Histopathology lab. role in
diagnosis of tumors.
Practical No 1
Dr.Ashraf Abdelfatah Deyab
Histopathology lab. role in diagnosis of
tumors
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• 1) Differentiate macroscopically as
well as microscopically between
benign and malignant tumors.
• 2) Enlist & describe various types of
biopsies for diagnosing tumors.
Participation of the surgical
pathological in the hospital care?
Early detection-screening program
Diagnosis
 Classification (histo&clinical)
Staging& grading
prognosis
Teaching & training, researches
Hospital information > Autopsy.
Relationship between the surgical
pathological Dept. & clinician??
* Microscopic diagnosis is a subjective
evaluation that acquires full essential
clinical data, types of surgical& findings.
•Surgical pathology depends heavily on
the input of clinicians and surgeons.
• Multidisciplinary efforts= classification
of tumors into benign & malignant
(accurate diagnosis) , prognosis, and
predictive considerations.
First step: How to Differentiate between
benign and malignant tumors??
• Update clinical
• Apply approved
knowledge
pathology
• Close affiliations with diagnostic criteria.
surgical specialties,
• (Macroscopic &
internal medicine,
Microscopic
dermatology,
neurology, diagnostic examination.
radiology, radiation • apply necessary:
therapy, and medical • ancillary special
oncology.
techniques)
Second steps: Criteria to differentiate
between Benign & Malignant Tumors
• These can be discussed under the headings:
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1)Morphological macroscopic pattern
2) Morphological microscopic pattern:
a) Differentiation and Anaplasia
b) Rate of Growth SGR=percentage
increase per unit time, DT= markers
• c) Local aggressive Invasion
• d) Metastasis
Third steps: How to Differentiate between
benign and malignant tumors??
• I. Clinical information:
• 1) Full essential clinical
data.
• 2) Surgical findings.
• 3) Type of surgery.
Very dangerous: lacking
adequate clinical
information e.g. metastatic
nodule in known case.
End result: Adequate pathologic
interpretation
EX1:“Again” How Differentiate between benign
& malignant tumors?? Pancreatic mass
• II. Morphological
assessment (macroscopic):
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structures components??
Lump: Shape, number& color
Depth of invasion, capsule status
Dimension(cm)? (Staging)
Weight (adrenal tumor)
Consistency? (cystic, solid,
Scirrhous +desmoplastic)
Outline border?
Surgical margin assessment
Cut section findings??
Necrosis, ulcer & hemorrhages.
Lymph node: Mets. (staging)
Microscopic appearance showed infiltrating
adenocarcinoma with Scirrhous stroma
EX2: Examine and enlist the morphological
findings? Diagnosis?- both are breast lumps
EX3 :Gross (macroscopic)
features of two breast
neoplasms
Benign – circumscribed,
often un-encapsulated,
pushes normal tissue
aside
Malignant – infiltrative
growth, ill-define
margins, with no
capsule, destructive of
normal tissues
Breast”suspicious” lump-high power (left)
Fibroadenoma : breast
3
2
1
EX4: Examine and enlist the morphological findings?
Left: kidney & Right: small intestine (No obvious tumor)
Renal infarction
Bowel ischemia
EX5 (a): Examine &enlist the morphological findings?
Diagnosis? kidneys (solid mass vs Cystic lesion )
Renal cell carcinoma
Acquired benign cystic lesion
EX5(b): Kidney Solid tumor differences?
Renal cell carcinoma
Renal adenoma
Pathology Findings
• RCC: distortion of the normal renal parenchyma.
This malignant neoplasm has a variegated
appearance on its cut surface, with yellow to
white to red to brown areas.
• Renal adenoma: well circumscription, multiple
• The corner stone for the diagnoses is
histology\microscopic appearances in some
cases
EX6: Examine and enlist the morphological
findings? Diagnosis? Liver metastatic nodules
EX7:Examine and enlist the morphological
findings? Diagnosis? Ovarian cystic tumor
Ovary – correlate with gross pathology findings?
M. cystadenocarcinoma
Mucinous Cystadenoma
EX8:Examine and enlist the morphological findings?
Diagnosis? Brain liquifactive necrosis
EX9: COLON- POLYPS (multiple vs solitary lesion, rule-out stalk
invasion-microscopic)
Adenocarcinoma
Adenomatous polypColonic
EX10; Describe & diagnosis?(Localized vs diffuse + Bland
looking vs necrotic+ local aggressiveness )
Endometrial hyperplasia
Cervical SCC
Summary
Morphological (Macroscopic) assessment
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structures components??
Lump: Shape, number& color
Depth of invasion, capsule status.
Dimension(cm)? (Staging)
Weight (adrenal tumor)
Consistency? (cystic, solid, Scirrhous +desmoplastic)
Outline border, invasion to adjacent structure?
Surgical margin assessment
Cut section findings??
Necrosis, ulceration & hemorrhages.
Lymph node: Mets. (staging)
Criteria to differentiate between Benign &
Malignant Tumors
• These can be discussed under the headings:
• 1)Morphological macroscopic pattern
• 2) Morphological microscopic pattern:
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a) Differentiation, architecture& Anaplasia
b) Rate of Growth, mitotic rate
c) Local aggressive Invasion, neural involvement
d) Metastasis (lympho-vascular permeation, LN)
3) Histological origin of Neoplasms
If cells LOOK GOOD, they are probably going to BEHAVE GOOD
Looking “good” means looking like cells they supposedly arose from!
EX11:Leiomyomata of the uterus: Noticed the bland-looking
cells + the nuclear differentiation compare to the normal histology in the
corner
If cells LOOK BAD, they are probably going to BEHAVE BAD
The strong relationship between histology &biologic behavior
Ex12: Skin biopsy: SCC of scalp
• Loss of normal maturation, arrangement& + Cellular
atypia+ Nuclear pleomorphism + prominent nucleoli+
high N:C ratio+ keratosis + Local Invasion + ulceration
Ex (13) Lung: Anaplastic large cell carcinoma
Anaplasia: Ugly and nasty, loss differentiation,
Loss of polarity, abnormal mitoses, High N:C, Giant
bizarre cells, Hyperchromaisa, prominent nucleoli
EX (14) Soft tissue: Sarcoma
• Mitotic activity – Monotonous sheet pattern, Increased in
malignant tumors with abnormal ones, bizarre cells
Ex 15 (a):
Neural involvement
Lymphovascular permeation
Ex 15 (b): Tumor capsular invasion
Follicular carcinoma of thyroid
Ex (16): enlarged Lymph node biopsy(malignant metastatic deposits)
EX(17): Lymph node biopsy- reactive follicular hyperplasia
Clinical history & microscopic pattern : Preserved architecture, intact
capsule, free sub-capsular sinuses (high & lower power)
Ex(18) Lymph node- needed bcl2 (special stains)
Reactive hyperplasia
Follicular Lymphoma (effacement)
Bcl-2 positivity in Follicular lymphoma
Bcl2: Immunohistochemical stain
Ex19:Prostatic biopsy – confluent atypical glands,
lack of normal architecture, lack of myoepithelial cells
(A)BPH
(B) Prostatic carcinoma
Ex(20) Lymph node: effacement (Total in a & focal in b)
note RS cell in (b) + needed special stains
a)Non-Hodgkin’s Lymphoma (b) Hodgkin’s Lymphoma with Typical RS cells
21-Intestinal adenomatous Polyp (colon):
Benign neoplasm, note stalk is free of invasion
Ex 22: Colonic polyp: adenocarcinoma,
stalk is involved by invasive neoplastic glands
Benign neoplasm - morphological findings?
How to confirm this Diagnosis? What’s the Criteria?
- No invasion.
- Orientation& architecture.
- Degree of cellular atypia.
- Mitoses. (not specific).
- locally not aggressive.
Ex 23-Cervical atypia : Ranging from
severe dysplasia TO Invasive cancer
carcinoma
Cervical cytology Pap smears- different
cytology pattern- different stages
Cervical intraepithelial neoplastic
CERVICAL BIOPSY
Squamous cell carcinoma: see invasion
BREAST LUMP- DCIS
Atypia, Increased nuclear cytoplasmic ratio and
without anaplastic, presence of necrosis,fenstration,
Proliferative markers- as diagnostic and prognostic
markers
Ki 67 in Pituitary tumor
Ki76 in prostatic ca
Histological Origin of Neoplasms
1.
2.
3.
4.
5.
Epithelial: glandular
Mesenchymal: SM, SM, Bone, collagen
Neural& Neuroectoderm
Hamopoietic and lymphoid cell
Germ cells
N.B: All neoplasm have two basic components:
1. Neoplastic cells
2. Supporting stroma (connective tissue & blood
vessels)
For large excised specimen: the surgeon already
knows the microscopic diagnosis of the lesion???
• Now interested in other information??
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1) Extent of the lesion.
2) Invasion of neighboring structures.
3) Presence of tumor at the surgical margins.
4) Vascular invasion.
5) Lymph node metastases (Numbers of nodes
involved) .
TUMOUR SATGING & GRADING
GRADING/STAGING
• GRADING: HOW “DIFFERENTIATED”
ARE THE CELLS?
• STAGING: HOW MUCH ANATOMIC
EXTENSION? TNM
• Which one of the above do you
think is more important?
WELL?
(pearls)
MODERATE?
(intercellular bridges)
POOR?
(WTF!?!)
GRADING for Squamous Cell Carcinoma
Grading of Malignant Neoplasms
• Grade Definition:
Grade I → Well differentiated
Grade II → Moderately differentiated
Grade III → Poorly differentiated
Grade IV → Nearly anaplastic
ADENOCARCINOMA GRADING
Staging
• The staging of cancers is based on:
• 1) The size of the primary lesion.
• 2) Its extent of spread to regional lymph nodes.
• 3) The presence or absence of blood-borne
metastases.
• The major staging system currently in use is the
American Joint Committee on Cancer Staging:
Tumor-node-metastasis (TNM) system used for
most cancers
Staging – “T”
Size of primary tumor (T) in cm
TX
No information available on primary tumor
T0
No evidence of primary tumor
Tis
Carcinoma in situ at primary site
T1
Tumor less than 2 cm
T2
Tumor 2-4 cm in diameter
T3
Tumor greater than 4 cm
T4
Tumor has invaded adjacent structures
Staging – “N”
Lymph node involvement (N)
NX
Nodes not assessed
N0
No clinically positive nodes (not palpable)
N1
Single clinically positive ipsilateral (on same side) node
less than 3 cm
N2
Single clinically positive ipsilateral node 3 to 6 cm; or
Multiple ipsilateral nodes with all less than 6 cm; or
bilateral or contralateral nodes with none greater than
6 cm
N3
Node or nodes greater than 6 cm
Histopathology lab. role in diagnosis of
tumors
___________________________________
• 1) Differentiate macroscopically as
well as microscopically between
benign and malignant tumors.
• 2) Enlist & describe various types of
biopsies for diagnosing tumors.
Types of biopsy procedures used to
diagnose Tumors
__________________________________
Interpreting biopsies is important duties of the
surgical pathologist.
Type of specimens- in surgical pathology
Lab::
• Cytology
• Biopsies (Histopathology) .
• Autopsies (necropsy)
Types of perservative
site of the lesion
Types of tissue biopsy
• TYPES;
• Incisional& excisional biopsies (Main type).
• Classified according to the instrument
used to obtain them (cold knife, cautery,
needle, or endoscope, colonoscopy,
cystscope, clopscope, curettage
bronchoscope, image-guided, Nasoscope)
Sites of tissue biopsy
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BM
GIT
UGT- including female GT
Lung and respiratory system
Liver
CNS
Others: Soft tissue mass,breast, skin,
Lymph node, Prostate, muscle, etc…
How biopsy helpful in handling
any lesion\ tumour??
• Final diagnosis.
• Extent of the lesion.
• Invasion of neighboring
structures.
• Assess surgical margins.
• Vascular invasion+ Peri-neural
• Lymph node metastases
Types of biopsy procedures used to
diagnose Tumors
I. Cytology specimen.
It is a simple and economic, minimally invasive
method of obtaining of a patient's material\cells
of:
Corporal fluids-cytology (ascitic, pleural,
and pericardic fluids, urine, sputum)
Imprint of organs (lymph node,brain).
Brushings (bronchial, esophagi, etc.).
Gynecological extensions- exfoliative
Fine needle aspiration biopsy- FNAC
Fine needle aspiration biopsy
Types of biopsy procedures used to
diagnose Tumors
II. Biopsy.
It is a tissue sample obtained with the objective
of arriving to a diagnosis.
Types of biopsies:
1-Incisional: Alone it takes a small fragment to
study. surgical incision-is strictly of a diagnostic
in nature
2- Excisional: the whole lesion is extirpated to
study with a margin of healthy tissue- for large
lesion (Both therapeutic and diagnostic in nature)
Types of biopsy procedures used to
diagnose Tumors
3- Curettage biopsy- for endometrial biopsy and evucation of
other uterine content.
4- Frozen biopsy: (Intra-operative identification about type of
tumor, to assess surgical margins, special stains, molecular
applications) e.g. Renal, muscle biopsy, Intra-operative assessment
of tumor type and margin.
5- NEDDLE BIOPSY
• Core biopsy.
• IMAGE GUIDED NEEDLE BIOPSY (Can't be felt).
• VACCUM ASSISSTED NEEDLE BIOPSY (suction device).
• Bone marrow biopsy.
6- Endoscopic biopsy:
- GIT endoscopy (Upper: esophagus, stoma, duodenum+
Lower: colon), GUN Cystoscopy, etc..
trocar biopsy
Liver biopsy
III. Autopsies.
It is the opening of a cadaver in their three cavities,
cranial, thoracic and abdominal with the objective of
studying the possible alterations of the illness that it
possessed, to determine the causes of the death.
Two fundamental types of autopsies exist.
1) Clinical (when the death is product of an illness) .
2) Forensic. (death is produced
by non-natural elements,
murders, burns either suicide
or accidental) .
Some general rules for the biopsy
procedure
• The larger the lesion- the more numerous the
biopsies should be taken.
• Ulcerated tumors, biopsy of the center- show only
necrosis and inflammation.
• The biopsy should be deep enough.
• When several fragments of tissue are obtained, they
should be sent to Lab.
• Avoid Crushing or squeezing of the tissue .
• Select suitable container and adequate volume of
fixative immediately
• Consideration of special studies (IHC,
Flowcytometry, cytogenetic, molecular)
Important pre-analytical precaution
in tissue biopsy handling
• Ensure fixation+ Proper identification (request
form)
• Orientation& Gross appearance documentation
(number, size(cm), weight, shape, color,
consistency, Land mark& surgical margins.+\photo& radiography.
• Trimming\cutting to obtain a representative
section ”in case of large bx” or submit all.
• Send for tissue processing and H&E slides
preparation as adopted protocol or send for
frozen preparation immediately.
the best biopsy
• Ideal requisition.
• Proper identification and orientation
• Adequate for diagnosis (esp. depth, volume,
size and according to numbers required e.g.
prostatic biopsy).
• Cleanly excised, uncrushed wedge .
• Obvious anatomic landmarks (surgical
labels “suture material”, stains, cautery )
• That includes a junction between normal
and neoplastic tissue.
• “Tissue unsatisfactory for interpretation.”
PERSERVATION
• Formalin fixative – for routine hematoxylin and eosin staining
of tissue sections
• Bouin’s fixative for testicular biopsy.
• Glutaraldehyde for electron microscopy (renal & muscle
biopsies)
• Refrigeration – for hormone, receptor or other molecular
analysis.
• Frozen section – for determining the nature of the lesion and
the surgical margins of the tumour. ( renal & muscle biopsies)
Specimen receptionInformation management
Cutting or Trimming of biopsy
Uses of Biopsies received in the
fresh state
• Cultures – bacterial, fungal, viral. (infected biopsies)
• Electron microscopy (renal & researches biopsies)
• Histochemical and Immunohistochemical stains(muscle
study& tumor)
• Imprints (touch preparations) –(lymph node e.g. HL& NHL)
• Cytogenetic studies (CML, Burkett's lymphoma)
• Molecular genetics studies.
• Photographs, whether conventional or digital.
• X-ray studies.
• Special fixatives (other than routine formalin)
• Tissue culture
• Tumor procurement/tumor bank needs
TISSUE PROCESSING
TISSUE BIOPSY EMBEDDINMG
MICROTOMING OF BIOPSY
Floating-out water bath for slides
preparation
H&E slides auto-staining (H&E,or
further Special stains)
Slides cover slipping
METHODS OF evaluation& Diagnosis
I. SPECIAL STAINS.
* Immunohistochemistry (diagnosis &Tumor
origin, phentotying, prognosis (c-erB2),
therapeutic purpose (ER).
* Further Cytochemistry (renal, liver, muscle)
II. Electron microscopy (e.g. Renal biopsy).
III. Biochemical test(e.g. Enzymes, hormones).
I V. Tumor markers (AFP, HCG, PSA, CEA,
CA125 )= DIAGNOSIS & FOLLOW-UP
TUMOR MARKERS example
• HORMONES: (Paraneoplastic Syndromes)
• “ONCO”FETAL: AFP- liver HCC& non-seminomatous germ
tumor,
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- CEA-ca colon, pancreas, stomach, breast.
ISOENZYMES: PAP- prostate, NSE- SCC lung
PROTEINS: -PSA-prostate tumor.
GLYCOPROTEINS:CA-125- ovarian, CA-19-5- colon,
pancreas, CA-15-3- breast
MOLECULAR: p53, APC, RAS- Colon ca (stoo l+ serum)
P53- (urine)- bladder,P53+RAS-LUNG,. Pancrea
• Immunoglobulin's: Multiple myleoma
ELECTRON MICROSCOPY
Immunohistochemical stains
breast carcinoma her2- prognosis & therapy
METHODS OF evaluation& Diagnosis
V. flow Cytometry (e.g. Leukemia\lymphoma ).
VI. DNA DIAGNOSTIC METHODOLOGIE
(Clonality assessment, diagnostic &
prognostic classification, residual tumour e.g.
Lymphoma: PCR, Southern Blot Assay, DNA
microarray, etc.) .
S
VII. Cytogenetic assessment, - hybridization
(FISH) -study the numerical and gross
abnormalities of whole chromosomes
)
Burkitt’s Lymphoma
karyotype of 46, XY, t (8;14)
INHERETED GENETIC DISEASES
PREDISPOSING TO CANCER
Xeroderma
pigmentosum (P53)
Retinoblastoma (Rb)
Familial adenomatous polyposis
coli (APC suppressor gene)
Neurofibromatosis (NF1)
MICRO-ARRAYS
THOUSANDS of genes identified from
tumors give the cells their own identity
and FINGERPRINT and may give
important prognostic information as well
as guidelines for therapy. Some say this
may replace standard histopathologic
identifications of tumors.
What do you think?
Biopsies analysis
• Tissue Processing
• Pathologists
• Issuing the
histopathology
report.
Keep specimen according
The institute protocol
What’s the differential diagnoses??
• Inflammatory conditions
• Non-inflammatory lesion
• Benign neoplastic tumor
• Precancerous conditions.
• Malignant neoplasm “Cancer”
• MIMKER & Others
Differences ??
• Metaplsia
• Dysplasia
• Hamartoma
• Choristoma
• Teratoma
Epithelial metaplasia: change of mature to mature
Esophageal biopsy
Larynx biopsy
Ocular Lesion: Choristoma, form of
heterotopia, normal tissue found in abnormal location
Lung nodule; encapsulated Hamartoma:
benign developmental lesion, disorganized benign tissue