I. HISTOPATHOLOGY OF THE HEART
1. Recent myocardial infarction: 50-year-old man with a three-day history of left ventricular myocardial
infarct. The patient died of an heart insufficiency. An example of coagulative necrosis. Judging from the lack of
staining of the nuclei of cardiac muscle cells (with increased eosinophilia of the cytoplasm) and the diffuse
neutrophilic infiltrate in the interstitium, it has to be more than 24 hours old. Subendocardial layers survive
(supplied through diffusion through the endocardium).
2. Older myocardial infarction: Clinical history of this patient corresponds with the morphological appearance
of his myocardial infarct. The patient died of heart insufficiency in a lung oedema. The heart weighed 420 grams.
There was a paler yellowish area in the posterior wall of the left ventricle, surrounded by a darker rim of
granulation tissue. A white scar was present in the neighbourhood of this infarct. This infarction may be 2-3
weeks old. Necrotic tissue, now completely devoid of nuclei, is being slowly resorbed by macrophages (see
residual granules of lipofuscin from necrotic muscle cells in their lysosomes) and replaced by graulation and by
fibrous tissue.
3. Postinfarction scar of the myocardium: 60-year-old patient with a two-month history of a myocardial
infarct. The cause of his death was heart insufficiency and lung oedema. The heart weighed 450 grams, the
bulging apical part of the left ventricle was of a whitish colour and was about 3mm thick. Necrotic muscle has
been completely resorbed and the granulation tissue has been replaced by connective tissue scar. Note residual
muscle fibers included in the scar tissue (possible source of arrhythmia).
4. Diphtheric myocarditis: This five-year-old boy died with signs of an heart failure after one week of
diphtheria. There was pseudomembranous tracheitis, the heart weighed 120 grams. Left ventricle was markedly
dilated. Diffuse infilammation of the myocardial interstitium, consisting of leucocytes and macrophages involved
in resorption of disperse necrotic muscle cells.(effect of the exotoxin of corynebacteria. Advanced stage of
resorption, almost no necrotic cells remain (pale small foci in the tissue). Similar changes can appear in
influenza, polyomyelitis, Coxsackie virus.
5. Rheumatic myocarditis: 30-year-old male patient developed arthralgias and hear failure approximately ten
days after tonsillitis (angina). The heart weighed 320 grams, left ventricle was dilated. The myocardial
interstitium contains the so-called Aschoff nodules, with eosinophilic necrosis and with the basophilic Aschoff
cells (modified macrophages). The muscle cells are undamaged. The nodules may be difficult to find in some of
the slides.
6. Bacterial endocarditis: Aortic valve from the heart of a 50-year-old woman with an high septic fever that
developed during her pneumonia. The patient died of a complicating brain abscess.The heart weighted 350
grams, left ventricle 12 mm.Trombotic vegetations were present on the surface of aortic valve. Microbiologic
examination of vegetations revealed G+ microbes, Staphylococcus epidermidis. Deformed (aortic?) valve is
covered by huge thrombotic vegetation with foci of accumulated neutrophils. Finely granular masses of
microbial colonis are scattered inside the thrombus. Note small areas of resorbed necrtosis in the adjacent
myocardium (possibly from coronary microembolism by fragments of the valvular thrombus).
7. Acute fibrinous pericarditis: This 45-year-old woman had chronic glomerulonephritis and died of renal
insufficiency. Serum creatinine was 600 umol/L (normal range 55-110). At autopsy the lungs appeared
oedematous, with fibrinous exudate on the pleural surface. Epicardial surface was also covered by fibrinous
threads. Causes often unknown (uraemia, viral infections, over myocardial infarction, acute febrile rheumatism,
tumours). Epicardial surface is covered by a thin eosinophilic layer of fibrin.
8. Tuberculous pericarditis: A 60-year-old female patient was followed for a destructive pulmonary process
predominantly in the upper lobes. The pericardial cavity contained haemorrhagic exudate. The patient died of
respiratory insufficiency. A portion of the wall of left atrium shows chronic inflammatory infiltrate in the
subepicardial fat, with several epithelioid granulomas, some of them with central caseous necrosis and scattered
multinucleated Langhans’ cells.
9. Rhabdomyoma of the heart: A premature newborn died at the age of two days of pneumonia. There were
scattered cysts in the liver and in kidneys. The heart muscle contained some ill-circumscribed paler foci, the
heart was slightly enlarged. Immature cardiac muscle with smaller and thinner myocytes contains several paler
nodules consisting of large cells with watery pale cytoplasm (cytoplasmic glycogen washed out during
processing of the tissue) and central nucleus hanging on thin eosinophilic threads of cytoplasm. Some cells can
contain fibres of myofibrils.
10. Myxoma, cardiac:A 50-year women with transitory left-sided hemiparesis. Signs of embolisation into the
brain, spleen and heart were present. On the dorsal wall of the left atrium, the pedunculated myxoid mass which
almost completely occupied left atrium was found. This mass was the source of embolism. The cause of death
was massive trombembolism of pulmonary artery. This benign mesenchymal tumor is composed of globular or
star-like cells, endothelial cells and smooth muscle cells. The myxoid stroma is composed of acid
mucopolysacharides. Locally, glandular formations and vessels may be present.
11. Erdheim’s cystic medionecrosis: This 40-year male patient suffered from severe retrosternal pain that
started suddenly, he died 12 hours after the onset of clinical symptoms. Cardiac enzymes (CK, LDH) were
negative. Autopsy revealed extensive mediastinal haemorrhage with a rupture in the wall of ascending
aorta, the wall of aorta in the neighbourhood of the rupture tore easily on traction. Multifocal necrosis of
muscle cells with disappearance of elastic fibres (pale areas) and accumulation of acid mucopolysaccharides
(small basophilic areas) (chondroitin-6-suplhate) in the aortic media. Note multifocal laminar splitting of
aortic media, the origin of aortic dissection.
12. Arteriosclerosis: 70-year-old patient with a history of stroke and ischaemic heart disease, he was also
suffering from renal insufficiency. Grossly the aorta showed severe atherosclerotic changes especially in its
descending portion. Principal morphological events: fatty streaks, fibrous plaques, atheromas, ulceration,
and dystrophic calcification. Mostly intimal involvement.
13. Arteriolosclerosis of kidney: Kidney tissue from the same patient. Both kidneys were smaller, weighing
100 grams each, their surface was coarsely granulated, thickness of the cortex was reduced to 4 mm.
Laboratory: higher serum creatinine and urea. Note obliteration of some of the glomerular and concentric
thickening of arterial and arteriolar walls with accumulation of hyaline and fibrinoid masses. Severe
vascular atrophy of renal parenchyma with confluent areas of tubular atrophy, hyalinization of gromeruls
and increase of the connective tissue interstitium.
14. Polyarteritis nodosa-heart: 40-year-old female patient with signs of ischaemic heart disease. The
patient died suddenly of malignant arrhythmia. Grossly, the heart showed slight dilatation of the left
ventricle and scattered small subepicardial haemorrhages over the anterior wall of the left ventricle.
Systemic disease, which involves mostly small arteries and arterioles. Microscopical findings: segments of
fibrinoid necrosis of arterial media, swelling of endothelium, thrombosis, defects in internal elastic
membrane. Mixed inflammatory infiltrate. Healing by segmental scar-rosary-like appearance of involved
vessels. Complications: thrombosis, aneurysm.
II. PATHOLOGY OF BLOOD VESSELS. HAEMATOPATHOLOGY.
1. Myeloproliferative syndrome, polycytemia vera:60-year-old female with several, repeated thromboses
of low extremities. During last days anginous pain of the chest. In peripheral blood picture excessive
increase of erythrocytes, thrombocytes and neutrophils. MPS is clonal disease of stem cells resulting in
increase of one or several cell lines in peripheral blood. The haematopoiesis is effective. Cells are
differentiated and have not signs of dysplasia. Hepatosplenomegaly is frequent finding. The bone marrow is
hypercellular with hyperplasia of all three major lines – erythropoiesis, granulopoiesis, and
megakaryopoiesis. The important finding is lack of hemosiderin. This syndrome may develop into secondary
myelofibrosis, sometimes into the blastic acute myeloid leukaemia.
2. Extramedullary haematopoiesis: Description of patient in case 5. Myeloproliferative diseases cause
hyperplasia of haematopoiesis, which is disseminated into the liver, spleen, lymphatic nodes and cause
hepatosplenomegaly. There are isles of haematopoiesis scattered with different intensity in liver
parenchyma. Physiologically is Extramedullary haematopoiesis present during embryogenesis.
3. Myeloproliferative syndrome, chronic myeloid leukaemia (Ph+), liver: 52- years-old male patient
with asymptomatic increase of neutrophils in peripheral blood (promyelocytes in 10%). Last examination of
the blood revealed leucocytosis of 350×109//L. Physical examination revealed marked hepatosplenomegaly.
The patient died of bronchopneumonia. Neoplastic infiltrations both in portal triads and in liver sinusoids, in
some areas almost diffuse (cells of the granulocytic lineage in various stage of maturation).
4. Chronic myeloid leukaemia, lymph node:An enlarged lymph node from the same patient. Massive
infiltration by the immature cells of myeloid lineage only scattered residual lymphoid follicles.
5. Myelodysplastic syndrome, bone marrow: 76-year-old male with general fatigue. Cytopenia in the
peripheral blood especially anaemia. No hepatosplenomegaly. Asymptomatic clinical course. Clonal disease
of stem cells with ineffective haematopoiesis, within the hypercellular bone marrow are cell with signs of
dysplasia. The presence of blasts is also characteristic. There is poor response to chemotherapy and risk of
progression into the acute myeloid/lymphocytic leukaemia.
9
6. Chronic lymphocytic leukaemia, liver: Leuocytosis of 25x10 /L was found in this 60-year-old female
patient, with 75 per cent of lymphocytes in the differential. The patient died of a stroke four years later. The
liver weighed 1.990 grams, the cut surface showed whitish reticular pattern. Mostly B-cell leukaemia,
infiltration of the portal triads by differentiated lymphocytes which express pan-B markers (CD20) and
CD23 a CD5.
7. Follicular lymphoma:50-year-old male with left inguinal lymph node enlargement. The most frequent
adult lymphoma, almost in all cases nodal. Histologicaly it is nodaly arranged and composed of centrocytes
(cells with irregular grooves in nuclear membrane) and centroblasts (larger cells with several nucleoli in
hypochrome nuclei). The prognosis is related to number of centroblasts (grading of these neoplasms is
mostly based on centroblasts count – grade 1-3). Immunophenotype: pan B+, bcl-2+, CD5-, CD23-. Genetic:
t (14; 18).
8. Mantle cell lymphoma (only DIA): Often extranodal lymphoma of elderly males. Prognosis is poor due
to aggressive behaviour and chemoresistance. It arises from small mantle cells localised around germinal
centre. It is arranged nodulary in the early phases, diffusely in the late phases. Immunophenotype: pan B+,
CD5+, cyclin D1+, CD23-. Genetic: t (14; 18)
9. Diffuse large B cell lymphoma:75-year-old male with general lymphadenopathy, fatigue and
subfebrilias. Often extranodal lymphoma of various age groups. Many subtypes exists (mediastinal large
cell B lymphoma, large cell B lymphoma rich of T cells, etc.). Treatable but highly aggressive tumour.
Original structure of lymph node is substituted by infiltration of large lymphoid cells with high mitotic
activity. Immunophenotype: pan B+. Genetic: in 30% t(14;18).
10. Non-specified peripheral T cell lymphoma (only DIA): Tumour is composed of small, medium and
large cells with irregular nuclei together with venules, plasmocytes, eosinophils. So called Lennert`s
lymphoepitheloid lymphoma is characterised by presence of numerous epitheloid histiocytes. Aggressive
behaviour. Relatively often in Far East. Immunophenotype: various T antigens, most often CD3, CD4, less
often CD8.
11. Anaplastic large cell T lymphoma: 30-year-old male with peripheral and abdominal lymphadenopathy
with skin infiltrates. Subfebrilias and night sweats. This tumour appears both in the childhood and elderly
and is often extranodal (skin). Histologicaly it may resemble undifferentiated carcinoma or malignant
lymphoma. Immunophenotype: CD30+, EMA+-, T markers +-, B markers always negative! Sometimes
expression of ALK (anaplastic lymphoma kinase). Genetic: t (2,5).
12. Nodular lymphocytic-predominance Hodgkin`s lymphoma (NLPHL): 22-year-old female patient
was suffering from fatigue and night sweats. Physical examination revealed enlarged cervical lymph nodes,
otherwise it was unremarkable. Fine needle aspiration biopsy of a node was positive. There was slight
eosinophilia in peripherial blood. Disease of various age groups.
Classic Hodgkin lymphoma (CHL)
Types: nodular sclerosis (NSCL)
mixed cellularity (MCHL)
lymphocyte rich classic HL (LRCHL)
lymphocyte depletion (LDHL)
The tumour cell is HRS – Hodgkin mononuclear or Reed-Sternberg binuclear cell, both with characteristic
inclusiform nucleolus. The background is filled with various inflammatory cells (see slide) – T cells, B cells,
eosinophils, histiotyocytes. Prognosis depends on morphological type (LRCHL has best prognosis), NSCL
is most common type with predilection in mediastinal nodes.
III. PATHOLOGY OF THE RESPIRATORY TRACT, PART ONE
1. Nasal polyp: This 45-year-old patient was suffering from nasal obstruction. Personal history included
repeated bouts of chronic rhinitis and sinusitis. Multiple polypous formations, pedunculated and sessile,
were excised from the nasal cavities. Increased level of IgE should confirm allergic origin of the patient’s
problems. Inflammatory pseudotumour (chronic allergic hypertrophic rhinitis), oedematous, sometimes
resembling myxoma. Uneven cellularity, with few cells in some areas and more cellular, infiltrating with
eosinophils, lymphocytes and plasma cells elsewhere.
2. Laryngeal (singer’s or preacher’s) nodule: 20-year-old patient, 2 years singing in a choir, had a 3month history of hoarseness. A small polyp on the right vocal cord was excised. The lesion is lined by
metaplastic squamous stratified epithelium; sub-epithelial stroma consists of eosinophilic and vacuolated
poorly cellular collagenous fibrous tissue, with a fibrin content, in which there are thin-walled blood vessels.
3. Laryngeal carcinoma: 57-year-old patient who had suffered for some month from afonia, ORL
examination revealed a tumour located in the supraglottic portion of the larynx, the patient underwent
partial laryngektomy. The tumour exhibits papillary growth and there is ulceration and infiltration of the
underlying tissues, too. It consists of sheets of moderate or low-differentiated squamous epithelial cells with
only minimal foci of keratinisation. At the margin the non-neoplastic metaplastic squamous epithelium is
visible.
4. Pseudomembranous tracheitis: 79-year-old man with clinical symptoms of influenza suffering from
distressed breathing died of pneumonia. The patient’s larynx and trachea were severely congested and
oedematous, with an adherent pseudomembrane on the mucosal surface. Cross section of tracheal wall
formed from a superficial part of fibrinous exsudate and a deeper portion formed by necrotic mucosa
permeated by fibrin. There is erythrostasis in mucosa and submucosa, blood vessels are dilated. It is an
examle of superficial (croupous) pseudomembranous inflammation.
5. Bronchial asthma: This 38-year-old male patient had a history of an atopic eczema, allergic rhinitis,
dyspnoea with a "wheezing breath", dyspnoea and cough. His IgE was elevated and the white blood cell
differential revealed eosinophilia. The patient was admitted for bronchospasm with suspicion of pneumonia.
He died four days later. Lungs are oedematous, heavy. Bronchi are dilated, with hypertrophic muscular layer
and mucinous glands, hyperaemia and thick basemembrane. There is infiltration of lymphocytes, plasma
cells and eosinophils in the wall. Many bronchi are filled with thick mucus containing numerous
eosinophils. Note scattered Curshmann’s spirals and Charcot-Leyden’s crystals.
6. Chronic bronchitis (hypertrophic type) with emphysema (COPD), exacerbating: A man of 65,
cigarette smoker, living in an industrial town had a chronic productive cough for several years. Recently he
had been suffering from exertional dyspnoea, he died of cardial insufficiency. Lungs have emphysematous
configuration with perivasal and peribronchial antrakosis. The bronchi are lined by hypertrophic mucosa
with an increase in goblet cells. Bronchial walls are oedematous, thickened by hyperplastic and hypertrophic
mucus-secreting glands, increase amounts of smooth muscle and capillaries. Basement membranes are also
thickened. An increase in chronic inflammatory infiltration has been documented (lymphocytes, plasma
cells, eosinophils). In airways there is excess mucus with small amount of polymorphonuclear leukocytes.
7. Silicosis of the lungs: This 50-year-old glass cutter had a long history of lung fibrosis died form
pneumonia that complicated exacerbating bronchitis. Both lungs were tough, with small, sometimes
coalescing nodules that reached several centimetres in diameter. Some nodules contained a necrotic centre,
some were calcified. Regional lymph nodes showed similar changes. Nodules are formed from fibrous tissue
with low content of fibrocytes, increased hyalinization, antracotic pigment and SiO2 crystals /evidenced by
polarised light/. Coniofibrosis with three stages: 1-stigmatization with SiO2 crystals in similar location as
antracotic pigment. 2-formation of silicotic nodules, 3-massive fibrosis.
8. Lung emphysema: Same patient as above. There is emphysematous configuration of lung parenchyma
next to the above described nodules. Alveoli are extended with destruction of septa together with thickening
of arterial wall as the sign of pulmonary hypertension. Various types: senile, centroacinar, paraseptal,
panacinar, bullous.
9. Atelectasis of the lung: This asfyxiated stiiborn fetus died during a complicated prolong labour.
Noninflated lungs can’t swim after immersion into water. There are collapsed or slit shaped alveoli.
10. Lung oedema: 70-year-old patient with a history of ischemic heart disease was coughing a frothy pink
sputum. At autopsy both lungs were heavy, weighing 950 and 820 grams, with pink watery fluid running
from the cut surface. Hyperaemia of lung tissue. Eosinophilic fluid in the alveoli,variable etiology.
IV. PATHOLOGY OF THE RESPIRATORY TRACT, PART TWO
1. Acute catarrhal-suppurative bronchopneumonia: This 87-year-old female patient underwent
osteosynthesis after a fracture of her left femur. An x-ray revealed bilateral shadows in the lower lobes of
her lungs. At autopsy both lower lobes were congested and oedematous, with disperse consolidation of the
lung tissue on palpation. Both main bronchi contained mucus while peripheral bronchial branches were
filled with pus. Acute superficial inflammation of the lungs, spreading from minor bronchi and bronchioles,
aetiology variable. Alveoli are filled with polymorphonuclear leukocytes, little fibrin can be seen. The
appearance of exudate may differ in various parts of the inflamed area.
2. Lobar pneumonia: 45-year-old male patient with a short history of malaise, fever and dyspnoea. In spite
of an antibiotic treatment, the patient died in respiratory and circulatory failure. The upper lobe of the left
lung showed fibrinous pleuritis, the parenchyma of the lobe was consolidated, resembling on cut surface
liver tissue (grey hepatisation). Mostly infection with Diplococcus pneumoniae. Fibrinous inflammation,
involving major areas of lung parenchyma, spreading quickly through neighbouring alveoli. Several stages:
inflammatory oedema, grey hepatisation (grossly resembles liver tissue), red hepatisation, and resolution.
3. Lung carnification (caro = meat): This 68-year-old patient had a history of ischaemic heart disease and
pneumonia died of cardiorespiratory failure. The surface of the posterior segment of the left upper lobe
showed organizing fibrinous pleuritis. The segment itself showed hypoventilation, on section the
parenchyma appeared rubbery, resembling skeletal muscle in consistency. Caused by incomplete resolution
and organisation of the intraalveolar exudate with formation of non-specific granulation tissue (concentric
arrangement of fibroblasts and collagen fibres in the alveoli).
4. Nonsuppurative interstitial pneumocystis pneumonia: This 58-year old patient with history of
carcinoma showed signs of a pulmonary infiltrate. Pneumocystis carini was found in the bronchopulmonary
lavage. At autopsy non-specific finding. Microorganism Pneumocystis carinii (fungus, yeast-like) can be
visualised in the spumoid masses in alveoli. Alveolar septa are thickened with mononuclear (plasmocytic
and lymphocytic) infiltrate. Typical in immunocompromised patients, sensitivity to UV light.
5. Lung abscess: This 59-yeard old female patient was suffering from repeated inflammation of veins in her
lower extremities; she died of massive pulmonary embolism. The lungs showed several subpleural infarcts,
one of them with gangrenous destruction of the necrotic tissue. Acute abscess: irregular shape, peripheral
zone of hemorrhagic lung and area of inflammatory oedema. Possibility of further spreading. Chronic
abscess: regular shape, its wall composed of pyogenic membrane, impossibility of collapse (cavitary
abscess). Three ways of spreading: bronchogenous, haematogenous, lymphogenous.
6. Squamous cell carcinoma: This 65-year old patient had been treated unsuccessfully for chronic cough
by his physician. He had been smoking 20 cigarettes/day for about 40 years. Hospital check-up revealed
dysplastic squamous cells in his sputum and chest x-ray showed suspicious lesion in the upper lobe of his
left lung. A greyish-white nodule was found in the wall of the main bronchus for the upper lobe. Hilar nodes
were free of tumour. Most frequent histological form of bronchial carcinoma, especially in smokers
(preceding squamous cell metaplasia and dysplasia of the bronchial epithelium). Various degree of
differentiation with keratinisation and formation of keratin pearls in the differentiated forms.
7. Small cell cancer of the lungs: A 52-year-old smoker with a history of shortness of breath and
expectoration of purulent sputum with occasional streaks of blood. A forceps biopsy from the bronchus for
the right upper lobe confirmed the diagnosis of cancer. The patient died 10 months later with extensive
dissemination of the tumour. The hilar region of the right lung was infiltrated by whitish tumorous masses
that were encircling and compressing the aortic arch, distal oesophagus, and the origin of the left main
bronchus. Bilateral hilar lymph nodes were infiltrated by the tumour. Second in frequency, this is the most
malignant histological type. Oat cell, round cell type, with occasional neurosecretory granules on electron
microscopy. Sometimes accompanied by paraneoplastic syndromes (Cushing’s syndrome, hypercalcemia,
carcinoid syndrome).
8. Adenocarcinoma: This 57-year-old female patient had had a history of hysterectomy for cervical
carcinoma ten years ago. Recently, she became dyspnoeic and anaemic, with a considerable weight loss.
The patient died from cardiorespiratory failure. At autopsy the right pleural cavity was massively filled by
tumour masses that focally appeared gelatinous and caused severe compression of the totally collapsed
lung. Metastases in lymphatic nodes, opposite lung, suprarenal glands and in other organs were found.
Tumour rises from bronchial epithelium or bronchial glands, but also without connection with bronchus.
9. Bronchioloalveolar carcinoma: Special form of adenocarcinoma (10%). Tumour cells lining alveolar
ducts and alveoli without destruction of their septa. The most frequent localization is the periphery of
bronchial tree – terminal bronchioli and alveolar ducts.
10. Large cell carcinoma: Non-differentiated variant of carcinoma, without morphology of squamous,
small cell and adenocarcinoma.
V. PATHOLOGY OF THE GASTROINTESTINAL TRACT, PART I
1. Epulis gigantocellularis: A 26-year-old female patient noticed a swelling in the retromolar region of her
upper jaw, sitting on the surface of the alveolar processus. The excised white round formation measured
1.5cm in the greatest diameter and was of a firm consistence, it was covered with an unchanged mucosa.
Tumoriform formation with markedly vaskularised stroma, focally looking like non-specific granulating
tissue, contents multiple multinucleated giant cells /most common type of epulis in childhood and middle
age/.
2. Leukoplakia: (see the slides).
3. Carcinoma of the oral cavity: (see the slides)
4. Radicular cyst: This 53-year-old lady had a history of chronic periodontitis. Lateral x-ray revealed focal
lucidity next to the root of one of her molars. Surgical excision revealed whitish tissue specimen with a small
collapsed cavity. A cyst resulting form epithelisation of a chronic apical root abscess. Squamous epithelium
derives from the cell rests of Malassez, stimulated by the inflammatory process. There is dense chronic
inflammatory infiltrate under the epithelial lining.
5. Ameloblastoma: This 40-year-old male patient had a polycystic lesion of the alveolar processus excised.
The specimen for histology was formed by a whitish firm tissue with fragments of bone. The patient noticed
loosening of his teeth on the site of the polycystic growth. Epithelial tumour of borderline biological
behaviour, developing in the processus alveolaris of the jaw. Slowly growing with bone destruction, grossly
solid or polycystic. Microscopically reticular arrangement of loosely arranged stellate epithelial with
interposition of islands of vascularised oedematous stroma.
6. Pleiomorphic adenoma: A 61-year-old female patient with a recurring growth in her right parotid eight
years following the original excision. Fragments of tissue with white firm stripes were removed; together
with the rest of the gland 2×4×3 cm. Previously called myxochondroepithelioma for its microscopical
appearance (only the epithelial and myxoid structure is visible in our slide). Epithelial, with locally variable
differentiation, cells form stripes, glandular and solid structures. Benign but poorly outlined, without capsule
(frequent recurrences with incomplete excision).
7. Adenoid cystic carcinoma: This 37-year-old female patient developed a slowly growing tumorous lesion
on the right side of her hard palate. A whitish tough formation was excised and sent for histological
examination. Former cylindroma, malignant. Lace-like arrangement of epithelium, what appears like
adenoid glandular structures is actually oedematous stroma.
8. Cystic adenolymphoma of parotid (Warthin’s tumour): An 87-year-old lady had a swelling in her
right parotid excised. The specimen consisted of a round whitish piece of tissue, grossly resembling a lymph
node. Less frequent, localized in the parotid gland. Glandular and papillary formations are lined by tall
columnar epithelium with apically located nuclei. Dense lymphoid infiltrate in the stromal septa, sometimes
with formation of lymphoid follicle.
9. Chronic gastritis: A 39-year old woman had a 20-year history of pernicious anaemia. A biopsy was
taken from her gastric mucosa for assessment of cellular dysplasia. Two main forms – atrophic and
hypertrophic gastritis. In hypertrophic g. there is thickening of the mucosa with dense chronic inflammatory
infiltrate, appearance of lymphoid follicles, possibility of intestinal metaplasia. Atrophic gastritis – grossly
the mucosal layer is thinned and smoothened, disappearance of gastric glands, intestinal metaplasia.
10. Acute peptic ulcer of stomach: (see the slide).
11. Chronic peptic ulcer of stomach: This 68-year-old lady died from ischaemic heart disease. She had a
history of rheumatoid arthritis that was treated with nonsteroidal antiphlogistic drugs. A mucosal defect
with slightly raised margins was found in the pyloroduodenal transition. The defect measured 2 cm in
diameter and its base was formed by the submucosal connective tissue. Chronic peptic ulcer, note three
layers at the base – necrotic debris with leukocytes, layer of fibrinoid necrosis, layer of non-specific
granulation tissue, then peripheral fibrosis. Thickened walls of adjacent arteries, hyperthrophy of nervous
fibres and fibrosis in the basal part of wall are signs of chronicity.
12. Adenocarcinoma of the stomach – well differentiated: This 60-year-old male patient had a history of
dysorexia with weight loss (8 kilograms in two months) and anaemia. Ulceration with elevated margins was
found on the major curvature and an excision was taken for histological examination. Transmural
infiltrative adenocarcinoma, microscopically tubular and acinar structure. Laurén’s classification: intestinal
form producing extracellular and intracellular acid mucin (this case), and diffuse type with less tendency to
produce mucin (HE and PAS stain). (Note - sample of adenocarcinoma originates from large intestine,
greading in this localization is identical).
13. Adenocarcinoma of the stomach – moderately differentiated: Same patient as above; endoscopy
established thickened wall with smooth mucous in great curvature. Neoplastic cells grove in stripes and
solid formations, glandular formations are not apparent.
14. Adenocarcinoma of the stomach – poorly differentiated – scirrhous carcinoma: This 70-year-old
female patient was thoroughly examined for anorexia, severe weight loss and fatigue. Sonography showed
small-constricted stomach of a "leather bottle" shape. Biopsy confirmed cancer of the stomach. Dissociated,
less differentiated epithelial cells with mucus production (HE and PAS stain - presence of signet ring cells)
with rich desmoplasia.
15. MALT lymphoma of the stomach: This 55-year old male patient with a past history of chronic
gastritis had been loosing weight for about four months. He had crampy epigastric pains and was vomiting
several times. Endoscopy revealed a tumour mass on the lesser curvature of the stomach. The patient was
treated by gastrectomy. The resection specimen revealed whitish tumour measuring approximately 3 cm in
diameter. Regional lymph nodes were enlarged. Malignant B lymphoma of low-grade malignity. Arising
from lymphatic tissue of GIT mucosa. An excision from the tumour is totally infiltrated by slightly
pleiomorphic neoplastic cells with irregular nuclei and scanty cytoplasm. There are many apoptotic cells.
The tumour cells are CD20 and CD79a positive, CD45RO, CD5, CD10, CD23 negative. Note that may be
preceded by Helicobacter gastritis.
VI. PATHOLOGY OF THE GASTROINTESTINAL TRACT, PART II
1. Haemorrhagic infarction of the intestine: Similar morphology with arterial or venous occlusion,
haemorrhagic necrosis and oedema of the intestinal wall, fibrinous exudate on the peritoneal surface. Causes
paralytic ileus. By arterial occlusion is necrotic part well defined, by venous occlusion is margin worse
defined.
2. Acute catarrhal enteritis: Severe diarrhoea appeared in this 13-year-old boy after one week in a
summer camp, the diarrhoea was accompanied by vomiting and gradual development of fever. The stools
showed admixture of mucus and blood. Microbiological culture grew Shigella sonnei. Variable causes
(cholera nostras), the serosa is pink, intestinal content is aqueous, hyperaemia and odema of the mucosal
stroma and of tunica propria. Grundhagen’s spaces - separation of the superficial epithelium from the
basement membrane, sometimes eosinophils in the infiltrate.
3. Pseudomembranous colitis: Some patients develop colitis after treatment with broad-spectrum
antibiotics, such as lincomycin and clindamycin, which depress the normal flora. The disease is caused by
anaerobic organism, Clostridium difficile, the toxin of which damages the wall of the bowel to cause
superficial necrosis of the mucous membrane. The deeper parts of the colonic glands remains. The severity
can vary widely, from mild colitis to fulminating pseudomembranous, haemorragic necrosis with ulcers of
the mucosa.
4. Ulcerative colitis: 35-year-old woman suffering from diarrhoea (15 bloody stools daily), lost of weight,
low-grade fever. A biopsy of rectal mucosa was required to establish the diagnosis. In the hyperaemic
mucosa there is dense infiltrate of inflammatory cells (neutrophil prevalence), several glands are distended
with mucus and inflammatory cells,(the contents appearing pus-like) - crypt abscess.
5. Crohn´s disease: 23 –year-old man with recurrent abdominal pain, diarrhoea (3-6 stools per a day) and
fever. Bioptic examination revealed mixed (lymphocytes) transmural inflammation all layers of the bowel
wall are affected, non-caseating epitheloid cell granulomas and presence of fussuration in the wall.
6. Diverticulitis of the large bowel: A 56-year old man developed acute GI symptoms during ski-vacation
in Austrian Alps (abdominal cramps in left hypogastrium, nausea, vomiting, constipation). Guarding and a
painful resistance in the left lower abdomen were found during physical examination. The temperature was
39°C. Surgery revealed multiple prolapses of the intestinal mucosa through the intestinal wall into
mesosigmoideum. One of these diverticles was distended and inflamed. Low-power view of the section
shows (pseudo)diverticulum with mucosa and tunica propria protruding through the muscularis layer into
the fibrotic and inflamed subserosal fat tissue. The mucosal surface is ulcerated in the proximal part of the
diverticulum.
7. Meckel’s diverticulum: This 40-year-old lady underwent urgent laparotomy with symptoms of acute
appendicitis and beginning peritonitis. Her appendix and the right-sided adnexa were grossly normal. An
inflamed Meckel’s diverticulum (ductus omphaloentericus remnant) was found 20 cm proximal to the
ileocaecal valve. Cross section through a diverticulum with small bowel-type mucosa, slightly fibrotic
tunica propria and thickened muscularis layer. Gastric mucosa can occur heterotopically – common
complicated by ulcer.
8. Intestinal tubulovillous adenoma: A 61-year old man was suffering from anal bleeding, feeling of
fullness, flatulence and abdominal cramps. Endoscopy revealed multiple polypoid lesions in his whole large
intestine, some of them on a narrow stalk, other sessile. Most frequent in the large intestine, with narrow
elongated or broad and short stalk, tubular, villous or tubulovillous, some dedifferentiation of the superficial
epithelium (disappearance of goblet cells). Possible dysplastic changes or cancerization.
9. Ulcerophlegmonous appendicitis: A 29-year-old febrile woman with acute abdominal symptomatology,
signs of peritoneal irritation and positive rebound phenomenon. Laboratory examination showed
leukocytosis with neutrophilia and a left shift. Appendix with congestion a partial adhesion to
neighbourhood. Diffuse transmural leukocytic (polymorphonuclear) infiltrate, ulceration od the mucosa,
suppurative exudate in the lumen, fibrinous layer on the serosal surface. Complications: gangraene,
periappendiceal abscess (localized peritonitis).
10. Carcinoid of the appendix: A 52-year-old man was complaining of an occasional pain in his right
hypogastrium. An appendectomy was performed and the appendectomy specimen showed signs of chronic
inflammation. A greyish intramural nodule was found, measuring 1 cm in diameter. Epithelial tumour
consisting of cells of the diffuse endocrine system of gastrointestinal tract. Solid alveolar arrangement of
small regular cells with small amount of cytoplasm. Benign if localized in appendix.
11. Chronic cholecystitis: This 53-year-old female patient had a history of biliary stones, intermittent pain
under the right costal margin related to meals. Episodes of tremor, fever with sweating occasional moderate
jaundice, skin prurience. Laboratory tests revealed leukocytosis. Gall bladder is reduced, adherent to liver,
contents number of mixed stones. His wall is thick, whitish, firm. Scattered chronic inflammatory infiltrate
in the thickened mucosa focal forms lymphatic follicles, atrophic forms with smooth mucosa.
12. Absceding cholangitis: 65-year-old woman with a history of bile stones and repeated inflammation of
the extrahepatic biliary tract. The patient refused surgical intervention. Following a biliary colic, she
developed high fever and was icteric and confused. Laboratory tests indicated failing liver and kidneys. At
autopsy the liver showed greenish discoloration and small abscesses on cut surface.
Ascending bacterial infection (E. coli) usually accompanying obturation of the biliary tract. Choleangiogenic
sepsis. Portal fields and adjacent parenchyma are infiltrated by neutrophils, necrosis of hepatocytes are
common.
13. Cystic fibrosis of the pancreas: This 28-year-old asthenic male patient with markedly enlarged
abdomen was treated for sterility. His personal history reveals tabescence in despite to good appetite,
steatorrhoea. Analysis of duodenal secretion provided extreme viscosity and absence of proteases, lipases
and amylases. In sweat extremely elevated levels of Na, Cl and K. Pancreas is firm with large cysts
contenting dense mucus. Note marked reduction in the acinar secretory part of the gland, the ducts are
present, some of the wide dilated with inspissated secretion, fibrotisation and chronic inflammation in
surrounding tissue. Langerhans’ islets are preserved.
Frequently complicated by diabetes. Disappearing exocrine parenchyme replaced by the newly formed
connective tissue with scattered lymphocytic infiltrate. Sometimes increased fat tissue - lipomatous atrophy.
Islets of Langerhans often well preserved.
14. Acute haemorrhagic necrosis of pancreas: This 40-year-old obese male patient developed severe
abdominal pain after a celebration with consumption of fatty meals and alcoholic beverages. The pain was
located in the epigastrium and was radiating towards his the back. Meteorismus appeared after a few hours
and the abdomen was painful on palpation. The patient had leukocytosis and laboratory examination
revealed raised serum amylase. Pancreas is slightly enlarged, oedematous. Combination of necrosis of the
pancreatic parenchyme, necrosis of the fat tissue, haemorrhage. Intraglandular activation of pancreatic
enzymes (proteo- and lipolytic).
15. Colorectal adenocarcinoma: 78-year-old woman was complaining of constipation, weight loss.
Laboratory examination revealed hypochromic, microcytic anemia. Colorectal cancer is common in
developed counties; adenomatous polyps and ulcerative colitis belong to the most important risk factors.
Macroscopically this tumour took the form of an ulcer, visible also histologically, in cross-section in this
field. Carcinomatous tissue, consisting of malignant cells of adenocarcinoma (more basophilic), which are
invading downwards, destroying muscle fibres, pericolic fat and affects lymph nodes, too. (Dukes C).
VII. PATHOLOGY OF THE LIVER
1. Haemochromatosis: This 35-year-old patient was suffering from refractory anaemia that required
multiple transfusions. The patient’s skin was dark, she also had diabetes. At autopsy the liver was harder
and nodular, of a rusty brown colour. Lysosomal storage of an iron-positive (Pearls’ reaction) pigment in
the lysosomes of hepatocytes and Kupffer cells. Associated micronodular cirrhosis. Unregulated absorption
of iron from the intestine. Compare with haemosiderosis (caused by accelerated red blood cells breakdown
in haemolytic anaemias, repeated blood transfusions), here haemosiderin appears primarily in the Kupffer
cells.
2. Congestion of the liver: This 65-year-old patient was treated for cardiac failure. He was short of breath
and had hepatosplenomegaly and ankle oedema. The liver was enlarged, with "congestion lines". Most
pronounced in the lobular centers, sometimes accompanied by centrilobular steatosis and by zonal fibrosis.
3. Viral hepatitis: Activation (swelling) of Kupffer cells, baloon degeneration and monocellular necrosis
(apoptosis, eosinophilic cytoplasm, Councilman bodies) of hepatocytes. Predominantly small cell
inflammatory infiltrate in the portal fields. Chronic hepatitis: persistent (benign course) or active (with
piecemeal necrosis). Ground-glass appearance of cytoplasm of hepatocytes with HBsAg storage in the
tubules of endoplasmic reticulum.
4. Massive necrosis (hepatodystrophy, yellow atrophy): This 26-year-old technician was exposed to
chlorinated hydrocarbons, and to aniline derivatives. She suddenly became icteric and laboratory tests
indicated severe damage to the liver. The patient died in hepatorenal syndrome. At autopsy the liver was
slightly paler and softer. Massive necrosis of the liver parenchyma sparing portal areas, from which
regeneration may start. Smaller and flabby liver, yellow at the beginning, turning red (resorption of necrotic
parenchyma and congestion) and then gray (reparative fibrosis).
5. Atrophic (micronodular, Laennec’s) cirrhosis: This 55-year-old patient was admitted because of
bleeding from his oesophageal varices. Physical examination revealed gynaecomastia, ascites and signs of
haemorrhagic diathesis. The liver was smaller and nodular.
Often caused by chronic alcohol cnsumption. Nodular regeneration of the liver tissue with displacement and
compression of the veins, fibrosis with inflammatory infiltration, and proliferation of small bile ducts.
Grossly small, hard liver.
6. Zonal (centroacinar) necrosis of the liver. A 74-year-old man operation of oesophageal carcinoůma
died of hepatorenal failure. At autopsy liver showed signs of an acute congestion. The liver tissue shows
severe centrilobular congestion with necrosis of hepatocytes, with infiltration by neutrophils and with
activation of endothelial and Kupffer cells.
7. Cavernous haemangioma: A 63-year-old woman died of cardiac failure. A circumscribed dark red area
measuring 3 cm in diameter was founds in the right lobe of her liver (incidental finding).
The most frequent liver neoplasm (except for the metastases). Benign, but danger of haemorrhage in
diagnostic liver needle biopsy – absence of myoepitelial cells. Scattered thrombi in various stages of
organization are present in the wide vascular spaces, otherwise filled with blood.
8. Hepatocellular carcinoma: This 49-year-old male patient had a history of B hepatitis and liver cirrhosis.
He was losing weight in the last six months and developed icterus and ascites. Liver was enlarged, with
coarsely nodular surface. The patient died of pulmonary embolism. At autopsy the liver had an ill-defined
area measuring five cm in diameter in the right lobe. The tissue of the nodule was more friable than the
surrounding liver parenchyma. Frequently as complication of liver cirrhosis. Solitary or multicentric.
Invasive growth into hepatic vessels, haematogenous metastases into lungs and bones. Note irregular
arrangement of the tumour cells, with occasional glandular formations and with production of bile.
9. Cholangiocellular carcinoma of the liver
dia
VIII. PATHOLOGY OF KIDNEYS
1. Microcystosis: Recessive mode of inheritance, leads to death in renal insufficiency in newborns. Grossly
enlarged kidneys with smooth surface, sponge-like appearance on section. Note multiple small cysts with
renal parenchyma and primitive tubules in between. This newborn boy died of renal insufficiency. At autopsy
both kidneys were enlarged, grossly of spongy appearance.
2. Vascular nephrosclerosis: Scattered scars in arteriosclerosis, smaller kidneys with granular surface and
extensive glomerular obsolescence and hyalinization in arteriolosclerosis of the kidneys. Sometimes with
fibrinoid deposition in the walls of small arteries and arterioles, especially with arterial hypertension. Note
splitting of elastic fibers in arterial walls. This 75-year-old female patient was suffering from a slowly
progressing deterioration of renal function over a period ov several years. At ysotupsy both kidnexys were
symmetrical and smaller, with coarsely granular surface and several depressed scars.
3. Diabetic glomerulosclerosis (Kimmelstiel-Wilson): Nodular (this slide) or diffuse form. Segmental
accumulation of mesangium, mostly mesangial matrix, usually also hyaline, PAS-positive thickening of the
walls of afferent arterioles.Other forms of diabetic involvement of the kidneys: accelerated arteriosclerosis,
pyelonephritis, necrosis of renal papillae, Armani’s cells (glycogen accumulation in cells of tubular
epithelium). This 45-year-old femmale patient with type I diabetes and progressing renal failure during last
year. There were signs of diabetic angiopathy. At autopsy both kidneys were slightly enlarged, reddishbrown, with some granularity on the surface.
4. Armani’s cells: In pars recta of proximal tubules, deposition of glycogen in the water-clear cytoplasm,
PAS-positive, amylase-digestible. Same patient. PAS staining for the demonstration of glycogen.
5. Non-suppurative interstitial nephritis: Variable aetiology (scarlet fever, cytomegaloviral infection,
transplant rejection etc.). Interstitial chronic inflammatory infiltrate, with time leading to interstitial fibrosis
with tubular atrophy.
6. Acute diffuse glomerulonephritis: Most frequently poststreptococcal (ASLO-positive, 1 to 2 weeks after
infection), diffuse involvement of glomeruli that are hypercellular (polymorphonuclear leucocytes and
macrophages with proliferating endothelial cells blocking lumina of the gloimerular capillaries).On
immunohistology and electron microscopy focal deposition of immunocomplexes on the outer surface og
the glomerular basement membranes ("humps"). Numerous casts in the tubular lumens. Very good
prognosis, usually heals without any residues. This 19-year-old young man developed suddenly oliguria and
hypertension two weeks following an angina. He noticed dark urine and puffing oedema of the face. There
was high titre of ASLO. Renal biopsy revealed IgG and C3 complement deposits in the glomerular loops,
electron microscopy showed subepithelial deposits (humps).
7. Chronic (membranoproliferative) glomerulonephritis: Pronounced lobularity and hypercellularity of
some glomeruli, the rest of glomeruli show fibrosis and hyaline change. Tubules extensively atrophic,
interstitial connective tissue increase, with occasional inflammatory infiltrate. This 48-year-old man had had
failing kidneys for about 10 years. Laboratory revealed haematuria and proteinuria, decreased C3
complement. Renal biopsy showed subendothelia deposits and splitting of the glomerular basement
membrane.
8. Focal glomerulonephritis: Focal proliferation and fibrotic obsolescence of scattered glomeruli, other
glomeruli are of normal appearance. 45-year-old patient with haematuria and proteinuria. Renal biopsy
revealed lesions in a minority of glomeruli.The patient was suffering from infective endocarditis and died of
a brain haemorrhage.
9. Rapidly progressing (crescentic) glomerulonephritis: The slide represents a more advanced stage of
the disease, where all glomeruli present in the section show some degree of fibrosis. There is only disperse
presence of cellular crescents in some of the Bowman spaces. Tubules show variable degree of fibrosis, with
a general increase in the connective tissue interstitium. This 55-year-old patient had haematuria, proteinuria
and severe hypertension of an acute onset, he died af a complicating brain haemorrhage. Both kidney
showed multiple disseminated subcapsular small haemorrhages and whitish small nodules.
10. Acute suppurative pyelonephritis: Ascending infection, with inflammatory infiltrate in the tubules and
in the connective tissue interstitium, with focal formation of abscessses. In chronic pyelonephritis interstitial
fibrosis with chronic inflammatory infiltrate and hyaline casts in areas of the cortical tubules with atrophy of
the epithelium ("thyreoidisation"). This 73-year male patient had a history of prostate hypertrophy with
repeated bouts of ascending urinary infection. The patient died of urosepsis. Autopsy revealed small
contracted kidneys with scarring and suppurative inflammation.
11. Amyloid nephropathy: Deposition of amyloid in the walls of arteries and arterioles, less in the
glomeruli and under the tubular epithelium. AA = secondary amyloidosis.This 53-year-old male patient had
been treated for multiple myeloma. He developed progressive renal insufficiency with severe proteinuria in
the last years of his disease.
12. Biliary nephrosis: Secondary to severe obstructive jaundice 9conjugated bilirubin excreted in the
urine). Look for pigmented casts in the renal tubules, pigmentation of epithelium of the proximal tubules.
This 63-year-old female patient had generalized carcinoma of the head of her pancreas that caused
compression of the common bile duct and severe cholestatic jaundice. At autopsy both kidneys showed
greenish discoloration.
13. Chronic hydronephrosis: Severe pressure atrophy of the renal parenchyma caused by obstruction of the
ourflow of urine (renal stones, ureteral obstruction by stones, tumours, compression, diseases of the urinary
bladder, in males often hypertrophy of prostate). May be complicated by (usually ascending) infection hydropyelonephritis. Numerous hyaline casts in the atrophic tubules, glomerular obsolescence, thickening of
arterial walls. A 58-year-old female patient with cancer of the right ovary compressing the neighbouring
right ureter. Both proximal ureter and the right renal plevis were severely dilated and the thickness of the
parenchyma of right kidney was reduced.
14. Wilms’ tumour (nephroblastoma): Typical for small children, malignant, fast growing but curable by
radiation and surgery. Cellular immature tissue resembling renal blastema, with focal differentiation of
tubules, glomeruloid structures, cartilage, muscle etc. This two-year old boy was admitted for haematuria.
CT examination revealed a large tumour in his right kidney.
15. Renal cell carcinoma, clear cell type: Assesment of malignancy unreliable on morphological grounds,
malignant tumours may appear differentiated and encapsulated. Small tumours (under 2cm in diameter)
considered benign (clear cell adenoma). Vascular, sometimes cystic, consisting mostly of lear ccells
containing glycogen. Sometimes with oxyphilic cells, sarcomatoid variant. This 60-year- old man had had
intermittent haematuria for several months but did not visit his physicians. He came only later because of a
flank pain and a palpable tumor on the right side. The nephrectomy specimen revealed an round
circumscribed pale-yellow tumour which did not penetrate into the pelvis and did not grow into the renal
vein.
IX. PATHOLOGY OF THE URINARY OUTFLOW TRACT, MALE AND FEMALE GENITAL TRACT
1. Chronic follicular urocystitis: A 75-year-old male patient, parlyzed after a stroke, immobile, was
repeatedly catethrised, and was complaining of dysuria. The patient died of bronchopneumonia. The mucosa
of the urinary bladder was congested, with small whitish nodules. Chronic inflammation with accumulation
of lymphocytic infiltrate in follicles, usually grossly visible under the superficial epithelium. Other frequent
findings in chronic inflammation – squamous metaplasia of the superficial epithelium, hypertrophy of the
muscular layer (obstruction).
2. Papillary carcinoma of the urinary bladder: This 50-year old heavy smoker with severe dysuria and
haematuria, fatigue. A large papillary growth is found at cystoscopy. Tumours are most common derivated
from trigonum urethrae. Epithelial layer thicker than in papilloma (over 6 layers), less differentiated cells,
disperse mitoses. May show infiltrative growth into the bladder wall.
3. Testicular fibrosis (atrophy): This 22-year old patient had been treated for infertility. His right testis
was undescended. A small sample was taken for peroperative biopsy during surgical intervention and
revealed atrophy and fibrosis. Marked thickening of the basement membranes of seminiferous tubules,
atrophy or total disappearance of the seminiferous epithelium. Sometimes increase in number of the
interstitial Leydig cells. Another case stained by the green trichrome stain (unfortunately bleached out)
shows interstitial fibrosis and the Leydig cell hyperplasia. In old patients, in liver cirrhosis, after radiation, in
some genetic defects, cryptorchism, cytostatics, chronic inflammation, etc.
4. Seminoma: This 36-year-old man noticed gradual enlargement of his left testis which was painful. The
most frequent tersticular tumour of midle age, consists of nests of large cells with large nuclei and
prominent nucleoli and with a glycogen-rich cytoplasm in the connective tissue stroma showing
lymphocytic infiltration, sometimes even formation of granulomas.
5. Adenomyomatous hyperplasia of the prostate: A 57-year old patient is coming because of progressing
problems with urination. He has had repeated bladder inflammation. Rectal examination reveals
symmetrical enlargement of the prostate which feels hard, slightly nodular. Some degree of hyperplasia in
practically all males more than fifty years old. Microscopically variable proportion of hyperplastic fibrous,
muscular and glandular tissue, typically nodular. Often leads to urethral obstruction and ascending infection.
Carcinoma of prostate usually does not originate from the hyperplastic areas.
6. Carcinoma of prostate: This 76-year-old patient is complaining of severe pain in the lumbar region, the
pain has lasted for the last two months. Rectal examination reveals enlarged, rock-hard prostate. PSA 15.4
(normal up to 4.0 g/l). A variety of differentiation degrees (Gleason’s classification with prognostic
significance). Our case shows microacinal glandular formations. Direct continual progression into adjacent
structures. Metastases: regional lymph nodes, often bones (osteoplastic metastases).
7. Mucinous cystadenoma of ovary: This 36-year-old female patient comes with diffuse abdominal pain.
Palpation of the hypogastrium reveals a resistance in the region of the right ovary, measuring
approximately 15x7cm. Sonography reveals multicystic ovarian tumour.
Large cysts with mucinous content, lined by tall columnar epithelium positive with the mucin stain. Usually
multicystic (20-30 cm), internal surface is smoth (in proliferative form formation of pseudopapillar
structures) malignant transformation in 10 per cent of cases.
8. Serous cystadenoma (border-line): A regular checkup of this 48-year-old woman revealed a painless
tumour measuring 5 by 4 cm in her right ovary. At operation the tumour is cystic, with some warty
excrecences in some of the cysts. Often unilocular, with many irregular papillary formations protruding into
the lumina of the cysts, content is serous. Malignant transformation in 25 per cent of cases.
9.Tumors metastatic to the ovary: Approximately 8% of ovarian tumors, mostly breast and GIT
adenocarcinomas. Krukenberg tumors – (bilateral less common ubilateral) metastases in which the tumor
appears as nests of mucin-filled “signet-ring“ cells within a cellular stroma. The stomach is the primary site
in 75% of cases, the colon is a less common primary site.
10. Granulosa cell tumour: Derivated from gonadal stroma. Consists of small cells with coffee-bean nuclei
and scattered lipid vacuoles in the cytoplasm. May show hormonal activity – production of oestrogens.
Forms - adult (common postmenopausal) and juvenile (children and young women).
11. Ovarian teratoma, immature: Variable degree of differentiation, with structures derived from all three
germ layers. Note presence of various kinds of epithelium, cartilage etc., including embryonal tissues.
Almost always is in the form of solid teratoma.
12. Dermoid cyst, mature teratoma: This 30-year-old woman was complaining of hypogastric pain.
Surgery revealed an unilocular cyst 5×5 cm in her left ovary. The cyst contained a fatty matter and with a
convolute of hairs. The most frequent type of ovarian teratoma, benign. Unilocular cyst filled with keratin
and hairs, islands of tissues derived from the three germ layers can be found in the wall of the cyst.
13. Chronic salpingitis (only a slide): This 29-year-old woman has been treated for infertility. Personal
history reveals recurrent adnexal inflammation and an ectopic (tubar) pregnancy. Fibrous thickening of the
wall with chronic inflammatory infiltrate. May lead to stricture and adhesions, danger of extrauterine
pregnancy. Possibility of pyosalpinx when exudate is colected, risk of rupture into peritoneal cavity and
peritonitis.
X. PATHOLOGY OF THE FEMALE GENITAL TRACT II, PATHOLOGY OF BREAST
1. Cervical polyp: This 40-year-old patient had a history of occasional postcoital bleeding during last three
months. Colposcopy revealed a polypoid growth protruding from the external os of the cervical canal.
2. Condyloma accuminatum of vulva: This 25-year-old female patient had several wart-like polypoid soft
growths in endocervical epithelium, measuring up to 0,5 centimeters in the greatest dimension, focally
hyperkeratotic rough cover. Polypoid lesion with papillary, wart-like arrangement, covered by squamous
epithelium with the presence of koilocytes – epithelia with waterclear cytoplasm and shrunken
hyperchromatic nucleus-related to HPV (human papillomavirus 6,11) infection. Stroma with inflammatory
infiltrate, acantosis.
3. Poorly differentiated (nonkeratinizing) squamous cell carcinoma of the cervix: A routine checkup
revealed an exocervical ulcerative lesion with bulging margins and indurated base in this 52-year-old
patient. In the greatest diameter 1cm. More common in women with history of delivery. Cytology –
evidence of precancerosis. Forms: exophytic and endophytic. Metastasis – in lymphatic nodes, risk of
ureteral stenosis, later hydronephrosis. Importance of HPV virus in oncogenesis of this tumour. Moderately
differentiated, nonkeratinizing carcinoma showing both superficial growth min the glands (replacing the
original columnar epithelium) and intralymphatic invasion.
4. Dysfunctional hyperplastic proliferative endometrium: A 49-year-old patient with metrorrhagia.
Uterine currettings contained voluminous fragments of endometrium. Last menstruation three months ago.
From overwhelming oestrogenic influence, hyperproliferation. Mitotic activity both in the gnandular
epithelium and in the stromal cells. Sometimes cystic dilatation of some of the glands – "swiss-cheese
hyperplasia"- glandular cystic hyperplasia.
5. Leiomyoma of the uterus: A nodular enlarged uterus was palpated in this 58-year-old patient. The
hysterectomy specimen showed multiple round hard grayish-white nodes inside the myometrium and bulging
under the serosal surface. The most frequent of all the uterine tumours, benign, consists of smooth muscle
cells mostly in fascicular arrangement, with variable admixture of fibroblasts (secondary change). Solitary
or multiply, subserosal, intramural, submucosal, well circumscribed, may calcify. Low number of mitoses
(contrary to leiomyosarcoma).
6. Endometrial adenocarcinoma: . This 63-year-old patient presented with a metrorrhagia of 3 days.
Uterine curettage revealed endometrial carcinoma. This diagnosis was followed by an urgent hysterectomy.
Possibly originating in an endometrial polyp (overall arrangement with abundant non-neoplastic stroma
containing larger vessels). Back-to-back glands with high mitotic activity of the epithelium. Many areas of
squamous metaplasia (adenoacanthoma). Appears at higher age than cervical cancer, more frequently in
nulliparous women
7. Residua post abortum: This 19-year-old student has been bleeding for 8 days. Last menses before two
months, before bleeding he had spastic pain in lower abdomen. Orifice is open, degrease of basal
temperature. Note secretory endometrium with ferning (zig-zag pattern) of glands containing secretion,
foetal remnants. Placental villi are immature, slightly oedematous, mostly avascular, there are foci of
accumulation of the trophoblast. Look for the nucleated red blood cells in the placental vessels - normal up
to the 10th week of gestation.
8. Hydatidiform mole: This 38-year-old woman with rapid growth of uterus after conception had an
abortion of an hydatidiform mole in 5th month. Friable grape-like structures consisting of enlarged markedly
oedematous avascular villi mostly with flattened trophoblastic lining. Foetus is not present. There is marked
proliferation of trophoblast in between the villi. Dysplastic changes in the epihtelium, risk of development of
choriocarcinoma (residual mole or CHC- persisting high level of HCG). 30% risk for choriocarcinoma
9. Chorionepithelioma (choriocarcinoma): This 29-year-old patient had her hydatidiform mole removed
six months ago. After an intermittent drop in the serum HCG the values are raising again.
Malignant tumour of trofobloast, deeply invading the myometrium, angioinvasion, focal necrotizing.
Tumour doesn’t have own stroma. Early haematogenous metastases in lungs and brain. Diagnose: levels of
HCG in blood. Treatment: Chemotherapy is successful nearly 100% of cases.
10. Ectopic (tubal) pregnancy: This 21-year-old woman had a history of repeated adnexal inflammation.
After about three months following conception she suddenly felt severe hypogastric pain on the left side.
Culdecentesis revealed blood in the space of Douglas. The wall of the Fallopian tube is only paritally
present in the section. Note immature placentar tissue with signs of trophoblastic invasion into the mucosa
and muscularis layers of the tube. Danger of: tubar abortion, rupture of the tube and peritoneal bleeding.
11. Fibrocystic changes: 49-year-old patient has multiple hard, painful nodules in the upper lateral
segments of both breasts. Very frequent, with combination atrophy, hyperplasia, and metaplasia of both the
ducts and the lobules. Caused predominantly by hormonal dysbalance and infalammation. Simple dysplasia:
fibroproliferation predominates, fibrous dysplasia, or fibrocystic dysplasia (cystic dilatation of some of the
ducts). Sclerosing adenosis – accompanied by proliferation of the myoepithelial cells (can be erroneously
diagnosed as cancer!) Proliferative dysplasia – predominating epithelial proliferation. With cellular atypia –
atypical proliferative dysplasia, risk of cancer development.
12. Fibroadenoma: This 28-year.-old female patient noticed for 2 month a slowly growing hard, indolent
nodular hazelnut-size formation in the upper lateral segment of her right breast. The most frequent
neoplasia of breast in young women, benign. Combined proliferation of ductal epihtelium and epiductal
stroma. Two histological forms – peri- and intracanalicular.
13. Commedocarcinoma (IDC): This 61-year-old patient noted a centrally located tangerine-size hard
node in her left breast. Frozen sections from a diagnostic excision reveald carcinoma. The mastectomy
specimen contained a nodular growth measuring approximately 4 cm in diameter. The cut surface was
grayish-white, with yellow necrotic commedo-like areas of necrosis. Intraductal necrotizing carcinoma,
noninvasive at the beginning. Central necrosis evidence pure differentiated type of intraductal carcinoma,
that can develop in to pure differentiated ductal carcinoma (there are integrated different mutations of
genetic sequences compared to low and intermediate grade carcinomas. Occasional microcalcification of the
necrotic material – visible on mammography.
XI. PATHOLOGY OF THE NERVOUS SYSTEM
1. Cerebral infarct (encephalomalacia): A 75-year-old patient had been admitted with an anterior
myocardial infarct four weeks ago. Just before release from the hospital for further outpatient care, he
became unconscious and hemiplegic. Ischemic colliquative necrosis, vital reaction – activated microglia
(enlarged cells with vacuolated cytoplasm) so called “granular cells” (rich in lipids), healing by formation of
a pseudocyst. Causes: thrombosis, embolism. Hemorrhagic infarct (usually caused by embolism, small,
cortical) through reflux of blood into the necrotic focus – red encephalomalacia. Diagnostic features –
leucostasis, diapedesis of leukocytes and erythrocytes, activated microglia disintegration of necrotic tissue.
2. Cerebral hemorrhage: This 60-year-old woman had a history of arterial hypertension of many years.
She was admitted because of a severe headache with progression of neurological symptomatology two
weeks ago. CT scan of the head showed a suspicious area measuring 1 cm in diameter in the right basal
ganglia.
Intracerebral -possible causes: hypertension, most common in basal ganglia. Extracerebral - subarachnoid –
possible causes: aneurysm, atherosclerosis, most common basis of brain with progression in to parenchyma.
In subdural localization (between dura mater and arachnoidea) risk of hygroma, expansion and increase of
intracranial pressure. Epidural localization (between dura mater and bone) – at least dangerous. Small
hemorrhages scattered through the nervous tissue - cerebral purpura (bleeding disorders, sepsis).
3. Suppurative leptomeningitis: This 20-year-old male patient had been on his compulsory military
service. An inflammation of upper respiratory tract was complicated by a febrile state with headache and
with nuchal stiffness. A sample of cerebrospinal liquor was obtained through lumbar puncture and was send
for biochemical and for microbiological examination. Cultures grew Neisseria meningitidis. Ours slide:
enlargement of leptomeningeal space which is filled with neutrophils. Cortical oedema. Healing by
resorption, formation of adhesions (epilepsy, hydrocephalus).
4. Multiple sclerosis: This 50-year-old patient developed first signs of multiple sclerosis 23 years ago. She
was suffering from paresthesias of upper extremities, occasional vertigo, and general apathy. This was
followed by remission of several years’ duration, then by elapses with ever shorter symptom free-intervals.
Now the patient is bedridden, with continuing progression of her symptoms. She died of bronchopneumonia.
Complex pathogenesis: genetic, environment, immunity. Typical gross appearance with greyish-brown areas
scattered irregularly in the white matter. Histology: periventricular located areas of demyelization are
revealed by the myelin stain, axons without damage. Principe: direct destruction of myelin or destruction of
oligodendroglial cells, which produce myelin. There is no cellular reaction.
5. Meningeoma: This 50-year-old female patient was suffering from headaches and epileptic paroxysms. Xray examination showed a density of 2cm in diameter in connection with dura mater, dilatation of vessel at
cranium. Frequent, originates from leptomeninx. Benign, well circumscribed, may cause impression (local
pressure atrophy) of the brain tissue. Variable morphology, most frequent is the epithelioid type with
formation of whorls , onion-like structures of tumour cells. Calcification is common.
6. Astrocytoma: A 45-year-old man with a two month’s history of headaches and occasional epileptic
paroxysms. CT examination of the brain shows a circumscribed lesion in the left frontal and parietal lobes.
Progression of malignancy from differentiated astrocytoma through anaplastic astrocytoma to glioblastoma.
Signs of malignancy - cellular pleiomorphism, necroses, neovascularization. Sometimes formation of cysts.
Gemistocytic astrocytoma - consists of plump enlarged astrocytes.
7. Ependymoma: This 17-year-old boy suffered from headaches, vomitus, and ataxia. CT scan revealed a
tumor in the 4th ventricle. Most frequently in the 4th ventricle in children. Is formed of regular oval cells
arising from ventricular ependymoma. Note characteristic formation of rosettes and pseudorosettes
(perivascular arrangement) of tumour cells. In 50% GFAP positive.
8. Glioblastoma multiforme: This 45-year-old patient had a history of changing behaviour and occasional
confusion for several months, these led to his hospitalization in a psychiatric clinic. Examination at the
clinic revealed an ill-circumscribed tumor in the left frontoparietal lobe, measuring 4 cm in the greatest
dimension. Marked cellular pleiomorphosm, scattered necroses (compared to astrocytoma), highly
vascularized. Malignant.
9. Neurinoma (Schwannoma): A 40-year-old man was complaining of vertigo, instability and hearing loss.
Audiological examination supported a diagnosis of a retrocochlear lesion.
Typical location – cerebellopontine angle. Benign, but unfavourable site. Histologically typical structure Apalisading of nuclei, structure B-less cellular, with round cells, remind of myxoma, probable degenerative
changes. Cells build whorls and fascicules.
10. Alzheimer’s disease: A 60 year old male, progressive deterioration of psychical functions, neurologic
symptomatology Degenerative disorder of brain, changes visible in cerebral cortex (especially hippocampus)
– senile plaques and neurofibrillary tangles, decrease in number of neurons.
XII. PATHOLOGY OF THE MUSCULOSKELETAL SYSTEM. ENDOCRINE PATHOLOGY.
1.Gout: This 52-year-old slightly obese man with a history of a sudden onset of pain in his right big toe during
the night. The pain lasted for several days. The metatarsophalangeal joint was reddened, swollen and very
painful on palpation. Laboratory: increased serum uric acid, relief of pain 24 hours after a dosage of colchicin.
An excision has been taken from a paraarticular nodule. Sections show loose connective tissue forming septa
with fibroblasts and some giant cells. The septa surround deposits of urates, most of them dissolved during
processing of the specimen. The rest of the deposits can be visualized in polarized light.
2. Osteochondroma (exostosis): This 20-year-old football player has been feeling pain in the distal part of left
tibia. X-ray shows an area of bone formation, perpendicular to the surface of the tibia. The lesion results from a
local displacement of epiphyseal cartilage that grows perpendicular to the normal growth plate. According to the
age of the lesion (and the patient) is the surface of osteochondroma covered by cartilaginous cup of variable
thickness that undergoes enchondral ossification. Deeper parts are formed by bone trabeculae and by fatty bone
marrow.
3. Gigant cell tumour of the bone: A 30-year-old young lady with a five-month history of pain in the distal left
femur. X-ray examination reveals a lucent area next to the distal epiphysis of the femur. Also called giant cell
tumour or brown tumour (haemosiderin deposits). In younger patients (3rd and 4th decade), distal femur and
proximal tibia, highly vascular, predominant spindle pulpy cells with scattered multiple multinucleated giant
cells. Osteolytic aggressive growth, but almost always benign. Healing after extirpation but recurrence is also
possible.
4. Osteogenic sarcoma: This 20-year-old man was suffering from a growing pain in his left distal femur. The
pain was more severe at night and during walking. Physical examination showed dense swelling without fixation
of the overlying skin and soft tissue. X-ray: Signs of bone destruction and neoformation in the metaphyseal
region.
Highly malignant, most frequent in young patients. Haematogenous metastases in the lungs. Variable histology –
osteoplastic, osteolytic osteosarcoma. Malignant bone aneurysm.
5. Sarcoma of Ewing/PNET (primitive neuroendocrine tumour): A 10-year-old boy was intermittently febrile
and had leukocytosis, increased sedimentation rate and slightly painful region of the fibular diaphysis on the
right side. X-ray examination revealed central osteolysis with thinning of the corticalis and some periostal
aposition of new bone. A haematogenous osteomyelitis was suspected and the patient was treated with antibiotics
without effect. Angiographic examination revealed malignant character. Diaphysis of long bones, in children,
insidious beginning in the bone marrow cavity. Microscopy: small cells ("small blue cell tumour"), occasionally
rosettes, glycogen in the cytoplasm of the neoplastic cells, large necrotic areas. Ewing’s sarcoma is
histogeneticaly close to PNET and microscopic picture is similar, tharefore they are uvažují togeather. Tumour is
radiosensitive.
6. Pituitary adenoma: This 40-year-old male patient was complaining of growing headaches. He had some
vision problems, impotence and noticed swelling of his breasts. X-ray showed widening of sella turcica with 1cm
lesion. Laboratory: raised serum level of prolactin. May cause pressure atrophy of sella turcica and of the prechiasmatic part of the optic nerves. Endocrine effect according to the cell of origin: gigantism or adromegaly in
eosinophilic adenoma - STH, basophilic adenoma – Cushing syndrome, ACTH hypersecretion. Most frequent
chromophobe adenoma without endocrine symptoms. Microscopy: uniform ovoid cells with hyperchromic
nuclei, make palisade structures around vessels.
7. Craniopharyngeoma: An eight-year-boy was complaining of headaches, he also had vision problems and
signs of retarded growth and maturation. X-ray revealed a suprasellar tumour measuring 3.5 centimeters in
diameter at the base of the brain, the formation was partly cystic. Erdheim’s tumour, benign, usually arise ftom
the intermediary part of hypophysa or hypothalamus. Expansive and destructive growth at the skull base
compression of hypophysis, resembles adamantinoma. Cysts with epithelial nonkeratinizating squamous cell
layer.
8. Pheochromocytoma: A 35-year-old woman has been complaining of intermittent epigastric pains, palpitation
and anxiosity. Physical examination reveals hypertension of 210/100 mmHg, sometimes raising up to 240mmHg
systolic pressure. Laboratory: Marked increase in the urinary vanilmandelic acid. Benign tumour arises in
medulla of adrenal glands, with paroxysmal, less frequently continuous hypertension. 90 per cent isolated, 10 %
in the MEN II a, b syndrome. Highly vascular, with large and scattered bizzare giant cells. Chromogranin
positivity, ultrastructureally catecholamine granules in the cytoplasm, secreting epinephrine and norepinephrine.
9. Hashimoto’s thyroiditis: A 30-year-old woman comes to her physician with a painless symmetrical
enlargement of her thyroid gland. Laboratory examination reveals hypothyroidism, fine-needle aspiration biopsy
shows lymphocytic infiltration and serum examination reveals high titre of antithyreoglobulin antibodies.
Thyreoidectomy specimen shows symmetrical enlargement of the gland, the cut surface is yellowish-white, the
gland is well circumscribed. Autoimmune pathogenesis, well circumscribed, usually enlarged thyroid gland.
Microscopically marked lymphocytic interstitial infiltrates (struma lymphomatosa) with formation of lymphatic
follicles. Focal oxyphilic metaplasia of the follicular epithelium. Most frequent in middle age female patients.
Increased risk of MALT lymphoma and carcinoma.
10. Diffuse colloid goiter: This 50-year-old patient visits her physician complaining of enlargement of her
thyroid gland. Laboratory examination is unremarkable. Grossly the gland is symmetrical. Partial strumectomy
is done. The specimen consists of a yeallowish-brown gland tissue. Symmetrical enlargement of both lobes
(contrary to nodular goiter), large follicles with flat epithelium and abundant eosinophilic colloid. Usually
euthyroid, occasionally signs of hypo- (especially in children) or hyperthyroidism. Nodular structures are not
present.
11. Hyperthyroidism – thyreotoxicosis: A 40-year-old female patient comes with enlargement of her thyroid.
She is complaining of irritability and increased sweating. Further examination shows tachycardia and tremor of
her fingers. The skin is warm and moist. The patient has some orbital pain. Laboratory examination reveals
increased TSH. Graves’ (Basedow) disease. Parenchymatous (diffuse) goiter. Highly cuboidal to columnar
epithelium focally arches into folicules (Sandersen’s pillows), decreased eosinophilia of colloid with signs of
resorption, lymphoid interstitial infiltrates. Forms: diffuse or nodular (hyperfuncional adenomatous nodules).
12. Follicular adenoma of thyroid: This 45-year-old man came for a regular checkup. A painless nodule
measuring 1 cm in diameter was found in the right lobe of his thyroid. The nodule was excised; it was well
circumscribed, yellowish-brown on cut surface with pressure atrophy of surrounding tissue. Variable
microscopic appearance (makrofollicular, microfollicular (fetal), trabecular (embryonal), oxyphilic /Hürtle cell/
adenoma). Common regressive changes, without fibrous capsule. Toxic adenoma – hyperfunctional.
Cystopapillary adenoma – danger of malignant transformation.
13. Papillary carcinoma of the thyroid gland: A 15-year-old boy has swollen nodes along the left
sternocleidomastoid muscle. Further examination reveals a "cold nodule" in the thyroid on the same side. A
biopsy of the lymph node shows metastasis of a papillary carcinoma. Total thyroidectomy is performed and the
thyroid nodule examined.
Most common thyroid tumour type, almost all cases are carcinomas, mostly papillary, less often follicular,
undifferentiated, 5 per cent medullary (from C cells, calcitonin production, amyloid in the stroma).
Predominantly in middle-aged females, occasionally in children. Radiation danger (increased frequency in
children after the Tchernobyl accident). Papillary formations, often psammoma bodies in papillary carcinoma,
cellular atypias. Focally cells with groundglass-grows nuclei, nuclear pseudoinclusions and grooves in
longitudinal axis.
14. Adenoma of parathyroid: This 40-year-old woman suffers from fatigue, muscle weakness, nycturia and
obstipation. Laboratory examination reveals hypercalcaemia, hypofosfataemia, there are signs of an increased
bone resorption on x-ray exmination. A small greyish-brown nodule measuring less than 1 cm is found on the
dorsal side of the left thgyroid lobe. Partial thyroidectomy containing the nodule is performed. Most frequent
cause of the primary hyperparathyroidism. Benign, usually solitary, sometimes cystic, variable size and cell
composition (chief cells, oxyphilic, water-clear cells), nuclei are common irregular, some can be enlarged. Well
circumscribed, with signs of compressive atrophy of the surrounding parathyroid parenchyma (in contrast to
parathyroid hyperplasia). Imunohistochemical staining evidences parathormone. Carcinoma – extremely rare.
15. Nesidioma: Benign, solitary or multiple, originating from the cells of the Langerhans’ islets. Endocrine
activity and symptoms according to the cell(s) of origin (A,B,D,G). Tumour originating from B cells is called
inzulinoma, from G cells is called gastrinoma, from A cells glucagonoma and from D cells somatinostatinoma.
Vipoma is tumour characterized by production of vasoaktiv intestine peptide (VIP). Some tumours can produce
more hormons simultanously. Their size is usually small. Carcinoma – often without endocrine secretory
activity.
XIII. PATHOLOGY OF THE SKIN. PERINATAL PATHOLOGY, PATHOLOGY OF THE NEWBORN
AND INFANT
1. Inflammatory dermatosis – overview.
2. Spongiotic dermatitis (subacute eczema dermatitis): A 32-year-old female, several months anamnesis
of recidiving confluent red maculae, papulae and vesiculae localized on fingers and palms. In the period of
inactivity these lesions are only slightly red and covered by scales. Combination of chronic changes
(psoriasiform dermatitis with hyperplasia of epidermis, hyper- and parakeratosis) with acute changes
(intracellular edema-spongiosis, formation of blisters). Perivascular lymphocytic infiltrates in papillary
corium with exocytosis into the epidermis.
3. Psoriasis vulgaris: A 22-year-old student with multiple reddish-brown plaques and papules
predominantly over the extensor regions of extremities. In some areas there is whitish scaling on the surface
of the spots, removal of scrapes by superficial gentle scraping here results in appearance of small bleeding
points (Ausspitz phenomenon). Histological examination shows acanthosis with elongation and widening of
the basal parts of the interpapillar epidermal areas (rete ridges) with suprapapillar thinning of epidermis.
There is marked parakeratosis on the surface, with occasional formation of the Munro abscesses
(accumulation of pyknotic nuclei of neutrophils). Oedema and some chronic inflammatory infiltrate can be
seen in the dermal papillae, in older lesion also fibrosis of papillae.
4. Psoriasis pustulosa: A 19-year-old male with small pustules on plants and palms, sterile content. During
course their extinction, atrophy of the skin and new attack with new pustules. The same picture as in
psoriasis vulgaris, moreover the presence of typical intraepidermal pustule – Kogoj`s spongiform pustules.
5. Lupus vulgaris: This 30-year-old patient has multiple yellowish-brown spots on the skin of his face.
Proliferative form of skin TBC with epitheloid granulomas with small caseification. Small number of
Mycobacterium tuberculosis in Ziehl-Neelsen staining, PCR more sensitive. Differential diagnosis:
sarcoidosis (deeper in the dermis) lepra.
6. Atheroma of the skin with inflammatory and giant cell reaction: A middle aged man visits his
dermatologist with a slowly growing soft circumscribed lump under the skin of his scalp. The lump is not
fixed to the surface and measures about 1 centimetre in diameter. A small cystic lesion is present in the
dermis. It is filled with keratin and sebum. Atrophy of the wall of cyst. A rim of granulomatous resorptive
inflammatory reaction can be seen around the cyst, the infiltrate consists of lymphocytes, epithelioid and
multinucleated giant cells.
7. Verruca vulgaris: This 12-year-old boy has some small rubbery papules with rough segmented surface
on fingers of his right hand. Akanthosis, papillomatosis, hyperkeratosis and parakeratosis. In superficial
layer of stratum spinosum there is presence of koilocytes and pale cells with oxyphilic cytoplasmic
inclusions. The effect human papilloma viruses (HPV type 2, 4, 7). Verruca palmaris, plantaris – with
marked hyperkeratosis.
8. Molluscum contagiosum: A 13-year-old girl comes with a waxy, centrally slightly depressed papule on
the skin of her face. A cheesy material appears on gentle pressing of the papule. Endophytic circumscribed
pear-shaped formation of hyperplastic confluent follicular infundibles. Infection by poxvirus - enlarged cells
with cytoplasmic inclusions turning more distinct and slightly more eosinophilic towards the surface –
molluscum bodies.
9. Seborrhoic keratosis (seborrhoic verruca): This 60-yea-old man comes with some brownish warty
growths on the skin of his back. Verrucous and partially endophytic proliferation of bazaloid cells with
abrupt keratinization and formation of keratin pearls, without transitional zone accordant with stratum
spinosum and granulosum.. Differential diagnosis – keratoakanthoma.
10. Bowen’s dermatosis: A 65-yea-old man with a sharply demarcated greyish-brown lesion on the trunk.
The surface of the lesion is uneven, scaly, with scattered small ulcerations. The lesion is enlarging. A
variant of intraepithelial squamous cell carcinoma. Varied cellular composition with giant cells, base
membrane is not broken. Note cellular atypias and increased mitotic activity and intact basal membrane.
Sometimes present in sun exposed areas of solar keratosis. The presence of HPV (type 16, 18) was detected
in lesions in anogenital region. 10% risk of development of invasive squamous cell carcinoma.
11. Keratinizing squamous cell carcinoma: An 80-year-old woman comes with a warty growth on the skin
of her forehead; the lesion grows slowly over years and is fixed to its indurate base. These tumours usually
arise on the basis of solar keratosis and neoplastic cell are similar to ones in stratum spinosum.
Differentiation (grading) is based on the presence of cell polymorphism, mitotic activity and keratinization.
In well differentiated forms the presence of keratinization - cancroid pearls, is typical. Slow destructive
growth and late formation of metastases. More malignant than basal cell carcinoma.
12. Basal cell carcinoma: 75-year-old man with an ulcerated lesion above his left eyebrow. Ulceration has
rigid with raised margins. Slow growth. Most frequent tumour in elderly, arise in the areas of solar
keratosis. Often on the face, nose, eyelids. Slow progress, with destructive growth. Various histological
types, sometimes multicentric origin. Basic type consists of small basophilic cells, palisading of tumour cells
at the periphery of the tumour cell islands. Resembles cells of the basal layer of epidermis. Sometimes
ulcerate. Typically without metastasis.
13. Junctional nevocellular nevus: A 12-year-old boy with several light brown well demarcated flat lesions
not exceeding 5mm. Usual nevus in children and young adults. Melanocytes are present in the border
epidermis-corium, especially in the tips of interpapillar epithelial interdigitations. There is also lentiginous
hyperplasia of stratum basale (i.e. increased number of typical melanocytes in stratum basale).
14. Intradermal nevocellular nevus: A 42-year-old female has some flat and slightly elevated pale or dark
brown lesions on her skin, predominantly on the trunk. The lesions measure mostly 0.5 to 1 cm in dimension.
Most frequent pigmented nevus in the adulthood. Nevus cells (melanocytes) located in the corium, in deeper
parts they change into spindle shaped cells similar to Meissner tactile bodies or neurofibroma.
15. Malignant melanoma: This 32-year-old man noticed an irregular, ill-circumscribed dark brown flat
lesion 1cm in diameter on the skin of his waist region. The lesions are sometimes painful and itching, there
is some occasional spotty bleeding from the surface. Nodular melanoma with vertical growth. Two types of
cells – epitheloid cells with prominent nucleoli and spindle shaped cells without nucleoli. Variable presence
of melanin. Typical immunohistochemical positivity in S100, HMB 45 and Melan A. Prognosis depends of
vertical invasion (Clark, Breslow classification).
16. Aspiration of amniotic fluid: This hypotrophic male baby was born by cesarean section during
complicated delivery at the end of week 40. Apgar score was 5, 5, 6. The baby died after three hours with
signs of respiratory insufficiency. Macroscopically there are areas of collapsed lung and areas of
emphysematous configuration. The immature lung tissue shows alveolar distension. Bronchi, bronchioles
and partially alveoli are filled with keratinized cells from aspirated amniotic fluid (vernix, mekonium,
epithelial skin cells). Aspiration results from intrauterine irritation of respiratory centre due to asphyxia.
17. Respiratory distress syndrome – hyaline membranes: Immature baby, born in week 28, weight
1600g. Immediately after delivery resuscitate with quick improvement of breathing and pink skin. During 2
hours worsening dyspnoe, cyanosis, died three days after delivery. Within the alveoli and bronchioli there
are homogeneous eosinophilic membranes, partially fixed to the wall. Majority of alveoli are atelectatic.
18. Respiratory distress syndrome – acute catarrhal bronchopneumonia: New born baby delivered in
term, weight 4500 g, mother suffering from diabetes mellitus. Half an hour after delivery development of
dyspnoea and cyanosis. Five days of intensive therapy (oxygen), than increase of temperature, exitus.
Within the alveoli and bronchioli residua of hyaline membranes and rich inflammatory exsudate with
neutrophil leukocytes. Infection complication of respiratory distress syndrome.