Surgical Pathology
Sentinel lymph node biopsies (sampling)
" the guard nodes" where metastatic disease will show up first; samples the lymph nodes that drain the neoplasm and surrounding tissue
appropriate procedure for metastatic lesion
"radical procedure"; mastectomy
What is GMS stain used for?
"silver stain"; Fungi
What is Warthin-Starry stain used for?
"silver stain"; bacteria/spirochetes
What is Reticulin stain used for?
"silver stain"; highlights the supporting reticulin network in tissues (supporting collagen); basement membranes (basal lamina)
What is Bielschowsky's stain used for?
"silver stain"; neural tissue
Ziehl-Neelson Stain
Acid Fast Stain--> mycobacterial tissue stains --> TB and leprosy
Congo Red Stain
Amyloid stain--> apple green birfringence with polarization of sample
CD19 and CD20
B-cell markers
What color is associated with immunostains?
Brown
Oligodendrogliomas
Central nervous system glial neoplasms "derived" from or having the characteristics of an oligodendrocyte; 1p and 19q mutations are common in this neoplasm
Prognostic and therapeutic immunostains
ER, PR, CD20, Her2-neu, MIB-1, CD117
If a sentinel lymph node is negative after frozen sectioning, what happens next and why?
For frozen section "negative" lymph nodes, all the lymph node tissue is submitted for permanent sections Occasionally, the additional tissue and/or deeper sections of the tissue (3 levels examined microscopically) will reveal metastatic disease and the patient will undergo a full lymph node dissection at this point
What is the most common fixative used in permanent section diagnosis
Formalin
CK20
GI tract
Class I and II Intermediate filaments
Keratins
CD45
LCA- leukocyte common antigen
appropriate procedure for benign lesion
Lumpectomy
Histological appearance of lymphomas vs. carcinomas
Lymphomas are discohesive Carcinomas are more cohesive
Flow cytometry
Most often used in hematopathology to evaluate for the presence or absence of cell surface antigens to provide an immunophenotype
Fite Stain
Mycobacterial tissue stain for leprosy
What are neurofilaments markers of?
NEURONS
Class V intermediate filaments
Neuroalmins
Class IV Intermediate filaments
Neurofilaments
solution used to cover tissue in cryosectioning
OCT
What are Giemsa stains used for?
Parasites, microorganisms
How are sentinel lymph node biopsies done in order to prevent damage?
Radioactive colloid (protein with a radioactive label) and/or vital dye are injected into and/or around the neoplasm or prior biopsy site The Surgeon uses a "Geiger counter" and visualization of stained tissue to identify and then remove the "sentinel" lymph node or nodes (most commonly 1 to 3 lymph nodes)
Use of Electron Microscopy
Renal biopsies - essentially all renal biopsies Nerve biopsies - many to most biopsies Muscle biopsies - many to most biopsies Virus identification
Electron microscopy
Sections are nanometers in thickness, rather than the microns seen with paraffin embedded tissue; can see organelles
Prussian Blue Stain
Stains iron blue
CD1-CD8
T-cell lymphocyte markers
Complication with sentinel lymph node biopsies (sampling)
Try to make diagnosis of lymph node involvement with minimal disruption of lymphatic drainage to prevent chronic lymphedema that commonly occurs after more aggressive lymph node dissections
When is is appropriate to use frozen sectioning?
Used where the information gained will affect the surgical procedure or immediate therapy, NOT for the convenience of the Surgeon Patient Family
Class III Intermediate filaments
Vimentin, Desmin, Peripherin, GFAP
Her2-neu
a transmembrane growth hormone receptro found in breast and esophageal/gastric malignancies; high grade and have a poor prognosis with an aggressive clinical course
The use of polyclonal Ab as immunostains: where are they obtained from?
animals that have been exposed to the antigen of interest
MIB-1
antibody against Ki-67, a protein expressed in proliferating cells - a "proliferation" marker; indication of a more aggressive malignancy
CK7
breast and pulmonary cancers
Estrogen Receptors (ER) and Progesterone receptors (PR)
breast carcinoma; tend to be lower grade with better prognosis; treated with estrogen inhibition
What color and what "area" of tissue does hematoxylin stain?
dark blue, nucleus
What are desmins markers of?
demonstrates muscle differentiation; will be positive in leiomyomas, leimosarcomas, rhabdomyomas, rhabdomyosarcomas
Disadvantages of frozen sectioning
determining subtleties; can distort the tissue
1p and 19q mutations
diagnostic of oligodendrogliomas
Signs of a malignant spindle cell neoplasm
elongated nucleus; stretched out cytoplasm;
What are keratins markers of?
epithelial cells; will be positive in malignant carcinomas
Pankeratin
epithelial neoplasms (carcinomas)
EMA (epithelial membrane antigen)
expressed in certain glandular tissues and neoplasms
CEA (carcinoembryonic antigen)
fetal glycoprotein; colorectal adenocarcinoma
Auromine O Stain
fluorescent stain of mycobacteria
What is GFAP a marker of?
found in CNS glial cells (astrocytes, oligodendrocytes, ependymal cells); will be positive in glial neoplasms such as astrocytomas, ependmomas, oligodendrogliomas, glioblastomas
p63
found in nuclei of basal epithelial cells of the prostate, myoepithelial cells of the breast, urothelial cells and squamous cells
What is Periodic Acid Schiff Stain (PAS) used for?
fungi, intestine mucins (goblet cells), basement membranes, glycogen; "magenta stain"
hybridomas
fusion of mouse myeloma cells with mouse splenic lymphocytes; produces specific Ab and has longer cell life; able to proliferate (clones)
How are immunostains actually used in a clinical setting?
generally best used in a panel of stains to establish an immunophenotype; H&E is most commonly used for diagnosis
most prominent histochemical stain used in surgical patology
hematoxylin and eosin stain
Pancreatic endocrine hormones
hormone expressed in islet cell neoplasms
Calcitonin
hormone expressed in medullary carcinomas of the thyroid
Parathyroid hormone
hormone expressed in parathyroid neoplasms
Pituitary hormones
hormone expressed in pituitary neoplasms
Thyroglobulin
hormone expressed in thyroid neoplasms
Cytogenetics
involves cell replication with interruption of mitosis and assessment of individual chromosome numbers and structure after Giemsa staining (G banding) Assess for trisomies, monosomies, duplications, deletions and translocations Morphologic changes are assessed Therefore, we don't need to know the specific sequence
The use of polyclonal Ab as immunostains: recognition
less specific; several epitopes of the antigen
CD45 cancers
leukemias and lymphomas
Oil Red O Stain- what type of tissues can this be performed on
lipophilic red dye that dissolves into triglycerides (fat); frozen tissues
Histochemical Stain
may react with a specific cellular component; may precipitate in a certain area
S100
melanocytes
What are vimentins markers of?
mesenchymal cells (fibroblasts, adipocytes, Schwann cells, myocytes, chondrocytes); positive in sarcomas and mesenchymal neoplasms
Vimentin
mesenchymal neoplasms (sarcomas)
The use of monoclonal Ab as immunostains: where are they obtained from? how?
mice splenic lymphocytes; fused with mouse myeloma cells to form a hybrid cell that produces specific Ab
What is an Immunostain?
monoclonal Ab that have a "marker" substance attached that allows microscopic determination as to the presence or absence of these Ab on the slide; sensitive but not specific; primary and secondary Ab used (mouse, anti-mouse)
The use of monoclonal Ab as immunostains: recognition
more specific; recognize only one epitope on the antigen; somewhat LESS sensitive
Gleevac (imatinib)
mutations in CD117 are responsive to Gleevac; tyrosine kinase inhibitor
Neuron Specific Enolase (NSE)
non-specific immunostain
Prostate Specific antigen (PSA)
only made in prostate cells- both benign and prostatic adenocarcinoma
Placental Alkaline Phosphatase (PLAP)
placental tissues and germ cell neoplasms
p504/p63
prostate cocktail; allows us to differentiate between benign prostate glands and high grade PIN and prostatic carcinoma
Immunophenotype
protein expression of a cell; what antigens are present; used for diagnosis
What is the main use or benefit of frozen section diagnosis?
rapid diagnosis of a mass; even while patient is on operating table
What color and what "area" of tissue does eosin stain?
red-pink, cytoplasm
p504S
restricted to prostatic carcinoma and high grade prostatic intraepithelial neoplasia
Intermediate Filament Proteins
series of structural proteins with similar structural and sequence features
K-RAS
site of mutation in colon carcinomas; therapeutic use
CD34
stem cell and blast marker; acute leukemias are CD34 positive
Rituxan
therapeutic: anti-CD20 antibodies used for treatment of B-cell Non-Hodgkins lymphomas; Chronic lymphocytic lymphoma
Herceptin
therapeutic: anti-Her2-neu antibody, can be used as part of the patient's breast carcinoma therapy
Trichrome Stain
three colors: smooth muscle= red; connective tissue (collagen)= blue; neural tissue= pink
TTF-1 (thyroid transcription factor)
thyroid and pulmonary neoplasms
Philadelphia Chromosome
tip of 22 added to 9; drives chronic mylogenous leukemia
CD117
tyrosine kinase protein; mast/stem cell growth factor; proto-oncogene; chronic myelogenous leukemias (CML) and gastrointestinal stromal tumors (GISTs)
What is an immunofluorescent stain?
use MAb that fave a fluorescent tag (fluorochrome) attached; no chemical reaction is needed here--> more difficult and time consuming
FISH (fluorescent) and CISH (chromogenic)
use complimentary nucleic acid probes to detect specific nucleic acid sequences in the tissue/cells being analyzed
In-situ hybridization
used for diagnosis
What are CD markers used for?
useful to immunophenotype hematopoietic neoplasms; used in conjunction with flow cytometry