Chapter 10 Diseases of Lymphoid Tissue and Hematopoietic System
OBSERVATIONAL METHODS OF SEPCIMEN
Organs of the hematopoietic and lymphoid system mainly include: marrow,
spleen, lymph node, thymus and extra nodular lymphatic tissue.
Marrow in long bone of adult is yellow (yellow marrow), which is red in
children (red marrow). We should observe the change of its color and texture, whether
cortex thicken or is damaged.
Spleen weighs 120-150g, (3-4)cm×9cm×(12-14)cm. Parenchyma of the spleen is
composed of white pulp, marginal zone and red pulp. We should observe size, color
and structure of spleen, whether capsule is smooth and whether it thicken or
conglutinate. We also should observe number, size, distribution, color and texture of
focuses if focuses are found.
Lymph node is discrete encapsulated structures, usually ovoid and ranging in
diameter from a few millimeters to several centimeters. Parenchyma of lymph node is
composed of the cortex and the medulla. The cortex is composed of superficial cortex
containing nodules of B-lymphocytes; the paracortex or deep cortex, which is the
T-cell-dependent region; and cortical sinuses. The medulla contains medullary cords
and medullary sinuses (Fig.10-01). We should note size, capsule and color and texture
of cut surface.
AIMS
To be familiar with the pathological features of reactive proliferation of lymph node,
and that of Hodgkin’s disease, non-Hodgkin’s lymphoma and leukemia.
CONTENTS
Gross specimen
Tissue section
Reactive
Reactive hyperplasia of lymph
node
hyperplasia
of
lymph node
Hodgkin’s disease
Hodgkin’s lymphoma
Hodgkin’s lymphoma
Non-Hodgkin’s lymphoma
Non-Hodgkin’s lymphoma
Non-Hodgkin’s lymphoma
Leukemia
Leukemia
KEY POINTS OF SPECIMEN OBSERVATION
1. Reactive hyperplasia of lymph node
Basic pathologic changes
(1)Gross morphology
◆
Lymph nodes are soft, slightly enlarged, usually 1-2cm in diameter, with smooth
capsule, and presenting a gray-red or gray-white cut surface.
(2)Histopathology
◆
The lymph node structure is preserved. It usually presents the patterns of
hyperplasia of lymphoid follicle (big and more follicle), paracortical lymphoid
hyperplasia (wide paracortex area), and sinus histocytosis (distention and
prominence of the lymphatic sinus and the lining macrophages hyperplasia), or
three patterns mix together.
Specimen observation
Case abstract: Male, 17-year-old, complained of a sore throat for half a month
accompanying with lymph node swelling for one week. Physical examination:
pharyngeal are red and swollen, the left cervix lymph nodes are enlarged, 1.5cm in
diameter, tenderness.
Tissue section: (Fig.10-02) To observe the changes of nodules, paracortex and
lymphoid sinus, which one is obvious?
2.Hodgkin’s lymphoma (HL)
Basic pathologic changes
(1) Gross morphology
◆
HL is easily involved in lymph node and extra nodular lymphatic tissue.
◆
Affected lymph nodes are enlarged, with a smooth surface. The cut surface is
usually homogeneously white, and shows fish-meat like or rubber like
appearance with yellow-white small necrotic focus.
◆Size
of involved spleen is increased. Some gray nodules in different sizes
diffusively distribute on the cutting surface, showing ground glass like
appearance.
(2) Histopathology
◆
Structure of lymph node or spleen is devastated partially or completely, which is
replaced by tumor cells.
◆
There are kinds of tumor cells: R-S cell which have a large, multilobed nucleus
and a prominent eosinophilic nucleolus about the size of a red blood cell, and
R-S cell variant popcorn-like cell (multilobate nuclei) and lacunar cell
(abundant pale cytoplasm) and Hodgkin cell (mononucleate tumor giant cell).
◆
There are lymphocytes, plasma cells, neutrophilic granulocytes, acidophilic
granulocytes and histiocytes among tumor cells with different amount.
Specimen observation
Case abstract: Female, 28-year-old. She suffered painless mass in left cervix for two
months. The masses enlarged and increased in number gradually, accompanying with
fever 38.2℃ for half a month. Physical examination: several nodes, from 1 to 4cm in
diameter, were conglutinated.
Gross specimen: (Fig.10-03) To observe the abnormalities are on cutting surface and
size of lymph nodes.
Tissue section: (Fig.10-04a,b) ① To observe whether lymph node structure is
damaged and to observe its morphology；What kinds of tumor cells can be seen?
Which kind of cell is significant to diagnosis? ②Which type of disease is this
section?
Question: ①What clinical manifestations do Hodgkin’s lymphoma patients show?
②What’s the diagnostic gist of Hodgkin’s lymphoma? ③How many histological
types of Hodgkin’s lymphoma can be divided into; Which one does show the best
prognosis and which one the poorest prognosis?
3. Non-Hodgkin’s lymphoma
Basic pathologic changes
(1) Gross morphology
◆
Involved lymph nodes swell. The cut surface is homogeneous, yellow-white to
pearl gray, and the consistency varies from soft to moderately firm. Necrotic
focus can be seen.
(2) Histopathology
◆
Structure of lymph node is devastated completely, which is replaced by tumor
tissue.
◆
A predominant population of tumor cells efface the lymph node architecture,
morphology of tumor cell is consistent.
◆
Tumor cells distribute diffusively or arrange in nodular shape.
◆
Tumor cells infiltrate into capsule of lymph node and extra nodular tissue.
Specimen observation
Case abstract: Male, 12-year-old. He suffered painless swelling of superficial lymph
nodes for three months, and had fever, weight loss, hepatomegaly and splenomegaly,
accompanying itching for one week. The specimen of the cervix lymph node was
obtained by biopsy.
Gross specimen: (Fig.10-05) To observe whether lymph nodes enlarge, or
conglutinate to each other? What’s the characteristic of its cutting surface?
Tissue section: (Fig.10-6)
1) To observe whether lymph node structure is damaged；
2) To observe the morphology, arrangement of tumor cells;
3) To observe the infiltration area of tumor cells.
Question: What disease can patient suffered if his local lymph nodes enlarge? How to
diagnose this disease is non-Hodgkin lymphoma?
4. Leukemia
Basic pathologic changes
(1) Gross morphology
◆
Leukemia is mainly involved in hematopoietic organs (liver, spleen, bone
marrow) and other organs.
◆
Marrow: The most apparent lesion is involved in yellow marrow of long bone,
marrow is grey red or grey green color, mash like appearance, cortex attenuates.
◆
Liver, spleen, lymph node: Swollen, the cut surface show grey white or grey red
color.
(2) Histopathology
◆
Marrow: Immature granulocytes or lymphocytes proliferate apparently,
constitution of platelet system and red blood cell system decrease.
◆
Liver, spleen, lymph node: Plenty of leukemia cells infiltrate.
Specimen observation
Case abstract: Male, 11-year-old. He suffered fever, easy fatigability for one month.
Physical examination: lymph nodes of the cervix and groin are enlarged,
hepatomegaly and splenomegaly. RT: RBC and platelet reduction, and immature
lymphocytes appearance.
Marrow
Gross specimen: (Fig.10-07): To observe the change of marrow; what’s the change of
bone cortex?
Tissue section: (Fig.10-8a, b) (a) Acute lymphoblastic leukemia, promyelocyte
infiltrate diffusively in marrow. (b) Chronic lymphoblastic leukemia, myelocyte and
metamyelocyte infiltrate diffusively in marrow.
Question: ① What’s the main clinical manifestation of leukemia? ② What’s the
main gist to diagnose leukemia? ③ Can it be diagnosed as leukemia if granulocytes
increase apparently (above 50×109/L) with appearance of myeloblasts in peripheral
blood? Why?
CASE DISCUSSION
Case abstract. Female, 24 years old. Chief complaints: Powerlessness for 2 months,
both upper limbs numb and paralyzed for 1 day. Patients suffered weakness, poor
appetite about 2 months ago, which is alleviated after taking drug. She suffered leg
pain half a month ago, which is aggravated in rest and alleviated when walking.
Anti-rheumatism therapy took no effect. Both lower limbs numb and stiffen
accompany with lumbago 1 day ago. Physical examination: body temperature:
37-39℃, pulse: 76/min, breath 20/min, BP 16/10.7kPa. There was a hard texture,
immobile mass between the first and second lib of left chest. Heart and lung are
normal. Grip power of left hand decreases, tongue apex is oblique to left, abdomen
reflex disappear. Laboratory examination: blood routine: Hemoglobin: 98g/L, WBC
11.0×109/L, myeloblast 0.29, promyelocyte 0.04; marrow examination: myeloblast
0.65, promyelocyte 0.12; protein in cerebrospinal fluid 6.4/L, Cl 203mmol/L, total
cell number 8×106/L. Anti-infection and anti-symptom therapy took no effect. The
patient was dead.
Autopsy records。
There was a round tumor node with 1.5cm in diameter at the second lib of left
pleura. The cut face is green. Lung suffers congestion and edema. There is a little
yellow lipid deposit on aortic endometrium. Liver swells with blunt margin. There is a
round 2cm green node in the center of right lobe. Spleen enlarged, texture is soft. The
cut surface is grey red color. Mucosa of bladder is hemorrhaged. There are several
green nodes in yellow bean to green bean size on cerebral dura mater. Brain stem and
spinal cord suffered focal softening with yellow bean size infiltration focus. Bone
marrow of stem of femur is grey.
Microscopic: In marrow of stem of femur and sternum, granulocyte proliferate,
proliferating cells are myeoblasts mainly. Myeoblasts infiltrate in liver sinus, some of
which form nodes. Myeoblasts infiltrate in splenic sinus. Green nodes on pleura and
cerebral dura mater are granulocytes. Tumor cells infiltrate in posterior peritoneum
lymph node, brain stem, dura meter of dorsolumbar spinal cord. Neurons in anterior
crus of lumbar spinal cord suffered degeneration and necrosis. Both of lungs suffered
congestion and edema accompany with focal neutrophilic granulocyte infiltration.
Discussion
1. Diagnosis and gist of diagnosis.
2. Cause of death.
3. Why the tumor nodes on pleura and cerebral dura mater show green color?
What’s the significant of this kind of nodes?
4. Explain clinical symptoms with pathological manifestation.
QUESTIONS FOR REVIEW
1.
What’s the difference in pathological changes and clinical characteristics
between Hodgkin’s disease and non-hodgkin lymphoma?
2.
What’s the difference in pathological and clinical characteristics between
acute leukemia and chronic leukemia?
3.
What’s the difference between reactive hyperplasia of lymph node and
lymphoma?
(Dalian Medical University Sun Lei)