp-oid mass
1st sigh of formalin exposure
Burning throat
1st sign of formalin exposure
Burning throat
Anatomy of Thyroid
Butterfly-shaped organ: 2 lobes connecting to central isthmus (can also have pyramidal lobe)
Removal of organs
By preference of pathologist, use Virchow
Why is *regionalizing* sections for MEN syndrome thyroid important?
C cell hyperplasia & medullary carcinoma most likely to occur in middle of lobe
What does entire submission of MEN syndrome thyroids detect?
C cell hyperplasia or medullary carcinoma
H&E Problem:Cytoplasm overstained - differentiation is poor
C: 1) Eosin solution too concentrated, or stained too long. 2) Dehydrating steps after eosin too quick - OH for differentiation S: 1) Dilute eosin or decrease staining time 2) Allow more time in dehydrating steps 3) Thickness = 3mm
H&E Problem:Cytoplasm overstained - differentiation is poor
C: 1) Eosin solution too concentrated, or stained too long. 2) Dehydrating steps after eosin too quick - OH for differentiation S: 1) Dilute eosin or decrease staining time 2) Allow more time in dehydrating steps 3) Thickness = 3mm
H&E Problem: White spots seen in section after deparaffinization (gives spotty staining).
C: 1) Not dried properly before deparaffinization. 2) Not in xylene long enough to get remove paraffin. S: 1) Treat w/ 100% OH & retreat w/ xylene. 2) Return slides to xylene for longer.
H&E Problem: White spots seen in section after deparaffinization (gives spotty staining).
C: 1) Not dried properly before deparaffinization. 2) Not in xylene long enough to get remove paraffin. S: 1) Treat w/ 100% OH & retreat w/ xylene. 2) Return slides to xylene for longer.
H&E Problem:Nuclei too pale (ie hematoxylin too light).
C: 1) Not stained long enough w/ hematoxylin. 2) hematoxylin solution overoxidized 3) Bone sections may be overdecalcified S: 1) Section must be restained. 2) Use fresh hematoxylin
H&E Problem:Nuclei too pale (ie hematoxylin too light).
C: 1) Not stained long enough w/ hematoxylin. 2) hematoxylin solution overoxidized 3) Bone sections may be overdecalcified S: 1) Section must be restained. 2) Use fresh hematoxylin
H&E Problem:Nuclei are overstained or diffused hematoxylin into cytoplasm
C: 1) Too long in hematoxylin 2) Sections too thick 3) Differentiation step too short. S: 1) If not too thick, then decolorize and restain. 2) If too thick, recut section.
H&E Problem:Nuclei are overstained or diffused hematoxylin into cytoplasm
C: 1) Too long in hematoxylin 2) Sections too thick 3) Differentiation step too short. S: 1) If not too thick, then decolorize and restain. 2) If too thick, recut section.
H&E Problem:Pale eosin stain
C: 1) pH of eosin above 5 2) sections too thin 3) dehydrated too long S: 1) adjust eosin to pH 4.6-5 & remove bluing agent completely before eosin. 2) Thickness = 3mm 3) don't let stand in lower conc. of OH after stain - H2o pulls eosin out
H&E Problem:Pale eosin stain
C: 1) pH of eosin above 5 2) sections too thin 3) dehydrated too long S: 1) adjust eosin to pH 4.6-5 & remove bluing agent completely before eosin. 2) Thickness = 3mm 3) don't let stand in lower conc. of OH after stain - H2o pulls eosin out
H&E Problem:hazy blue nuclei
C: 1) too much heat on processor 2) holding specimen too long in hot paraffin 3) too short fixation followed by direct higher OHs S: 1) Heat only used for paraffin infiltration step 2) do not hold tissue in hot paraffin 3) fix tissue well & dehydrate starting with 65%-70% OH
H&E Problem:Red/red-brown nuclei
C: 1)Hematoxylin breaking down 2) section not blued sufficiently S: 1) Check oxidation of hematoxylin 2) Bluing time longer
H&E Problem:Red/red-brown nuclei
C: 1)Hematoxylin breaking down 2) section not blued sufficiently S: 1) Check oxidation of hematoxylin 2) Bluing time longer
H&E Problem: Mounting medium retracted from edge of cover glass
C: Cover glass is warped or mounting medium thinned w/ too much xylene S: Apply new cover glass w/ fresh mounting medium
H&E Problem:Cannot focus some areas of tissue with LM
C: Mounting media on top of cover glass S: Remove glass and remount w/ clean cover glass
H&E Problem:Uneven H&E staining - poor nuclear chromatin detail
C: Water/fixative in the infiltrating paraffin - contaminated reagents or absorption of atmospheric H2O S: 1) high humidity? Substitue toluene for xylene 2) check for equipment malfunction
H&E Problem:Uneven H&E staining - poor nuclear chromatin detail
C: Water/fixative in the infiltrating paraffin - contaminated reagents or absorption of atmospheric H2O S: 1) high humidity? Substitute toluene for xylene 2) check for equipment malfunction
H&E Problem:Water and slides turn milky when slides placed in water after rehydrating
C: Xylene not completely removed S: Change OHs, back up to absolute alcohol and dehydrate sections
H&E Problem:Brown stippling & glossy black nuclei
C: allowed to air-dry before adding cover slip S: remove cover glass and medium with xylene and rehydrate. Put in H2O for several minutes - then dehydrate, clear and remount. Do not let slide air-dry.
H&E Problem:dark basophilic staining of nuclei and cytoplasm, especially around edges of tissue
C: laser/electocautery techniques denature macromolecules & produce heat artifact S: no solution
H&E Problem:Blue-black precipitate on top of sections
C: metallic sheen from hematoxylin develops on slide S: filter hematoxylin solution daily
H&E Problem:mounted stained sections do not show the usual transparency/crispness when viewed with LM
C: mounting medium too thick S: remove cover slip and medium with xylene, and remount with fresh medium
H&E Problem:Water bubbles seen microscopically
C: sections not completely dehydrated S: remove cover glass and mounting media with xylene. Dip in absolute OH and clear again with fresh xylene - mount w/ synthetic resin.
H&E Problem:Slide are milky in last xylene prior to cover slipping
C: water not completely removed before xylene step S: change OH solutions and re-dehydrate
What is an example of a sensitive but not specific test?
CA125
Characteristics of reversible injury
CAF 1. *Cell swelling* 2. *ATP Depletion* (due to mitochondria injury & lack of ATP reduces ion-pump activity) 3. *Fatty change* via cytoplasmic lipid vacuoles
Tissue patterns of necrosis
CCFGL 1. Coagulative 2. Caseous 3. Fibrinoid 4. Gangrenous 5. Liquefactive 6. Fat
Which nerve is the spinal accessory nerve?
CN XI
Consent must be:
COL -*Completed & witnessed* -*Obtained in person or by phone*, from a 1st degree relative/guardian -*Limitations must be stated*
Specimen Dissection
CSPE 1. *CHECK:*req, cap, cassette, container, clinical history, special testing 2. What *structures* are present? 3. What *pathology is present*/reason for surgery? 4. How *extensive* is process? (ie what structures involved w/ pathology - margins, adherent organs, LN etc)
What is a sialolith?
Calculi (stone) of the salivary gland
Disadvantage to using formaldehyde as fixative
Can be oxidized to produce formic acid - causes "formalin pigment" (birefrigent) to precipitate in blood-rich tissues
What are characteristics of malignancy?
Can invade and destroy tissue of origin, can move to adjacent and distant sites, and can cause death by either structural or metabolic change in patient
***Cancerous LN***
Cancerous LN = grossly pos for metastatic tumor -enlarged -not painful when compressed in situ -firm on palpation -gray or white cut surface (except in melanoma or anthrocosis)
Dx for extensive extrathyroidal extension?
Carcinoma beyond thyroid gland with direct invasion into 1 or more of following: -subcutaneous soft tissues -adjacent viscera (larynx, trachea and/or esophagus -recurrent laryngeal nerve, carotid artery or mediastinal blood vessels
Transglottic carcinoms
Carcinoma that crosses ventricles in a vertical direction arising in glottic or supraglottic larynx
What is true about tumors with "close" margins?
Carry increased risk for local recurrence
Folliculites
Caused by staphoreus and limited to hair follicles. Can use antibiotic therapy. Can be secondary where you have bacteria that develop in area.
Stem Cells
Cells able to turn into one or more of any of the other cells. They are pluripotential
Columnar? Found where?
Cells are taller than wide, with a nucleus close to the base of the cell. Found in small intestine, goblet cells are found in columnar cells and secrete mucus.
Stem cells
Cells capable of becoming another type of cell (ie pleuripotent cells)
Keratinized cells
Cells containing keratin, found where tough impermeable layer is necessary
Functional Disorder
Change in performance of cells, tissues & organs
Functional Disorder
Change in the performance of cells, tissues, and organs
PET detects:
Changes in cellular function (how cells utilizing nutrients - sugar, oxygen)
Rokitansky Technique
Characterized by in-situ dissection combined with the removal of organ blocks.
Before you cut:
Check ID (MRN, name, birthday)
What should you do first when receiving a surgical salivary gland?
Check clinical history to find out why you received it.
What should you always check for before the next specimen?
Check forceps to make sure tissues is not tuck in tip before doing next specimen
What's most important thing after chart review?
Check name on chart matches wristband or toe tag before you cut. Use more than just the name (I.E. MR # and birthday)
Dissection of specimens: what are the three fundamental issues?
Check: Name, MRN, cap, cassette, why is it being grossed? What structures are present? What pathology is present/reason surgery is performed? How extensive is the process: I.E. what structures are involved with the pathology (margins of resection, adherent organs, serosal surfaces, lymph nodes, etc)
What is synoptic reporting?
Checklist reports (structured & pre-formatted method for entering clinically & morphologically relevant details of surgical specimens)
Recognition of danger
Chemicals (formalin, xylene, ammonia, acetic acid, alcohols, etc), Biological Hazards (HIV, hepatitis, mycobacterium (TB), sharps
Vesicular:
Chickenpox (children), herpes zoster/shingles (adults)
What are disease-related changes in LN?
Chronic Disease: -Lymphocyte depletion, fibrosis & hyaline deposits w/in LN -particularly in cancer
Describe normal lymph
Chylous fluid (milky white opaque)
What happens to trachea tissue after consistent smoking?
Cilia die off and replaced with squamous cell metaplasia
What are cataract specimens?
Circular, disc-like opaque, thin, concave specimen
Macule
Circumscribed, flat usually pigmented lesion 5mm or <
Incision
Clean, linear cut with smooth edges
Serosanguinous
Clear but blood tinged fluid
Serous
Clear extra cellular fluid
Basal cell carcinoma (BCC)
Clinical features • Flesh-colored to pearly raised papules and nodules on sun exposed sites • Indurated plaques - May bleed or ulcerate • Pigmented variants with hyperpigmentation Histopath: • Several histologic patterns • Invasive nest or cords of basophilic cells resembling basal keratinocytes • Nuclear palisading at edges of nests • Peri-tumoral mucin production Note: • Most common cancer in man • Most common malignant skin cancer • 4 times more common than SCCa • 34 times more common than malignant melanoma • Very rarely metastasize (0.01 to 0.1%) • Locally destructive Risk factors: • Arsenic • Irradiation • Coal-tar derivatives • Ultraviolet light • Immunosuppression (immunosuppressed patients show a reversal in the usual 4:1 ratio of BCC to SCC — SCC more common in immunosuppressed patients)
Squamous cell carcinoma (SCC)
Clinical features • Most commonly affect the head and neck of elderly • Quickly growing flesh colored to red nodules • Overlying scale or crusting • Usually asymptomatic unless perineural invasion present • Ulcerating, papillomatous and subcutaneous variants Histologic: • Aggregates of atypical epithelial cells invading the dermis • Keratin pearl formation / keratinization • Variable mitotic activity Note: • Second most common form of skin cancer • Most common inciting cause of skin SCC is cumulative ultraviolet radiation • Capable of metastasis Risk factors • UV light • HPV • X-rays • PUVA therapy • Polycyclic aromatic hydrocarbon exposure • Immunosuppression • Preexisting chronic dermatoses and ulcer/sinus tract
Angiomas
Clinical features: Multiple variants of hemangiomas: • *Capillary hemangioma* (juvenile or strawberry hemangioma) (Small vessels filled with red cells) • *Cavernous hemangioma of liver* (larger vessels filled with red cells) • Don't treat as will regress with time, especially on the head and neck Histopath: • Benign vascular proliferation • Capillaries or • Cavernous vessels • Both
In-transit metastasis - melanoma
intralymphatic tumor in skin or subcutis tissue more than 2cm from primary tumor but not beyond nearest regional LN basin
Kaposi Sarcoma (KS)
Clinical features: • *Classic (European)*: predominantly men, older than 50 years old, Ashkenazi Jews or Mediterranean descent, distal lower extremities • *African (endemic)*: males, younger age • *AIDS-associated (epidemic)*: homosexual men more than other risk groups, upper half of body, early lesions are small pink to purple progress to disseminated disease • Immunosuppression: organ transplant recipients, disseminated disease Histopath: • Three stages: - *patch stage, plaque stage, nodular stage* • *Spindle cell infiltrate with irregular blood vessels* or slit-like spaces containing red cells Note: • Isolation of herpes virus-like DNA sequences (human herpes virus or HHV 8) strongly suggest a role in pathogenesis
Xanthomas
Clinical features: • *Yellow plaques associated with hyperlipidemias* 4 classic types of xanthomas 1. Tuberous xanthoma - Site: elbows, knees 2. Tendinous xanthoma - Site: extensor tendons of hands, feet, achilles 3. Xanthelasma - Site: eyelids 4. Eruptive xanthoma - Site: buttocks and other sites Histopath: • *Foam cells* arranged interstitially between collagen bundles • *Few to no lymphocytes, neutrophils, eosinophils* Eruptive xanthoma is exception: • Fewer foam cells • More lymphocytes, neutrophils, and eosinophils • Intracellular and extracellular lipid
Benign fibrous histiocytoma (dermatofibroma)
Clinical features: • Papule or nodule, most less than 1.5 cm • Overlying skin erythematous or hyperpigmented • Dimple sign Histologic • Symmetric & Well circumscribed but not encapsulated • Confined to dermis • Fibrohistiocytic cells entrap preexisting collagen bundles • Fascicles in a storiform pattern • Persist for many years, some regress spontaneously • Recurrence is infrequent following complete excision Note: • Pathogenesis in unknown • Tumors with hyperpigmentation mistaken for a melanocytic lesion • Commonly encountered • Reactive process??? • Young to middle aged adults
Actinic keratosis (AK)
Clinical features: • Small erythematous keratotic lesions on sun damaged skin • Scale may be white to yellow brown • Asymptomatic/itching or tenderness Histopath: • Hyperkeratosis with intermittent parakeratotic nuclei • Keratinocyte atypia along the basal layer • Budding of basal layer keratinocytes BUT no invasion • Perivascular inflammation and solar elastosis Note: • AK's are squamous cell carcinoma-in-situ • 10 - 20% develop invasive SCCa over 10 years • AAD recommends destruction of AK's as a means of preventing progression to invasive squamous cell carcinoma • Proposed grading system for AK's = keratin-intraepithelial neoplasm (KIN), grade I to III
Acanthosis nigricans
Clinical: • Most common in those of African and Hispanic descent. • Velvety pigmented plaques involving folds of the axilla and neck • Mucosal lesions can be seen Histopath: • Benign papillomatosis, hyperkeratosis, and thinned epidermis • Mild perivascular inflammation Note: • Associated with obesity, underlying malignancy (50%), various syndromes, nicotinic acid, estrogens, systemic corticosteroids, insulin, etc. • BThought to result from extended growth factor stimulation of keratinocytes and dermal fibroblasts.
Urticaria
Clinical: • *Common transient eruptions* • Affect 15% of population at some time in life • *Palpable erythematous papules or wheals* • Wax and wane without a clinical residuum • Acute (etiologic triggers often identifiable) or chronic Histopath: • *Edema with dilated lymphatics* • Sparse *variable inflammation*
Psoriasis
Clinical: • *Sharply circumscribed plaques with silvery scale* • Auspitz sign, Koebner phenomenon • Predilection for scalp, groin, extensor surfaces, nails • Inherited component Histopath: • Hyperkeratosis w/ parakeratosis • Uniform elongation of rete ridges • Papillary dermal edema with dilated capillaries • Thinned suprapapillary plates • Neutrophils within the stratum corneum (Munro's microabscesses) • Perivascular lymphocytic infiltrate Note: • Affects about 1 % of U.S. population • Chronic relapsing course • Characterized by increased epidermal turnover rate leading to thickening of the epidermis and accumulation of scale. • HLA-B13 and HLA-BW17 association
Acne vulgaris
Clinical: • Adolescence, early adulthood • Men>women • Face>>back, chest, shoulder • Comedones • Erythematous papules, pustules, nodules, cysts • Occasional scarring Histopath: • Comedone: dilated follicular infundibulum with keratinous plug, open to surface or closed • Follicular pustule with or without rupture • Inflammatory response • Cyst and sinus tract formation • Dermal scarring
Molluscum contagiosum
Clinical: • Common in childhood, rare under 1 years old • Face, limb and trunk • Second peak in young adults associated with sexual transmission • Involves genital and perineal skin • Translucent skin-colored to whitish dome-shaped papules, characteristically umbilicated with a central pore • Self limited, resolve within 6 to 9 months • Most common human disease induced by the poxviruses Histopath: • The epithelial cells contain characteristic eosinophilic cytoplasmic inclusion bodies
Pemphigus vulgaris
Clinical: • Flaccid bullae on skin: face, scalp, chest and intertriginous areas • Oral mucosa involved 100% • Older individuals Histopath: • Suprabasal acantholysis with blister formation • Involvement of hair follicles by acantholysis • Superficial perivascular mononuclear infiltrate • Direct immunofluorescence: squamous epithelial intercellular deposition of IgG and possibly C3 (Chicken wire pattern) Note: • IgG against the pemphigus vulgaris antigen, desmoglein 3, a desmosomal cadherin that mediates cell binding. • Desmoglein 3 appears to be in greater concentration in the lower epidermis
Impetigo
Clinical: • Honey-colored crusted lesions, usually acute onset • Bullae in bullous impetigo • Children more commonly affected • Paranasal, axilla, groin are common sites Histopath: • Subcorneal pustule filled with neutrophils • Sometimes gram positive cocci found in the pustule • Variable dermal inflammatory infiltrate Notes: • Common superficial bacterial infection • May follow trauma to skin, abrasion or insect bites • Etiologic agents are Staphylococcus aureus and Streptococcus pyogenes • Diagnosed on clinical grounds, with or without cultures, biopsies often not performed
Verruca vulgaris (warts)
Clinical: • Hyperkeratotic papules, plaques • Solitary or grouped lesions • Fingers, hand, face • HPV types 1, 2, 3, and 4 Histologic: • Hyperkeratosis • Focal parakeratosis overlying epidermal papillomatosis • Digitated epidermal hyperplasia • Hypergranulosis • Koilocytosis
Lichen planus
Clinical: • Prominent pruritus • Violaceous polygonal papules • Flexural surfaces favored • Oral and genital involvement frequent Histopath: • Acanthosis, hypergranulosis, "sawtoothing" of rete ridges • Basal vacuolization • Band of lymphocytes in upper dermis Note: • An inflammatory disorder of uncertain cause • Serves as prototype for several disorders
Epithelial Cyst
Clinical: • Solitary or multiple • Face, neck, torso Histopath: • Benign, stratified squamous lining with varibly thick granular and loose, laminated keratin • Ruptured associated with foreign body giant cell reaction and scarring. AKA: wen, epithelioid cyst
Bullous pemphigoid
Clinical: • Tense, intact blisters on erythematous base • Favors extremities Histopath: • Subepidermal blister • Inflammatory infiltrate in papillary dermis • Abundant eosinophils • No necrosis of epidermis Note: • Linear IgG (60-90%) and C3 (100%) at dermal-epidermal junction • Immune complexes localize to roof of blister with salt-split skin • Two antigens localized, 230 kd-BPAG1 and 180 kd-BPAG2 • Antigens are intracellular and transmembrane protein which contributes to dermal-epidermal adherence • Indirect immunofluorescence positive in most patients • Usually elderly patients
Seborrheic keratosis (SK)
Clinical: • Tan to dark black papules -Middle-aged to older pts- head, neck, and trunk • 1 mm to several cm in diameter/sharp demarcation • Smooth to verrucoid texture Histopath: • Benign squamoid and basaloid proliferation with acantosis, hyperkeratosis, papillomatosis, and horn pseudocysts • Basal layer hyperpigmentation -Infiltrating lymphocytes in the dermis and epidermis Note: • Most common human neoplasm • Sign of Leser-Trelat- sudden eruption of SKs in persons with concomitant cancer, most commonly adenocarcinoma of GI tract
Opaque
Cloudy or non-transparent
Serofibrinous to fibrinous
Cloudy with strands of opaque white to yellow fluid
Syndrome
Collection of clinical signs, symptoms & data characteristic of disease process. (Not always definitive).
Syndrome
Collection of clinical signs, symptoms, and data which are characteristic of a disease process
Symptoms
Complaints reported by patient as part of medical history
Symptoms
Complaints reported by patient or caregiver as part of medical history
Moh's Surgery
Complex concurrent FS/Surgery, while patient is open. Tissue sparing: Performed on areas where difficult to do large rejections: face, head. Tissue is mapped then cut by FS in planes horizontal to epidermis. If any positive margin additional tissue is taken. Continues until there is no more positivity.
Neurons
Conducting cells of nervous system
Blood cells
Connective tissue: RBC & WBC (including those found in lymph & spleen)
Autopsy report
Considered medical expert opinion and evidence. Generates an evidentiary documents that forms a basis of opinions rendered in a criminal trial, deposition, wrongful death suit, medical malpractice civil suit, administrative hearing, or workman's compensation hearing.
Ribosomes
Consist of small and large subunits. Carry out protein synthesis, either free-floating or attached to rough endoplasmic reticulum.
Cytoplasm
Consists of cytosol, inclusions and organelles. Carries out work ordered by nucleus.
What is often needed before dissection?
Consultation with surgeon for orientation info
Stratum Granuolsum
Contains building blocks of keratinization.
Subcutaneous Layer cells
Contains loose connective tissue fat, muscle, nerve receptors (Paccinian Corpuscles) function is a protective cushion, it helps monitor heat gain and loss.
How do you measure tumor metastasis in LN?
Cross-sectional diameter of largest LN metastasis (not LN itself) (measure when grossing)
What is "C" section?
Cut almost all the way through - not last little bit
Bisected
Cut into 2 pieces
Trisected
Cut into 3 pieces
Quadrisected
Cut into 4 pieces
What does "on edge" mean?
Cut surface down (see all layers)
Eosin stains what cell components?
Cytoplasm and intracellular organelles.
Endophytic
invasion of surface in spreading pattern
What is extrathyroidal extension?
involvement of perithyroidal tissues by primary thyroid cancer
DC: cause of death lines
DC form permits only 3 or 4 lines to be entered as to the sequence of events in COD -only 1 cause may be entered per line
Why gross skins?
DIE 1. Dx tumors 2. ID/confirm nature of cutaneous inflam diseases 3. Ensure complete excision
Inspect and dissect
DO THIS TO ENTIRE SPECIMEN
Atrophy
Decrease in metabolic activity and size of cells
Paraglottic space location
Deep to ventricles, btwn thyroid cartilage & vocal cord base membranes (conus elasticus & quadrangular membrane) -composed of loose CT
Structural disorder
Defect in form
Structural Disorder
Defect in form - usually links to a functional disorder. (ie strep infxn of mitral valve causes hole in valve & backflow of blood, heart works harder -> heart failure)
Ulcer:
Defect of the epidermis with evidence of reaction
Contour
Degree to which the lesion is elevated or depressed
Anterior commissure
Dense ligamentus attachments from vocal cords to thyroid cartilage (carcinomas invade cuz thyroid cartilage lacks perichondrium)
Ulceration
Denuding of the skin showing complete loss of the epidermis revealing dermis or subdermis
What are parameters of a maxillectomy?
Depends on location & spread of tumor
What does # and type of margin sections depend on?
Depends on nature & extent of resection (margins change depending on tumor location)
How do you know which method to use in detecting tumors in sentinel LN
Depends on pathMD, place you're working & tumor level
Dermal nevus:
Dermis
What does the mesoderm differentiate into?
Dermis, bone, skeletal muscles, blood vessels, smooth muscle, pleura, peritoneum, pericardium
In dictating a maxillectomy, how should you describe the tumor?
Describe tumor cut surface & characteristics: -color -demarcation -fungating -exophytic -erosive -invasive
How should you document & section tumors found in larynx?
Describe/Document: (with supraglottis, glottis & subglottis locations in mind) -side, size & exact tumor location, exophytic, endophytic -depth of tumor invasion & relationship to uninvolved mucosa -mucosa of pyriform sinuses, epiglottis, aryepiglottic folds, *false cords, ventricles, true vocal cords*, anterior commissure & subglottis (longitudinal section) -thyroid & cricoid cartilage (submit for decalc)
What does colloid mean?
Descriptive term - massive storage of colloid w/in follicles (flattened epithelium of follicles)
IHC
Detects cell products/surface markers using specific Ab (visualized via fluorescence or chem rxns)
When opening an sectioning the specimen?
Determine before opening specimen if anything special is needed, how and where the specimen is opened, palparé for pathology
Nevis
Developmentally abnormal skin. Activation of mutations of RAS signaling pathway. Normal skin elements arranged abnormally
What are some reasons to gross skins?
Diagnose tumors, identify or confirm the nature of cutaneous inflammatory diseases, and to ensure complete excision
Punch biopsies:
Diagnostic, never fully excisional. Put 1/2 in Zeus fixative! Measure the diameter of the
Incisional
Diagnostic. They do not expect to have taken entire lesion
How should you note the tumor spread of maxillectomy?
Dictate: -structures involved by tumor -tumor distance to closest margin -if tumor crosses midline
What should you remember if you want to submit 2 LN in 1 cassette?
Differentially ink LN
What is the consequence of a specimen section at too high a temperature?
Difficulty cutting tissues, "mushy section"
Acanthosis
Diffuse epidermal hyperplasia
What is a critical component in specimen orientation/sectioning?
Direct communication btwn surgeon & PA
Signs
Direct observations by clinical examiner
Erosion
Discontinuity of the skin showing incomplete loss of the epidermis
Dermatopathology
Disease or pathology of skin
Dermatophathology
Disease/pathology of skin
Dysplasia
Disordered growth, most often seen in epithelia
What cancer most commonly metastasizes via Lymphogenous spread?
Dissemination for carcinoma (epithelial cancer)
What type of metastasis is considered in the mediastinum (but not in level VII)?
Distant LN metastasis
Why should you photograph a specimen?
Documents: -location of tumor -size of tumor -annotation where sections taken
Question to ask yourself while processing hemithyroidectomy
Does pathology involve the isthmus & thyroid capsule?
Bone Marrow Biopsies
Don't leave them in decal for a long time! (RDO 15 mins)
How many samples to take from multinodular goiter (enlarged thyroid) to reduce sampling error?
Don't submit too many sections 1-2 sections selectively taken from from periphery of each nodule (up to 5 nodules per lobe)
How should you remove organs?
Done by PathMD preference 1. Virchow: remove organs one by one -Adv: very fast/easy -Dis: Lose relationships btwn organs/pathology 2. Rokitansky: enblock/enmasse removal -Adv: Fast & can quickly release body -Dis: Can be overwhelming, prosector must be very good with anatomy
Why is a tumor staging procedure done?
Done by surgeons during LN removal *when there's a concern for metastasis*
Endoscopic
Done endoscopically, usually GI biopsies. Important for Hirschsprungs disease (typically done for infants and children)
Core
Done in a variety of tissues (thyroid, LN, breast). Needle biopsies (very small hair like biopsies). Linearly place in filter paper!!
Wedge
Done with organs(liver, lung) usually just take a wedge of solid organ
What should you try to include with complex specimens?
Drawing or photo of resected specimen showing tumor extent & its relation to the anatomic structures of the region (Also lines/resection extent should be on surgical path request forms)
What should you do before inking a maxillectomy?
Dry bone & mucosal margins or these will run when inked
Xerostomia
Dry mouth (1st indication of Sjogren's syndrome)
It is important to _______ between runs to prevent contamination/carry over
Dry the back of the slide
Dessicated
Dryed out
What can you wipe down the cryostat with to reverse static electricity?
Dryer Sheets
Distinctive features of necrosis
EFFNG 1. *Eosinophilic* (pink) 2. *Fragmented Cell membranes* 3. *Fatty soaps formed* (from attracting calcium-salts) 4. *Nuclear changes* -> pyknosis (small, dense), karyorrhexis (fragmented), karyolysis (faint, dissolved), 5. *"Glassy"* & may be vacuolated (from glycogen loss)
What are the 3 primitive embryologic tissues every cell is Derived from?
Ectoderm, mesoderm, endoderm
Anatomic Margin
Edge of actual specimen in body Concern: does tumor extend to edge & beyond to adjacent structures?
What are gluteraldehyde fixed tissues used for?
Electron Microscopy
a) Papule b) Nodule
Elevated, dome-shaped lesion. a) <5mm & b) >5mm
Which have more favorable prognosis of carcinomas, encapsulated or unencapsulated
Encapsulated tumors
What are the different types of biopsies
Endoscopic, core, suction, wedge, incisional, excisional, shave
Examples of where simple squamous can be found
Endothelium, mesothelium,
Pros and Cons of Enface vs. Perpendicular Margins
Enface Pros: can evaluate entire margin. Con:will not give you distance of tumor to margin Perpendicular pro: can give distance of tumor to margin Con: don't evaluate entire margin.
What does melanoma do to the sclera of eye?
Engorge veins & some eye attachments have pigment changes
How do lymphomas typically present?
Enlarged, nontender LN
What is the definition of a goiter?
Enlargement of thyroid gland for any reason -Euthryoid (thyroid not working -Hypothyroid -Hyperthyroid
How should you submit a LN not involved with tumor?
Entirely submit
Stratum Basale
Epidermal/Dermal junction. Single layer of cuboidal to low columnar cells with a number of dispersed melanocytes. More numerous in areas exposed to UV light. Not necessarily greater amount in darker skin.
Example of simple squamous non-keratinized epithelium can be found?
Epidermis
What are the 3 layers of the skin?
Epidermis, dermis, subcutis
Carcinoma
Epithelial cancer
What is the most common cutaneous cyst received?
Epithelial cyst
What is a carcinoma?
Epithelial tumor
What does patient safety movement emphasize? Hopes to?
Error reduction & greater transparency for medical errors. Hopes to reduce recurrence and increase patient trust.
Minor Error
Error that causes harm, but is NOT permanent nor potentially life-threatening
Serious Error
Error that causes permanent injury or potentially life-threatening
Near Miss
Error that could have caused harm, but did NOT by chance or intervention
Stomach
Essentially same as whipple includes esophagus, stomach, duodenum, pancreas
Normal Range
Established range for quantitative results that have numerical values
What are the cartilages of the larynx?
Even Tanks Carry Artillery -Epiglottis cartilage -Thyroid cartilage -Cricoid cartilage -Arytenoid cartilage
What is important for safety regarding chemicals in the lab?
Every chemical must have SDS!
Diffuse
Everything in the frame of reference is abnormal or affected
Abdominal block
Everything inferior to the diaphragm. Distal esophagus, stomach, small intestine, large intestine, rectum, liver, pancreas, abdominal aorta, kidneys, pelvic organs in one block.
Congestion
Excessive accumulation of a substance such as blood or fluid
What is a sign of Graves disease?
Exophthalmos (eye bulging)
CLL & SLL immunophenotype
Express CD19, CD20 & CD5
What is endophytic?
Extending into tissues
Y incision
Extends from the acromion process to the xiphoid process to the pubic symphysis (Y) shape. Sometimes U shape in women with large breasts and larger bodies. Normally you circumvent the umbilicus because it is hard to cut through. Take gauze and pull, then cut
What is the radioactivity concern of sentinel LN?
Extremely LOW (~same as microwave)
CLL & SLL prognosis
Extremely variable (4-10 years)
Medical Error
Failure to complete planned action OR implementation of wrong plan (leads to serious, minor, or near miss)
True or false submandibular gland is included in maxillectomy
False (submandibular gland included in radical neck dissection)
What is Dif-Quik good for?
Fast - excellent cytologic detail
What kind of fixative is formalin?
Fast penetrating (methylene glycol), slow fixative
When would you do the Letulle/Roki method?
Fast, you can examine the pathology better
"Rok it" Advantages and Disadvantages
Fast, you can remove entire organs, release the body. Disadvantages: it can be very overwhelming and it's long. Prosector must be very familiar with anatomy.
What is included in radical neck dissection, Level V?
Fatty tissue triangle posterior to SCM
Fixation for Bone
Fix in 1/2 formalin and 1/2 decalcification solution (not recommended for tumor specimens)
How do you fix larynx specimen?
Fix while pinned open for a few hours - overnight
What is a CON to fixation?
Fixation can change antigenic sites on cells so that immunohistochemical staining can occur.
What is AZF or B3/B5 used for in Lymphoma protocol?
Fixatives for nuclear detail
Macule:
Flat, pigmented lesion >5mm/0.5 cm.
What does mucoceles look like?
Fluctuant swelling with blue hue (w/in minor salivary glands - along lip)
Interstitial fluid
Fluid btwn tissues & cells
Vesicle:
Fluid filled, elevated, bubble-like lesion, generally >5mm
Arrector pili muscles
Follicle-associated smooth muscle bundles
Why do a punch biopsy?
For Inflammatory conditions: -Systemic lupus erythematous -T Cell Lymphoma (mycosis fungoides)
When is consent from family not required for autopsies?
For autopsies that fall under medical examiners jurisdiction (ie body unidentifiable)
***What is the purpose of a Radical neck dissection?***
For en bloc removal of cervical LN (make sure to find them ALL!)
Why are parathyroid glands removed?
For patients with hypercalcemia (via parathyroid adenoma)
Staging Groupings - Merkel Cell carcinoma
For primary merkel cell carcinoma with no evidence of regional/distant metastasis is 2 stages: Stage 1: primary tumors <2cm Stage 2: primary tumors >2cm
What is a big oversight while evaluating parathyroid?
Forgetting to weigh it
How do fixed bones pose a safety risk?
Formalin-infused bones create shavings when sawed makes dust that can be inhaled - causes lung infections
Vacuolization
Formation of vacuoles within or adjacent to cells; often refers to basement membrane area
Fungi are most commonly found where:
Found in dead surface layers (thick keratin), hair and nails (unguium)
Transitional
Found in organs that stretch (bladder). Cells can slide over each other to form laters depending on if organ is distended or contracted.
What is the supraglottic larynx region?
From epiglottis tip to horizontal line thru ventricle apex Structures: -epiglottis (lingual & laryngeal) -aryepiglottic folds -arytenoids -false vocal cords -ventricle
What is the glottic region?
From ventricle to ~1cm below true vocal cords Structures: -anterior commissure -posterior commissure -true vocal cord
What is the subglottic larynx region?
From ~1cm below true vocal cord to inferior rim of cricoid cartilage
Tinea Capitis
Fungal infection of head
Tinea unguium:
Fungal infection of nail or nail bed
Tinea corporis:
Fungal infection of the body (called ringworm in skin).
Tenia pedis:
Fungal infection of the feet
Tinea cruris:
Fungal infection of the groin region
What does the endoderm differentiate into?
GI system, internal linings (mucosa) of intestines and respiratory tracts, lives, pancreas, parenchyma of thyroid and parathyroid, tonsils, thymus, epithelial lining of urinary bladder and urethra, epithelial lining of parts of the ear
Where is cobblestone typically seen?
GI tract, most often chrones disease
Albinism
Generalized hypopigmentation, caused by inborn errors of metabolism. Individuals with albinism lack one of the essential enzymes for synthesis of melanin. These individuals are pale, never tan, have white hair and red eyes, and there is an increased risk for skin cancer.
Anatomic Orientation:
Generally, a complex specimen cannot be reconstructed once cut. Proper orientation is pertinent to the dissection an ultimate diagnosis provided to the clinician. A strong knowledge of anatomy is necessary, with the ability to recognize and interpret unique anatomic landmarks.
Why would you do a perpendicular margin section ?
Gives distance btwn tumor & margin (microscopically demonstrates this measurement)
What questions should you ask yourself for *diffuse* lesions?
Gland: symmetrical/asymmetrical? Lesion: -confined or extend beyond thyroid capsule? -cystic or solid? -soft or hard? -well-demarcated or poorly defined?
Apocrine glands
Glands of groin/axilla (produce odor)
What is alternative fixative to formalin for ocular tissue?
Gluteraldehyde 4% (good for light & electron microscopy - doesn't shrink tissue)
What is most common manifestation of thyroid disease?
Goiter (thyroid enlargement)
GMS stand for:
Gomori Methenamine Silver
What is required to be able to correctly orient a specimen?
Good knowledge of anatomy
What size of follicular carcinoma lesions are associated with worse prognosis?
Greater than 3.5cm
Why should you take time to give a really good gross description of salivary glands before processing?
Gross appearance of some salivary gland neoplasms are characteristic & can drastically help dx
Measurements in Surg Path Reports
Group = smallest to largest Single = largest to smallest Decimals in one # = Decimals in ALL #s
What are OH-fixed touch preps used for?
H&E
What does the ectoderm differentiate to?
Hair, nails, epidermis, brain and nerves, sensory epithelium of ears eyes and nos,
What is important to remember when processing a punch biopsy for an inflammatory condition?
Half of specimen put into Zeus transport media for *immunofluorescence* (looking for Ag)
Actinic Keratosis:
Has a precancerous disposition, nitrogen spray can be used to burn off along with glycolic acid peels.
Safe minimum margin for melanoma
Has not been established yet
Advantage to synoptic reporting over free-text reporting
Has relational structure & thus searches and retrieval processing are faster and more efficient
Concave
Having a spherically depressed surface
What part of ear does a wedge ear resection typically come from?
Helix & Antihelix
What is necessary for hematoxylin to stain?
Hematoxylin needs to be oxidized to hematein (weak anionic dye) to stain. Mordant added to hematoxylin acts as link btwn dye & tissue - stabilizes until oxidized
Rule of sensitive vs specific tests
Highly SENSITIVE tests are NOT very SPECIFIC Highly SPECIFIC tests are NOT very SENSITIVE
Bubbles during OCT application can result in what?
Holes and/or tears in sections.
Centriole
Hollow cylinder, wall of nine evenly spaced tubule bundles. Occur in pairs, perpendicular to each other. -Forms spindles responsible in cell division.
Excavating or Excavated
Hollowed out, forming a depression
What should you include in the decription if tumor located in glottic region?
How much of ventricle (if any) tumor extends into it
What bone is not technically part of the larynx but can still be included in resection specimens?
Hyoid bone
Hypergranulosis
Hyperplasia of the stratum granulosum, often due to intense rubbing`
Clark levels
I - intraepidermal tumor only (in situ -no vertical growth) II - tumor present in but does not fill/expand papillary dermis III - tumor fills & expands papillary dermis IV - tumor invades into reticular dermis V - tumor invades subcutis
Sublevels of neck for describing location of LNs
IA: Submental group IB: Submandibular group IIA: Upper jugular nodes along carotid including subdigastric group IIB: Upper jugular nodes in submascular recess VA: Spinal accessory nerves VB: Supraclavicular & transverse cervical nodes
What should you do for LN groups removed from areas not included in Levels I-VII? Ex of type of group?
ID & reported from all levels separately Example: scalene, suboccipital & retropharyngeal
What could be a special procedure for confirmation of medullary carcinoma?
IHC (including calcitonin & neuroendocrine markers)
What could be a special procedure for confirmation of papillary carcinoma?
IHC (including thyroglobulin)
If unable to specify anatomic landmarks, what are the estimated neck LN levels?
II: Upper 1/3 of IJ vein or neck specimen III: Middle 1/3 of IJ vein or neck specimen IV: Lower 1/3 of IJ vein or neck specimen (All anterior to SCM)
What can be a treatment for tumors?
IMRT (Intensity Modulated Radiation Therapy)
Why is it important to ensure that OCT infiltrates the ridges of the chuck?
If OCT doesn't get into ridges, block will pop off while cutting.
Why would saliva be high in sialomucin?
If secreted by mucous glands
Why would saliva be high in amylase?
If secreted by serous glands
What ups the staging in a larynx squamous cell carcinoma?
If the tumor crosses the midline
Radioactive specimens
If there are any issues with these specimens see the radiation safety officer.
How to gross Skin Ellipses unoriented:
If unoriented: measure LxWxD of excision. Describe lesion, distance from closest margin. Describe cute surface and distance from deepest point of resection. Ink one color, tips in one cassette, serially section and sequentially submit 2-3 pieces/cassette. Submit superior -->inferior
Disease
Impairment of health or condition of abnormal functioning
Disease
Impairment of health, or condition of abnormal functioning
Raised
Implies that "something is added" to the organ or tissue to cause expansion
Depressed
Implies that something is removed or lost
What should you include if tumor is located in pre-epiglottic space?
Important to discuss how far tumor is from vallecula
Follicular Lymphoma morphology
In LN: nodular/diffuse prolifs composed of centrocytes & centroblasts
When might there be few to no LN present?
In colon dissections: patient may have undergone radiation treatment
Where is a good place to search for LN in radical neck dissection?
In each level, they can be found in fatty CT
What are/where do most mislabels for pathology happen?
In grossing room of pathology lab. Breast, skin and colon biopsies/during analytical phase in the pathology lab
Lacerated
irregular tear
Shave
In skin they just take the epidermis, just diagnostic and/or the clinician is pretty certain it is just a benign process
Cellulite
In subQ layer, gives bumpy appearance.
Hyperplasia
Increase in # of cells
Hypertrophy
Increase in size of cells
PET Pinpoints
Increased metabolic activity in cells
Why use touch preps?
Increased nuclear detail & cytoplasmic components (vacuoles, mucins & colloid)
What can you use for inking?
India ink, silver nitrate sticks, tattoo inks, commercially prepared inks for tissues
Margins of SCC
Indicate peripheral margin positions of tumor (if specimen oriented)
Why would you orient a salivary gland?
Indicated by surgeon concerned for malignancy, checking margins are clear.
What structures make up the boundaries of the paraglottic space?
Inferior - conus elasticus Lateral - thyroid cartilage Medial - quadrangular membrane Posterior - piriform sinus
Exocytosis
Infiltration of the dermis by inflammatory cells
Adverse Event
Injury caused by medical management rather than by patient condition
What does "enface" mean?
Inked side down (in cassette)
What is the endothelium? What is its function?
Inner lining of blood vessels, functions for diffusion
What is IMRT?
Intensity Modulated Radiation Therapy -state of the art treatment -delivers precise radiation doses to a malignant tumor or specific areas within the tumor -gives ability to "sculpt" edges of a tumor, sparing adjacent healthy tissue
Spongiosis
Intercellular edema of the epidermis
What special lymphoid structure is unique to parotid gland?
Interparenchymal LN
Hydropic swelling
Intracellular swelling of the keratinocytes, often seen in viral infection
What is the definition of a positive margin?
Invasive carcinoma or carcinoma in situ/high grade dysplasia present at margins
What are midline nodes considered?
Ipsilateral nodes
How do you orient hemithyroidectomy?
Isthmus margin is always medial & most likely on inferior aspect (no laterality? Refuse)
What can happen if you used gluteraldehyde with PAS stain?
It can cause false positive (stain diffusely & nonspecifically)
When a lesion passes through the basement membrane, What does that mean clinically?
It has become more aggressive
What happens if a total thryoidectomy pathology crosses midline of isthmus?
It increases the staging
Why is it important to include if tumor crosses midline when dictating for a maxillectomy?
It increases the tumor's staging
When can congestion be 2ndary?
It is 2ndary to decreased ability of heart to pump during congestive heart failure
Wheal
Itchy, elevated lesion - variable blanching or erythema - caused by dermal edema
Thoracic block
Just the heart and lungs together, may include aorta and great vessels from the trachea to the primary bronchi. This allows for quick removal but maintenance of pulmonary arteries to check for pulmonary embolisms as well as any other pathology or obstructions. This may also include the thoracic segment of the esophagus.
Habits to keep in the grossing station
Keep work area clean. Free of blood, tissue, uncluttered of papers and containers, NEVER have more than one case on the board at a time! Keep necessary instruments only on board, change pads after every case, ALWAYS KNOW WHERE YOUR SHARPS ARE. Don't leave it in a body, have one designated area for sharps. Always call out sharps when working with multiple people
Scales:
Keratin layers that cover the skin in flakes or sheets, and are easily scraped away.
Nails
Keratin plates - strengthen tips of fingers/toes
Microscopic characteristics of squamous cell carcinoma
Keratinaceous pearls, nests of tumor cells
Epidermis cells:
Keratinocytes: In the most superficial layer, they develop at the bottom of the epidermis, rise to the top, and shed as dead cells Melanocytes: produce melanin and provide UV protection, at the bottom of the epidermis in the basal layer Dendritic cells: cells of the epidermal immune system, they engulf foreign material that invades the epidermis and migrate out of the skin to produce an immune response. Basal Cells: small cells found in bottom of epidermis, BCC arises from non-differentiated cells in this layer
What is the periauricular pit associated with?
Kidney issues & mental cognitive deficiencies
Inking specimens
Know why you're inking it. Dry specimen before inking, meticulously apply ink to surface to avoid running ink. Cut from tissue to ink if possible, avoiding dragging ink through tissues. Apply a mordant (i.e. Bouins, vinegar) although many no longer require a mordant. Make sure ink is dry or "dabbed" before cutting
Temperature requirements of the Cryostat?
LESS THAN -20 degrees F (-27 degrees C)
What happens to LN when small cell carcinoma metastasizes into LN?
LN coalesces
Clinical detection of Merkel cell carcinoma
LN examination: -Inspection, palpation &/or imaging -*Micrometastasis* (ID on pathologic inspection) -*Macrometastasis* (clinically detectable nodal metastasis) -*Transit metastasis* (tumor distinct from primary lesion & located either btwn primary lesion or distal to primary lesion Use immunostains to increase detection of LN metastases (must have at least 1 to deem LN as negative)
What is a modified neck dissection include?
LN from levels I-V are included but 1 or more of major structures (internal jugular vein, spinal accessory nerve, SCM muscle) is not included
What is a selective neck dissection?
LN from only some levels are included
How does structure affect LN function?
LN is organized to detect & inactivate foreign antigen in lymph (chylous fluid)
Benign
LUC -Localized Lesions -Unremarkable Microscopic/gross characteristics -Cured on resection & patient survives
White to gray or yellow color
Lack of blood
What confers higher risk of locoregional recurrence in thyroid cancer?
Larger size LN metastasis - report size of largest focus
Bullae:
Larger, fluid-filled vesicles <5mm secondary to burns
Autopsy consent
Legal documents that vary from state to state, consent must be complete an witnessed (obtained in person or by telephone, from a first degree relative or guardian) and limitations of autopsy must be clear.
What is an entire cataract considered?
Lesion
Flat
Lesion is neither raised nor depressed with respect to the surrounding tissues
Random
Lesion occurs without reference to particular organ or tissue structures
Uniform Size
Lesions are all about the same size
Non-uniform size
Lesions are differing size
What are exceptions of characteristics of benign neoplasm?
Lesions can occur in multiple sites, sometimes they get to a certain size and can cause death
Nevi:
Lesions where normal skin elements are arranged in an abnormal manner
Paraglottic space
Less well-defined & composed of loose CT
Locations of differing levels of LN in neck
Level I: Submental group & Submandibular group Level II: Upper Jugular Group Level III: Middle Jugular group Level IV: Lower Jugular group Level V: Posterior Triangle Group Level VI: Anterior (central) compartment Level VII: Superior Mediastinal LN
What levels are included in supraomohyoid region of selective neck dissection?
Levels I-III
What levels are included in lateral region of selective neck dissection?
Levels II-IV
What levels are included in posterolateral region of selective neck dissection?
Levels II-V
How is a radical neck dissection shaped?
Like a "Z"
Highly specific tests
Likely to be negative in healthy people (true negative) but they also may be negative in people with disease.
Highly Sensitive Tests
Likely to be positive in disease (truly positive), but can also be positive in healthy people as well.
Highly specific tests
Likely to be truly negative in healthy people, but can also be false negative in disease (ie if positive, more sure person has the disease)
Highly sensitive tests
Likely to be truly positive in disease, but can be false positive in healthy people
What is a fissure?
Linear retraction
It is important that biopsies and cores are always placed:
Linearly/evenly lined up
Mesothelium? Function?
Lining of pleural and pericardial spaces, production of fluid to provide lubrication
Where are peyer's patches located?
Little bumps on terminal ilium
What is the frenulum?
Little fibrous tissue connecting tongue to mouth floor
Most common site for hematogenous spread (metastasis)
Liver & Lungs
Melanocytes (epidermis)
Located in basal layer. Produce melanin and pass to keratinocytes. Provide UV protection
Merkel Cell Neurites
Located in basal layer; sensory neuroendocrine cells
Merkel cells (epidermis)
Located in basal layer; sensory neuroendocrine cells
Golgi Apparatus
Looks like maze. -Golgi modifies and packages proteins for transport to cell surface.
Characteristics of dysplasia?
Loss of uniformity of individual cells, loss of architectural orientation, considerable pleomorphism, large hyper chromatic nuclei, high nuclear cytoplasmic ratio
Level IV
Lower Jugular Group -LN in lower 1/3 of IJ vein from omohyoid (superiorly) to clavicle (inferiorly) -Post boundary = SCM posterior border -Ant. boundary = lateral border of sternohyoid
What is included in radical neck dissection, Level IV?
Lower jugular group
Which tissues used for TOUCH PREPS?
Lung tumors, Thyroid, and Lymph nodes
Afferent vessels
Lymph *A*rrives into node
Efferent vessels
Lymph *E*xits nodes
N Category of melanoma
Lymph Nodes (N) 1 = draining nodal basin 2 = contiguous draining nodal basins M1 = metastasis to nondraining nodal basin
Touch prep is primarily done on what type of specimen? What is the reason for touch prep?
Lymph Nodes, Thyroid, lung tumors Gives increased nuclear detail of cytoplasmic components.
What is the preferential route of spread for papillary carcinoma?
Lymphatics
What would you witness on a squash prep between lymphoma & carcinoma epithelial cell?
Lymphomas dissociate into single cells. Epithelial cells (ie carcinomas) will be clumpy and cohesive.
Metastasis Contiguity
M: tumor spreads from primary site of origin to distant 2ndary site M: tumor invades into adjacent sites C: tumor spreads from primary site to adjacent site (ie LN)
Types of Maxillectomies
MISST -Medial -Infrastructure -Suprastructure -Subtotal -Total
Homeostasis
Maintenance of a steady physiologic state
What should you do before you start dictating a thyroidectomy while you're still new?
Make notes, then dictate!
Squamous cell carcinoma:
Malignant, seen on sun-exposed skin. Can metastasize, but 2%. Prognosis depends on stage at resection. Flat plaque, small persistent ulcer.
Pathophysiology
Manner in which the incorrect function is expressed (disease state)
Multifocal to Coalescing
Many lesions present that appear to be growing together or fusing
How does lymph flow relate clinically to cancer?
Mapping procedures of lymph flow are done to find where metastasis is headed
What does "en face" mean?
Margin (inked) side down
What is a required data element with thyroid cancers?
Margin status
What is the most important thing when grossing an ear resection?
Margins
What is a resection of a maxilla called?
Maxillectomy
Polychromatic Stains
May-Grunwald Giemsa Stain
Sequestered
isolated or away from a normal position; shut off from other parts or systems
Red or reddish black color
Means blood or hemoglobin pigment
Maculopapular rash example:
Measles
How to gross Skin Ellipses oriented:
Measure LxWxD of excision. Describe lesion, size, and distance from designated margin. Ink differentially.
How to gross shave biopsies:
Measure in 2 dimension: describe lesions, measure distance from edge. Ink deep surface, bisect if >0.3-0.4 cm. Put two halves flat between 2 sponges. Write "on edge" on side of cassette.
How to gross punch biopsies:
Measure the diameter and depth of excision. Describe skin surface, meticulously ink resection margins, bisect if <4 mm. Put cut surface down in between 2 sponges. Write "cut surface down" on side of cassette.
How should you process salivary gland from Level I?
Measure, describe & serially section
Number 1 reason for decline in autopsies?
Medical prof not asking for permission to have autopsy performed on their patient
Black - brown color
Melanin
Melanocytic Nevi
Melanocytes arranged in an abnormal manner
What is a component of formalin that is required for its fixation mechanism?
Methylene glycol (produced in aqueous formaldehyde) is required for the covalent chemical rxn occuring in fixation
Describe the reaction of formalin fixation.
Methylene glycol forms covalent crosslinking of carbonyl formaldehyde with proteins, glycoproteins, polysacchararides and nucleic acids in tissues (ie creates fixation).
Occult tumor
Microscopic tumor that cannot be seen grossly
What is an occult tumor in LN?
Microscopic tumor that cannot be seen grossly
Level III
Middle Jugular Group -LN in middle 1/3 of IJ vein from carotid bifurcation (superiorly) to omohyoid/cricothyroid (inferiorly) -Post. boundary = SCM posterior border -Ant. boundary = lateral border of sternohyoid muscle
What is included in radical neck dissection, Level III?
Middle jugular group
Chylous
Milky white fluid. Lymph
Mitotic rate of cutaneous melanoma
Mitotic rate = powerful adverse prognostic tool (Find "hot spot" and continue counting mitotic cells until 1 squared mm) -*Mitoses must be melanocytic & dermal* -ID of even single mitosis in dermal component is sufficient to report mitotic rate greater than 1 per square mm & upstage
Autopsy Tech: Modified Ghon
Modifications 1. *Thoracic block* - heart & lungs together to maintain pulmonary arteries (ck for pulmonary embolisms) 2. *Thoracic & Cervical* - thoracic block + tongue/cervical organs (larynx, thyroid, cervical spine) 3. *Abdominal* - everything inferior to diaphragm 4. *Kidney* - bilateral kidneys, aorta, bilateral ureters & urinary bladder 5. *Stomach* - same as whipple procedure, includes esophagus, stomach, duodenum & pancreas
M&M
Morbidity and mortality conferences. Review of predestined patient history, course of treatment and autopsy findings. Was the diagnosis/treatment correct? Was the actions by the residents and clinicians correct? Did they find what they expected to find in the autopsy?
What is a "lake" in respects to tissue staining?
Mordant + dye = lake (this is basic in action)
Multifocal
More than a single discrete lesion on a background
Stratified
More than one layer of cells, with only one layer touching the basal lamina. Can withstand large amounts of stress.
Cobblestone
Morphologic pattern characterized by multiple rounded densities with linear fissures interspersed
What makes the parotid gland a unique salivary gland?
it harbors a number of intraparenchymal LN
What is the dominant tumor defined as?
Most aggressive tumor (imparts highest stage & dictates pt management)
Basal cell carcinoma
Most common malignant skin tumor of epithelial origin. Low grade malignancy, doesn't metastasize, very rarely causes death. Slightly elevated nodule with central depression. Surgical resection or cauterization.
ALL immunophenotype
Most express Terminal deoxytransferase (TdT)
What is a PRO to fixation?
Most stains are made to work with fixed tissues
Dermis Cells:
Mostly connective tissue Bloo vessels: O2 and nutrients, carries away trash Meissner's corpuscles: detect touch, or slow, fleeting movement Paccinian Corpuscle: detect vibrations, deeper pressure Free nerve endings: detect itchiness (urticaria), heat Nerve Fibers: forward information to the nervous systems Sebaceous glands: sacculated organs that secrete sebum (moisturizer, abundant in scalp and face. You can get wens or sebaceous cysts) Hair follicles: produce hair Arrector Pili: small muscle attached to base of hair follicle during cold or fright, this muscle pulls the hair into the upright position
Wedge biopsies:
Mostly done on skins on the lip, ear, labia. Will have wedge shaped skin with 2-3 cm margins. If it is oriented, ink differentially.
What is function of ciliated pseudostratified columnar epithelium of the trachea?
Mucociliary escalator (push mucus up and out of airways. Interspersed goblet cells secrete mucin/mucous)
What carcinoma is histologic grading based on combo of growth patterns & cytomorphologic findings?
Mucoepidermoid Carcinoma
If processing a fresh maxillectomy, what can go wrong?
Mucosal margins can be compromised (can retract/slip & ruins margins)
When should a thyroid be ENTIRELY sumbitted?
Multiple Endocrine Neoplasia (MEN) syndrome
What is MEN syndrome?
Multiple Endocrine Neoplasia syndrome -caused by germ-line intrusion of RET proto onco gene-----thyroid can be prophylactically removed
What is the most common plasma cell neoplasm?
Multiple Myeloma
Most commom plasma cell neoplasm?
Multiple myeloma
Chart review
Must be done prior to autopsy procedure, take extensive notes made to incidences and conditions around time of death (especially if there's surgery) differential diagnosis made
how to handle biopsies
Must be handled cautiously, (write the # of pieces on the side of the cassette) and indicate in dictation. Care must be taken in the transfer of the specimen from container to cassette not to crush the delicate tissues-use disposal pipette. If forceps are used, tissue must be gently handle. Must be placed in fixative immediately
What is a major rule when inking skins, in particular?
NEVER USE BLACK INK!!!!
Pathogenesis
Natural history and development of the disease
What is a modified neck dissection?
Neck dissection sparing 1 or more of classic radical neck dissections (type I, II or III)
Difference between apoptosis and necrosis?
Necrosis = cell death via irreversible injury that results in loss of membrane & ion homeostasis, and initiates immune response (always pathologic) Apoptosis = programmed cell death when cell DNA are damaged beyond repair (normal cell process)
Gangrenous
Necrosis followed by putrefaction
Hodgkin Lymphoma
Neoplasms of Reed-Sternberg cells & variants
Radial growth of melanoma
Neoplastic melanocytes growing in horizontal array as single cells & small nests predominantly in intraepidermal location (May also include papillary dermis)
What are the four types of tissue?
Nerve, muscle, connective, epithelial
What type of specimen is an eye typically considered?
Neuro specimen
What is NBF? What does it do?
Neutral buffered formalin 1) prevents oxidation of formaldehyde to formic acid w/in aqueous solution 2) Enhances action of formaldehyde as fixation agent
Neoplasia
New growth
When autopsy not required by ME, who gives consent?
Next of kin
Frozen sections must be no larger than a ______ (2)
Nickel, the slide
What should you be especially careful of when performing autopsy?
No not make incisions to skin, especially at neck or face
What carries worse prognosis of medullary thyroid cancer
Nodal metastasis
What is another name for goiter?
Nodular Hyperplasia
Limitations of Autopsy
NoneABC -No limitations: entire body is yours -Abdominal only -Brain only -Chest only (do not start until this has been documented)
Is grading useful for squamous cell carcinomas?
Not really - does not perform well as a prognosticatork
What should you note when submitting LN in neck dissection?
Note how many nodes in a cassette & indicate level
Hematoxylin stains what cell components?
Nuclear
Incidence of Disease
Number of cases per year
Prevalence of Disease
Number of persons that have a disease at any given moment
Who regulates formaldehyde for research and industrial use?
OSHA - occupational safety and health administration
Circumferentially
Occupying the entire outer edge or border of a lumen
What should you used the Millipore filter prep technique for?
Ocular fluid specimens (MUST BE FRESH): +vitreous hemorrhage +prolif vitreoretinopathy +intraocular tumors -Fix rapidly 95% EtOH - NO air dry -Stain with modified Papanicolaou, Gomori's & PAS
Why are they done
Often done for inflammatory conditions (systemic lupus erythematosus), consider or question need for Immunofluoresence (looking for antigens) transport media should be Zeus's
Where are parathyroid glands located?
On posterior aspect of thyroid gland
How many sections from submandibular gland?
One
What do synoptics provide?
Online dx worksheet easily learned & deployed -MDs can enter dx info themselves, no need for transcription services (reduces TAT) -Enhances PathMD to MD communication by presenting large amts of dx info (important for surgical resections)
Stratum Lucidum
Only in the palms and soles of feet consists of 5 layers of dead, flattened keratinocytes.
Pseudostratified
Only one single layer of cells, but the position of the nuclei gives the impression that it is stratified
Purulent to seropurulent
Opaque, thin to thick fluid. Pus
Palpate for pathology: open the specimen so as not to cut through:
Open it such that the lesion is maintained and its relationship to surrounding structures is still intact
OCT
Optimal Cutting Temperature
What does OCT stand for?
Optimal Cutting Temperature
Example of simple squamous, non keratinized epithelium can be found?
Oral cavity, esophagus, pharynx, vocal folds in larynx, vagina and anus.
What is the most important thing when processing a larynx specimen?
Orientation
What is very important before you start to gross an Ear Resection?
Orientation
What is typically not as important when grossing a salivary gland?
Orientation (unless indicated by surgeon)
Epithelial tumor:
Originate from epidermis, hair follicle, sebaceous glands, sweat glands. Most common: seborrhic keratosis (shaved off), acrochordos (skin tags/fibroepithelial polyps) completely benign & normally seen in heavy indiviuduals between skin folds and in Diabetes Mellitus patients.
Dermal CT Tumors
Originate from fibroblasts, blood vessels and other samples, benign or low grade malignant. Benign=dermatofibroma Malignant: Kaposi's Sarcoma (multiple hemorrhagic nodules/plaque)
What is an example of acute disease?
Otitis media
Mitochondria
Outer (protective) and inner membrane (folds to easily carry out oxidative reactions for cell). Produces energy for cell.
Epidermis
Outermost layer, composed of keratinocytes and scattered melanocytes
Where should blood vessels be located to be determined vascular invasion?
Outside the tumor, within the capsule, or outside the capsule
Structure of parathyroid gland
Oval, encapsulated nodules that have homogeneous red-brown cut surface (may resemble LN or thyroid nodule)
When should you take pictures of an eye specimen?
Overall specimen AND after bisecting
How do you fix a maxillectomy specimen?
Overnight: -formalin -1/2 formalin & 1/2 decalcification (ideal) (commonly grossed fresh)
Grossly describe a palatine tonsil
Ovoid tan-pink cerebriform tissue w/ cryptic/furrowed cut surfaces
What is the most important section of an eye specimen?
P-O section (pupil-optic nerve)
Structural changes of reversible injury
PEM 1. Plasma Membrane alterations 2. ER dilation 3. Mitochondria changes (swelling)
PET & CT together:
PET detect changes in cellular function & pinpoints increased metabolic activity in cells while CT give anatomical reference to those changes
Causes of cell injury
PIGNICO 1. *Physical agents* - trauma, heat, cold, radiation, electric shock 2. *Infectious agents* - virus, bacteria, fungi, parasites 3. *Genetic derangements* - chromosomal alteration & gene mutations 4. *Nutritional imbalances* - protein deficiency/lack of vitamins or excess nutrition 5. *Immunologic rxn* - autoimmune disease & cell injury 6. *Chemical agents* - rx drugs, poisons, env. pollutants, social drugs/OH 7. *Oxygen deprivation* (hypoxia)
5 functions of skin
PSSTM 1. *Protection* - from UV light, chemical, invasions 2. *Sensation* - ie merkel cells 3.. *Sexual Attractant* 4. *Thermoregulation* - heat regulation 5. *Metabolic Functions* - ie synthesis of Vit D3 --> further processed by liver & kidneys, important in bone formation & calcium metabolism
Requisition Requirements
PTCA 1. *Patient ID* - full name, identifying #, DOB 2. *Type of specimen* - date of collection, site of specimen, type of procedure 3. *Clinical history* - pertinent clinical history, ddx, operative findings 4. *Additional Notations* - special requests, biohazard alerts, MD contact info
Free nerve endings
Pain & temp receptors
Fibrosis
Pale to white color. Scar tissue, often depressed
The fat pad of the body
Panniculus adiposus
What is an example of a highly sensitive test?
Pap Smear
Dermis
Papillary and reticular layers, contains connective tissue, blood vessels, nerves, hair follicles, adnexal glands (sebaceous and sweat glands), collagen and elastic fibers (made by fibroblast) responsible for skin tone and strength, and toughness of skin. Usually much thicker in males
What pathology presents with high PTH levels?
Parathyroid adenoma (parathyroids can go up to 1 gram)
What should you look for before inking thyroid gland?
Parathyroid glands (4 on posterior aspect)
What should you dictate if you cannot find parathyroid glands?
Parathyroids not grossly appreciated
Where can stratified non keratinized epithelium be found?
Parotid salivary gland
Anaplasia
lack of differentiation
Symmetrical
Pattern with some degree of organization apparent in the abnormality
Irregularly shaped specimens
Pay meticulous attention to gross appearance of tumor and its relationship to margins
Nodular
large bumps or masses
WHat is the adam's apple made of?
laryngeal prominence of thyroid cartilage
What is the only way to definitively confirm/Dx a disease
Perform an autopsy
Why perform pathologic staging
Performed after surgical resection of primary tumor & depends on pathologic documentation of anatomic extend of disease
Death Certificate (DC)
legal document which records cause & manner of death (used for legal & epidemiological purposes)
Elongated
lengthened from the usual form
Removal of Sentinel LN - melanoma
Performed for pts w/ primary localized cutaneous melanomas w/ thickness of 1mm or greater (FS of sentinel LN not advised)
What would increase the stage of a parotid gland if sent looking for malignancy?
Perineural invasion - nerve margins are extremely important!!!
Perineural invasion - melanoma
Perineural invasion in melanoma correlates with increased risk for local recurrence
PAS stands for:
Periodic acid-schiff
What stain can cause false positive with 3% gluteraldehyde fixative?
Periodic acid-schiff (PAS)
Transparent
light passes through clearly
Circumscribed
limited to a space
Mesothelium
lining of pleural, pericardial, peritoneal, and pelvic cavities (simple squamous epithelium) Function = production of serous fluid, gives organs lubrication
What is the standard type of section cut for soft tissue margins?
Perpendicular
What is the standard type of section cut for mucosal margin?
Perpendicular (unless from margins along alveolar process, then perform shave sections)
Plasmalemma
Phospholipid bilayer membrane around organelles. Plasma membrane is unique - has glycocalyx coat for cell-cell recognition.
Mechanism of death
Physiological derangement set in motion by the causes of death that leads to the cessation of cellular electrical activity
Describe a typical submandibular gland
Pink-tan, lobulated
What is transillumination?
Place eye in front of small, intense light against dark background to detect inner hemorrhage/tumor
Surgical Margin
Place that surgeon actually cut on specimen
What are peyer's patches often mistaken for by newbies?
Polyps
Nevus Flammeus
Port wine mass, congenital aggregate of small blood vessels. These are genetic
What is PET?
Positron Emmision Tomography
What phase of the process is returning the specimen to the container/storing it?
Post-analytical
Level V
Posterior Triangle Group (VA & VB) -LN in lower 1/2 of spinal accessory nerve & transverse cervical artery (includes supraclavicular nodes) -Post boundary = anterior border of trapezius -Ant boundary = posterior border of SCM -Inf boundary = clavicle
Dysplastic nevus:
Precursor to malignant melanoma
Possible test question: What type of acini are submandibular glands?
Predominately serous, but have some mucous acini
In-transit metastasis & satellitosis - melanoma
Presence of both = poor prognosis
What is an important predictor of poor prognosis in head & neck cancer (of all sites)
Presence of perineural invasion in primary cancer
Bacterial infections
Primarily caused by: Caused by pyoderms mainly staph and strep
Labial
lip-like
What location is considered "high-risk" factor for SCC?
Primary site on ear or hair-bearing lip
Where on the body is melanoma is commonly found?
Prime site for melanoma is on foot and in between toes
Requisition Requirements
Prior to dissection, a discussion with the surgeon is often required for orientation. If stitches of any sort are present, attempt to contact the surgeon and make note of the attempt of conversation on the requisition. Specimen may need to be held until information is provided
Pros & Cons of Perpendicular margins
Pro: Can give distance of tumor to margin Con: Doesn't eval entire margin
Pros & Cons of Enface margins
Pro: can eval entire margin Con: cannot give distance of tumor to margin
What is a trick to finding the obstruction in a salivary gland sent for sialolith?
Probe the dilated duct (can lead you to obstruction)
What should you do if you find a thyroid gland?
Process it as you would a thyroid gland submitted separately - check for parathyroids!
Eccrine glands
Produce sweat (body cooling)
Hair follicles
Produces hair
Protuberant
Prominence beyond a surface
What are the functions of the skin?
Protection: from UV light, chemical, invasion, thermal protection, Metabolic: vitamin D3 synthesis, then processed by liver and kidneys, very important in bone formation and calcium metabolism Sensation: Thermoregulation: sweating and blood flow Sexual attractant: texture and appearance
PAD
Provisional anatomical diagnosis gives path idea of immediate gross findings of autopsy must be written an completed within 24 hours of performing autopsy
What is the equivalent to tumor deposits w/in lymphatic spaces for papillary thyroid carcinomas?
Psammoma bodies
Green-Black color
Pseudomelanosis or Aspiration pneumonia
What does the P-O section include?
Pupil, Optic nerve head, macula
Why is formalin no longer recycled?
Puts a lot of vapors into the air & dilutes the formalin (doesn't fix as well)
What are commonly included in larynx resection but is actually part of hypopharynx?
Pyriform sinuses
Why do an autopsy?
QUCM 1. *Quality Assurance* - info for MD & family to check if dx & treatment was correct 2. *Understand new diseases* 3. *Confirm dx* - especially in hereditary disease 4. *Medical Education* - learn about what is normal
What is rule for proper ratio of formalin?
RULE: use 15-20 times formalin to specimen`
Who do you talk to if you're concerned with the radioactivity of sentinel LN?
Radiation Safety Officer
Elevated
Raised
Blood cells
Red and white blood cells including those found in lymph nodes and spleen
Be able to describe this thyroid nodule:
Red, glistening tissue with well-demarcated, round, raised solitary red-tan lesion (PICTURE)
What is dry mouth syndrome?
Reduction in function of myoepithelial cells leads to less salivation --> dry mouth Can lead to tooth decay & halitosis (bad breath)
What type of metastasis is considered at level VII (mediastinal)?
Regional LN metastasis
Difference btwn regressive & progressive H&E
Regressive - overstain then differentiate to correct intensity Progressive - stain stepwise, no differentiation needed
What is Ahmed drain used for?
Relieves eye pressure for glaucoma patients (when meds don't work)
What is a selective neck dissection?
Removal of lymph-bearing tissue from lateral, posterolateral & supraomohyoid regions
Ghon:
Removal of the thoracic and cervical organs, the abdominal organs, and the urogential system en bloc. Moving from tongue to anus with everything together.
What should you do if a radical neck dissection is attached?
Remove it and examine separately as you would any radical neck dissection
Germ Cells
Reproductive cells
Germ cells
Reproductive cells - spermatozoa & oocyte
What is need in sentinel lymphadenectomy?
Requires radioactive tracers (blue dye) taken up by node
What is Enucleation?
Resect entire eye globe w/ optic nerve & possibly surrounding muscles
Why is iron hematoxylin preferred nuclear stain in some special staining techniques?
Resists decolorization in acidic staining solutions
What is a silicone band used for?
Retinal detachment
What should you do if you have a personal exposure?
Rinse affected area with either eye wash or shower for at least 15 min
Glottic squamous cell carcinoma
SCC that involves glottis (Includes anterior/posterior commissures & true vocal cord)
Supraglottic squamous cell carcinoma
SCC that involves structures of supraglottic larynx (Including epiglottis (lingual & laryngeal), aryepiglottic folds, arytenoids, false vocal cords & ventricles)
Subglottic squamous cell carcinoma
SCC that involves subglottic (Includes everything btwn ~1cm below true vocal cord to cricoid cartilage inferior rim)
Types of LN specimens/dissections (all handled differently)
SCRAL -Sentinel Node Procedures -Colon node dissections -Radial Neck dissections -Axillary Node dissections -Lymphoma protocol
What do all chemicals need?
SDS sheets, can be found online through manufacturer. In order to pass inspection have it easily available
Malignant
SIC -Spread to other sites -Invades tissue of origin -Cause death by structural/metabolic change in patient
What things should you externally examine in an eye specimen?
SSIO 1. *Sclera* - discolorization (&iris), distortion, engorged veins (melanoma?) 2. *Scars* - cataract surgery 3. *Implants* - medical devices (silicone band/Ahmed drain) 4. *Optic Nerve* - (retinoblastoma)
Why do you take photos for a maxillectomy?
STOMS -Section locations -Tumor location -Orientation -Margin locations -Structure involvement (from tumor)
Lysosomes
Sacs filled with hydrolytic enzymes. -Part of cell defense system; digest worn out organelles, food, or engulfed microorganisms.
Why is it important to check for LN in salivary glands?
Salivary glands (parotid) have intraparanchymal LN and therefore can have lymphoma
How should you sample ancillary structures of maxillectomy?
Sample as if they were a separate specimen -eye (P-O section most important!!) -parotid (tumor relationship to parotid) -Lymph nodes (typically sent separately from maxilla)
What is GMS preferred for?
Screening (gives better contrast)
Sebaceous glands
Sebum-producing holocrine glands
The number of "dips" for H&E staining depends on:
Section thickness and type of tissue.
Amorphous texture
Semisolid, unorganized surface that can't hold shape or be cohesive
Should you do sensitive test first or later?
Sensitive first, specific later
What is the 1st blue stained node called in sentinel lymphadenectomy? What does this mean clinically?
Sentinel node -first place where metastasis will occur
Serially sectioned
Sequentially section the specimen completely (bread loafed <- but don't use that!)
How should you submit a tonsil looking for occult primary neoplasm?
Serially section and submit entirely
Endoplasmic Reticulum
Series of membrane-bound channels variable in configuration & extent. Pathways for transportation of secretory products: rough = secretions for outside cell smooth = regulates/releases Ca++ and processes toxins
Dissection of Organs
Sew body up, put in cooler. Weigh SOLID organs, take measurements of organs for notes, note abnormalities inside and out, and take appropriate sections. Don't be afraid to take photos!
What is epithelium classified by?
Shape, stratification, specialization
Epithelium classifications
Shape, stratification, specializations
Cuboidal? Found where?
Shaped like a cube, width the same height, usually with a central nucleus. Found in ducts. (Think glands)
Fissure:
Sharp edged defect of the epidermis extending to deep layers of the skin. Seen in athletes foot or any fungal disease
Papule:
Shiny, elevated indurated lesion
Papule
Shiny, elevated indurated lesion (ie dermatofibroma) -macroscopic lesion
How to GI biopsies:
Should be oriented mucosal side up, wrapped in filter paper, between sponges
What does perpendicular cut show?
Shows the distance from the margin to the tumor
How do leukemias typically present?
Sign & symptoms related to suppression of normal hematopoiesis (ie infxn, bleeding, anemia)
Nodule:
Similar to papule, but larger <5 mm. E.G. Moles and sebaceous cysts
What are isolated tumor cells (ITCs)?
Single cells or small clusters of cells not more than 0.2mm in greatest dimension
Focal
Single defined lesion on a background
Simple
Single layer of cells
What are patterns of spread of carcinomas of the larynx dependent on?
Site of origin & well-defined anatomic barriers
Derma
Skin
Derma-
Skin
Plaque
Slightly elevated, flat-topped lesion usually >5mm
Tumor-infiltrating Lymphocytes (TILs) - melanoma & Merkel cell carcinoma
Small amounts of TILs is adverse prognostic factor for cutaneous melanoma 1. *TILs not Identified* = no lymphocytes present 2. *TILs Nonbrisk* = lymphocytes infiltrate melanoma only focally 3. *TILs Brisk* = lymphocytes diffusely infiltrate entire base of vertical growth phase, or entirely invasive
Simple columnar
Small intestine
Give example of simple columnar
Small intestine microvilli
What is the cause of laryngeal tumors?
Smoking & alcohol use
Why should surgeons supply info on type of neck dissection they perform & details of local anatomy?
So that PA know which LN groups to submit, as this depends on the type of dissection received
Sarcoma
Soft tissue tumors of mesenchymal origin
How should ITCs be classified?
Some say: N0 or M0 Other studies say: ITCs are poor prognosticators in terms of local control
Distribution
Spatial arrangment of the lesions in the organ/tissue
Basement membrane (epidermis)
Specialized structure produced by epidermis and dermis; ties the epidermis to dermis.
What is the most important step before starting maxillectomy dissections?
Specimen orientation
Globular
Spherical
Systemic infection
Spreads by blood or lymphatics. More common in immune-suppressed. Skin abscesses
What is the most common pathology for receiving an Ear Resection (ie a skin)?
Squamous Cell Carcinoma
Laryngeal Tumors type
Squamous cell carcinoma
Biopsy Dictations:
Standard: "Received in formalin labeled 'patients name' and (what the specimen is labeled (tissue type or site))" is/are #, color (tan/pink/white) soft tissues, ranging from 0.2x0.1x0.1 to 0.3x0.2x0.1 submitted in toto as A1"
Are lymphoma protocols routine or stat?
Stat
What if there is capsular/extracapsular involvement?
State in your dictation
What is the single most important prognostic factor in aerodigestive cancer?
Status of cervical LN
Duct associated with parotid gland?
Stensen's duct - opens into oral cavity opposite crown of 2nd molar
What type of tissue is true vocal cord of larynx?
Stratified squamous epithelium
Fibrous Tissue Septae
Strengthens adipose tissue & ties subcutis to both dermis & underlying structures (fascia)
2nd Malignancy of Merkel Cell carcinoma
Strongly associated w/ number of cutaneous & hematological malignancies (mostly squamous cell carcinomas & chronic lymphocytic leukemia)
Langer Lines
Structural lines of fibrous tissue (natural cleavage lines). Incisions made parallel to these lines to reduce scarring and promote faster healing Important in face & breast surgeries
Clinical Pathology
Study functional aspects of disease by lab studies (of tissue, blood, urine & other bodily fluids)
Autopsy
Study of after death or post-mortem changes. To determine cause of death as well as other facts about the patient, especially the condition of the patient surrounding time of death
Pathology
Study of changes in bodily structure & function occurring as result of disease
Clinical Pathology
Study of functional aspects of disease by the lab study of tissue, blood, urine, and other bodily fluids.
Autopsy
Study of post-mortem changes to determine cause of death & other facts about patient surrounding time of death
Enfac and Perpendicular
Sub-sequentially submitted edges in a clock wise fashion.
Level IB
Submandibular Group -LN w/in boundary of ant/post digastric & mandible body -Submandibular gland included
How do viral infections affect salivary glands?
Submaxillary gland can swell due to rubella virus (mumps)
Level IA
Submental Group -LN w/in triangular boundary of ant. digastric & hyoid bone
How should you submit a grossly positive LN?
Submit 1 section of each grossly positive LN
How to gross wedge biopsies:
Submit 2 end margins end face. If it is oriented, submit in 2 different cassettes, indicating which is which. If not oriented, can be put in one cassette designated as "margins." Submit the 1-2 cross sections in an additional cassette.
What should you do if LN are matted?
Submit 2 sections thru each level involved to document the extensive nature of tumor
Histologic Examination of LN - melanoma
Submit entire LN for evaluation
How should you submit macroscopically negative LN for aerodigestive cancer?
Submit in toto
How should you submit grossly positive LN for aerodigestive cancer?
Submit partially
Entirely submitted
Submitted all the tissue, but you have cut it in some way
In toto
Submitted w/out cutting it (biopsies, tiny LN or blood clot)
Impetigo
Superficial infection caused by streptoccocus or strepharius. Superficial pustules which rupture, leaving honey colored crusts.
Excoriation:
Superficial skin defect caused by scratching
Level VII
Superior Mediastinal LN
What surgical margins are important to know of for larynx?
Superior Ring -anterior = vallecular (perpendicular section) -laterally = pyriform sinuses -posterior = posterior cricoid mucosa Inferior Ring -trachea = en face (shave) margin unless tumor <1cm from margin, then perpendicular
Cutaneous Plexus
Supplies deep dermis & subcutis
Papillomatosis
Surface elevation caused by hyperplasia and enlargement of contiguous dermal papillae
Solid texture
Surface with apparent structure or architecture that holds together or maintains shape
Dehiscence
Sutured incision that bursts open (D&E - dehiscence & eviceration)
What is a paraneoplastic syndrome?
Symptoms not explained by indigenous tumor spread/hormone release
TNM staging - SCC
T = tumor not previously treated p = pathologic classification of TNM pT = resection of primary tumor or bx adequate to eval pN = entails removal of nodes adequate to validate LN metastasis pM = implies microscopic examination of distant lesions cTNM = clinical, by referring MD before treatment during initial eval of pt
TNM Staging - Merkel Cell carcinoma
T based on size = <2cm (T1), >2cm (T2), <5cm (T3) & extracutaneous invasion into bone/muscle/fascia/cartilage (T4), indeterminate (TX) M based on LN burden = microscopic vs macroscopic & radiologic evidence Distant Metastasis = spread beyond draining LN basin
What is OSHA requirement for formalin monitoring?
TWA (time-weighted average) = 0.75 ppm in 8 hours STEL (short-term exposure limit) = 2 ppm per 15 min
What order should you sample the tumor?
Take slides in order of dictation
Purpose of X-rays in autopsy
Taken to locate bullets, to locate broken bones and foreign bodies. In children and infants full body x-rays are taken to document old and new fractures or any sort of bone injury.
What would be the cut surface description for a Wharthon's tumor?
Tan/gray, verrugated (or pleomorphic) surface punctuated by narrow cystic or cleft-like spaces - filled with mucinus secretion
What does a normal or a reactive LN look like?
Tan/pink and homogeneous
Describe normal parenchyma for parotid/salivary gland
Tawny (golden-brown, yellow color) & lobulated -intraparenchymal LN of parotid can be confused as mass w/in lobulated parenchyma
Specificity
The ability of a test to be negative in the absence of disease
Sensitivity
The ability of a test to be positive in the presence of disease
Poorly demarcated
The boundary between normal and abnormal is blurred or not easily seen
Letulle:
The cervical, thoracic, abdominal, and thoracic organs removed in one block and then dissected into organ blocks.
Dermatophytoses:
The condition of having resident dermatophytes
Neurons
The conducting cells of the nervous system
Iatrogenic
The disease or injury is produced by medical treatment or diagnosis (E.G. Chemotherapy that causes leukemia as a result).
Cause of death
The disease/injury that sets in motion the physiologic train of events that end in cerebral & cardiac electrical silence
Anatomic Margin:
The edge of the specimen that is that anatomic edge.
Idiopathic
The etiology is unknown
Characteristics of benign neoplasm
The lesion remains localized, it cannot spread to other sites, generally cured on surgical resection an patient survives
Benign
The microscopic and gross characteristics are unremarkable. The lesion looks very similar to tissue of origin
What can happen if leftover OCT is on chuck when adding new OCT?
The new OCT will not adhere to chuck and can cause block to pop off when cutting!
Who is the intermediary between pathology and other departments?
The pathologists' assistant
Surgical Margin:
The place the surgeon actually cut on the specimen
Lesion
The structural abnormality produced by the disease or injury
Anatomic Pathology
The study of structural changes caused by disease
Negative Test Results
There is a normal state or a disease is absent
Positive test results
There is an abnormal condition present
What does edema of salivary gland mean?
There is an obstruction, and fluid cannot drain
How to gross Large Elliptical, Irregular, or Circular skins (unoriented):
They are done as resection. Measure LxWxD. Describe lesion or previous biopsy site, distance from closest edge.
How are adenocarcinomas, NOS histologically graded?
They do not have a formalized grading scheme. They are graded intuitively (ie based on cytomophologic features)
Excisional
They expect margins to be clear, they do not expect to go back for more. Complete excision with diagnostic specimen
Why do most salivary gland carcinomas not require grading?
They have a biologic behavior defined by their categorization
What should be done with the specimens after dissection?
They should be stored properly in the right amount of formalin. Store for at least three weeks until signed off, review CAP checklist
Lichenification
Thickened, rough skin, caused by repeated rubbing; callus
Hyperkeratosis
Thickening of the stratum corneum, can be associated with abnormal keratin
Currentage
Thin shaving of skin, usually in many pieces. Cannot determine adequacy or margins. Purely diagnostic
How should you think of a maxilla specimen to help with orientation?
Think as a cube
Thoracic cervical block
Thoracic block with addition of tongue an cervical organs including larynx, thyroid, cervical spine
Ghon
Thoracic, cervical, abdominal, and urogenital organs removed as organ blocks (ie "en bloc" removal) --widely used.
What is the adam's apple?
Thyroid cartilage
Removal of bowel
Tie or clamp duodenum at ligament of Trietz, AKA: the suspensory muscle of the duodenum, then, keeping tension on the bowel, snip or cut along length of bowel. At the rectum, (listen for sound) unleash rectum from abdominal wall, milk back contents from anus, DO NOT CUT!, tie or clamp and cut. CUT ON DISTAL SIDE. Put in bowl for late
Miliary
Tiny foci that are too numerous to count
How and where the specimen is opened depends on:
Tissue type and pathology involved
Ethyl Alcohol
Tissue: All Special Stain: Congo Red (amyloid), Von Kossa (calcium), Weigert's stain (fibrin), Mallory's stain (iron), Gomori's methenamine silver stain (urate crystals), <dont use with Ziehl-Neelsen (AFB)> Adv: enzyme histochem, molecular analyses, impression smears, blood smears, preserves glycogen, preserves crystals-uric acid/sodium urate Dis: causes excessive hardening, routine fixative, dissolves lipids
2% Gluteraldehyde
Tissue: All Special Stains: *false pos with PAS* ie don't use Adv: Electron microscopy, collagen preservation Dis: Routine fixative, slow penetration, must be refrig
Zenker's
Tissue: All Special Stains: Sheehan (chromaffin), Mallory's PTAH (collagen & muscle), Viral inclusions (negri bodies), Feulgen (DNA), Trichomes (collagen & muscle), Verhoeff-van Gieson (elastic fibers) Adv: Routine fixative, preserves mitoch Dis: must wash overnight, requires iodine treatment before routine staining, must prepare fresh, molecular analyses, no metal instruments, IHC
10% NBF
Tissue: All Special Stains: Warthin-starry (spirochetes), Oil Red O (fat), Grimelius (neuroendocrine granules) Adv: Routine fixative, preservation (gen staining), IHC, molecular analyses, LT storage Dis: ---
Acetone
Tissue: All Special stains: <Ziehl-Neelsen (AFB)> not good Adv: Enzyme histochem Dis: routine fixative, must be refrig, dissolves lipids
Carnoy's
Tissue: All Special stains: methyl-green pyronin (DNA/RNA), congo red (amyloid), giemsa (mast cells) <Ziehl-neelsen (AFB)> not good Adv: cytologic fixative, rapid penetration, nuclear detail, fixes RNA, preserves glycogen Dis: dissolves cytoplasmic elements, hemolyzes RBC
Zenker's formol
Tissue: BM, spleen, all blood-containing organs Special Stains: --- Adv: Routine fixative, preserved mitoch, preserved RBCs Dis: must wash overnight, requires iodine treatment before routine staining, molecular analyses, IHC
B5
Tissue: LN, spleen, Bone Marrow (BM) Special stains: --- Adv: Cytoplasmic/nuclear staining Dis: Routine fixative, must prepare fresh, requires iodine treatment before routine staining, overfixation causes hardening
Bouin's
Tissue: testicular biopsies Special Stain: masson trichrome (collagen & muscle) Adv: Routine fixation Dis: lyses RBC, removes ferric iron, dissolves proteins, molecular analyses, IHC, carbs
What is the goal of examining a radical neck dissection?
To ID all the LN within specimen and how many are involved by tumor at each level
Why autopsy?
To confirm a diagnosis, understand new diseases, quality assurance (was the best course of treatment taken?), toxicology
What is the objective of LN disscetions?
To detect & process every LN contained in specimen
Stage (staging a tumor)
To determine the degree to which the cancer has spread
What is the objective for Multi-nodular goiter dissections?
To ensure any areas of trans-capsular or vascular invasion not missed
What is the goal of a radical neck dissection?
To find & document as many LN as possible
Why would you use transillumination for eye?
To give you a plane of sectioning, it helps you see tumor
When would you use a highly specific test?
To sort out true positives and negatives
What should you always remember to do when doing a thyroid specimen?
Touch Prep
Pacinian Corpuscles
Touch receptors for deep pressure & vibration
Ciliated
Trachea
What is the inferior mucosal margin consist of?
Tracheal stump
Excoriation
Traumatic lesion breaking the epidermis, causing a denuded linear area (scratch)
Pre-epiglottic space
Triangular space composed of soft tissue & CT (aka vallecula)
What is the most important thing to remember for any encapsulated nodule?
Try to show tumor-capsule-thyroid interface (Entirely submit)
How many sections should you submit of LN?
Tumor grossly uninvolved = submit entire LN Tumor grossly involved = submit 2 sections & measure tumor (be sure to include rim of perinodal fat)
4 types of neoplasms of the skin
Tumor of the epithelial cells, melanocytes, dermal connective tissue =, blood born immigrant cells
Why might someone have a maxillectomy?
Tumor of the face sinuses
Malignant melanoma
Tumor originating from melanocytes. Most malignant of all skin tumors. Melanoma cells are very inefficient cells of melanin. Cause immune reaction which destroys cells. Bad=amelanocytic melanoma A: macular-->elevated B: Borders (usually quite irregular) C: Color (variations in color throughout a single lesion. Red-brown to black with some pale areas) D: Diameter <6mm=cause for suspicion! The younger the diagnosis the more aggressive the tumor/disease. E: Evolution/Change in the lesion over time. Treatment is surgical excision. If metastases are present, they also do chemo and radiation. Survival is 5 yrs @ 60%. New treatment is a vaccine
What is another treatment for tumors that is relatively new?
Tumor vaccines -becoming more effective -use tumor tissue to make vaccine, immunotherapy allows body to make antibodies to attack tumor tissue only
What are poorly differentiated carcinomas?
Tumors that display solid, trabecular/insular growth pattern and show 1 or more of following: -greater than 3 mitoses/10 high-power fields -necrosis -nuclear convolution
Location of melanom
Typically in sun-exposed areas
How can sarcomas spread?
Typically spread hematogenously, but can also spread lymphatically
How can carcinoma spread?
Typically spreads lymphatically, but can also spread hematogenously
Biopsies for Melanoma
USE: intact lesion removed (well-cut, well-fixed, well-embedded, well-stained in H&E) Do NOT use: shave, punch, FS
What is a dominant prognostic factor in invasive cutaneous melanoma w/out metastasis?
Ulceration
Neoplasm
Uncontrolled growth of new cells (either benign or malignant)
Sentinel Event
Unexpected event that results in patient death or serious physical/psychological injury not related to patient's illness
Intraparenchymal LN
Unique for parotid glands (LN w/in their parenchyma)
Level II
Upper Jugular Group -LN in upper 1/3 of IJ vein & adjacent spinal accessory nerve from carotid bifurcation/hyoid bone to skull base -Posterior boundary = posterior border of SCM -Ant. boundary = Lateral border of stylohyoid muscle
What is included in radical neck dissection, Level II?
Upper jugular group
Stratum corneum
Uppermost, most superficial layer. Entirely composed of dead keratinocytes
Give example of transitional
Urothelium - cells in the bladder
Fixation techniques for breast tissue
Use Pen-Fix or 1/2 37% formalin and 1/2 100%OH put sections in for 2 hours or specimens in up for 4-6 hrs.
How to reduce false positives in fungal staining?
Use both GMS & PAS
How do you orient total thyroidectomy?
Use contour of organ (curve on posterior aspect)
How can you detect metastasis?
Use of PET/CT scans (combines functional info from PET w/ anatomical info of CT)
Removal of chest plate
Use stryker saw or rongeurs. (Some places use garden shears). Cover edges of rib with towel to prevent stick injuries. Remember what looks normal/abnormal! What does the pleural surface look like? Visceral and parietal. What does the pericardium look like? How much fluid is there?
How should you close up body?
Use whip stitch
How does WHO classify lymphoid neoplasm categories?
Uses morphologic, immunophenotypic, genotypic & clinical features to sort the lymphoid neoplasms into 5 categories.
Suction
Usually done endoscopically, can get with sessile polylps
What should you evaluate while grossing an eye specimen?
VILCRO 1. *Vitreous fluid*- s/b clear, semi-gelatinous & non adherent 2. *Iris* - variations s/b noted (ie melanoma) 3. *Lens* - s/b smooth & hard 4. *Ciliary body* 5. *Retina* 6. *Optic nerve head*
Malignant
Vaguely or not at all resemble tissue of origin.
What is the best section to take in glossectomy?
Vallecula to epiglottis
Pleomorphism
Variation in size and shape of the cells, different than normal
Pseudostratfied columnar non ciliated
Vas deferens
Vascular Invasion - melanoma
Vascular invasion by melanoma correlates with worsened overall survival
Shave Biopsies
Very superficial, thin biopsies for diagnosis, different from currentage because it will only be one piece. Can be full excision
Pustules:
Vesicles filled with pus. Seen in impetigo
Risk factors for melanoma
WASPs are greater risk than non-WASPs (WASP = White, Affluent people who are Sun-sensitive & have Precursor moles)
Core biopsies must always be:
WRAPPED (prostate, lung, liver, small breast cores)
Keeping cryostat 'top' open results in what?
Warmth, humidity, static
What are the Reasons and consequences of water in tissue before embedding? How can this be avoided?
Water from: Edema, blood, brain matter, -Ice crystals will change the diagnostic morphology of the section -Be sure specimen is adequately dried, DAB DRY ON TISSUE before embedding
How does an ear resection usually come?
Wedge (total ear resection rare)
What is the most important element to grossing parathyroids?
Weight (change in weight indicates pathology)
Why is weight the most important info to include in parathyroid gross?
Weight distinguishes btwn Isolate Adenoma & Diffuse Hyperplasia
Segmental
Well defined portion of segment of tissue that is abnormal and sometimes a distinct geometric shape
What is follicular carcinoma?
Well-differentiated carcinoma type defined by invasiveness in absence of diagnostic nuclear features of papillary thyroid carcinoma
Submandibular/Submaxillary gland contains what duct?
Wharton's duct - empties into floor of mouth on both sides of frenulum of tongue
What is etiology?
What caused it? How did the disease begin?
Determine before opening specimen if anything special is needed?
What kind of testing? Micro, chemistry, serology, etc.
Fixation for Lymph Nodes (colon and axillary dissections)
When specimen arrives, open/fix/slice fix in 1/2 formalin and 1/2 Dissect Aie
Specimen ID Error
When specimen has incorrect/missing site of origin or time of collection, but patient is correct
Patient ID Error
When specimen is mislabeled with incorrect patient
True Negative Test Results
When the test is negative and the patient doesn't have the disease
False Negative Test Results
When the test is negative but the patient has the disease
True positive test results
When the test is positive and the patient has the disease
False Positive test results
When the test is positive but the patient doesn't have it
Dehiscence:
When you have a sutured incision that bursts open. D&E common in bowel surgeries (dehiscence and evisceration), can also often occur in C sections.
Stratum Spinosum
Where keratinization begins
Virchow Technique:
Where the organs are removed one by one, this technique is used most widely usually with some kind of modifications. The fist step originally was to expose the cranial cavity then spinal cord, and then you removed the thoracic cervical and abdominal cavity organs.
What is Moh's Surgery
While pt is under/wound anesthetized, excise tissues little by little (frozen section each time) to reduce tissue amt taken
How should the normally sclera look?
White & smooth
Exudates
White to yellow color. Raised because of exuded fluid
Cruciate margin
Will allow you to give a measurement microscopically. (Incisional section)
Chronic viruses:
Will cause warts (verucca vulgaris), some are caused by HPV can be acute/self limited
How are eyelid resections typically processed?
With frozen section (take little as possible to get positive margin)
Why is cellulite typically only seen in women?
Women subcutaneous fat layers are column-like chambers separated by CT that allow fat projections to go into the dermis. Men have crosshatching within their subcutaneous fat layer and therefore the fat is unable to reach the dermis. This is regulated by hormones and men deficient in male hormones will get cellulite.
External exam
Work from head to first, check name and MRN make sure it matches info, measure body length, approximate weight or actual weight, deceive from head 2 toe back or dorsal surface, look for scars, tattoos, anything out of the ordinary (take copious notes), the hair (patterns of baldness, color, and length), eyes (color of sclera, iridies and pupil symmetry. In a deceased individual you give the measurement of pupils. asymmetrical pupils indicate brain injury) look at dentition (Teeth. Complete or no? Are they edentulous? Do they have primary dentition or secondary dentition?) work your way to face. Are there piercings, tattoos, scars, or markings on face? Photograph all tattoos, all stab marks and lacerations, or any identifying scars on the body. Note the ears. Are they symmetrical? What is the setting of the ears? The pinna of the ear should make a straight line with the eye. The extremities should also be bilaterally symmetrical with same number of digits. Finally describe genitalia. Describe of normal adult female/male, or if different gender than on form. In chest note lowest/normal nipples, in the abdomen is it protuberant? Is it fluctuant? Is it taut?
Why shouldn't you puncture an eye specimen?
You want to keep the vitreous fluid (fixing won't penetrate) for possible drug testing
What is an example of maxillectomy dictation
___x___x___cm tumor is gray-tan, ill-defined & erosive, involving the alveolar processes on the anteriolateral aspect, originating on the medial aspect of maxillary sinus (where tumor evolves & originates)
Ulcer;Ulcerated
a break in skin or mucous membrane with loss of surface tissue, disintegration and necrosis of epithelial tissue, and often pus
Surgical pathology report
a comprehensive statement that integrates the macroscopic & microscopic findings of surgically excised tissue
Mucus
a viscid slippery secretion that is usually rich in mucins and is produced by mucous membranes which it moistens and protects
Specificity
ability of test to be negative in absence of disease
Sensitivity
ability of test to be positive in presence of disease
Tenacious
adhesive, sticky
Modified neck dissection, type III
aka "functional neck dissection" -includes all classical radical neck dissection, except spinal accessory nerve, internal jugular vein & SCM muscle
Where are tonsils located in situ?
aka palatine tonsils Located laterally on each side of oral cavity/oropharynx
Where are adenoids located in situ?
aka pharyngeal tonsils -located along roof of nasal cavity/nasopharynx
Total Laryngectomy orientation
anterior = epiglottis (flap closes posteriorly) or if epiglottis not included: AnterioSuperior = superior horn of thyroid cartilage
Where is most pathology located in a larynx specimen?
anterior aspect (mostly due to gravity)
Viscus
any internal organ within a cavity
Mucin
any of a group of mucoproteins that are found in various human and animal secretions and tissues (as in saliva, the lining of the stomach, and the skin) and that are white or yellowish powders when dry and viscid when moist
What is formalin?
aqueous solution of formaldehyde and water (37-40%)
Germinal Center
area of lymphatic tissue containing *rapidly differentiating lymphocytes*
Microscopic Examination
assessment of magnified images of small structures (ie study of cellular morphology)
Gross Examination
assessment of tissue specimens, either surgical or autopsy, with the unaided eye
Sessile
attached by a broad base
Medicolegal Autopsies
autopsy performed under provisions of the medical examiner's office of that state
What is halitosis
bad breath
Vallecula
base of tongue (btwn tongue & epiglottis)
Ossified
bone-like
Grumose
lumpy, clotted
Idiopathic
cause of disease unknown (etiology unknown)
Etiology
cause or how disease began
Mesenchyme
cells filling spaces btwn organs (ie fat, cartilage, muscle, bone & tendon cells)
Give example of pseudostratified columnar, non-ciliated
cells in vas deferens
Transitional
cells slide over each other to form layers if organ is distended or contracted. Found in organs that stretch (ie bladder)
Myoepithelial cells
cells that embrace secretory units, contracting to expel product
Macrometastasis - melanoma
clinically detectable nodal metastases confirmed by lymphadenectomy or when node shows gross extracapsular extension
Gelatinous
coagulum of fluid mass, semi-solid
Cylindrical
column-like, tube-like
Anasarcic
condition of having full body edema (used in autopsy, late state cancers)
Anatomic landmark
consistent features (shape, contour, structure) that serve to indicate a specific structure or designate a position.
Fibrinoid or fibrinous
containing acellular refractile fibrin
Calcific
containing calcium
Cavernous
containing hollow spaces
Filamentous
covered with long thread-like structures
Bosselated
covered with small rounded eminences
Cuboidal
cube-shaped; width same as height w/ central nucleus (ie ducts)
Necrotic
dead tissue
Homicide
death at the hands of another (not necessarily murder)
Natural
death due to natural disease process
Therapeutic Misadventure
death due to unforeseen complication of therapy
Unknown
death in which the manner of death is not known
Dx of follicular carcinoma
depends on ID of invasion of the tumor capsule and/or vascular spaces
What is helpful in determining extrathyroidal extension?
desmoplastic response
Ragged
diffusely roughened sometimes with defects; it looks like someone chewed on it
Mottled
discolored areas
Underlying cause of death
disease or injury starting train of morbid events leading directly to death, or the circumstances or violence that produced the fatal injury
iatrogenic
disease/injury caused by medical treatment or dx
Septate
divided by a fibrous wall
Segmental
divided into parts
Scale or scaly
dry, flaky keratin sheets
Margin
edge or boundary of specimen (ie plane where surgeon has removed specimen from patient)
Give example of stratified squamous, keratinized
epidermis
Supraglottis location (structures)
epiglottis --> apex of ventricle (epiglottis, aryepiglottic folds, arytenoids, false vocal cords & ventricle)
Carcinoma
epithelial cancer
How will a tumor spread if 1st located in nasal cavity (medial)?
extends further into nasal cavity
How will a tumor spread if 1st located in floor of sinus?
extends inferolaterally into palate & alveolar processes of maxilla
Diffluent
extremely soft or mushy
What is karyolysis?
faint, dissolved nucleus
Papillary
finger-like projections
Indurated
firm or hard where once was soft
What is formaldehyde?
flammable gas at RT
Squamous
flat, irregularly shaped cells, relatively metabolically inactive (ie alveoli of RT, capillaries, tubules of kidneys & mesothelium)
a) Vesicle b) bulla(e)
fluid filled raised lesion (usually burns, also Herpes) a) <5mm b) >5mm
What is karyorrhexis?
fragmented nucleus
Pathophyisology
manner in which incorrect function is expressed (ie the disease state)
Multiple
many, several
Vesicular
small fluid filled sacs
What is pyknosis?
small, dense nucleus
Glassy
smooth, shiny
Serpiginous
snake-like looping
Sarcoma
soft tissue cancer (mesenchymal origin)
Velvety
soft with a thick pile or surface
DC: contributing causes line
space is given to list those processes which contributed to the death but which did not lead to proximate COD
Lumen
space within a tubular structure
Glistening
sparkling, shining, gleaming
Where does tumor from sinus floor typically spread?
spreads inferiorly/laterally into palate & alveolar process of maxilla
Where does tumor medially placed typically spread?
spreads into nasal cavity
Where does tumor on sinus roof typically spread?
spreads into orbital cavity, ethmoid air cells/sinus, or cribriform plate
Where does tumor on lateral wall typically spread?
spreads into skin/soft tissue of cheek
PREMALIGNANT MELANOCYTIC LESIONS DYSPLASTIC NEVUS SYNDROME (DNS):
• An inheritable clinico-pathological syndrome, first described in 1976, of multiple "dysplastic" (but benign) nevi, some of which may progress to malignancy (melanoma). Covered portions of the body are usually affected (in contrast to traditional nevi and freckles). The back usually involved (33%), but sites are "family-specific." Small dark macules noticed around age 6 ... expand in adolescence. New ones develop throughout adult life. Gross: • multiple macules, usually greater than 5 mm, with irregular outlines. Micro: • melanocytic pleomorphism and hyperchromatism ("dysplasia") with underlying lymphocytic inflammation and fibroplasia.
How do you orient tissue in a block?
• Fat = last thing to hit blade (or hits blade by itself) -- can smear and ruin rest of section • Tissue of most importance should be PERPENDICULAR or DIAGONAL to blade - should not be 1st or last aspect to touch blade...aka in the middle...(Epithelial & mucosal lined tissues (aka skin, GI, bladder, uterus and cervix) should have epithelium PERPENDICULAR to blade. - can arrange tissue with longitudinal margins to hit blade last). • Embed tough tissues (that cause chatter) on a diagonal & cut as warm as possible
Neoplastic Nevus (Common "moles")
• Nevus cells resemble melanocytes but lack dendritic processes (by ultrastructure). The cells tend to arrange themselves in "nests." Main histologic kinds of nevi include: 1. JUNCTIONAL: a flat pigmented lesion (macule) consisting of nevus cells in nests at the dermal/epidermal "junction" (basal layer of epidermis) 2. INTRADERMAL: usually an elevated lesion (papule or nodule) showing nests of nevus cells within the dermis (minimal or no junctional activity) 3. COMPOUND: a flat to slightly raised lesion (papule) with features of both a junctional and an intradermal lesion Other, less common nevi include: 4. Neural nevus - a nevus with maturation into neural-type tissue 5. Blue nevus - benign, deeply pigmented "mole" 6. Spitz nevus ("Spindle and Epitheloid nevus") - benign "mole" occuring in childhood or adolescence which mimicks melanoma 7. Congenital nevus (including giant hairy nevus) - occasionally develop melanoma 8. Dysplastic nevus (Clark's nevus) - may be precursor to melanoma
Melanin
• an endogenous, non-hemoglobin-derived, brown-black pigment synthesized from tyrosine in melanocytes. Accounts, in part, for skin color. Protects skin from damaging ultraviolet rays (absorbent). Formation: tyrosine ---(tyrosinase)------> dopa dopa -----(multiple steps)---> melanin
Melanosomes
• cytoplasmic, membrane-bound organelles containing melanin Best appreciated by electron microscopy.
Melanocytes
• melanin-producing cells
Melanophores
• phagocytic cells containing melanin
Vitiligo
• skin depigmentation, possibly autoimmune etiology
Non- Neoplastic Freckle (ephilid) Lentigo
• small brown macules scattered over the skin in exposed areas. Exposure to sun deepens the pigmentation; lack of sun exposure causes them to fade. Microscopically they show hyperpigmentation of the basal cell layer, but no junctional change or acanthosis. • small macules (resembling freckles) commonly present in adults and may occur at any age. The pigmentation does not deepen with sun exposure. Microscopically they show hyperpigmentation of the basal layer, and acanthosis (elongation of the rete ridges).
Albino
• someone lacking tyrosinase. Increased risk of skin damage.
Nevus (pleural "nevi")
• term used by dermatologists to refer to any skin blemish ("mole")
