Marmara University School of Medicine
Year 2
2015-2016
Pathology Laboratory Guide
CONTENTS
1- Cell and tissue injury course I; 4 HOURS
Assoc. Professor Pelin Bagci
2- Cell and tissue injury course II; 8 HOURS
Assoc. Professor Kemal Turkoz
Assis. Professor Deniz Filinte
3- Hematopoeietic System and Related Didorders Course; 2 HOURS
Assoc. Professor Kemal Turkoz
4- Musculoskelaetal, Integumentary Systems and Realted Disorders:
2 HOURS
Assoc. Professor Kemal Turkoz
5- Respiratory System and Related Disorders Course: 4 HOURS
Assis. Professor Emine Bozkurtlar
1
INTRODUCTION TO MICROSCOPIC EXERCISES
A considerable time of the Pathology Course is devoted to microscopic analysis of tissues.
This is not because we wish you all to become pathologists, but we believe that
understanding the cellular and structural changes in the tissues is essential for you to
understand the biological nature and the clinical expression of human diseases. Thus,
the laboratory material must be approached with this perpective.
Much of what you'll acquire in the way of histopathologic information will be self-taught.
You will utilize the microscope and the slide sets loaned to you for each laboratory
session. In the beginning of the year, a text syllabus will be supplied, by the Department
of Pathology. The laboratory sessions are intended to assist you in your efforts to learn
pathologic anatomy. The design of these sessions assumes a significant effort on your
part, before coming to class.
Coming to class without a reasonable study will ensure that your time in class will be
wasted. Ordinarily, if you've been staring at a given slide for 10-15 minutes to figure it
out, without any success, additional time spent will not be rewarded. Any additional time
you could spare would better be spent after discussion in lab, reviewing what you been
stumped by.
Experience has shown that a systematic approach to each slide works the best.
1. Familiarize yourself with the text and lecture material relevant to the condition under
consideration before studying the slide.
2. Inspect the slide carefully with the naked eye before putting it under magnification.
This will often enable you to spot the one focal area which is abnormal, an area which
might be missed under the microscope with its narrow field.
3. If you have not been told, begin the microscopic exercise by deciding what tissue is
represented on the slide (Is it a pancreas, brain, etc?). If you have been told, review the
features which would allow you to identify it. In either event, you should next look up to
the image of the tissue in your histology textbooks. It aids you in recognizing the normal
composition of the tissue you are examining.
4.Then, and only then, continue the exercise by examining the section for deviations
from that of normal.
a. Be systematic. Devise a personal system which ensures that you will cast an
eye over every bit of the section. Get into the habit for instance of sweeping back
and forth from top to bottom or up and down from left to right of the section
covering it completely.
b. Start with the lowest available magnification which provides the widest
field. When you recognize any abnormality under the lowest power, go after it at
higher magnification in order to figure it out,for instance, what kind of cells make
up that purple blotch. When you have figured it out, go back to the lowest
magnification to see it again. Before long, you'll be telling polys from plasma
cells with the low power scanning lens. As you get comfortable with the low
power, you'll be able to diagnose things by pattern recognization (which is how
you now recognize your friend's face in a crowd).
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c. Avoid to give any diagnosis, since it's often wrong for beginners. Instead
describe the abnormal elements to yourself one by one. For example vessels in
left field, fibroblasts in center field, and atypical pleomorphic cells in right field.
Then, try to put the elements together into a diagnosis. It works.
d. Before long, you'll be able to generate a differential diagnostic list appropriate
to various situations. It is just a matter of matching up the described elements
with this list.
5. As questions appear in the syllabus, answer them carefully. They are desingned to
be helpful and freguently will give you insight into important clinical considerations.
PATHOLOGY LABORATORY EXAMINATION:
Pathology practical examination will be held in the subject course theoretical examination.
This exam contains multiple choice, open ended or an assay questions from slide
presentation.
The score of each pathology labaratory examination changes. It is decided by chairman of
subject course in each course.
Students who do not fulfill the minimal required attendance limits, are not eligibal to participate
in the pathology practical exam.
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CELL AND TISSUE INJURY COURSE I
Objectives for the students: At the end of this 4 hours practise, second year students
will be able to;
*describe and recognize gross and microscopical changes in the size,
consistency , color and composition of organ
*revognize adaptive cell reactions, identify gross and microscopical appearence
of atrophy, hyperplasia, metaplasia,
*describe cell response to injury and recognize gross and microscopical
appearence of tissues undergo pathological injury
*recognize gross and microscopical changes of organs and tissues in
hemodynamic disorders
*recognize gross and microscopical appearence of organs and tissues in acute
and chronic inflammation
*recognize gross and microscopical appearence of abnormal accumulations.
SYSTEMATIC APPROACH FOR THE EXAMINATION OF
MACROSCOPIC SPECIMENS
• IMPORTANT NOTE : In order to understand the pathologic findings, you have to know
the normal anatomic structure of the organs and tissues.
• In order to uderstand the underlying mechanism off these pathologic findings, you have
(to know the pathopysiological mechanisms of these pathologic processes that are going to
be examined.
• When examining the gross specimens, (try to answer the following
questions?
Is there any change in the size of the organ ?
If there is, is it diffuse or focal?
Is there any change in the color of the organ ?
If there is, is it diffuse or focal?
Is there any change in the consistency of the; organ ?
If there is, is it diffuse or focal?
Is there any tissue defect in the organ ?
If there is, is it superficial, intraparemchymal, or subepithelial
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CHANGES IN THE SIZE, CONSISTENCY, COLOR, AND
COMPOSITION OF ORGAN'S
CHANGES IN THE SIZE OF ORGANS
Increase in the Size of the Organ
Diffuse — > Increase in Cellular Content
( Increase in either cellular content or size of the cells)
Local Cells of the Organ
*hypertrophy
HYPERTROPHY - HEART
*hyperplasia
HYPERPLASIA - PROSTATE
NODULAR HYPERPLASIA - THYROID
* neoplasia
LYMPHOMA - SPLEEN ( Normal Spleen)
Non-local cells
*inflammatory cells
MILIARY TUBERCULOSIS - LUNG GRANULOMATOUS INFLAMMATION
TESTIS ACUTE REJECTION – KIDNEY
*neoplastic cells (invasion / metastasis) LINITIS PLASTICA STOMACH
Increase in Luminal content
*dilatation
HYPERTROPHY -URINARY BLADDER
HIDROPS – GALLBLADDER
Increase in Ground Substance
*mucin, fibrin, pigments, etc,
FATTY CHANGE -- LIVER
ANTHRACOSIS - LUNG
ATHEROSCLEROSIS - CHOLESTEROL ACCUMULATION FATTY CHANGE - HEART
AMILOIDOSIS - KIDNEY
Increase in Blood Volume
*Increase in Blood In flow
-Hypererma
* Impaired Blood Outflow
-Congestion
NUTMEG LIVER (systemic)
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TORSION - TESTIS (Local)
MENINGEAL CONGESTION
Focal
*Inflammatory
*Blood Accumulation
*Neoplastic
Decrease inSize
Diffuse
*atrophy RENAL ATROPHY ----> flbrosis
*hypoplasia
RENAL HYPOPLASIA
Local
*local atrophy
*scar formation
CHRONIC PYELONEPHRITIS
CHANGES IN THE CONSISTENCY OF ORGANS
Softening
*destruction of the architecture of an organ (necrosis)
INFARCTION - SPLEEN
INFARCTION - MYOCARDIUM
TRANSMURAL INFARCTION - SMALL BOWEL
*decrease in ground substance
*edema, serous fluid accumulation
NASAL POLYP
HEMATOMA – SPLEEN
Hardening
* increase in ground substance
CIRRHOSIS – LIVER
*infiltration by inflammatory cells / neoplaistic cells
BRONCHOPNEUMONIA - LUNG
CHONIC CHOLESISTITIS - GALLBLADDER
FIBROMA - OVARY
*abnormal, accumulations (calcification, amyloidosis) AMYLOIDOSIS KIDNEY CALCIFICATION -• PLACENTA.
Crispyness
*necrosis
TUBERCULOSIS - APEX OF THE LUNG
COAGULATION NECROSIS - KIDNEY - RENAL, CELL CARCINOMA
*decrease in substances giving elasticity to organs (osteogenesis imperfecta,
osteoporosis
DEGENERATIVE ARTRITIS
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CHANGES IN THE COLOR AND COMPOSITION OF ORGANS
Darkening
*increase in blood flow
MENINGEAL CONGESTION
CHRONIC PASSIVE CONGESTION - LUNG
CHRONIC PASSIVE CONGESTION - LIVER (NUTMEG LTVER)
TORSION - TESTIS
INFARCTION - SMALL INTESTINE
HEMATOMA.- SPLEEN
*deposition of lipofuscin
* increase in melanin pigment
*increase in pigment
ANTRACOSIS – LUNG
Paleness
*decrease in blood flow
INFARCTION SPLEEN
INFARCTION MYOCARDIUM INFARCTION
PLACENTA
ACUTE REJECTION - KIDNEY
*decrease in melanin pigment
*scar tissue formation
CHRONIC PYELONEPHRITIS
Discoloration
*accumulation of pigments
ANTRACOSIS - LUNG
* accumulation of lipid
FATTY CHANGE - LIVER
NUTMEG LIVER
ATHEROSCLEROSIS - CHOLESTEROL ACCUMULATION FATTY CHANGE
- HEART AMILOIDOSIS - KIDNEY CHOLESTEROLOSIS - GALL BLADDER
MACROSCOPIC EXAMINATION OF THE SPECIMENS
HD-l . HYPERTROPHY
ORGAN: Heart
Gross Findings: This transverse slice from the heart displays prominent difference
between the diameters of ventricle walls. Notice a white area of flbrosis in one of the walls.
Descriptive Notes: Hypertrophies heart may achieve weights of 700 to 800 gr instead of
350gr.Normally the thickness of the wall of the right ventricle is 3 to 5 mm and that of the left
ventricle 1.3 to 1.5 cm. Greater weight or ventricular thickness indicates hypertrophy.
HD-2: HYPERPLASIA
ORGAN: Prostate
Gross Findings: Two prostatic lobes are seen. They are enlarged, firm and nodular. The
cut surfaces are also nodular and contains some minute cysts. The size of nodules vary from
0.5 to 1.5cm.
Descriptive Notes: This increase in size is in response to hormonal changes that
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occurs with the aging process.
HD-3: HYPERPLASIA
ORGAN: Thyroid (Nodular Hyperplasia)
Gross Findings: Thyroidectomy specimen with glistening, jelatinous, nodular surfaces
is seen. At cut section you can discriminate fibrous bands causing nodular structures.
Descriptive Notes: In the adult, the normal thyroid gland weighs 20 to 25 gm. The
most common cause of the nodular hyperplasia is the of lack of iodine in the diet
resulting insufficient production of throid hormones. This cause increase the
sythesis and release of TSH (thyroid stimulating hormone), resulting in
enlargement of the thyroid.
HD-5: MILLIARY TUBERCULOSIS
ORGAN: Lung
Gross Findings: There are multiple small (pin-point to a few millimeters), yellow white
distinct foci. This leads to diffuse enlargement of the lungs.
Descriptive notes: These foci are formed by granulomatous inflammation.
HD-9: HYPERTROPHY – DILATATION
ORGAN: Urinary Bladder
Gross Findings: This is a partial cystectomy spesimen. The bladder is turned inside
out so that you can see the pale mucosa. The cavity of the urinary bladder is enlarged.
The bladder wall is thicker than normal.
Descriptive Notes: Vesical obstuction caused dilatation of the baladder and hypertrophy
of the muscle layer. Hypertrophy of the muscle bundles produce trabeculation.
HD-11: FATTY CHANGE
ORGAN: Liver
Gross Findings: A slice of the liver is seen. Liver is enlarged, yellow, smooth, firmer than
normal and greasy. The capsule remains smooth and glistening.The lumina seen on the cut
surface are the branches of the portal vein.
Descriptive Notes: the normal adult liver weighs 1400 to 1600 gms. Fatty change results
from defective oxidation of fatty acids and aberrant mitochondrial function.
HD-12: ANTHROCOSIS
ORGAN: Lung
Gross Findings: Accumulation of this pigment blacken the tisues of the lung.
Descriptive Notes: The most common exogeneous pigment is carbon or coal dust, which is
a virtually ubiquitous air pollutant of urban life.
HD-13: ATHEROSCLEROSIS-CHOLESTEROL ACCUMULATION
ORGAN: Vessel Wall
Gross Findings: You see an opened vessel wall. On the inner surface there are elevated
areas of different diameter in size, yellow-white in colour and with irregular lipid
plaques.Some plaques are calcified, these can be recognised with their white color and rigid
appearance. The size of the atheromatous plaques are varible and some show coalescence.
Descriptive Notes: Endothelial cell damage and increased total cholesterol and
decreased HDL cholesterol cause atherosclerotic plaq formation.
HD-14: FATTY CHANGE
ORGAN: Heart
Gross Findings: The heart is enlarged and softened. It is yellow in colour. You can also see
atherosclerotic yellow lipid plaques in the opened vessels.
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HD-15: AMYLOIDOSlS
ORGAN: Kidney
Gross Findings; Kidney is enlarged , firm and have a waxy appearance.
Descriptive Notes: Extracellular hyaline amorphous material is accumulated in
glomeruli and vessel wall. Painting the cut surface with iodine imparts a yellow colour is
transformed to blue violet.
HD-16: PASSIVE CONGESTION
ORGAN: Ovary
Gross Findings : The organ is diffusely enlarged, firm, and cyanotic.
Descriptive Notes: This is due to twisting of ovary that cause obstruction of venous return
resulting in intense congestion. Ovarian torsion is uncommon.
HD-17: CHRONIC PASSIVE CONGESTION
ORGAN: Liver
NUTMEG LIVER (normal adult liver weight is 1400-1600gm.)
Gross Findings: There is dusky red cyanosis and diffuse increase in liver size and
weight. On the cut surface the central congested areas appear darker than the pale
peripheral portions of the lobules and thus compose the so-called nutmeg pattern.
Descriptive Notes: Passive congestion of the liver results from right-sided heart failure
or obstruction of the inferior vena cava or hepatic vein. When you think about the normal
circulation of the liver you will easily understand why the central areas are primarily
affected. We see hemorrhagic necrosis in the pericentral zones. Whereas the peripheral
hepatocytes, suffering from less hypoxia, develop fatty change. This zonal difference
gives red [centre of the lobule] and yellow (periphery-of the lobule) discoloration socalled "nutmeg" liver to the organ.
HD-18: PASSIVE CONGESTION
ORGAN: Testis (Torsion)
Gross Findings: Testis shows slight but diffuse enlargement The organ is tense and
cyanotic.
Descriptive Notes: There is an impairment of venous return from the testis due to the
twisting of the spermatic cord resulting compression of testicle veins.
HD-20: ABSCESS
ORGAN: Spleen .
Gross Findings: Spleen is enlarged. Acute inflammatory cell infiltration results with a
tissue defect that you can notice on the cut section of the spleen.
Descriptive Notes: Normally in the addult spleen weighs, about 150 gm and measures
12 cm in lenght, 7 cm in width, and 3 cm in thickness.
HD-21: TUBERCULOSIS
ORGAN: Apex of the Lung
Gross Findings: At the apex of the lung there is an intraparanchymal tissue defect. At
the centre of the defect with a close inspection one can easily identify the necrosis.
Descriptive Notes: Mycobacterium cause tuberculosis.The type of the necrosis is
called caseification necrosis.
HD-22: ATROPHY
ORGAN: Kidney
Gross Findings: The cut section of the kidney reveals dilatation and deformation of
the calyces, irregular loss of renal parenchyma with scarring. Its surface is granular with
depressed scars.
Descriptive Notes: Atrophy is due to progressive destruction and loss of renal
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parenchyma.
HD-23: HYPOPLASIA(congenital)
ORGAN: KIDNEY
Gross Findings:The size of the kidney is diffusely decreased. Its surface is smooth and
normal in appearance. The number of renal lobes and pyramids is 6 or fewer (normal
kidney has about 12 pyramids).
HD-25: INFARCTION
ORGAN: SPLEEN
Gross Findings: On the cut section of the spleen you see multiple, pale, wedge
shaped, well deliniated infarcts beneath the capsule. The infarcts which are wedge
shaped have their apex pointing toward the focus of vascular occlusion. Since all the
dependent tissue out to the periphery of the organ is affected, the external aspect of the
organ forms the base of the wedge.
Descriptive Notes:This is an example of white infarct which is seen secondary to the
arterial occlusion of the solid organs.
HD-26: INFARCTION
ORGAN: Placenta
Gross Findings: On cut section of the placenta reveals a white-tan and firm area of
necrosis. It is also wedge shaped with apex at the maternal surface.
Descriptive Notes: This is also an example of white infarct. It results from cessation of
blood supply to intervillous space and necrosis of villi .
HD-27: TRANSMURAL INFARCT
ORGAN: Small bowel
Gross Findings: A segment of small bowel is seen. A large part of this segment is
intensly congested and dark purple. This discoloration fades gradually into the adjacent
segments of the normal bowel, that is the demarcation is not sharply defined.
Descriptive Notes: This is also an example of a red infarct. We see red infarct both in
arterial and venous occlusions of the small bowel due to the fact that it has rich in
arterial anastomoses.
HD-29: CIRRHOSIS
ORGAN: Liver
Gross Findings: The liver is harder than normal due to fibrosis. Its surface shows
diffuse nodularity that reflects nodular regeneration and scarring.
Descriptive Notes: Cirrhosis of the liver is the terminal sequel of repeated injury to the
liver parenchyma. The result is the formation of broad fibrous bands separating
regenerative nodules that do not have the normal achitecture of liver lobules.
HD-31: CHOLESTEROLOSIS
ORGAN: Gall bladder
Gross Findings: Its mucosal surface shows minute yellow patches due to cholesterol
accumulation . This is called as a "strawberry gallbladder".
Descriptive Notes: It is results from abnormal deposition of mixtures of cholesterol and
triglyceride in macrophages in the lamina propria of the gallbladder.
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MICROSCOPIC EXAMINATION OF THE SLIDES
CELL RESPONSE TO INJURY AND ADAPTIVE CELL REACTION
N- 18 FATTY CHANGE
Organ: Liver
PATHOLOGICAL FINDINGS
Gross findings: HD-15
Microscopic findings: This H&E stained slide is prepared from a grossly yellow
colored enlarged liver. The parenchymal cells (hepatocytes) show marked fatty change.
Note the variable sized lipid vacuoles in the cytoplasm and peripherally displaced
nuclei. Remember that fat globules appear as empty spaces with routine H&E stain.
A-1 COAGULATION NECROSIS
Organ: Placenta
PATHOLOGICAL FINDINGS
Gross findings: HD-26
Microscopic findings: The section is prepared from placenta. One part of the section
has undergone coagulation necrosis. These areas are acidophilic. The cells have
“tombstone” appearence that is nuclear detail is lost, only the basic cellular shape, the
silhouette of the villi and cells are preserved. You can still recognise the cell outline and
tissue architecture.
A-3 FAT NECROSIS
Organ: Breast – fat tissue
PATHOLOGICAL FINDINGS
Microscopic findings: The section is from an ill-defined mass in the breast present for
3 weeks. This section consists largely of fibrous tissue with scattered lymphocytes.
Nearby there are islands of fat tissue which is replaced by histiocytes in some areas.
Note that you can see the shadowy outlines of necrotic fat cells and they do not have
nuclei.
B-8 CASEIFICATION NECROSIS
Organ: Lung
PATHOLOGICAL FINDINGS
Gross findings: HD-21
Microscopic findings: In this section of the lung, there are several round, nodular
structures which are called granulomas. Each granuloma consist of epithelioid
histiocytes (macrophages) in the middle, surrounded by lymphocytes. You may see
langhans type giant cells in some of them. This type of giant cells, nuclei arranged
peripherally. In the center of a few of the granulomas, necrosis is seen. This is a special
type of necrosis called caseification necrosis. The outlines of the cells are not
preserved. Instead you see amorphous eosinophilic (pink) material which contains
cellular debris.
A-13B METAPLASIA
Organ: Stomach
PATHOLOGICAL FINDINGS
Microscopic findings: The section is from a gastrectomy specimen. On the slides you
will see the gastric mucosa lined by columnar epithelial cells. At some parts the gastric
epithelium is replaced by intestinal metaplasia which is composed of goblet cells,
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absoptive ‘brush border’ cells. On the other slide stained with PAS-Alcian Blue 2,5
normal gastric epithelium is bright pink (neutral mucin) and the intestinal metaplasia
areas are purple (acidic mucin) in color. There are goblet cells in these metaplastic
areas.Mark the difference.
A-14 ATROPHY-NODULAR HYPERPLASIA
Organ: Thyroid
PATHOLOGICAL FINDINGS
Gross findings: HD-3
Microscopic findings: You see one of the nodules which has various sized follicles.
These follicles have colloid in their lumen and their epithelial lining is cuboidal. Around
some follicles a homogenous pink area of hyalinisation is noted. Surrounding the
nodule fibrous tissue and atrophic thyroid follicules and granulomatous inflammation
are seen. Atrophic follicles which are compressed are small and their epithelial lining is
flattened.
HEMODYNAMIC DISORDERS AND ABNORMAL ACCUMULATIONS
A-15 ANTHRACOSIS
Organ: Lymph node
Histology of the organ: A lymphoid stroma which contains lymphoid follicles some of
which have germinal center. The node is surrounded by a fibrous capsule beneath
which are found lymphatic sinuses.
CASE
Clinical history: A 78 year-old man underwent lobectomy and lymph node dissection
with diagnosis of lung cancer.
PATHOLOGICAL FINDINGS
Gross findings: HD-12(Antracosis in lung)
Microscopic findings: In the center of the lymph node lymphoid tissue is replaced by
a fibrotic stroma rich in blood vessels. This stroma is infiltrated by histiocytes which
contain black granules (carbon pigment). You may also see carbon pigment within the
extracellular space.
C-6e INFARCTION
Organ: Small intestine
Histology of the organ: The gut wall consists of a mucous membrane, muscular coat
and a serous membrane. The mucous membrane has a lamina propria lined by surface
epithelium which exhibits villi. In the lamina propria glands are found.
CASE
Clinical history: A young man who had appendectomy 6 months ago presented with
symptoms of ileus. At operation intestinal adhesions and a strangulated segment of
ileum was found.
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PATHOLOGICAL FINDINGS
Gross findings: HD-27
Microscopic findings: An intense congestion and silhouettes of intestinal villi are
seen. In some slides there is extensive red blood cell extravasation and necrosis of the
bowel.
C-4A, 4B THROMBOSIS
Organ: A: Artery, B: Vein
Histology of the organ: The artery is composed of an intima, muscular coat and an
adventitial fibrous tissue. In the vein these layers are not as prominent as in the artery.
CASE
Clinical history: The leg of a 70 year-old woman has been amputaded due to vascular
occlusion.
PATHOLOGICAL FINDINGS
Microscopic findings:
A: This slide illustrates artery occluded by thrombi. This is an organized thrombus.The
wall of the arteries is calcified.
B: In this section we see an enlarged vein in which the lumen is completely obliterated
by an organized thrombus.
M-36a ACUTE INFLAMMATION
Organ :Appendix
Histology of the organ: The wall of the appendix is composed of a mucous layer rich
in lymphoid follicles with prominent germinal centers, a muscular coat and a serous
membrane.
CASE
Clinical findings: A 30 year-old female with severe abdominal pain underwent
appendectomy with a diagnosis of acute appendicitis.
PATHOLOGICAL FINDINGS
Microscopic findings: In this slide you see an inflamed appendix wall. Try to examine
each layer subsequently. There is a purulent exudate in the lumen. The continuity of
the mucous membrane is not maintained because of the erosion seen just beneath that
exudate. Note that the edematous wall is diffusely infiltrated by neutrophils.
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CELL AND TISSUE INJURY COURSE II
Purpose:
At the end of this 8 hour laboratory course, second year students will be able to
describe a mass lesion as a basis for differential macroscopic diagnosis in the
following years. They will also understand the basic concepts and features used
for classifying tumors. They will see basic samples of infectious agents/
diseases in tissue sections.
Objectives for the students:
At the end of this laboratory, you will be able to,
 describe the macroscopic features of a mass lesion or tissue defect using
proper terms
 explain the basic principles of classifying a mass lesion as a neoplasm or
tumor like lesion using appropriate nomenclature
 describe basic differentiating features of a malignant and a benign
neoplasm in tissue sections
 describe and recognize structural features used for classifying a neoplasm
as epithelial/ mesenchymal/ mixed tumor or a teratoma
 classify the infectious microorganism causing the pathologic lesion as
bacteria / fungus /virus / parasite either by recognizing the microscopic
features of the organism or the specific pathologic tissue changes
 have a general concept about clinico-pathological correlation in tumors and
infectious diseases (Brief clinical histories are given for each case).
Please make sure that you have read the highlighted part: PATHOLOGY of
MASS LESIONS and TISSUE DEFECTS before coming to the laboratory. You
cannot describe a neoplasm / a mass lesion without knowing how to describe it.
Please read the texts and try to correlate them with the related power point
presentations.
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CELL AND TISSUE INJURY COURSE II
PATHOLOGY of MASS LESIONS and TISSUE DEFECTS LABORATORY
Tissue defects
Superficial (On the surface)
Erosion
Ulcer
Mass lesions
Growing on the surface/ into the
lumen of viscera:
Polyp – polypoid growth (sessile or
pedunculated)
Papilloma – papillary growth
Verrucous / fungating / exophytic /
vegetating growth
Tissue defects
Within the solid tissue:
Abscess
Cystic change (due to old hemorrhage,
necrosis, etc.) – pseudocyst
True cyst: non neoplastic (congenital or
acquired)
Cystic neoplasm
Parasitic cyst
Mass lesions
Within the solid tissue (local growth):
encapsulated / unencapsulated (well
demarcated or invasive border)
Features to be taken into consideration when examining a mass lesion:
 Localization and extent within the organ (or depth of invasion for hollow viscera)
 Size
 Number: Single - multiple
 Growth pattern: polypoid, ulcero-infiltrative, nodular, etc.
 Consistency (usually harder than surrounding normal tissue) soft – rubbery
(elastic) – hard (more fibrous tissue) – stone hard (calcified)
 Border: encapsulated - well demarcated but unencapsulated - invasive with
irregular border
 Cut surface:
Homogenous – heterogeneous
 solid, nodular - predominantly cystic - predominantly solid with
small cystic areas
 fibrillary, myxoid / gelatinous, ......- like (cartilage –like /
cartilaginous)
 color (predominantly ): white - yellow (lipid content) - various
colors (variegated) - unremarkable (not different from surrounding
organ) - other (specify)
 Other features : the presence of prominent areas of: fibrosis / fibrous scars necrosis – hemorrhage
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MACROSCOPY
M1 - RENAL TUBERCULOSIS
The kidney is slightly enlarged with irregular nodular cortex. The cut surface shows
multiple\ round\ yellowish to grey-white cavitary areas lined with soft friable material
(caseous necrosis) and walled off by white, solid fibrous tissue in the parenchyma. You
can see this material also filling the pelvis and calyces. Calyces and renal pelvis are
dilated.
M2 - SPERMATOCELE
You see a cystic mass with a thickened, fibrotic wall and a small compressed testis in
one pole. The internal surface is irregular, matte (dull) and yellowish to brownish color
due to accumulated cellular debris.
M3 - CHRONIC NON - SPESIFIC CERVICITIS WITH NABOTHIAN CYSTS
In this hysterectomy specimen, the cervix is studded with mucus containing cysts.
These are the result of obstruction of the openings of endocervical crypts; accumulated
secretion gives rise to retention cysts. It is a common finding resulting from obstruction
by chronic inflammation and epithelial metaplasia.
M4 - HYDATID CYSTS
This specimen is from a patient with a history of hepatic hydatid cyst rupture. You see
multiple, white colored, different sized cysts embedded in peritoneal fat tissue. These
are dense fibrous capsules enclosing true cysts. This membrane-like structure
represents the inflamed fibrous tissue, which is the result of host reaction. Some of
these capsules are opened and inside them you can see the semi - opaque, soft outer
layer of the hydatid cyst membrane (the cuticle). You can also see small, translucent
cysts - the daughter cysts.
M5 - SEROUS PAPILLARY CYSTADENOMA OF THE OVARY
This is a unilocular cyst. The cyst wall is very thin, almost semi- transparent to light.
The inner surface is smooth and glistening except for the small intracystic papillary
formations.
M6 - SEROUS PAPILLARY CYSTADENOCARCINOMA OF THE OVARY
This is a multiloculated cystic ovarian tumor with minor solid components. Papillary
structures are more abundant and in places, heaped up. There are also solid masses
with cauliflower like appearance.
M7 - BENIGN CYSTIC TERATOMA OF THE OVARY (DERMOID CYST)
This is a unilocular cystic tumor containing hair and cheese like brownish sebaceous
material. The cyst wall is thin inside is reminiscent of skin; only on one pole you see
solid area of heterogeneous, variegated appearance. This is a predominantly cystic
tumor with a small solid component as opposed to testicular teratoma which is a
predominantly solid tumor with small cystic areas.
M8 - TRANSlTIONAL CELL CARCINOMA OF URINARY BLADDER
You see a cystectomy specimen. You see exophytic tumors composed of tiny, fingerlike papillary structures growing from the bladder wall into the lumen.
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M9 - ENDOMETRIAL POLYPS
You see two hysterectomy specimens with large polyps filling the uterine cavities. The
polyps grow from the upper portion (fundus) of the endometrium. One is solid; the other
is predominantly solid with small cystic areas. The color change seen on the free tips is
due to trauma and bleeding.
M10 - MULTIPLE (INFLAMMATORY) POLYPS – COLON
A part of this colonic resection specimen has an atrophic mucosa, on the other (distal)
half, you see multiple, small, elongated polypoid growths. The normal mucosa is
practically absent in this area. The appearances of these polyps are different from the
neoplastic polyps seen in colon cancer specimen. These are not neoplastic polyps.
M11 - COLON CANCER
There are two examples: in both, you see tumors with both exophytic and endophytic
growth: raised – heaped up borders with central ulceration. Only on cut section you
realize their invasive character: Central parts are ulcero-infiltrative and tumor seems to
invade muscle layers of the bowel wall. In both, next to the tumor you see pedunculated
polyps, as coarsely lobulated structures attached to the bowel wall with slender stalks.
M12 - LEIOMYOMA NODULES – UTERUS
In this very large specimen, you may not understand that the organ is uterus because it
is so large and distorted by tumor nodules. You see the cut section three tumor nodules
of variable sizes are apparent: the nodules have solid, white, fibrillary appearances,
somewhat reminiscent of the surrounding myometrium. You see no capsules, but they
have well-defined borders.
M13 - RENAL CELL CARCINOMA
In this box, you see different examples of renal cell carcinoma. Cut sections of kidneys
have bright yellow to grey white solitary tumors with sharply defined or irregular
margins. You see a well demarcated round mass near one of the poles in one. It is
confined within the kidney capsule, but bulge into surrounding fat tissue. Another
example has again a rounded but more irregular border; it is a multinodular tumor
which bulges into calyces and pelvis. Another example has a tumor that grows in a
multinodular fashion replacing most of the renal parenchyma and also invading the
perirenal fat. See the areas of necrosis within some of the tumors. Notice areas of
central stellate fibrosis, cystic change and hemorrhagic areas.
M14 - BREAST CANCER
These are mastectomy specimens. (Black color is due to Indian ink which is used to
mark the surgical margins. The nipples are removed for microscopic sampling).You can
see breast tissue which has abundant fat tissue and the skin on it. On cut section white
colored, infiltrative cancers are visible. One is a very large tumor, both have irregular
borders –the smaller one has a spiculated border. The tumors are much firmer than the
surrounding breast tissue; such tumors are called schirrous carcinomas. This extreme
firmness is due to marked desmoplasia in the tumor stroma.
M15 - MALIGNAT FIBROUS HISTIOCYTOMA
You see the skin covering the muscle and soft tissues (of the thigh). A large fungating
growth can be seen on the surface. On cut surface, you can see the cancer is
infiltrating the soft tissues, also permeating the muscle. It is a fleshy, coarsely nodular
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tumor. It has more “pushing” borders when compared to irregular borders of breast
cancer. This is just deceptive, local invasion is always found in macroscopically well
bordered areas.
M16 - TUMOR METASTASES – PERITONEUM
This is from a patient who had a very aggressive ovarian cancer. On the peritoneal fat
tissue, you see multiple rounded masses of different sizes. These are not encapsulated
but seem to be well demarcated macroscopically. They have variegated colors; the
neoplasm was a malignant mixed tumor.
M18 - TERATOMA OF TESTIS
Inguinal orchiectomy specimens show enlarged testicle in huge dimensions. Cut
surface displays a variegated appearance. It is a gray white tumor with some solid and
multiloculated cystic areas. The compressed normal testis cannot be seen.
M19 - SEMINOMA OF TESTIS
One inguinal orchiectomy specimen shows a much enlarged testis. There was a serous
fluid between the layers of tunica vaginalis. The cut surface of the testis shows a large
homogenous, lobulated neoplasm of grayish white color. The tumor has barely
recognizable very small foci of necrosis (soft, yellow colored areas). A compressed
testicular tissue could hardly be seen at one side of the tumor. Tunica albuginea is not
penetrated but there is marked vascular congestion. Another example shows a nearly
normal sized testis with a white, lobulated, solid tumor in the parenchyma. Although the
sizes of the tumors are different, appearance on cut sections are very similar.
M20 - TERATOCARCINOMA OF TESTIS
This is an inguinal orchiectomy specimen with large tumor replacing the entire testis
and invading the testicular tunics. Cut surface displays a variegated appearance similar
to a pure teratoma: you can see cystic multiloculated areas and solid areas with
different textures, but this tumor also has the friable gray white appearance and
extensive necrosis.
PATHOLOGY LABORATORY GUIDE FOR MICROSCOPIC EXAMINATION OF
SLIDES
PATHOLOGIC DIFFERENTIATION of MALIGNANT AND BENIGN TUMORS MICROSCOPY
TTM- THYROID TUMOR MIX (ADENOMA, PAPILLARY CARCINOMA OF THE
THYROID WITH LYMPH NODE METASTASIS)
There are three different sections on this slide. One is from the adenoma of thyroid; the
other two are from a cancer. Both patients were females in their thirties with thyroid
masses. First look at the adenoma. You see a definite fibrous capsule; normal thyroid is
seen compressed around the tumor. The tumor is composed of larger follicles in this
sample. It may have smaller follicles most of the times. The tumor cells are very similar
to normal thyroid follicle cells. Compare the nuclei and cellular appearance of both.
They are very similar. Then, look at the cancer. It infiltrates the thyroid follicles and also
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the surrounding tissue around thyroid. Papillary structures are very abundant. They
have fibro vascular cores with overlying neoplastic cells. There are also solid masses of
neoplastic cells and at places, follicle like structures. The nuclei of tumor cells are much
larger than normal cells, but they are not hyperchromatic. Third, examine the metastatic
cancer. You can see the normal structure of the lymph node in some areas but most
areas are occupied by a metastatic carcinoma. Examine the histological appearance of
this carcinoma and compare it with the original papillary carcinoma.
S-8 FIBROADENOMA
This is from a young woman with a round, mobile breast mass. The mass is not
encapsulated but very well demarcated. Look at the slide macroscopically. You will see
its round homogenous appearance. Microscopically, this is a tumor composed of two
components: a fibrous component which looks like the ordinary edematous fibrous
tissue, and duct or cleft like structures lined by double layer of epithelial cells. Both the
fibrous and the epithelial components have bland, almost “normal” nuclei. You will see
compressed and atrophic breast acini around the tumor.
S-19 BREAST CARCINOMA
This is from the mastectomy specimen of an elderly lady with a hard mass. You cannot
see normal breast tissue but abundant fat tissue, because the patient was old and
obese and much of the breast mass was fat tissue. You see the infiltrative cancer in the
fat tissue. It has a very irregular border. You see small groups or cords or gland – like
structures or solid masses of tumor cells. Pleomorphism is not prominent.
Macroscopically, the tumor was very hard when compared to the surrounding breast
tissue. This extreme firmness is due to marked desmoplasia in the tumor stroma. You
see it as a pink colored fibrotic area in the center of the tumor.
D-10a METASTATIC CARCINOMA-LYMPH NODE
This slide is prepared from an enlarged axillary lymph node from the mastectomy
specimen. You can see the normal structure of the lymph node in some areas but most
areas are occupied by a metastatic carcinoma. Examine the histological appearance of
this carcinoma and compare it with the original breast carcinoma.
R-10 LEIOMYOMA
You have seen the macroscopic specimen. A 42 year old woman, who had complaints
of irregular shedding and dysmenorrhoea, underwent hysterectomy. Uterus was
enlarged and irregularly nodular. Many firm, round, white nodules were found in the
myometrium. You see a section prepared from one of these nodules. You see no
capsule, but there is a well-defined border from the surrounding myometrium.
Tumor is composed of fusiform cells with elongated nuclei which form bundles running
at various angles (you can see some bundles in cross section, others in longitudinal
section). Normal myometrium is seen compressed around the tumor. The normal
myometrial cells are seen in more parallel bundles. The tumor cell bundles are seen in
a more haphazard fashion. Other than that, the tumor cells are very similar to normal
smooth muscle cells. Compare the nuclei of the tumor with that of the normal
myometrium. They seem very “normal” in appearance.
V-39 MALIGNANT FIBROUS HISTIOCYTOMA
You have seen the macroscopic specimen. It was a rapidly growing tumor removed
from the thigh of a 62 year old male. You can see the cancer is infiltrating the fat tissue,
there is also the muscle. It seems to have “pushing” borders when compared to
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irregular borders of breast cancer. Look carefully and you will see invasion in the
periphery of the tumor. The tumor composed of highly pleomorphic cells: there are
fusiform cells arranged in whorls, rounded mononuclear cells with foamy cytoplasm,
multinucleated cells. Anaplasia is very prominent. The cells have very pleomorphic,
hyperchromatic nuclei with frequent typical and atypical mitoses. Note the very coarse
chromatin in clumps and very irregular nuclear shapes. Note the necrotic area within
the tumor. Try to see the skeletal muscle and adipose tissue invaded by the tumor.
MORPHOLOGIC DIAGNOSIS OF TUMORS AND TUMOR - LIKE LESIONS
Dx-ECTOPIC (HETEROTOPIC) PANCREAS IN STOMACH
This is also called a choristoma. It is a rest of normal tissue in an abnormal location. It
was an asymptomatic mass and an incidental finding. A 56 year old male patient
presented with an abdominal mass. Endoscopic examination of stomach was normal
except for a small nodule in the antrum. With CT and US examination, the patient was
found to have a primary liver tumor which caused the abdominal mass. When his liver
tumor was resected at operation, the small nodule in the antrum was also removed.
Macroscopically the nodule was 0.8cm in diameter and covered with mucosa. The
section is prepared from this nodule. Microscopically, you see a nodule of pancreatic
tissue in the submucosa and overlying normal gastric mucosa. The pancreatic tissue is
composed of closely packed acini and ducts lined with columnar epithelium – just like
the normal exocrine pancreas. There is mild edema and inflammation around the
nodule.
D-26 HAMARTOMA
This is a non-neoplastic lesion. The microscopic slide is prepared from a bulky mass
located in the hard palate of a young male patient. Note somewhat proliferated
keratinized squamous epithelium lining the surface of this particular mass. Beneath the
surface epithelium, there is abundant collageneous connective tissue containing
markedly proliferated but disorganized blood vessels in small diameter (capillaries).
The lumina of some capillaries are dilated but most of the remaining capillaries are slit
like vascular structures lined with swollen endothelial cells. You may see mononuclear
inflammatory cell infiltrate, extravasated erythrocytes, and hemosiderin laden
macrophages around capillaries.
D8- ADENOCARCINOMA OF COLON
This slide is prepared from a colon resection material with an ulcero-vegetating
carcinoma. If you examine whole surface of the section you will notice that on one side
of the section normal colonic mucosa can be seen. When you move your slide towards
the opposite side you will see the adenocarcinoma. It is composed of irregular glands
with atypical epithelium. The cells of this neoplastic epithelium have large pleomorphic
hyperchromatic nuclei. Also see mucin pools in stroma. This is a well-differentiated
tumor because it is recognizable as adenocarcinoma; it forms glands and secretes
mucin. You can see inflammatory cell infiltration in the stroma of the tumor and also
around the tumor. Notice that the tumor infiltrated the submucosa. Try to find the
normal colonic mucosa and compare the mucus content and nuclear size of its
epithelium with that of the cancer.
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K-22 SQUAMOUS CELL CARCINOMA-LARYNX
These samples are from the laryngeal cancer of a 47 year old male smoker who
complained of difficulty in swallowing and hoarseness. Macroscopically the tumor was
an ulcerating-fungating friable mass that arose from left vocal cord and extended
centrifugally. This slide is prepared from the outer border of the tumor. You can see
luminal surface lined by squamous epithelium. The edematous stroma beneath the
epithelium is invaded by the tumor. The tumor has highly differentiated areas where
squamous cells with large eosinophilic cytoplasm form nests with horn pearls in them.
In these areas, you can recognize it as a squamous cell carcinoma because it
resembles normal squamous epithelium with intracellular bridges and tendency for
keratinization. In less differentiated areas neoplastic cells having pleomorphic,
hyperchromatic nuclei and scanty cytoplasm, invade the stroma forming small groups
and chords – you cannot recognize the squamous nature of the tumor in these areas.
There is lymphocytic infiltrate in and around the tumor.
V-17 CHONDROSARCOMA
This is a malignant tumor which produces cartilage. Your slide belongs to a 46 year old
woman who was admitted to the hospital with a complaint of a rapid growing mass
around her pelvic bone. Her roentgenogram demonstrated a large lobulated mass with
evidence of calcification. The mass appeared to arise from the wing of the left ilium.
Hemipelvectomy was performed. Macroscopically, the tumor was 12x8x7cm in size and
it invaded soft tissues. The cut surface was glistening and showed focal calcification. In
your slides you are going to see a tumor quite similar to a hyaline cartilage tissue. If you
look closely you will notice that the neoplastic cells which are embedded within
basophilic matrix are plump and in contrast to mature chondrocytes two or three of
them share the same lacunae. You may also notice the pleomorphism of the neoplastic
cells.
D-25 TERATOMA
This section is prepared from an ovarian tumor removed from a 32 year old woman.
This tumor had a smooth external surface and predominantly solid but partially cystic
white to tan in color and areas of cartilage could be recognized on its cut surface.
Microscopically you see various sized cysts and various tissues scattered among them.
Examine and differentiate variable types of tissues. They are all mature. You can see
hyaline cartilage, nests of squamous cells with foci of keratinization in the center,
glandular structures fibrous tissue, smooth muscle and nodular masses of
mesenchymal tissue (abundant proliferation of spindle cells with fine chromatin and
scanty cytoplasm). Do you expect this tumor to behave in a benign or malignant
fashion?
0-25 WILM'S TUMOR (NEPHROBLASTOMA)
Mother of a one year infant felt a palpable mass in the abdomen of her baby. A tumor
was diagnosed on radiological examination and then nephrectomy was performed.
Grossly, the kidney appeared as huge irregular mass .The cut surface consisted mostly
of variegated solid tumor mass with areas of necrosis and hemorrhage, renal
parenchyma could only be seen at one pole of the kidney. Microscopic section includes
only a cellular tumor; you do not see adjacent kidney parenchyma. This tumor is
composed of three different cell types. The characteristic features of the tumor are 1compact masses of primitive - undifferentiated cells with round or oval hyperchromatic
nuclei and scanty cytoplasm (blastemal cells), 2- which form occasional abortive
tubules and glomerulus –like structures (epithelial differentiation), 3-intermixed areas of
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immature spindle shaped cells, which represent areas of mesenchymal differentiation –
they resemble primitive muscle cells. (What do you name a tumor that shows
differentiation of a single cell line into parenchymal cells representative of more than
one germ layer? Remember that ....blastomas –the so called “small round blue cell
tumors of childhood” can show such features.) You can see both single cell necrosis
and extensive necrosis.
PATHOLOGY LABORATORY of INFECTIOUS DISEASES - MACROSCOPY
HYDATID CYSTS
This specimen is from a patient with a history of hepatic hydatid cyst rupture. You see
multiple, white colored, different sized cysts embedded in peritoneal fat tissue. These
are dense fibrous capsules enclosing true cysts. Some of these capsules are opened
and inside them you can see the opaque, soft outer layer of the hydatid cyst membrane
(the cuticle). You can also see small, translucent cysts - the daughter cysts.
HEPATIC HYDATID CYSTS
This patient underwent partial hepatectomy (lobectomy) for hydatid disease. You can
see hydatid cyst cuticular and vegetative membrane and cysts embedded in the liver
parenchyma. An additional specimen shows the fibrous capsule around hydatid cyst.
This membrane-like structure represents the inflamed fibrous tissue, which is the result
of host reaction.
PULMONARY TUBERCULOSIS
This surgical specimen represents fibrocaseous tuberculosis. Lesion is located at lung
apex: a compressed cavity partially lined by yellow - gray caseous necrotic material and
walled off by white, solid fibrous tissue. Around the cavitary lesion, there are yellow
colored peribronchial infiltrates and yellow colored foci in the consolidated lung which
represent dissemination of infection (non - cavitary tubercules with caseous necrosis).
This is endobronchial dissemination of apical tuberculosis.
MILIARY TUBERCULOSIS
These specimens: lungs, heart, liver, spleen, and kidneys are from an infant who died
of disseminated tuberculosis. You can see multiple, small (usually pin - point to a few
millimeters), yellow - white, distinct foci disseminated in the organs. This miliary
seeding is especially prominent in the lungs and spleen. You can see fewer lesions in
kidneys and in liver but none in the heart. There is congestion in all of the affected
organs (dark red - brown color). [[The dark colored areas on the costal surface of lungs
and on the cut surface of liver are fixation artifacts]]
TUBERCULOUS PYELONEPHRITIS
The kidney is slightly enlarged with irregular nodular cortex. The cut surface shows
multiple round yellowish soft cavities in the parenchyma. These yellowish foci are
representative of caseous necrosis. See the soft friable material (caseous necrosis)
filling the pelvis and calyces.
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PATHOLOGY LABORATORY of INFECTIOUS DISEASES – MICROSCOPY
E-63 TUBERCULOUS LYMPHADENITIS
A 58 year - old smoker male patient, had a history of malaise, night fever and weight
loss. On chest x-ray, he had a large hilar mass with central cavitation, and an apical
cavity in his right lung. Mediastinal lymph nodes were enlarged. After a diagnosis of
squamous cell carcinoma by bronchoscopic biopsy, he underwent pneumonectomy
and mediastinal lymph node dissection. Lung harbored a central carcinoma and apical
tuberculosis. The lymph node specimens had multiple variously sized gray-white foci
on cut surface.
Lymph node sections show several pinkish, round, nodular structures which are
granulomas. Try to find Langhans type of giant cells and areas of caseation necrosis
seen in the center of some of the granulomas. In some areas you will see large and
confluent granulomas with extensive necrosis which appears as amorphous
eosinophilic granular material with cellular debris. You can see many multinucleated
plump histiocytic giant cells in the granulomas. Some have typical features of
Langhans type of giant cells, some do not. On high magnification, examine epitheloid
histiocytes which form the granulomas. They have cytoplasmic extensions contacting
with others, indistinct cell borders, elongated nuclei.
E-62 BACTERIAL COLONIES, (Tongue)
A 22 year old male patient a patient with a tongue mass which showed a slow but
considerable growth over many years underwent partial glossectomy to remove the
tumor. The tumor was a hemangioma. These sections are prepared from the surgical
margin of the specimen and do not contain any tumor. Due to poor oral hygiene, the
surface of the tongue is covered with bacterial colonies. You can see the squamous
epithelium of tongue is thicker than normal and shows keratinization (appearing dark
pink). On the surface of the papillae, you can see blue hazy material surrounding
clumps of keratinized cells. Examine the bluish areas: these are bacterial colonies. On
highest magnification you can differentiate cocci and thread-like filamentous bacteria
(probably Actinomyces). You do not see inflammatory cells. You would expect to see
polymorphonuclear leucocytes in a case of bacterial infection with cocci and/or
Actinomyces. Why do you think we do not see any inflammation in these sections?
E-4 MOLLUSCUM CONTAGIOSUM, (skin)
These sections are prepared from one of the multiple skin colored pruritic papules
with umbilicated centers on the trunk of a 6 year old boy. You can see a cup-shaped
lesion with distinct edges in the epidermis. Adjacent to a hair follicle, hyperplastic
epidermis has grown downward to dermis in lobules in the center of the lesion. In the
stratum granulosum and stratum corneum (upper layers of epidermis), you see
homogenous, red, large cytoplasmic inclusions which displace the nuclei of cells.
These inclusions, called "molluscum bodies" are aggregates of virions. They are
pathognomonic for molluscum contagiosum.
E-64 ASPERGILLOSIS, middle ear
These sections prepared from the middle ear of a patient who had a history of
itching and pain in the left ear and hearing defect. He had external ear infection which
perforated the tympanic membrane and involved the middle ear. As the keratinized
23
squamous epithelium, keratin and exudate filled the middle ear, he had to undergo an
operation to remove these. You see part of this material: squamous epithelium
overlying inflamed and fibrotic mucosa, inflammatory exudate and masses of fungi.
You can see the squamous epithelium is thick and shows keratinization (appearing
darker pink). Underneath the epithelium you can see mostly mononuclear
inflammatory infiltrate. Deeper areas of the tissue show fibrosis and some foreign
body type giant cells. On the surface, you can see dense clumps of hyphae and
suppurrative exudate. Hyphae are cut at various planes, but you can see the
septations and acute angle branching in many of them. As these are the typical
features Aspergillus, we can diagnose the infectious agent in this case.
E-61 ECHINOCOCCUS GRANULOSUS INFECTION, peritoneum
A 28 year old man with a history of ruptured hydatid cyst and current abdominal
pain was found to have multiple fluid-filled masses. At the operation, multiple soft,
white cysts found in the peritoneum removed. Cysts easily shelled out from the
surrounding fibrotic tissue. They were filled with clear fluid, with a white sand-like
material, which is called the hydatid sand (daughter cysts).
You do not see fibrous reactive host tissue in the sections. You can only see the
hydatid cyst. It is composed of a thick, multi-laminated, pink outer membrane - the
cuticle, inner germinative membrane and daughter cysts. The thin cellular layer with
tiny nuclei inside the cuticle is the germinative inner lining from which daughter cysts
bud off into the lumen. Some daughter cysts remain attached to the germinative wall;
some seem to be floating within the lumen. Daughter cysts are composed of
germinative membrane surrounding scoleces. You can also see free floating scoleces.
You can see the hooklets of some scoleces –which they will use if they get the chance
to develop into adult worms in the future.
24
HEMATOPOETIC SYSTEMS AND RELATED DISORDERS COURSE
Objectives for the students:
At the end of this 2 hours laboratory, you will be able to,
 describe basic differentiating features of a malignant and a benign
lymphoid pathology.
 recognize microscopical features of major malignant lymphoid neoplasms
 recognize microscopical features of a lymphoid hyperplasia
SLIDES YOU ARE GOING TO EXAMINE IN THIS LABORATORY SESSION
HE-2 LYMPHOMA
ORGAN: Spleen
Gross Findings: In the cut section of the spleen, numerous white-tan colored, slightly
elevated nodular masses can be seen.(approximately 0.6-0.8 cm. in dimension). This
leads to diffuse enlargement of the spleen.
Descriptive notes: These nodular masses are formed by neoplastic proliferation of small
B lymphocytes .
T-4 FOLLICULAR LYMPHOMA
Organ: Lymph node
CASE:A-55-year old woman with cervical lyrnphadenopathy underwent an
excisional biopsy .
PATHOLOGICAL FINDINGS
Microscopic findings: At low magnification, uniform sized, in back to back configuration
follicules are observed in the lymph node. When you examine carefully you will notice mainly
one cell type found in these follicular structures. This cell type is small cell with irregular or
cleaved nuclear contours and scant cytoplasm named as centrocytes. There are scattered
large cells with multiple nucleolies in between. Is there any tingible body macrophages in these
follicles? Please try to answer.
I-5 HODGKIN LYMPHOMA-MIXED CELLULAR TYPE
Organ: Lymph node
CASE:A-13-year old boy with supraclavicular lymphadenopathy underwent an
excisional biopsy.
PATHOLOGICAL FINDINGS
Microscopic findings:The normal architecture of the lymph node is effaced. The capsule of
the lymph node is thickened .There is a diffuse type of infiltration in this lymph node. This
infiltration consists of neoplastic cells called Reed-Sternberg(R-S) cells and
reactive cells. Some of R-S contain bilobated nuclei and prominent eosinophilic nucleoli. These
cells resemble to owl eyes. Reactive cells are composed of lymphocytes, histiocytes, plasma
cells and eosinophils.
T-8 SMALL LYMPHOCYTIC LYMPHOMA
Organ: Lymph node
CASE
;A 50-year-old man presented with large non-tender lyrnphadenopathy consisting
25
of a chain of lymph nodes in his right cervical region. He complained of weight loss and
fatigue for the last three months.
PATHOLOGICAL FINDINGS
Microscopic findings:This slide is prepared from the biopsy of the enlarged lymph
node. The normal architesture of the lymph node is destroyed by a diffuse infiltration
of monomorphic cells. The marginal sinuses are filled with malignant cells, which have dark
staining, monotonous nuclei with little cytoplasm. The capsule of the lymph node is generally
infiltrated by the same cells which is another criteria of malignancy.
I -.21 MULTIPLE MYELOMA
Organ: Bone-vertebra
CASE:A-67 year old female presented with severe back pain. X - ray showed fracture at T-7
vertebra. This area was operated.
PATHOLOGICAL FINDINGS
Microscopic findings:.Microscopic section shows cartilage, soft tissue, and neoplastic
tissue fragments. Neoplastic tissue is composed of mature appearing plasma cells.
Intranuclear inclusions ( Dutcher bodies ) and intracytoplasmic inclusions ( Russell bodies )
are seen.
HE-2: LYMPHOMA
ORGAN: Spleen
Gross Findings: In the cut section of the spleen, numerous white-tan colored, slightly
elevated nodular masses can be seen.(approximately 0.6-0.8 cm. in dimension). This
leads to diffuse enlargement of the spleen.
Descriptive notes: These nodular masses are formed by neoplastic proliferation of small
B lymphocytes .
HE-3: LYMPHOID HYPERPLASIA
ORGAN: LYMPH NODE
Gross Findings: In the cut section of the lymph node, you see white color homogeneous
enlargement .
Descriptive notes: These enlargement of the lymph node is formed by follicular
hyperplasia .
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MUSCULOSKELETAL SYSTEM AND RELATED DISORDERS
NON-NEOPLASTIC DISEASES
V-23 OSTEOPOROSIS:
Osteoporosis is the increased porosity of the skeleton due to reduction in bone mass. It
is mostly seen in senile and postmenopausal patients. Your slide belongs to a 75 yearold woman who admitted to hospital with a femur fracture. X-ray examination revealed
a fracture at the neck of the femur and osteoporotic changes. She had an operation
and a prosthesis was replaced in her hip.
Microscopic findings: You will easily notice that the bone trabecula is thinned and lost
their interconnections (which is the reason for the fractures). Also you will see that the
bone marrow is mostly replaced by fat tissue. This is not a feature of osteoporosis but a
finding of senility.
V-12 NON-SPECIFIC OSTEOMYELITIS:
Osteomyelitis is the inflammation of bone and marrow. Altough all kinds of
microorganisms can cause osteomyelitis the most common etiologic agents are
pyogenic bacteria and mycobacteria. Your slides belong to a 12 year-old boy who
admitted to hospital with a complaint of fever, severe local tenderness and pain at the
lower end of left femur. Blood culture revealed S. aureus. X-ray showed a lytic focus of
bone destruction surrounded by a zone of sklerosis.
Microscopic findings: Note that normal histology of bone tissue is disturbed. Instead of
marrow, you see dense inflammatory cells mainly neutrophil leucocytes and necrosis.
You may also see lymphoid aggregates.
NEOPLASTIC DISEASES
BONE AND CARTILAGE FORMING TUMORS
V-15 OSTEOID OSTEOMA:
This is a benign bone tumor which is less than 2 cm in diameter and usually occurs in
teens and at the age of twenties. They can arise in any bone but 50% is in femur and
tibia and usually involves the cortex. They are painful lesions and the pain is
dramatically revealed by aspirin. Your slide belongs to a 15 year-old boy who admitted
to the hospital with a complaint of localised pain at his left shoulder. X-ray revealed a
radiolucent lesion of 1 cm in diameter at the metaphysic of the humerus. He went on an
operation with the clinical diagnosis of osteoid osteoma.
Microscopic findings: You will see a circumscribed lesion which is composed of
randomly interconnecting trabecula of woven bone that are rimmed by osteoblasts. The
stroma surrounding the tumor bone consists of loose connective tissue that contains
many dilated vessels.
V-17 CHONDROSARCOMA:
This is a malignant tumor which produces cartilage. Usually seen over the age of 40.
your slide belongs to a 46 year-old woman who admitted to hospital with a complaint of
a rapid growing mass around her pelvis. Her X-ray demonstrated a large lobular mass
27
with evidence of calcification and ossification. The mass appeared to arise from the
wing of left ilium. Hemipelvectomy is performed.
Macroscopic findings: The size of the tumor was 12x8x7 cm and it invaded soft tissues.
The cut surface was glistening and showed focal calcification.
Microscopic findings: ın your slides you are going to see a tumor quite similar to a
hyaline cartilage tissue. If you look closely you will notice that the neoplastic cells which
are embedded witin basophilic matrix are plump and in contrast to mature chondrocytes
two or three of them share the same lacunae. You may also notice the pleomorphism of
the neoplastic cells.
OTHERS
V-18 EWING SARCOMA:
Ewing sarcoma is an uncommon malignant bone tumor composed of small, uniform,
round cells belonging to a family of primitive neuroectodermal tumors of childhood.
Your slides belong to a 12 year-old girl who admitted to hospital with a complaint of
weight loss, fever, local tenderness and pain at the end of femur. X-ray showed a lesion
at the lower end of femur which was characterized by cortical thickening and medullary
widening and circumferential periosteal thickening (onion skin pattern).
Macroscopic findings: The cut sections of the surgical material revealed a soft tumor
which enlarged the medullary cavity. Cortex and periosteum were thickened.
Microscopic findings: You will see a diffuse infiltration of tumor cells and a little amount
vascular stroma among them. The neoplastic cells are small and uniform with round
nuclei and small nucleoli and inconspicious cytoplasmic outlines. Some of you may see
the rossette formation; tumor cells arranged around a secretory material.
V-19 GIANT CELL TUMOR:
Giant cell tumor is an uncommon benign but locally agressive neoplasm. Its’ name
comes from the osteoclast like giant cells disributed in the tumor. Your slides belong to
a 45 year-old woman who admitted to hospital with femur fracture. X-ray showed a
pathological fracture on the upper end of the femur. At the epiphysis there was an
extensively destructive osteolytic tumor.
Macroscopic findings: The cut section of the resected tumor showed multiple cysts,
cortical destruction and areas of hemorrhagic necrosis.
Microscopic findings: you will see a tumor composed of stromal cells and
multinucleated giant cells resembling osteoclasts. Stromal cells have oval vesicular
nuclei and scanty cytoplasms; these cells are the neoplastic cells of this tumor.
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RESPIRATORY SYSTEM AND RELATED DISORDERSCOURSE
Objectives for the students: At the end of this 4 hours practise, second year students
will be able to;
*recognize gross and microscopical changes in acute and chronic inflammation of the
respiratory system.
*recognize gross and microscopical changes in obstructive and interstitial lung disease
*recognize gross and microscopical changes in neoplastic disease of the respiratory
system.
NON-NEOPLASTIC DISEASES
K- 5 Pneumonia
Organ: Lung
CASE:A 52 year old man who complained of persistent cough, foul smelling sputum,
and shortness of breath, was admitted to our hospital. He was a heavy smoker of 36
years duration. He had dyspnea , mild cyanosis and fever. Despite treatment of a
variety of antibiotics, pneumonic infiltration of right lower lobe persisted and the patient
underwent lobectomy.
PATHOLOGICAL FINDINGS
Gross findings:HD-30 Macroscopic examination revealed patchy distribution of areas
of consolidation (slightly elevated, firm ,grayish-red and yellow poorly delimited areas).
Microscopic findings:This section is prepared from a consolidated area of this lobe. .
The walls of the bronchi are intensely infiltrated with inflammatory cells and their lumina
are filled with pus. In addition to the features you see alveoli filled with pink
homogenous fluid with few erythrocytes and polimorphonuclear leucocytes in it. You
may also see alveolar histiocytes. Try to find areas where neutrophilic exudate is more
prominent.
K-6 Tuberculosis
Organ: Lung
CASE:50 years old male patient who complained of cough and night sweet. Chest xray revealed bilateral shadow appeareance in the lung. He undervent lobectomy.
PATHOLOGICAL FINDINGS
Gross findings:HD-21 Macroscopically, lobectomy specimen has irregular, cystic
nodular area filled by cheesy material ( grey- white necrosis foci).
Microscopic findings: You’ll see several large granulomas with central caseification
necrosis. These granulomas are confluent, markedly surrounded with lymphocytic rim.
In high magnification you’ll recognize that granulomas are made of epithelioid
histiocytes and Langhans type multinucleated giant cells.
EZN staining demonstrated pink (ARB positive) mycobacterium bacilli in the necrosis
areas.
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K-7 Aspergillosis
Organ: Lung
CASE: A 3 year old boy has a history of recurrent fever and cough attack. On his
physical examination there was a solid mass ( abcess formations) on his right scapula.
Abscess fluid was drained and sent to culture. In culture, aspegillus was growth. On CT
exemination there was a mass on his right lung which is thought to be aspergillus. Right
lobectomy was performed.
Microscopic findings: You’ll see several large granulomas with central necrosis
associated with PMNL infiltration in lung parenchyma. In GMS(Gomori Methinamine
Silver) stain, you can easily see hyphae of the fungi in the center of granulomas as
black color.
K - 14 SARCOIDOSIS
Organ: Lung
CASE:Shortness of breath, cough, and chest pain were the presenting symptoms of a
32-year old male to the hospital. Chest radiograph showed both bilateral hilar lymph
node enlargement and pulmonary infiltrates. During mediastinoscopy, tiny, white
nodules were determined on the surface of the visceral pleura.
PATHOLOGICAL FINDINGS
Microscopic findings: This section is prepared from the mediastinoscopic biopsy of
this patient. The lung architecture is partially replaced by multiple isolated or confluent
aggregates of well-formed granulomas. Please try to identify the distribution pattern of
the granulomas, that is along the lymphatic route. They are situated subpleurally, along
the septa and around the bronchovascular bundles. Epithelioid cells with a few
scattered multinucleated giant cells of Langhans and foreign body type form the largest
part of the granulomatous structures.
Granulomas lack significant peripheral
lymphocytic rim but have abundant collagen deposits surrounding them. They are tight,
well formed and non-caseating.
NEOPLASTIC DISEASES
K-22 SQUAMOUS CELL CARCINAMA
Organ:Larynx
CASE:A 47 year-old male patient complained of difficulty in swallowing and
hoarseness. A laryngeal tumor was found.
PATHOLOGICAL FINDINGS
Gross findings:
Macroscopically the tumor was an ulcerating, fungating friable mass that arose from left
vocal cord and extended centrifugally.
Microscopic findings: This slide is prepared from the outer border of the tumor. You
can see luminal surface lined by metaplastic squamous epithelium. The edematous
stroma beneath the epithelium is invaded by the tumor. Tumor has highly differentiated
areas where squamous cells with large eosinophilic cytoplasms form nests with horn
pearls in them In less differentiated areas neoplastic cells having pleomorphic,
hyperchromatic nuclei and scanty cytoplasm, invade the stroma forming small groups
and cords. Notice the infiltration of lymphocytes and plasma cells.
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RS-1 SQUAMOUS CELL CARCINOMA
Organ: Lung
CASE:A-56-year old heavy smoker male admitted to the hospital with cough, sputum
and weight loss approximately 10 kg. in 2 months.Chest x-ray revealed solid mass in
his right lobe. Lobectomy was done.
PATHOLOGICAL FINDINGS
Gross findings: There is a necrotic, solid, white-tan colored, 5x4 cm. in diameter
tumoral mass in cental bronchus of the lobe. The other areas of the lung has patchy
black discoloration(antracosis) and mucin accumulation in the bronchioles.
RS-2 ADENOCARCINOMA
Organ: Lung
CASE:A-61-year old female admitted to the hospital with cough, weight loss. Chest xray revealed coin lesion in the peripheral area of her right lobe. There is no smoking
history. Lobectomy was done.
PATHOLOGICAL FINDINGS
Gross findings: There is a solid, well delinieated,white-tan colored,
diameter tumoral mass in periphery of the lobe.
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3x2 cm. in