Anatomical Techniques FALL - COMBINED
Compound exocrine glands consist of
-Ductal portions -Acinar portions (serous, mucinus or mixed) surround sac-like portion of compound gland
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)
Septate
divided by a fibrous wall
Segmental
divided into parts
What does spread of carcinoma in larynx depend on?
on wall-defined barriers of larynx (thryoid cartilage & cricothyroid membrane)
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 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
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
Who discovered formaldehyde? How was it first used?
-Ferdinand Blum (in 19th century). -First used as antiseptic
What are Air-dried touch preps used for?
-Giemsa -Enzyme cytochemistry -Immunofluorescence for terminal transferase
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
Meissner corpuscles
-Papillary dermal touch receptors (hands & feet) -Detect light touch, soft fleeting movement
Paraglottic space
-Potential space deep to ventricles & saccules -Filled with adipose & CT -Lymphatics & blood vessels present, but No LN!!!
What is of less prognostic significance in thyroid cancer?
-Regional LN spread -Tumor deposits <2mm greatest dimension -Micrometastasis, isolated tumor cells & psammoma bodies
What structures are included in radical neck dissection?
-SCM muscle -Int. Jugular vein -Spinal accessory nerve (CN XI) -LN level I-V
What are the anatomic regions of larynx?
-Supraglottis -Glottis -Subglottis -Paraglottic space
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)
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
Dyskeratosis
-abnormal, premature keratinization w/in cells below the stratum granulosum -microscopic lesion
Nodal goiter
-calcified areas -colloidal areas
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
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
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 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
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
Subcutaneous (subcutis)
-lower layer -contains adipose, blood vessels, lymphatics & nerves
Humoral Immunity
-mediated by *B lymphocytes* via *Ab production* -effective against *extracellular* microbes
Melanocytic nevi
-melanocytes arranged in abnormal order -congenital disorder
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
Describe an unremarkable (normal) LN
-ovoid, with a tan-pink homogeneous cut surface -3mm - 1cm (any bigger may indicate pathology)
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
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
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
Folliculitis
-primary skin infxn -caused by staph & typically limited to hair follicles
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
How many sections from eye?
1-2 sections from P-O section & 1 optic nerve margin
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
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)
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
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 sample margins, even if thinking 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
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 & Hx - 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!!!***
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
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
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 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 - if so, Michele/Zeus!!! 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
3 primitive embryologic tissues every cell is derived
1. Ectoderm 2. Mesoderm 3. Endoderm
Biopsies types
1. Endoscopic - thru mouth or rectum (for hershsprung & 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 hershsprung) 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
Differentiation of Ectoderm
1. Epidermis/adnexae 2. Brain & nerves (CNS/PNS) 3. Sensory epithelium (ears, eyes & nose) 4. Glands developing from epidermis (subcutaneous, mammary, pituitary) 5. Teeth enamel 6. *Epithelial tissue - typically squamous epithelium*
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
Nucleic Acid Stains
1. Feulgen Reaction 2. Methyl Green-Pyronin Y
Most common stains for fungal/AFB
1. GMS (gomori methenamine silver) - Screen 2. PAS (periodic acid-schiff) - Confirm
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)
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
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
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
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
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
How do you reduce radiation exposure?
1. Reduce time 2. Increase distance 3. Use proper shields
6 things to check before dictating specimen
1. Req 2. Cap 3. Cassette 4. Container 5. Special Procedures 6. Clinical history
How to improved IHC staining
1. Sample representative of area to study 2. Stabilize tissue w/ appropriate method 3. Do not overfix tissue
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)
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)
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 you consider when sampling a tumor?
1. be sure to sample all areas of tumor that look different 2. large cyst sections - take 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
Touch Prep Procedure
1. dab dry section of tissue w/ paper towel 2. use forceps, touch & lift 3x on clean slide 3. fix &/or air dry
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 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
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
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
left ventricle walls thickness
1.0 cm
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
# of slides made for FS
2 slides per block
prostate (under 50)
20 gms
Chuck size uses
20mm - brain & cord biopsy 40mm - bone
Lentiginous
A linear pattern of melanocyte proliferation within the epidermal basal cell layer
Elliptical
A symmetrical oval
Glomus bodies
AV shunts, divert blood from skin to conserve heat (hands, feet & ears)
Specificity
Ability to test negative in people withOUT disease
Sensitivity
Ability to test positive in people WITH disease
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.
Fistula
Abnormal communication between organs (Caused by infxn - diverticulitis)
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")
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
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
Glomus bodies (dermis vessels)
Arteriovenous (AV) shunts, diverts blood from skin to conserve hat; found mainly in hands, feet, ears
When tumor sits over anterior commissure (above false cords) what is the most likely site for tumor extension?
Arytenoid cartilage
How long to fix tissues in formaldehyde?
At least 8-12 hours (others say 48hrs - 1 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)
Shattering caused by...
Block TOO COLD Higher H2O content in tissue (edematous/bloody tissues & brain biopsies)
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
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: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? 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:dark basophilic staining of nuclei and cytoplasm, especially around edges of tissue
C: laser/electocautery techniques denature macromolecules & produce heat artifact S: no solution
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
***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
Stem cells
Cells capable of becoming another type of cell (ie pleuripotent cells)
Functional Disorder
Change in performance of cells, tissues & organs
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 angulated 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
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
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
Opaque
Cloudy or non-transparent
Symptoms
Complaints reported by patient as part of medical history
Neurons
Conducting cells of nervous system
Blood cells
Connective tissue: RBC & WBC (including those found in lymph & spleen)
Ribosomes
Consist of small and large subunits. Carry out protein synthesis, either free-floating or attached to rough endoplasmic reticulum.
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)
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
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 - usually links to a functional disorder. (ie strep infxn of mitral valve causes hole in valve & backflow of blood, heart works harder -> heart failure)
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
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
Dessicated
Dryed out
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 gluteraldehyde fixed tissues used for?
Electron Microscopy
What is a carcinoma?
Epithelial tumor
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
What is included in radical neck dissection, Level V?
Fatty tissue triangle posterior to SCM
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
What does mucoceles look like?
Fluctuant swelling with blue hue (w/in minor salivary glands - along lip)
Interstitial fluid
Fluid btwn tissues & cells
Arrector pili muscles
Follicle-associated smooth muscle bundles
Why do a punch biopsy?
For Inflammatory conditions: -Systemic lupus erythematous -T Cell Lymphoma (mycosis fungoides) *Put into Zeus for IF!!!!*
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)
Pacinian corpuscles (Nerves- dermis)
Found deep in subcutis, for deep pressure and vibration, numerous in palm and soles of feet.
Where is cobblestone typically seen?
GI tract, most often chrones disease
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 (Skin adnexae)
Glands of groin and axilla; produce odor
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)
GMS stand for:
Gomori Methenamine Silver
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
Concave
Having a spherically depressed surface
Rule of sensitive vs specific tests
Highly SENSITIVE tests are NOT very SPECIFIC Highly SPECIFIC tests are NOT very SENSITIVE
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`
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 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
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
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
Paraglottic space
Less well-defined & composed of loose CT
What levels are included in supraomohyoid region of selective neck dissection?
Levels I-III
Most common site for hematogenous spread (metastasis)
Liver & Lungs
Afferent vessels
Lymph *A*rrives into node
What should you do before you start dictating a thyroidectomy while you're still new?
Make notes, then dictate!
Multifocal to Coalescing
Many lesions present that appear to be growing together or fusing
What does "en face" mean?
Margin (inked) side down
What is a resection of a maxilla called?
Maxillectomy
What is a PRO to fixation?
Most stains are made to work with fixed tissues
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)
Neoplasia
New growth
Purulent to seropurulent
Opaque, thin to thick fluid. Pus (sero - bloody pus)
OCT
Optimal Cutting Temperature
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
Plasmalemma
Phospholipid bilayer membrane around organelles. Plasma membrane is unique - has glycocalyx coat for cell-cell recognition.
Possible test question: What type of acini are submandibular glands?
Predominately serous, but have some mucous acini
What is an important predictor of poor prognosis in head & neck cancer (of all sites)
Presence of perineural invasion in primary cancer
Pros & Cons of Perpendicular margins
Pro: Can give distance of tumor to margin Con: Doesn't eval entire margin
Protuberant
Prominence beyond a surface
Green-Black color
Pseudomelanosis or Aspiration pneumonia
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
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
What is GMS preferred for?
Screening (gives better contrast)
What are patterns of spread of carcinomas of the larynx dependent on?
Site of origin & well-defined anatomic barriers
Derma-
Skin
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
What does edema of salivary gland mean?
There is an obstruction, and fluid cannot drain
B5
Tissue: *LN, spleen, 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 objective of LN disscetions?
To detect & process every LN contained in specimen
Pre-epiglottic space
Triangular space composed of soft tissue & CT (aka vallecula)
Adipose tissue (Subcutis)
Triglyceride (fat) store; provides insulation and structural padding.
What is the most important thing to remember for any encapsulated nodule?
Try to show tumor-capsule-thyroid interface (Entirely submit)
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 shouldn't you puncture an eye specimen?
You want to keep the vitreous fluid (fixing won't penetrate) for possible drug testing
Viscus
any internal organ within a cavity
Ossified
bone-like
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
Gelatinous
coagulum of fluid mass, semi-solid
Cylindrical
column-like, tube-like
Scale or scaly
dry, flaky keratin sheets
Margin
edge or boundary of specimen (ie plane where surgeon has removed specimen from patient)
Carcinoma
epithelial cancer
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
Hyperplasia
increased NUMBER of cells --> response to stimulus
Varigated
integrated different colors and streaks
Spongiosis
intercellular edema of epidermis
How will a tumor spread if 1st located laterally?
into bones, cheek & possibly parotid gland
How will a tumor spread if 1st located on roof of sinus?
into orbital cavity, ethmoid sinuses & cribriform plate
Endophytic
invasion of surface in spreading pattern
Grumose
lumpy, clotted
Pathophyisology
manner in which incorrect function is expressed (ie the disease state)
Multiple
many, several
Pedunculated
on a stalk
Granular
on a surface, sand-like, finely roughened
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).
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
Serrated
saw-like notches
Mucous acini
secrete mucus
Give example of simple cuboidal
secretory cells (ie glands, kidney tubules, terminal bronchials of lungs & ducts of reproductive tract)
Glistening
sparkling, shining, gleaming
Viscid
sticky, tenacious
Suicide
taking of one's own life
Columnar
taller than wide; nucleus close to base of cell (ie small intestine, microvilli)
Fungating
tumor crawling along a surface
Verrucoid
wart-like
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
What are midline nodes considered?
Ipsilateral nodes
Anasarca
full body edema
What is most common thyroid carcinoma?
-"Classic" papillary carcinoma
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
Necrotizing fasciitis
-secondary skin infxn -commonly caused by strep pyogenes
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
****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"
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
What type of specimen are tonsils typically?
'Gross-only' (Not submitted for microscopic exam)
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
Serous acini cells
-secrete fluid isotonic w/ plasma (serous fluid)
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!!!)
Sialadenitis
*Gland inflammation* - From trauma, infxn, or autoimmune (Sjogren's syndrome)
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*
Hydropic swelling
*Intra*cellular swelling of the keratinocytes, often seen in viral infection
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
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; cell DNA damaged beyond repair (normal cell process - embyrogenesis - NO inflam)
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)
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. *predominately 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
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
Feulgen Reaction
- shows DNA → mild HYDROLYSIS via HCl (removes purine bases, leaves sugars & phosphates of DNA intact) DNA = reddish purple Cytoplasm = light green
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)
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)
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 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
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 more than 1 tissue fragments / biopsies to cut them?
-Align VERTICALLY - (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 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 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?
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
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 does a classic lymphoma look like? And what should you perform?
-Glistening, shimmering, homogeneous cut surface -Perform lymphoma protocol
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)
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
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/involved? -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
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
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
Dermal Connective Tissue Tumors
-Originate from fibroblasts or blood vessels -Benign/low grade malignant 1. Dermatofibroma = benign 2. Kaposi's Sarcoma = malignant
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)
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 (true or false neg/pos)
-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)
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 does a radical neck dissection include?
-SCM muscle -internal jugular vein -spinal accessory nerve -LN from levels I-V
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)
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 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)
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?
CT provides
-a noninvasive way to see anatomy -give ability to rapidly acquire 2D scans (then computer turns them into 3D)
Which categories of salivary gland carcinomas DO require grading?
-adenoids cystic carcinoma -mucoepidermoid carcinoma (most common histologic type seen in larynx) -adenocarcinoma, nos
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
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
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
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)
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
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)
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
Papillomatosis
-hyperplasia of dermal papillae -causes surface elevation -microscopic lesion
Hypergranulosis
-hyperplasia of the stratum granulosum -microscopic lesion (often due to intense rubbing)
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
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)
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)
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!)
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
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)
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
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
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
Serous acini
-secrete serous fluid -PAS positive -intracytoplasmic granules basally located at intercellular capillaries
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
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
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)
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)
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
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
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
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)
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 is included in radical neck dissection, Level I?
-submandibular gland -triangle of soft tissue anterior to SCM muscle
What structures should you submit sections of in a neck dissection?
-submandibular gland - (1 section) -internal jugular vein margins & cross section of involved area (in 1 cassette) -SCM muscle margins & involved area
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
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
Nodular
large bumps or masses
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
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
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)
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
Categorical vocabulary
1. Specimen type 2. Histological type 3. Extent of tumor
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
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
Techniques for Cutting Fat
1. *Dissect off any unnecessary fat from tissues* 2. *Fat Gouge Trick* -if rotating block does not put fat behind more "cut-able" tissue) *remove blade first!* -Use DULL spatula to dig out unwanted portion while chuck in machine -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
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)
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*
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
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!)
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
Epithelium by Shape
1. Squamous 2. Cuboidal 3. Columnar 4. Transitional
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
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. *Photos!!!* 5. *Take Appropriate sections*
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
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)
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
Epidermis Layers
1. Stratum Basale 2. Stratum Spinosum 3. Stratum Granulosum 4. Stratum Lucidum 5. Stratum Corneum
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)
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
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
3 Layers of Skin
1. Epidermis 2. Dermis 3. Subcutaneous
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)
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 8. *Epithelial tissue of glands (ie thyroid gland, not from epidermis)*
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.
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
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
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
How many LN are typically included with *radical or modified radical* neck dissection?
10 or more
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) "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)"
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
2 types of cell death
1. Necrosis - death by Irreversible cell damage, inflammatory response (more common & always pathogenic) 2. Apoptosis - Programmed cell death, DNA damaged beyond repair (NO inflam) 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. Sections: -mucosal margins (inferior & superior) -soft tissue margins (anterior & posterior) -tumor (keep supraglottis, glottis & subglottis in mind) -from both sides to include false cords, ventricles & true cords -pyriform sinuses, epiglottis, aryepiglottic folds, anterior commissure, supglottis, thyroid cartilage, cricoid cartilage & hyoid bone -pre-epiglottic & paraglottic spaces and anterior commissure 7. 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
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
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
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*
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 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)
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"
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
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 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!!!
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
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)
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
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. *predominately 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.
Virchow
1. organs removed 1 by 1. 2. In order: cranial cavity -> spinal cord (from the back) -> thoracic organs -> cervical organs -> abdominal organs
Round cutaneous specimens
1. tangentially shave (all around) & embed separate cassettes (if oriented) 2. serial slicing of remaining central tissue
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?
mitral valve width
10 cm
Microtome Angle
10 degrees
How many LN are typically seen in a selective neck dissection specimen?
6 or more
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.
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)
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 many LN are typically included with *selective* neck dissection?
6 or more LN
How should you measure a maxillectomy?
3D measurement: -superior/inferior -anterior/posterior -medial/lateral
Size of section you cut for routine processing
3mm (no larger than a nickel) - must fit diagnostically on slide
prostate (over 50)
40 gms
lung
400 gms each
Section thickness
5 um (thicker for brain or difficult tissues: fat/bloody)
adrenal gland
6 gms
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
Nails
Keratin plates - strengthen tips of fingers/toes
Nails (Unguis) (Skin adnexae)
Keratin plates; strengthen tips of fingers and toes
What is the periauricular pit associated with?
Kidney issues & mental cognitive deficiencies
Cutaneous plexus (dermis vessels)
Supplies deep dermis and subcutis
papillary/superficial plexus (dermis vessels)
Supplies dermal papillae and epidermis together with superficial dermis
Dx of malignant melanomas
A = Asymmetry B = Borders (irregular) C = Color (variegated) D = Diameter (increasing) E = Evolution (change over time)
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
In toto
Submitted w/out cutting it (biopsies, tiny LN or blood clot)
What confers higher risk of locoregional recurrence in thyroid cancer?
Larger size LN metastasis - report size of largest focus
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
Excoriated
Abrasive surface
Dyskeratosis
Abnormal, premature keratinization within cells below the stratum granulosum
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
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%)
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
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
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
What does parathyroid regulate?
Amount of calcium in body (low blood Ca++ = more PTH secreted) (high blood Ca++ = less PTH secreted)
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
What does a grossly positive LN look like?
Areas (or entire LN) of ill-defined gray, white & firm tumor
Caseous necrosis
Lesions of TB soft, friable, "cheesy" material microscopically amorphous eosinophilic material w/ cell debris *(granuloma)*
How does lymph flow relate clinically to cancer?
Mapping procedures of lymph flow are done to find where metastasis is headed
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
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
What is an anthracotic LN?
Benign collection of carbon typically seen in lungs, trachea & intrapulmonary LN (common!) w/ lung
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
Green color
Bile or bile pigments
What tissue for squash prep?
Brain
Which tissues used for SQUASH PREPS?
Brain (or other gooey tissue)
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 sign of formalin exposure
Burning throat
Anatomy of Thyroid
Butterfly-shaped organ: 2 lobes connecting to central isthmus (can also have pyramidal lobe)
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
Cause of death
The disease/injury that sets in motion the physiologic train of events that end in cerebral & cardiac electrical silence
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: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: 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: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: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
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*
PET detects:
Changes in cellular function (how cells utilizing nutrients - sugar, oxygen)
What should you do first when receiving a surgical salivary gland?
Check clinical history to find out why you received it.
What is synoptic reporting?
Checklist reports (structured & pre-formatted method for entering clinically & morphologically relevant details of surgical specimens)
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 • Don't treat as will regress with time, especially on the head and neck • Cavernous hemangioma of liver • larger vessels filled with red cells Histopath: • Benign vascular proliferation • Capillaries or • Cavernous vessels • Both
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
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
Xanthomas
Clinical features: • Yellow plaques associated with hyperlipidemias • 4 classic types of xanthomas • Tuberous xanthoma Site: elbows, knees • Tendinous xanthoma Site: extensor tendons of hands, feet, achilles • Xanthelasma Site: eyelids • 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: • Young to middle aged adults • Papule or nodule, most less than 1.5 cm • Overlying skin may be erythematous or hyperpigmented • Dimple sign • Persist for many years, some regress spontaneously • Recurrence is infrequent following complete excision Histopath: • Symmetric • Well circumscribed but not encapsulated • Most confined to dermis • Fibrohistiocytic cells entrap preexisting collagen bundles • Fascicles in a storiform pattern Note: • Pathogenesis in unknown • Tumors with hyperpigmentation mistaken for a melanocytic lesion • Commonly encountered • Reactive process???
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.
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
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
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
Psoriasis
Clinical: • Sharply circumscribed plaques with silvery scale • Auspitz sign, Koebner phenomenon • Predilection for scalp, groin, extensor surfaces, nails • Inherited component Histopath: • Hyperkeratosis with confluent 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
Bullous pemphigoid
Clinical: • Usually elderly patients • Tense blisters on erythematous base • Blisters intact • Predilection for extremities • Mucosal surfaces sometimes involved Histopath: • Subepidermal blister • Dense inflammatory infiltrate in papillary dermis • Abundant eosinophils • No necrosis of overlying 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
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).
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
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 is endophytic?
Extending into tissues
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)
How should you note the tumor spread of maxillectomy?
Dictate: -structures involved by tumor -tumor distance to closest margin -if tumor crosses midline
What is the radioactivity concern of sentinel LN?
Extremely LOW (~same as microwave)
What should you remember if you want to submit 2 LN in 1 cassette?
Differentially ink LN
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
Question to ask yourself while processing hemithyroidectomy
Does pathology involve the isthmus & thyroid capsule?
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*
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)
Meissner corpuscles (Nerves- dermis)
Papillary dermal touch receptors concentrated in hands and feet (light, soft, fleeting touch). Rapid response.
Anatomic Margin
Edge of actual specimen in body Concern: does tumor extend to edge & beyond to adjacent structures?
Papule, Nodule
Elevated, dome-shaped lesion. Papule: <5mm, nodule >5mm
What pathology presents with high PTH levels?
Parathyroid adenoma (parathyroids can go up to 1 gram)
Which have more favorable prognosis of carcinomas, encapsulated or unencapsulated
Encapsulated tumors
What does melanoma do to the sclera of eye?
Engorge veins & some eye attachments have pigment changes
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
What is the most common cutaneous cyst received?
Epithelial cyst
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
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
Congestion
Excessive accumulation of a substance such as blood or fluid
What is a big oversight while evaluating parathyroid?
Forgetting to weigh it
Keratinocytes (epidermis)
Form Stratum corneum; Cells proliferate from base, migrate upward and keratinize to form non-living protective, abrasion-resistant waterproof keratin layer
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
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
Excavating or Excavated
Hollowed out, forming a depression
What is required to be able to correctly orient a specimen?
Good knowledge of anatomy
Arrector pili muscles (pilosebaceous units) (Skin adnexae)
Hair follicle associated smooth muscle bundles, function to pull hair erect in cold or fright
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)
Advantage to synoptic reporting over free-text reporting
Has relational structure & thus searches and retrieval processing are faster and more efficient
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
Centriole
Hollow cylinder, wall of nine evenly spaced tubule bundles. Occur in pairs, perpendicular to each other. -Forms spindles responsible in cell division.
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
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.
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
What happens to LN when small cell carcinoma metastasizes into LN?
LN coalesces
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 - (ishemia)
Spongiosis
Intercellular edema of the epidermis
PET Pinpoints
Increased metabolic activity in cells
Why use touch preps?
Increased nuclear detail & cytoplasmic components (vacuoles, mucins & colloid)
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 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
What special lymphoid structure is unique to parotid gland?
Interparenchymal LN
What is the definition of a positive margin?
Invasive carcinoma or carcinoma in situ/high grade dysplasia present at margins
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)
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, transient elevated lesion with variable blanching or erythema; usually result of dermal edema
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 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 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
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 are peyer's patches located?
Little bumps on terminal ilium
What is the frenulum?
Little fibrous tissue connecting tongue to mouth floor
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.
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
Efferent vessels
Lymph *E*xits nodes
What is the preferential route of spread for papillary carcinoma?
Lymphatics
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
What is a required data element with thyroid cancers?
Margin status
What is the most important thing when grossing an ear resection?
Margins
Polychromatic Stains
May-Grunwald Giemsa Stain
Red or reddish black color
Means blood or hemoglobin pigment
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
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
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
What is a "lake" in respects to tissue staining?
Mordant + dye = lake (this is basic in action)
Why is formalin no longer recycled?
Puts a lot of vapors into the air & dilutes the formalin (doesn't fix as well)
Multifocal
More than a single discrete lesion on a background
Cobblestone
Morphologic pattern characterized by multiple rounded densities with linear fissures interspersed
What is the dominant tumor defined as?
Most aggressive tumor (imparts highest stage & dictates pt management)
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
Most commom plasma cell neoplasm?
Multiple myeloma
What is a major rule when inking skins, in particular?
NEVER USE BLACK INK!!!!
How are adenocarcinomas, NOS histologically graded?
They do not have a formalized grading scheme. They are graded intuitively (ie based on cytomophologic features)
What is a modified neck dissection?
Neck dissection sparing 1 or more of classic radical neck dissections (type I, II or III)
Gangrenous
Necrosis followed by putrefaction
Hodgkin Lymphoma
Neoplasms of Reed-Sternberg cells & variants
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
When autopsy not required by ME, who gives consent?
Next of kin
Stripe on section caused by...
Nicks on blade - (from calcification/staples/sutures) Tissue stuck under blade - (must be wiped off)
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)
Why would you use transillumination for eye?
To give you a plane of sectioning, it helps you see tumor
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
Incidence of Disease
Number of cases per year
Prevalence of Disease
Number of persons that have a disease at any given moment
Botyroid
Numerous rounded protuberances resembling a bunch of grapes
Who regulates formaldehyde for research and industrial use?
OSHA - occupational safety and health administration
Circumferential
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
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)
What is typically not as important when grossing a salivary gland?
Orientation (unless indicated by surgeon)
Mitochondria
Outer (protective) and inner membrane (folds to easily carry out oxidative reactions for cell). Produces energy for cell.
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
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
What is the only way to definitively confirm/Dx a disease
Perform an autopsy
What would increase the stage of a parotid gland if sent looking for malignancy?
Perineural invasion - nerve margins are extremely important!!!
PAS stands for:
Periodic acid-schiff
What stain can cause false positive with 3% gluteraldehyde fixative?
Periodic acid-schiff (PAS)
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)
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
Level VII
Superior Mediastinal LN
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
What is PET?
Positron Emmision Tomography
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
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)
Eccrine glands (Skin adnexae)
Produce sweat for cooling the body
Hair follicles
Produces hair
Hair follicles (pilosebaceous units) (Skin adnexae)
Produces hair
What is the equivalent to tumor deposits w/in lymphatic spaces for papillary thyroid carcinomas?
Psammoma bodies
What does the P-O section include?
Pupil, Optic nerve head, macula
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
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 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 - 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
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
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)
Sebaceous glands (pilosebaceous units) (Skin adnexae)
Sebum (oil) producing holocrine glands
Sebaceous glands
Sebum-producing holocrine glands
What is the cause of laryngeal tumors?
Smoking & alcohol use
Amorphous texture
Semisolid, unorganized surface that can't hold shape or be cohesive
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
Epithelium classifications
Shape, stratification, specializations
Papule
Shiny, elevated indurated lesion (ie dermatofibroma) -macroscopic lesion
Why USE squash preps?
Shows COHESIVE nature of tissue - (Lymphoma dissociate into SINGLE cells - epithelials are clumpy) CT & brain tumors show cytoplasm fibrillarity - (ie thin strands in background)
What does perpendicular cut show?
Shows the distance from the margin to the tumor
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
Plaque
Slightly elevated, flat-topped lesion usually >5mm
Give example of simple columnar
Small intestine microvilli
How should ITCs be classified?
Some say: N0 or M0 Other studies say: ITCs are poor prognosticators in terms of local control
Chatter caused by....
Something LOOSE in cryostat Needs to be serviced
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
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
What is the most common pathology for receiving an Ear Resection (ie a skin)?
Squamous Cell Carcinoma
Laryngeal Tumors type
Squamous cell carcinoma
Fibrous Tissue Septae
Strengthens adipose tissue & ties subcutis to both dermis & underlying structures (fascia)
Fibrous tissue septae (Subcutis)
Strengthens the adipose tissue and ties subcutis to both dermis and underlying structures such as fascias.
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)
Pathology
Study of changes in bodily structure & function occurring as result of disease
Autopsy
Study of post-mortem changes to determine cause of death & other facts about patient surrounding time of death
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
What should you do if LN are matted?
Submit 2 sections thru each level involved to document the extensive nature of tumor
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
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
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
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
Poorly demarcated
The boundary between normal and abnormal is blurred or not easily seen
Tinea capitis
fungal infxn in head (most often seen in children)
Mucus
a viscid slippery secretion that is usually rich in mucins and is produced by mucous membranes which it moistens and protects
Why do most salivary gland carcinomas not require grading?
They have a biologic behavior defined by their categorization
Tinea corporis
fungal infxn of body (ie in skin = ring worm)
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!
Tinea pedis
fungal infxn of feet
Who is the intermediary between pathology and other departments?
The pathologists' assistant
Germinal Center
area of lymphatic tissue containing *rapidly differentiating lymphocytes*
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
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
Lichenification
Thickened, rough skin, usually result of repeated rubbing; callus
Hyperkeratosis
Thickening of the stratum corneum, can be associated with abnormal keratin
How should you think of a maxilla specimen to help with orientation?
Think as a cube
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
Miliary
Tiny foci that are too numerous to count
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
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
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: ---
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
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
Acetone
Tissue: All Special stains: <Ziehl-Neelsen (AFB)> not good Adv: *Enzyme histochem* Dis: routine fixative, must be refrig, dissolves lipids
What should you always remember to do when doing a thyroid specimen?
Touch Prep
Pacinian Corpuscles
Touch receptors for deep pressure & vibration
What is the inferior mucosal margin consist of?
Tracheal stump
Excoriation
Traumatic lesion breaking the epidermis, causing a denuded linear area (scratch)
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)
Why might someone have a maxillectomy?
Tumor of the face sinuses
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
How can sarcomas spread?
Typically spread hematogenously, but can also spread lymphatically
How can carcinoma spread?
Typically spreads lymphatically, but can also spread hematogenously
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
Give example of transitional
Urothelium - cells in the bladder
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)
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.
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*
What is the best section to take in glossectomy?
Vallecula to epiglottis
Tinea cruris
fungal infxn of genital tract
Tinea unguium
fungal infxn of nail/nail bed
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
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
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
Why USE touch preps? For which tissues?
Why? Increased nuclear detail & cytoplasmic components Tissue? Lung tumors, thyroid & LN
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.
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
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)
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%)
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)
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
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
Give example of stratified squamous, keratinized
epidermis
Supraglottis location (structures)
epiglottis --> apex of ventricle (epiglottis, aryepiglottic folds, arytenoids, false vocal cords & ventricle)
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 karyorrhexis?
fragmented nucleus
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)
Vesicle, bulla(e)
fluid filled raised lesion (usually burns, also Herpes) Vesicle <5mm, bulla >5mm
Sabulous
gritty
Fungating
growing along a surface
Exophytic
growing out of a surface in tree-like fashion
Indurated
hardened when it is normally soft
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
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
How should you ink a complex specimen?
ink margins differentially
Endothelium
inner lining of blood vessels (simple squamous epithelium) Function = diffusion
What is extrathyroidal extension?
involvement of perithyroidal tissues by primary thyroid cancer
Lacerated
irregular tear
Sequestered
isolated or away from a normal position; shut off from other parts or systems
What makes the parotid gland a unique salivary gland?
it harbors a number of intraparenchymal LN
Anaplasia
lack of differentiation
WHat is the adam's apple made of?
laryngeal prominence of thyroid cartilage
Death Certificate (DC)
legal document which records cause & manner of death (used for legal & epidemiological purposes)
Elongated
lengthened from the usual form
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
Labial
lip-like
Cachaxea
metabolic change where patient loses weight to skin & bones because tumor takes all nutrients
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
Cortex
nodules present with germinal centers where B cells mature into plasma cells after activation
Gangrenous necrosis
not a necrotic pattern *coagulative necrosis applied to ischemic limb* superimposed bact infxn gives liquid pattern (ie wet gangrene)
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
Mucinous
of, relating to, resembling, or containing mucin
What is a subtotal laryngectomy?
only portions of larynx resected (hemilaryngectomy, supraglottic laryngectomy)
Exudative
oozing of fluids
Give example of stratified squamous, non-keratinized
oral cavity, pharynx, vocal folds in larynx, vagina/anus
Excrescence
outgrowth from a surface
Purpuric
patches of purple discoloration from extravasation of blood into the skin and mucous membranes
Homeostasis
physiological state of regulation, maintaining internal environment
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
Keratinocytes
prolif from base, move upward & keratinize to form non-living protective (waterproof) keratin layer
collagen and elastin (dermis)
provide strength and elasticity in skin
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
Scabrous
shaggy
What are perithyroidal tissues include?
sizable blood vessels & small peripheral nerves that are continuous with pretracheal fascia
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
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
Lesion
structural abnormality produced by disease or injury
Anatomic Pathology
study of structural changes caused by disease
How many samples to take from encapsulated thyroid nodules to reduce sampling error?
submit entirely
Mordant
substances/metals that act as link btwn dye & tissue
Papillary/superficial plexus
supplies dermal papillae & epidermis w/ superficial dermis
What are the 3 anatomical regions of the larynx?
supraglottis, glottis & subglottis
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
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
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
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
Peltier plate
where you freeze chucks (btwn -50F & -70F)
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 be 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*
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.
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")
