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This tumor is in the area of the knee joint.

This is an OSTEOSARCOMA. It is the MC of
the malignant bone tumors. It occurs in younger
people, less than 20y/o. it is found MC in the
metaphysis of long bones (60% around the
knee) distal end of femur and proximal end of
tibia.

This histologic section of OSTEOSARCOMA

suggests malignancy. The pink areas that look
like collagen are osteiod (unmineralized bone)
and is diagnostic of osteosarcoma. Common
locaton = knee.
the mesenchymal cell here is what is malignant
and they act as osteoblasts and are making
osteoid. The osteoid is seen with cells on the
surface that look like osteoblast cells.

This is EWING'S SARCOMA. This primary bone tumor

mainly occurs in the diaphysis of long bones of children
and young adults. There is a slight male predominance. As
seen here, the irregular tan to red to brown tumor mass is
breaking through the cortex. More normal fatty marrow is
seen at the far right.
NOTES: ONION SKINNING!layering of periosteum
over the tumor.
1) ** Exam: ID

EWING'S SARCOMA is one of the "small round blue

cell" tumors histologically
NOTES:
Small malignant tumor of long bone, glycogen stain. Flat
bones of the pelvis, scapula and femur mid shaft
most often the sites of this tumor.
NEOPLASM OF THE FEMUR/DIAPHYSEAL
ONION SKINNING/PAS (+); GLYCOGEN STAINING
MIDSHAFT
Presents with fever, swelling, anemia, leukocytosis, pain
DDx!osteomyelitis
 MULTIPLE FOCI PALE IRREGULAR METASTASES.
The most common neoplasm in bone is a
metastasis. Metastases very common in the bone,
usually common from prostate and breast. Also,
from thyroid and lung cancer.

NOTES: Calcium is normal and !Alkaline phosphate

The most common primary bone tumors are
benign. The most common malignant primary
bone tumors are osteosarcomas.

This is an OSTEOCHONDROMA cut into three sections. A bluish-

white cartilagenous cap overlies the bony cortex. They are
benign. They are bone and cartilage-forming tumors.
NOTES:
o Develop from bones of the pelvis, scapula and ribs
o Young people get this.
o It’s an exophytic tumor where they often occur in the
growth plate
o Can lead to bone abnormalities, bony deformities
o It is rarely recognizable.
o Appears a lot on exams "
2) ** Exam: ID Osteochondroma

A "hot" joint that is swollen and tender may indicate an acute

suppurative arthritis. The gram stain shown here
demonstrates many neutrophils, one of which contains
gram negative intracellular diplococci indicative of
NEISSERIA GONORRHEAE infection.
most common cause of adult STD associated arthritis.
Classic presentation!sudden development of an acutely painful
and swollen infected joint that has a restricted range of
motion.

This is gout. Gouty arthritis results from deposition of sodium urate

crystals in joints. The joint most often affected is the first
MP joint (BIG TOE) as seen here. Acute attacks are
characterized by severe pain, swelling, and erythema of the
joint.
NOTES: Acute pain, red skin, big toe. Uric acid disease can be
treatable. Needle shaped crystals. Gout causes uric acid renal
stones, tophi in the kidney which can disrupt urinary flow,
renal failure. Gout can cause death. Nobody gets gout without
having elevated urate levels.
 PAGET'S DISEASE is seen in elderly Caucasians of European ancestry.
Under polarized light, the irregularities of the bony lamellae are
apparent, with a "tile-like" or "mosaic" pattern; where they are parallel
in a normal person.
NOTES:
* interlacing mosaic pattern of cement lines
Other clinical findings are urinary hydroxyproline, and elevated
alkaline phosphatase (but the serum calcium and parathyroid hormone
are not)
This is a dz of high metabolism.

• This baby's extremities are positioned oddly because there have

been multiple fractures d/t OSTEOGENESIS IMPERFECTA
(OI). The basic problem is a defect in the formation of TYPE 1
COLLAGEN that forms bone matrix. There are several types of
OI with different inheritance patterns

• NOTES: Multiple fractures, Brittle bones, group specific gene

mutations, definitions in collagen syntehesis. BLUE SCLERA,
childhood fractures. Dz of Collagen type 1.

• 3) Exam: Disorder of collagen

Note the WEDGE-SHAPED AREA OF AVASCULAR

NECROSIS (osteonecrosis = infarct) at the upper right
of this femoral head just beneath the cartilage.
Avascular necrosis (is the term used to describe bone
infarct) results from bone ischemia, which can be due to
many causes, including:
1- Trauma ( fracture)
2- MC is CORTICOSTEROID ADMINISTRATION
3- Sickle cell
4- The bends theory (diving ! decompression)
5- Idiopathic cases.

There is pain with activity, progressing to pain at rest.

Eventually, the necrotic bone collapses, distorting the
overlying and can cause secondary osteoarthritis.
(subchondral infarcts)
4) **Exam: secondary osteoarthritis
This is the synovium in RHEUMATOID ARTHRITIS. There is chronic
inflammation with lymphocytes and plasma cells that produce
the blue areas beneath the nodular proliferations. This "pannus"
is destructive and produces erosion of the articular cartilage,
eventually destroying the joint.
Typical features of Rheumatoid arthritis ( question):
Inflammation of synovium.+ It grows across the joints ! PANNUS **
NOTES:
Systemic Dz. Typically women. Mostly affects small joints of
hands and feet, then wrists, elbows, ankles & knees symmetrically.
Rheumatoid nodules seen all over including joints. Serum
rheumatoid factor. Articular cartilage cells are dying b/c of
inflammation. Erosion of bone d/t activation of T4 lymphocytes.
Prone to osteoporosis.

• Here is a "brown tumor" of bone in a patient with

hyperparathyroidism. The high parathyroid hormone levels
increase osteoclast activity and produce irregular bone
resorption with microfractures, hemorrhage, macrophage
proliferation, and fibrous connective tissue proliferation.
NOTES:
• Increase in serum alkaline phosphate, normal calcium and
phosphate. Involves spine, pelvis, calvarium of the skull, femur
and tibia.
• Bone Pain. Abnormal bony architecture.
• Increase in osteoclasts!erode bone matrix and mobilize
calcium salts particularly in the metaphyses of long tubular
bones.
• Bone resorption is accompanied by increased osteoblastic
activity.
• Mosaic pattern. Heavy bones, skull could get bigger.
• History: Hypercalcemia!brown tumor of hyperparathyroidism.
• What pathology of parathyroid that can lead to this? Adenoma
or generalized hyperplasia of parathyroid
• Known as generalized osteitis fibrosa cystica (von
Recklinghausen disease of bone)

The pale areas seen here are tophi, or nodular aggregates of

uric acid crystals surrounded by infiltrates of
lymphocytes, macrophages, and foreign body giant cells. A
TOPHUS is the characteristic finding of gout. Tophi are
most likely to be found in soft tissues, including tendons
and ligaments, around joints. Less commonly tophi appear
elsewhere. Tophaceous gout results from continued
precipitation of sodium urate crystals during attacks of
acute gout.
 Note the spindle cells without herring bone. Note the
Soft tissue mass in retroperitoneum,
cross-striations a/w RHABDOMYOSARCOMA.
spindle cells, slightly malignant.
Common in children. Common sites are Head, Neck,
RHABDOMYOSARCOMA
Nose, Female genital tract.
Stain for ACTIN/MYOSIN/DESMIN.
5) ** Exam: stain w/ Desmin
" The coronary artery shown here has narrowing of
the lumen due to build up of
ATHEROSCLEROTIC PLAQUE. Severe
narrowing can lead to angina, ischemia, and
infarction.
NOTES: Cholesterol clefts. When is this important?
This can lead to acute death of tissue.
Complication is occlusive thrombosis b/c of
hemorrhage of plaque.

" There is a pink to red recent THROMBOSIS in this

narrowed coronary artery. The open, needle-like spaces in
the atheromatous plaque are cholesterol clefts. As a
complication, this will get patient into trouble.

HEMORRHAGE ! THROMBUS ! OCCLUSION.

 SECOND

Must know ! EXAM!

This is the left ventricular wall which has been
sectioned length-wise to reveal a large Recent
MYOCARDIAL INFARCTION. The center of the
infarct contains necrotic muscle that appears
YELLOW-TAN (Pus). Surrounding this is a zone of
red hyperemia. Remaining viable myocardium is
reddish-brown.

Yellow-Tan color (Pus) indicates a time period of 48-72

hours post-acute infarct. 2-3 days!
Later ! Granulation tissue ! Scarring.
Scarring appears white in micro section.

FIRST
This high power microscopic view of the myocardium
demonstrates an infarction of about 1 to 2 days in
duration. The myocardial fibers have dark red
contraction bands extending across them. The
myocardial cell nuclei have almost all disappeared. There
is beginning Acute Inflammation. Clinically, such an
acute myocardial infarction is marked by changes in the
EKG and by a rise in the MB fraction of Creatine Kinase.
NOTES:
Evidence of Coagulation Necrosis! Loss of striations,
Loss of nuclei

THIRD

There is PALE-WHITE collagen within the

interstitium between myocardial fibers. This
represents an area of an old infarction !
FIBROUS SCAR.

Yellow! Acute
White ! Old Infarct ! 7-28 days old
This is an Intermediate Myocardial Infarction of 1 to 2
weeks in age. Note that there are remaining normal
myocardial fibers at the top. Below these fibers are
many macrophages along with numerous capillaries and
little collagen.

An AORTIC DISSECTION may lead to hemopericardium when

blood dissects through the media proximally. Such a
massive amount of hemorrhage can lead to fatal CARDIAC
TAMPONADE
NOTES:

• Commonly associated with Hypertension or with Cystic

Medial Necrosis

• Trauma to the free wall. Blood will go to the pericardial

sac, decrease in pressure and output.

• Causes! Knife through heart (trauma), some kind of

dissection (DISSECTING HEMATOMA)

This aorta has been opened longitudinally to reveal an

area of fairly limited dissection that is organizing. The
red-brown thrombus can be seen on both sides of the
section as it extends around the aorta. The intimal
tear would have been at the left. This creates a
"double lumen" to the aorta.
Common risk factors:
- # 1 most important cause is HYPERTENSION!
- Atherosclerosis.
- Cystic Medial Necrosis ! Degenerative changes in
the media w/destruction of elastic & muscular tissue
- 6) ** Exam: most likely caused by Hypertension

This aortic dissection occurred just above the aortic root in a

patient with Marfan's Syndrome. The tear extends across
the aorta. Hemopericardium with tamponade occurred
within minutes of this event.
 " This section is from the kidney, but this can occur in
"
any other part of the body which has MEDIUM-SIZED
VESSELS.
This is a form of arteriolosclerosis. The arteriole here has
an "ONION-SKIN" appearance typical of
HYPERPLASTIC/Hypertrophic arteriolosclerosis. This
lesion is most often associated with MALIGNANT
HYPERTENSION!**

" One complication of Hyperplastic Arteriolosclerosis

with malignant hypertension is FIBRINOID
NECROSIS , as seen here in a renal arteriole (red
spots)
Common in SMALL VESSELS.

" The left atrium has been opened to reveal the most common primary
cardiac neoplasm--an ATRIAL MYXOMA. These benign masses are
most often attached to the atrial wall, but can arise on a valve or in a
ventricle. They can produce a "ball valve" effect by intermittently
occluding the atrio-ventricular valve orifice. Embolization of
fragments of tumor may also occur. Myxomas are easily diagnosed by
echocardiography. They may also be seen with chest CT scan and with
magnetic resonance angiography.
NOTES: Common benign tumor.
Most common symptom is ! SYNCOPE

" This is CONCENTRIC HYPERTROPHY of the

heart. The left ventricle is markedly thickened
in this patient. Heart may weigh 400-500 g
Mainly caused by CALCIFIC AORTIC STENOSIS**.
Can also be caused by severe untreated hypertension,
but will not cause as much hypertrophy.
 " Patients with GIANT CELL ARTERITIS may have
a visible firm, palpable, painful Temporal Artery
that courses over the surface of the scalp.
Complication is Blindness!
7) On exam w/ next slide

" GIANT CELL (Temporal) Arteritis is uncommon before age

50. The sedimentation rate is often markedly elevated (100
mm/hr or more). Half of patients have Polymyalgia
Rheumatica. The focal granulomatous inflammation with
narrowed arterial lumen is seen here at high magnification.
NOTES: Complication is Blindness!
7) ** Exam: Giant Cell Granulomatous Arteritis

" Quiet! This is a LARYNGEAL NODULE (laryngeal polyp) that is a

reactive lesion which results most often from over use of the
voice (e.g., a "singer's nodule") or from smoking. Such polypoid
lesions are typically found on the true cord and covered by
squamous epithelium. They may impart a hoarse quality to the
voice, but they Do Not result in malignancy, though larger
ones (up to 1 cm) may ulcerate.
NOTES: Vocal cords, shouts a lot, hoarseness and squamous cell
epithelium, keratin pearls. Bad usage of the voice seen in
opera singers. Commonest symptom is HOARSENESS!
8) ** Exam: Laryngeal nodule

" This is a surgical resection of the epiglottis. Note the

exophytic SQUAMOUS CELL CARCINOMA.
The mass extends from the surface as irregular tan nodules and
Papilations.

. Squamous cell carcinomas in the upper airways are often

associated with a history of SMOKING AND ASBESTOS!**
NOTES:
- Vocal cord laryngeal carcinoma
- Associated as a cause is Smoking & Asbestoses,
" The enlarged Parotid Gland seen here at low power has
extensive lymphoid infiltrates and even a germinal center
just left of center. Such an intense mononuclear infiltrate
could be seen early in SJOGREN'S SYNDROME, an
autoimmune disease that involves salivary glands (with
Xerostomia) and lacrimal glands (with xerophthalmia).
NOTES: There is an increased risk for LYMPHOMA!

" Here is a "purple cow" or a lesion with a very

distinctive histologic appearance. This is a BENIGN
Papillary Cystadenoma Lymphomatosum, or
WARTHIN'S TUMOR of SALIVARY GLAND. A
rim of compressed normal parenchyma is seen at the
left. This is the second most common salivary gland
tumor. It is almost always found in the parotid gland, is
much more common in males, and in some cases can be
multi-focal or bilateral.
It has a characteristic feature of lots of lymphoid
tissue and is partially cystic which has papillary
epithelium.
Another benign tumor of the salivary gland is
Pleomorphic Adenoma which is also common.

" The low power microscopic appearance of a

PLEOMORPHIC ADENOMA (mixed tumor) of salivary
gland is shown here at the top and center extending into
surrounding normal parotid gland. Pleomorphic Adenomas
are the most common salivary gland tumor, and the
most common location for them is in the parotid gland.
These lesions are usually slow-growing, but can recur
following incomplete resection, since they are not strictly
encapsulated.
They are characterized by being solid tumors with a
granular area of some cartilaginous or mucinous looking
areas making up the stroma.
" Pulmonary congestion with dilated capillaries and leakage of
blood into alveolar spaces leads to an increase in
HEMOSIDERIN-LADEN MACROPHAGES, as seen here.
Brown granules of Hemosiderin from breakdown of RBC's
appear in the macrophage cytoplasm. These macrophages
are sometimes called "Heart Failure Cells" because of
their association with pulmonary congestion and with
Congestive Heart Failure.
NOTES: Chronic edema of the lung due to heart failure ! Left
Heart Failure
Patient will present with a productive cough. Sputum is blood
tinged.

" This is an example of HYALINE MEMBRANE formation !

ARDS.
This is the microscopic appearance of Diffuse Alveolar Damage
(DAD) in the lung. DAD is simply the final common pathway
for a variety of severe lung injuries. In early DAD, there
are hyaline membranes, as seen here, lining alveoli. Later,
Type II Pneumocyte proliferation and then interstitial
inflammation and fibrosis are seen. High oxygen tensions
needed to treat the hypoxia resulting from DAD and its
etiologies further exacerbates this disease!
NOTES: A/W Severe Head Injury, DIC, Aspirations,
Pancreatitis or Severe Burns.
50% Mortality! Treat with high levels of O2.
9) ** Exam: Hyaline

" Both Restrictive and Obstructive lung diseases can affect

the pulmonary arterial circulation. The loss of normal lung
parenchyma leads to PRIMARY PULMONARY
HYPERTENSION that leads to thickening of the small
arteries along with reduplication to form a PLEXIFORM
LESION, as seen here in a peripheral pulmonary artery, on
the left with H&E stain and on the right with elastic
tissue stain.
Exam material " ! KNOW! 10)**Exam: plexiform
capillary
" A closer view of " The cut surface of this lung
LOBAR PNEUMONIA demonstrates the typical
demonstrates the appearance of a
distinct difference BRONCHOPNEUMONIA with
between the upper lobe areas of tan-yellow
and the Consolidated consolidation. Remaining lung is
Lower Lobe. dark red because of marked
Radiographically, areas of pulmonary congestion.
consolidation appear as Bronchopneumonia (lobular
infiltrates. pneumonia) is characterized by
patchy areas of pulmonary
NOTES: ! of lung is consolidation. These areas
consolidated. A/w become almost confluent in the
BACTERIA. left lower lobe on the bottom
left of the photograph. The
Remember: Viral vs Bacterial. areas of consolidation are
firmer than the surrounding
Viral ! Interstial reaction lung.
Bacterial ! Reaction within
alveoli. Remember: Patch Consolidation for
Bronchopneumonia.
Strep. Pneumonia is the most
common cause for lobar There is also a tumor which looks
pneumonia. like bronchopneumonia !
Bronchoalveolar Carcinoma.
" There is a small Tan-Yellow
subpleural granuloma in the mid-lung
field on the right. In the hilum is a
small yellow tan granuloma in a hilar
lymph node next to a bronchus
(outer region) . This is the "GHON
COMPLEX" that is the characteristic
gross appearance with Primary
Tuberculosis. In most people, the
granulomatous disease will not
progress. Over time, the granulomas
decrease in size and can calcify,
leaving a focal calcified spot on a
chest radiograph that suggests
remote granulomatous disease.
NOTES: PPD Positive
Patient presents usually with Weight
Loss, Night Sweats and Cough.
Secondary TB will present in the
upper lobes. It is a necrotizing
process which results in cavitations.
" Classic Pneumonia. ALVEOLI ARE FILLED
WITH INFLAMMATORY CELLS
(NEUTROPHILLS)! INTRA-ALVEOLAR
PROCESS ! BACTERIAL.

The alveolar structure is still maintained, which is

why a pneumonia often resolves with minimal
residual destruction or damage to the lung.
NOTES: Pulmonary changes of a septic pneumonia
usually a/w strep pneumoniae
Viral pneumonia is interstitial process (alveolar walls
will be thickened).
** 11) Give antibiotics

Upon closer inspection, the pattern of patchy distribution of a

bronchopneumonia is seen. The consolidated areas here very closely
match the pattern of lung lobules (hence the term "lobular"
pneumonia). A bronchopneumonia is classically a "hospital acquired"
pneumonia seen in persons already ill from another disease process.
Typical bacterial organisms include: Staphylococcus aureus,
Klebsiella, E. coli, and Pseudomonas.

11)** Exam w/ previous slide: What would you give to this patient?
Antibiotics

" Microscopic view of a CASEATING

NECROSIS formation as a result of TB with
Giant cells.

If given a history of a black woman, young,

biopsy shows many small granulomas, especially
in the hilar region, with absent nodes in the neck
and around the neck then ! SARCOIDOSIS.
 " This shows the ACID-FAST nature
of Mycobacterium Tuberculosis.

" The chest cavity is opened at autopsy to reveal numerous large BULLAE
apparent on the surface of the lungs in a patient dying with
EMPHYSEMA. Bullae are large dilated airspaces that bulge out from
beneath the pleura. Emphysema is characterized by a loss of lung
parenchyma by destruction of alveoli so that there is permanent dilation
of airspaces which produces blebs.
NOTES:
# NOT A DISEASE OF FIBROSIS
# Obstructive lung dz are
o Asthma
o Emphysema (results from smoking and 1 anti-trypsin def. )
o Chronic bronchitis
o Bronchiectasis

EXAM what is the most likely cause of this patients death?

*** TENSION PNEUMOTHORAX resulting from ruptured bullae
12) **Exam: protease-antiprotease theory

Microscopically at high magnification, the loss of

alveolar walls with EMPHYSEMA is demonstrated.
Remaining airspaces are dilated
 " Here is a "SADDLE EMBOLUS" that bridges across
the pulmonary artery from the heart as it divides into
right and left main pulmonary arteries. Such a saddle
embolus is a cause for sudden death. This
thromboembolus displays the typical gross appearance.
The surface is somewhat irregular, and there are areas
of pale tan to white admixed with dark red areas. The
thrombus often has the outlines of the vein in which it
formed.
NOTES: Pt was probably bedridden or not moved on a
long flight
Most commonly the thrombus arises from deep veins of
the legs and pelvis. NOT from varicose veins.

" " Large THROMBOEMBOLI can cause death. Medium sized

thromboemboli (blocking a pulmonary artery to a lobule or set of
lobules) can produce the lesion seen here--a hemorrhagic pulmonary
infarction, because the patient survives. The infarct is wedge-
shaped and based on the pleura. These infarcts are hemorrhagic
because, though the pulmonary artery carrying most of the blood
and oxygen is cut off, the bronchial arteries from the systemic
circulation (supplying about 1% of the blood to the lungs) is not cut
off.

NOTES: Why are infarcts rare? B/c of dual blood supply

" This is a larger SQUAMOUS CELL CARCINOMA in

which a portion of the tumor demonstrates central
cavitation, probably because the tumor outgrew its blood
supply. Squamous cell carcinomas are one of the more
common primary malignancies of lung and are most often
seen in smokers. HYPERCALCEMIA!
NOTES:
Note the cavitations. D/D TB, abscesses, histoplasmosis.
 " In this SQUAMOUS CELL CARCINOMA at the upper
left is a squamous eddy with a KERATIN PEARL. At the
right, the tumor is less differentiated and several dark
mitotic figures are seen. NOTES: This is a well
differentiated sq cell carcinoma.
" HYPERCALCEMIA!

" This is the microscopic pattern of a SMALL CELL

ANAPLASTIC (OAT CELL) CARCINOMA in which small dark blue
cells with minimal cytoplasm are packed together in sheets. Oat cell
carcinomas, which are a highly malignant form of neuroendocrine
tumor, are often associated with PARANEOPLASTIC SYNDROMES
from hormonal effects. The ectopic ACTH syndrome and the
syndrome of inappropriate ADH are two such syndromes.

NOTES: to make sure this is not a lymphoma test for lymphocytes

common antigen.

If HYPERCALCEMIA ! think SQUAMOUS CELL CARCINOMA of

the lung.

" This is the causative agent for ASBESTOSIS.

This long, thin object is an asbestos fiber.
Some houses, business locations, and ships still
contain building products with asbestos,
particularly insulation materials, so care must
be taken when doing remodeling or
reconstruction
* This is a sputum sample with Asbestos bodies
seen. Can be stained with hemosiderin stain
b/c asbestos bodies are coated with
hemosiderin.
This is not a proof of asbestoses.
Asbestos exposure can lead to mesothelioma ~ 20-
40 yrs latency.
• " Regardless of the etiology for restrictive lung
diseases, many eventually lead to extensive
FIBROSIS. The gross appearance, as seen here in a
patient with organizing diffuse alveolar damage, is
known as "honeycomb" lung because of the
appearance of the irregular air spaces between
bands of dense fibrous connective tissue

• HAMMEN-RICH SYNDROME, or diffuse

proliferative fibrosis

• Obstructive disease does not involve fibrosis.

(COPD, bronchiectasis, bronchitis, asthma)

" A trichrome stain highlights the collagenous connective

tissue of pulmonary FIBROSIS in blue. The extent of the
fibrosis determines the severity of disease, which is
marked by progressive worsening dyspnea.
The classic idiopathic lung fibrosis is known as HAMMEN-
RICH SYNDROME

This is an example of BENIGN PROSTATIC

HYPERPLASIA. Nodules appear mainly in the
lateral lobes. Such an enlarged prostate can
obstruct urinary outflow from the bladder and
lead to an obstructive uropathy. Therefore must
be resectioned/removed.

Notes: Pt is having difficulty urinating, waking up at

night, having difficulty in maintaining a stream.

It is a central process, occurs around the urethra.

Where as cancer, is usually in the posterior lobe, and
less detectable b/c it produces a few symptoms.
 At higher magnification, the enlarged prostate has glandular
hyperplasia. The glands are well-differentiated and still
have some intervening stroma. The small laminated pink
concretions within the glandular lumen are known as
corpora amylacea.
NOTES: Noted convoluted pattern. Preservation of corpora
amylacea.

There are large glands with serrated edges and a double layer of
nuclei. (Single layer of nuclei indicates cancer)

Obstruction from nodular prostatic hyperplasia has led to

prominent TRABECULATION seen on the mucosal
surface of this bladder with hypertrophy. The
stasis from obstruction predisposes to infection.
The obstruction can also lead to bilateral
hydroureter and hydronephrosis.
NOTES: Where is the obstruction most likely to be?
Bladder Neck.

The enlarged prostate gland seen here not only has enlarged
lateral lobes, but also a greatly enlarged median lobe
that obstructs the prostatic urethra. This led to
obstruction with bladder hypertrophy, as evidenced
by the prominent trabeculation of the bladder wall
seen here from the mucosal surface. Obstruction with
stasis also led to the formation of the yellow-brown
calculus (stone).

Multiple Small round glands close to the periphery of the

prostate gland ! PROSTATE CANCER.

EXAM GLEASON system is used to grade

prostate cancer. ( He has a grading and scoring system)
•GRADING:In the Gleason system, grades 1-5 are given
to the predominant pattern & 1-5 to the second most
predominant pattern giving a combined score of 1+1= 2
At high magnification, this poorly differentiated
PROSTATIC ADENOCARCINOMA demonstrates
cells with nucleoli and mitotic figures.
NOTES; Notice the SMALL GLANDS, single layer of
nuclei, plenty of nucleoli.
Why are you more likely to palpate cancer at an early
stage? B/c it is hard and it tends to go
PERIPHERALLY. Favors posterior lobe.
Four things you need to do
1. PSA screen
2. Palpate
3. Biopsy (transrectal)
4. conventional Tx
13) **Exam: small glands, prominent nuclei

Here is a large hydrocele of the testis. Such HYDROCELES are

fairly common. Clear fluid accumulates in a sac of tunica
vaginalis lined by a serosa with a variety of inflammatory
and neoplastic conditions. A hydrocele must be
distinguished from a true testicular mass, and
TRANSILLUMINATION may help, because the hydrocele
will transilluminate but a testicular mass will be opaque.

This is the histologic pattern of the typical SEMINOMA.

Lobules of neoplastic cells have an intervening stroma with
characteristic lymphoid infiltrates. The seminoma cells are
large with vesicular nuclei, and pale watery cytoplasm
NOTES:

! CLEAR CELLS (“FRIED EGG APPEARANCE”)

! Lymphocytic infiltrate.
!Tumor of people in late 20’s early 30’s

This slide is almost undiagnosable/ undistinguishable.

Use the markers to determine.

!-hCG is elevated in choriocarcinoma. Patient is about 35 yo

"-fetoprotein is elevated in yolk sac tumor. Yolk sac in

child.
 VARICOCELE!
Note the bag of worms which can lead to
Infertility.

Here is a "HORSESHOE" kidney. This is a congenital anomaly

that most often occurs in association with other anomalies
or syndromes with specific genetic defects such as
TRISOMY 18- Edwards Syndrome. However, it can also
occur as an isolated anomaly. The possible problem here is
that the ureters take an abnormal course across the
"bridge" of renal tissue and this can lead to partial
obstruction with hydronephrosis

This child died soon after premature birth at 23 weeks

gestation from pulmonary hypoplasia as a result of
oligohydramnios. The oligohydramnios resulted from
markedly diminished fetal urine output as a consequence of
POLYCYSTIC KIDNEY DISEASE. Note the bilaterally
enlarged kidneys that nearly fill the abdomen below the
liver. The histologic appearance in this case, coupled with
the gross appearance, was consistent with RECESSIVE
polycystic kidney disease (RPKD).
Notes: Assoc. w/ pulm. Dysplasia & congenital hepatic fibrosis
May lead to portal HTN and splenomegaly! early death

Here is the microscopic appearance of recessive polycystic

kidney disease (RPKD). Note that the cysts fill most of the
parenchyma, and it is hard to find glomeruli. Many of the cysts
are elongated ovoid shaped and are at right angles.

The cysts in the dominant type are large round cysts. They also
get BERRY ANEURYSMS, and multiple cystic disease where
they have involvement of their other organs (pancreas and liver)
Notes: aneurysms ! subarachnoid hemorrhage
Also assoc. w/ hepatic cysts
 The tubular vacuolization and dilation here is a result of
ETHYLENE GLYCOL (ANTI-FREEZE) POISONING. This
is representative of acute tubular necrosis (ATN), which
has many causes. ATN resulting from toxins usually has
diffuse tubular involvement, whereas ATN resulting from
ischemia (as in profound hypotension from cardiac failure)
has patchy tubular involvement.

NOTES: kidney biopsy with marked ballooning degeneration of

the epithelial cells.

Exam Suicidal patient drank it.

This is a RENAL CELL ADENOCARCINOMA arising in the lower POLE of the

kidney. It is fairly circumscribed. The cut surface demonstrates a
variegated appearance with yellowish areas, white areas, brown areas,
and hemorrhagic red areas. Though these neoplasms are usually slow-
growing, they can often reach a considerable size before detection
because there is a lot of room to enlarge in the retroperitoneum and
there is another kidney to provide renal function. Thus, presenting
symptoms and signs usually include flank pain, mass effect, and
hematuria.
NOTES: classic pathology of renal cell ca is clear cells which gives it the
yellow color. This CA can grow along the renal vein up to the IVC to
the right side of the heart.

Exam Know the PARANEOPLASTIC effects of this tumor.

1- POLYCYTHEMIA** (increase # of rbc due to $ erythropoietin)
2- hypercalcemia.
3- cushing
4- leukomoid reaction

This is the classic histologic appearance of a renal

cell carcinoma: the neoplastic cells have clear
cytoplasm and are arranged in nests with
intervening blood vessels. This appearance is why
they are often called "clear cell carcinomas".
The HYPERCELLULARITY of post-streptococcal
glomerulonephritis is due to increased numbers of
epithelial, endothelial, and mesangial cells as well as
neutrophils in and around the capillary loops. This disease
may follow several weeks after infection with certain
strains of group A beta hemolytic streptococci. Patients
typically have an elevated anti-streptolysin O (ASO)
titer .
The immune complexes being deposited is what causes the
problem, not the organism. (Type III Hypersensitivity)

This is NODULAR GLOMERULOSCLEROSIS (the

Kimmelstiel-Wilson disease) of diabetes mellitus. Nodules
of pink hyaline material form in regions of glomerular
capillary loops in the glomerulus. This is due to a marked
increase in mesangial matrix from damage as a result of
non-enzymatic glycosylation of proteins.
Exam This occurs mainly as a result of LONG
STANDING DIABETIC NEPHRITIS.
14) **Exam: diabetic patient

Seen here within the glomeruli are CRESCENTS

composed of proliferating epithelial cells. Crescentric
glomerulonephritis is known as RAPIDLY PROGRESSIVE
GLOMERULONEPHRITIS (RPGN) because this disease
is very progressive. There are several causes, and in this
case is due to SLE. Note in the lower left glomerulus
that the capillary loops are markedly thickened (the so-
called "wire loop" lesion of lupus nephritis).

Crescents= Rapidly Progressive Glomerulonephritis

This small ADENOMATOUS polyp (tubular adenoma) on a
small stalk is seen microscopically to have more
crowded, disorganized glands than the normal
underlying colonic mucosa. Goblet cells are less
numerous and the cells lining the glands of the
polyp have hyperchromatic nuclei. However, it is
still well-differentiated and circumscribed, without
invasion of the stalk, and is BENIGN. Two
colonoscopic views of a small polyp that proved to be
a tubular adenoma are seen below.
All polyps of the colonic mucosa must be taken out because
they are all believed to arise from DYSPLASIA.

Hamartomatus polyps and hyperplastic polyps are very

benign. They give the least problems.

Another cause for inflammation is a so-called

"BARRETT'S ESOPHAGUS" in which there is gastric-
type mucosa above the GASTROESOPHAGEAL
JUNCTION. The metaplasia results from chronic
gastroesophageal reflux disease (GERD). Note the
columnar epithelium to the left and the squamous
epithelium at the right. This is "typical" Barrett's
mucosa, because there is intestinal metaplasia as well
(note the GOBLET CELLS in the columnar mucosa).
NOTE: Note the goblet cells which are not found in
the stomach.
Barrets esophagus increases the risk of
adenocarcinoma.
15) ** Exam: most likely cause adenocarcinoma
BARRETS ESOPHAGUS= ADENOCARCINOMA

This irregular reddish, ulcerated exophytic

MID-ESOPHAGEAL mass as seen on the
mucosal surface is a squamous cell carcinoma.
Endoscopic views of an ulcerated mid-
esophageal squamous cell carcinoma causing
lumenal stenosis are seen below. Risk factors
for esophageal squamous carcinoma include
mainly SMOKING & ALCOHOL in the U.S. In
other parts of the world dietary factors may
play a role.
 The normal tan upper esophageal mucosa is at the
far left. The distal esophagus is replaced by Barrett
mucosa, producing a darker, slightly erythematous
gross appearance. In the distal esophagus has arisen
a large ulcerating adenocarcinoma that extends into
the upper stomach. Adenocarcinomas can arise in
Barrett esophagus
NOTES: Pt must have had chronic reflux leading to
gastric metaplasia. Strong association with H. pylori.

Mid-Esophagus= SQUAMOUS CELL CARCINOMA

due to Smoking/Alcohol (May cause obstruction of
lumen)

Distal Esophagus= ADENOCARCINOMA due to

CHRONIC GERD

This is an example of LINITIS PLASTICA, a diffuse

infiltrative gastric ADENOCARCINOMA which gives
the stomach a shrunken "LEATHER BOTTLE"
appearance with extensive mucosal erosion and a
markedly thickened gastric wall. This type of carcinoma
has a very poor prognosis. The endoscopic view of this
lesion is shown below, with extensive mucosal erosion.

Exam if you take a biopsy you will find

SIGNET RING CELLS

This is a SIGNET RING CELL pattern of

adenocarcinoma in which the neoplastic cells are
filled with cytoplasmic mucin vacuoles that
compress the nucleus to one side, as shown at the
arrow.
Signet ring cell adenocarcinomas are poorly
differentiated and tend to be highly invasive.
They tend to metastasize to the ovaries causing
bilateral enlarged ovaries which are filled with
single ring cells ! krukenberg tumor.
 This is a COLONIC ADENOCARCINOMA arising in a villous
adenoma. The surface of the neoplasm is polypoid and
reddish pink. Hemorrhage from the surface of the tumor
creates a guaiac positive stool. This neoplasm was located in
the sigmoid colon, just out of reach of digital examination,
but easily visualized with sigmoidoscopy.
NOTES: KNOW CLASSIFICATIONS
A! limited to the mucosa
B1!extending into the muscularis propia but not
penetrating through it; uninvolved nodes
B2!penetrating through the muscularis propia; uninvolved
nodes
C1!extending into the muscularis propia but not
penetrating through it; involved nodes
C2!penetrating through the muscularis propria; involved
nodes
D!distant metastatic spread

ULCERATIVE COLITIS has the characteristic PSEUDOPOLYPS

which can be seen clearly as raised red islands of inflamed mucosa.
Between the pseudopolyps is only remaining muscularis. However,
the process is primarily mucosal, without transmural inflammation
and without fistula formation.
NOTES: Young person passing blood & mucous; spasmatic periods of
diarrhea, abdominal pain!Ulcerative colitis

Know the differences:

UC Crohns
Large & small bowel
Rectum Anal region
Develops on Left Develops on right
Cobblestone appearance
Skip Lesions
Pseudopolyps Transmural inflammation
Higher risk for malignancy a risk for malignancy
Fistula

The colonic mucosa of active ulcerative colitis shows "CRYPT

ABSCESSES" in which a neutrophilic exudate is found in
glandular lumens of crypts of Lieberkuhn. The submucosa
shows intense inflammation. The glands demonstrate loss
of goblet cells and hyperchromatic nuclei with
inflammatory atypia.

NOTES: See the glands filled with cluster of neutrophils

Crypt abcesses can be seen in both crohn and UC, but more in
UC.
 An ADENOCARCINOMA OF THE HEAD OF THE
PANCREAS is shown here obstructing the pancreatic
duct. This may well have produced a "painless jaundice" in
the patient. Adenocarcinomas at this site have a very poor
prognosis, even if a Whipple procedure is done, as shown
here.
NOTES: Remember one of the most horrible dzs is
pancreatic cancer. Keep in mind that the head of the
pancreatic tumor will produce clinically enlargement of
gall bladder b/c it is likely to occur slowly. This is a/w
drinking and smoking.
The patient will present with a DISTENDED GALL-
BLADDER. The history for this patient will include, that
he/she never had a history of distended gallbladder.

• This portion of terminal ileum demonstrates the gross

findings with Crohn's disease. Though any portion of the
gastrointestinal tract may be involved with Crohn's
disease, the small intestine--and the terminal ileum in
particular--is most likely to be involved. The middle portion
of bowel seen here has a thickened wall and the mucosa
has lost the regular folds. The serosal surface
demonstrates reddish indurated adipose tissue that creeps
over the surface. Serosal inflammation leads to adhesions.
The areas of inflammation tend to be discontinuous
throughout the bowel. The endoscopic appearance with
colonoscopy, demonstrating mucosal erythema and
erosion, is seen below

Exam "
This is an example of a MICRONODULAR CIRRHOSIS. The
regenerative nodules are quite small, averaging less than 3 mm in
size. The most common cause for this is chronic ALCOHOLISM.
The process of cirrhosis develops over many years.
16) Exam: cause ascites

Microscopically with cirrhosis, THE REGENERATIVE NODULES

OF HEPATOCYTES ARE SURROUNDED BY FIBROUS
CONNECTIVE TISSUE that bridge between portal
tracts. Within this collagenous tissue are scattered
lymphocytes as well as a proliferation of bile ducts.
NOTES: Micronodular cirrhosis.

Major effect is OBSTRUCTION OF PORTAL VEIN! PORTAL

 At high magnification can be seen globular red hyaline
material within hepatocytes. This is MALLORY'S
HYALINE (MALLORY BODIES) , also known as
"alcoholic" hyaline because it is most often seen in
conjunction with chronic ALCOHOLISM. The globules
are aggregates of intermediate filaments in the
cytoplasm resulting from hepatocyte injury.

This is an example of a "NUTMEG" LIVER seen

with chronic passive congestion of the liver. It is
an ischemic event where accumulation of blood
around the central vein occurs.

Exam It is associated with chronic

heart failure.

A green tumor (making bile) in the liver is not

likely to be metastatic, it is HEPATOCELLULAR
CARCINOMA. It is also cirrhotic. Remember the
ultimate complication of cirrhosis is
hepatocellular carcinoma.
“Solitary” lesion

Hepatocellular carcinoma
Can see bile inclusions
 - Note the numerous mass lesions that are of variable
size. Some of the larger ones demonstrate central
necrosis.

- The masses are METASTASES to the liver. The

obstruction from such masses generally elevates alkaline
phosphatase, but not all bile ducts are obstructed, so
hyperbilirubinemia is typically not present. Also, the
transaminases are usually not greatly elevated.

If nodules are dark ! think melanoma.

GI tract is the commonest to metastasize to the liver

especially from the colon.
17) **Exam, different picture: metastatic via vascular
path

This is another PAPILLARY CARCINOMA of thyroid. Note the

small PSAMMOMA BODY in the center. The cells of the
neoplasm have clear nuclei. Papillary carcinomas are
indolent tumors that have a long survival, even with
metastases. The most favorite site of metastasis is to
local lymph nodes in the neck. In fact, some papillary
carcinomas may first present as nodal metastases.
NOTES; Pt 16-20 yrs of age develops neck mass, with neck
lymph nodes.
Notice orphan annie eyes. Fantastic prognosis.

He showed a slide of a thyroid tumor which produces amyloid and calcitonin ! medullary carcinoma.

Here is a PARATHYROID ADENOMA, which is the most

common cause for PRIMARY HYPERPARATHYROIDISM.
Normal tissue of the parathyroid is ! fat and ! cells. Here,
we see a rim of normal parathyroid tissue is seen compressed
to the right and lower edge of the adenoma

Will have history of hypercalcemia and a neck mass.

The hypercalcemia results which leads to MC osteitis fibrosa

cystica bone disease.

The koilocytosis is seen at high power in the cervical squamous

epithelium. This type of change is usually produced with
HUMAN PAPILLOMAVIRUS (HPV) INFECTION. HPV
infection leads to changes in the cervical epithelium that
start down the road toward dysplasia and neoplasia.
Can lead to squamous cell carcinoma with certain serotypes.
 This is cervical squamous DYSPLASIA at high
magnification extending from the center to the right. The
epithelium is normal at the left. Note how the dysplastic
cell nuclei at the right are larger and darker, and the
dysplastic cells have a disorderly arrangement. This
dysplastic process involves the full thickness of the
epithelium, but the basal lamina is intact, so this is
cervical intraepithelial neoplasia (CIN) III.
NOTES: How do we know this is dysplastic!loss of nuclei
polarity.
Dysplasia in the cervix is often found next to a condyloma.

This is a Pap smear. The cytologic features of normal

squamous epithelial cells can be seen at the center top and
bottom, with orange to pale blue plate-like squamous cells
that have small pyknotic nuclei. The dysplastic cells in the
center extending to upper right are smaller overall with
darker, more irregular nuclei.
18) **Exam: do biopsy

Seen here are cells with MULTINUCLEATION (long arrow)

and steel grey to mauve INCLUSIONS (short arrow) typical
for HERPES SIMPLEX INFECTION.

Can also see ground glass nuclei, which represent whitish

changes in the cytoplasm of cells. ( red arrow)
19) ** Exam question: stubborn recurrence

Herpes simplex virus infection leads to a vesicle through dissolution of

the dermal-epidermal junction, as seen here microscopically
• THIS IS ADENOMYOSIS occurs when endometrial glands and
stroma are found in the MYOMETRIUM**, not just in the
endometrium where they belong. This condition leads to uterine
enlargement and irregular bleeding.

• If the implant of endometrium occurs in the ovaries or the

fallopian tube or back of uterus, it is called ENDOMETRIOSIS.

• When the pt. has endometriosis, the common symptom is pain.

It is associated with fibrosis and scarring. ! Patients present
with INFERTILITY.

• If the ovaries are involved, can result with a large hemorrhagic

cystic ovary filled with blood called chocolate cyst (see
below).

This is a section through an enlarged 12 cm ovary to

demonstrate a cystic cavity filled with old blood
typical for endometriosis with formation of an
endometriotic, or "CHOCOLATE" CYST. The
hemorrhage from endometriosis into the ovary may
give rise to a large "chocolate cyst" so named
because the old blood in the cystic space formed by
the hemorrhage is broken down to produce much
hemosiderin and a brown to black color.

The endometrial cavity is opened to reveal lush fronds

of hyperplastic endometrium. ENDOMETRIAL
HYPERPLASIA usually results with conditions of
prolonged estrogen excess and can lead to
metrorrhagia (uterine bleeding at irregular intervals),
menorrhagia (excessive bleeding with menstrual
periods), or menometrorrhagia.
It can lead to ENDOMETRIAL ADENOCARCINOMA
Exam ***

The ENDOMETRIAL ADENOCARCINOMA is

present on the lumenal surface of this cross section
of uterus. Note that the neoplasm is superficially
invasive. The cervix is at the right.
Seen in postmenopausal pts.
Common symptom!bleeding and nodules of the
uterus and it is enlarged
It is the commonest genital cancer.
20) ** Exam: endometrial adenocarcinoma
Endometrial Adenocarcinoma is a POST-MENOPAUSAL DISEASE
Cervical cancer is a PRE-MENOPAUSAL DISEASE

Microscopic view of ENDOMETRIAL

ADENOCARCINOMA.
Will see lots of glandular tissue infiltrating muscle.

What else is associated with its formation? Who

gets it?
! It is a post-menopausal disease.

Cervical cancer is a pre menopausal disease.

20) On exam w/ previous slide

Here are bilateral MATURE CYSTIC TERATOMAS of

the ovaries. These tumors represent one form of
ovarian germ cell tumor. A variety of mature, well-
differentiated tissue elements may be found from
all three embryologic germ layers (ectoderm,
mesoderm, endoderm). These tumors are often
called "dermoid cysts" because they are mostly
cystic and mostly contain ectodermal elements,
typically resulting in the abundant hair seen here.
NOTES: See Tooth in XRAY.
The cysts are filled with gelatinous material, hair,
teeth….etc.
It is a benign condition.

• Here is an example of an ectopic pregnancy in a

fallopian tube that was excised. Note the embryo in
the blood clot. This is a medical emergency because
of the sudden rupture with hemoperitoneum.
Ectopic pregnancy should be considered in the
differential diagnosis of acute abdominal pain in a
woman of childbearing age.

• It is usually preceded by another disease, for

example, endometriosis, chronic PID…etc.

• 21) **Exam: Tubal pregnancy

• A positive pregnancy test (presence of human
chorionic gonadotropin), ultrasound, and
culdocentesis with presence of blood are
helpful in making the diagnosis of ectopic
pregnancy. Seen here is tubal epithelium at the
right, with rupture site and chorionic villi at
the lower left.
Trophoblastic tissue.
This breast biopsy demonstrates a carcinoma. Note the
IRREGULAR MARGINS and varied cut surface. This small
cancer was found by mammography. The margins of the
specimen have been inked with green dye following removal to
assist in determining whether cancer extends to the margins
once histologic sections are made.
NOTES:
Hard white irregular mass, not encapsulated, non-movable.
“desmoplastic, scirrhous”
Commonest type of INVASIVE DUCTAL CARCINOMA
Most cancers in the breast are found in the upper outer quadrant.

Another example of microscopic FIBROCYSTIC CHANGES of

the breast are shown here. (commonest lesion in the breast)
Fibrocystic changes account for the majority of "breast lumps"
that are found in women of child bearing age, particularly
between age 30 and menopause; CLUES: BILATERAL dz;
Question? should you have a change occuring in it, which of
the change is associated with proliferative form of this dz
would worry you in terms of risk of malignancy? ATYPICAL
DUCTAL hyperplasia; LOOK OUT FOR EPITHELIAL
HYPERPLASIA CHANGES
Symptoms include: pain with pressure and discomfort pre –
menstrual ! it is hormonally stimulated

At low power, the prominent cysts of fibrocystic changes are

shown. The cysts are lined by a single epithelial layer of
varying height.
No change in epithelial lining.
It is a metaplastic change ! APOCRINE METAPLASIA.
 • This is ATYPICAL DUCTAL EPITHELIAL
HYPERPLASIA of the breast.

• A significantly increased risk (5 TIMES

NORMAL) for breast carcinoma occurs with
cytologically atypical epithelial hyperplasia

Here is a surgical excision of a small mass from the breast. The

mass is well-circumscribed. Grossly it felt firm and
rubbery.

This is a FIBROADENOMA. The blue dye around the

fibroadenoma was used to mark the lesion during needle
localization in radiology so that the surgeon could find this
small mass.

NOTES: Commonest benign lesion of the breast . Buzz words

! Solitary, encapsulated, freely movable, rubbery,
discrete <30

This is FAT NECROSIS of the breast. The most common

etiology is TRAUMA. It can be a localized, firm area with
scarring that can mimic a breast carcinoma.
Microscopically, however, fat necrosis consists of irregular
steatocytes with no peripheral nuclei and intervening pink
amorphous necrotic material and inflammatory cells,
including foreign body giant cells responding to the
necrotic fat cells. HISTORY OF TRAUMA, POST
SURGERY OR RADIATION ***
22) Exam: Fat necrosis

PAGET'S DISEASE of the breast is shown here. Note the

overlying hyperkeratosis of the skin, which helps to
produce the rough, red, scaling appearance seen
grossly, and there is often ulceration. The large cells
infiltrating into the epidermis represent
intraepithelial extension of an underlying DUCTAL
CARCINOMA IN SITU OR INVASIVE DUCTAL
CARCINOMA.
NOTES: Characterized by extension of duct carcinoma into
the skin of nipple and areola. HALLMARK
characteristic!involvement of epidermis by malignant
cells ! patient presents with an eczematous rash
around the areola of the nipple.
Remember that with paget’s disease there is always an
underlying cancer.
Also see paget’s cells.
 INTRACEREBRAL HEMORRHAGE involving the basal
ganglia area (the putamen in particular)
Common causes: HYPERTENSION **, trauma.
A mass effect with midline shift, often with secondary
edema, may lead to herniation.
NOTES: In risk of edema which can lead to raised
intracranial pressure which can lead to herniation.

The dura has been reflected above to reveal the bridging veins
that extend across to the superior aspect of the cerebral
hemispheres.
These can be torn with trauma, particularly if there is significant
cerebral ATROPHY (older individuals) that exposes these veins
even more, resulting in SUBDURAL HEMATOMA.
Therefore, the elderly are predisposed to get getting a sudural
hematoma.

Here is a BILATERAL SUBDURAL HEMATOMA. The blood clots

are brown to tan because of organization. Since the bleeding is
venous, subdurals can form more slowly and insidiously than clots
from arterial hemorrhages. Subdurals are most common in the very
young and the elderly.
 A blood clot is seen over the external surface of the
dura. Thus, this is an EPIDURAL HEMATOMA. Such a
location for hemorrhage is virtually always the result
of TRAUMA that causes a tear in THE MIDDLE
MENINGEAL ARTERY.

The white arrow on the black card marks the site of a ruptured
BERRY ANEURYSM in the circle of Willis. This is a major cause
for SUBARACHNOID HEMORRHAGE at the base of the brain.

Exam POLYCYCTIC KIDNEY DISEASE is associated

with berry aneurysms. The dominant type.
(ADPKD)

As the weak wall of the artery, which lacks an internal elastic

lamina and a media, expands to form the aneurysm, there may
initially be leakage of blood that produces headaches, but there
is risk for sudden rupture to produce a severe headache.
The blood irritates the arteries to produce vasospasm and
promote cerebral anoxia. Immediate symptom if pt survives
rupture is an EXCRUCIATINGLY SEVERE HEADACHE.

The yellow-tan exudate of ACUTE BACTERIAL

MENINGITIS seen here obscures the sulci. Organism most
likely can be meningococcal.

Exam Complication of this is HYDROCEPHALUS

• Microscopically, a neutrophilic exudate is seen
involving the meninges at the left, with prominent
dilated vessels. There is edema and focal inflammation
(extending down via the Virchow-Robin space) in the
cortex to the right. This ACUTE SUPPURATIVE
MENINGITIS is typical for bacterial infection.

• This edema can lead to herniation and death.

Resolution of infection may be followed by adhesive
arachnoiditis with obliteration of subarachnoid space
leading to obstructive hydrocephalus.

The cerebral atrophy seen here mainly in the

frontal and parietal regions is characterized by
narrowed gyri and widened sulci. The atrophy seen
here was due to senile dementia due to
ALZHEIMER'S DISEASE.

Microscopically look for the neurofibrilary tangles

and plaques.

The characteristic microscopic findings of Alzheimer's

disease include NEURITIC PLAQUES ("senile plaques")
which are extracellular deposits of the AMYLOID beta-
protein (Aß). In the more numerous, smaller diffuse
plaques this Aß alone is present as filamentous masses.
However, the diagnostic neuritic plaques also have
dystrophic dilated and tortuous neurites, microglia, and
surrounding reactive astrocytes. These plaques are best
seen with a silver stain, as seen here in a case with many
plaques of varying size.
The amyloid beta-protein (Aß) is derived by cleavage of
the larger amyloid precursor protein (APP). APP is
expressed in all mammals. In humans, the APP gene is on
chromosome 21. Mutations in the APP gene have been
found in familial cases of AD. Mutations in APP increase
production of Aß. There are additional genetic mutations
that play a role in development of AD. The E4 allele of
apolipoprotein E is a major risk for AD of late onset,
particularly if both alleles are E4. The gene is located on
chromosome 19. Over half of AD patients have the E4
allele. Apo E4 increases levels of Aß in the brain.
Silver stain is used.

This is a NEUROFIBRILLARY "tangle" of

Alzheimer's disease. The tangle appears as long
pink filaments in the cytoplasm. They are
composed of cytoskeletal intermediate
filaments (tau protein ).
They are very characteristic for Alzheimer’s
disease, but not diagnostic.

The "holes" in the cortex of the cerebrum seen here

represent a SPONGIFORM ENCEPHALOPATHY
known as Jacob-Creutzfeldt disease. This is a form
of rapidly progressive dementia. It is due to a poorly
understood PRION protein that has infectious
potential, but the cases appear sporadically (1 in a
million).
Exam ! this is an example of mad cow disease.

This is a MENINGIOMA.
This tumor is sitting right on the Dura and it has made an
impression in the brain ! therefore, it must be arising
from the Dura ! meningioma.
Rarely, meningiomas can be more aggressive and invade.
Meningiomas will cause increase in the intracranial
pressure because they become intracerebral lesions.
They will also produce edema in the surrounding tissue.
Patient will present with double vision, rapid rising
intracranial pressure…etc.
This is a Meningioma.

It is a benign lesion but can become a

space occupying lesion.

Meningioma is composed of whorled

nests of cells.

This low grade astrocytoma demonstrates

"satellitism" of the neoplastic cells invading around
the neurons in the cortex.

This is an ASTROCYTOMA.
There is an increase with cellularity.
The cells have pink cytoplasm.
! astrocytic cells.

It is not a benign tumor.

This is an example of pseudopalisading necrosis of large

neoplastic cells in a GLIOBLASTOMA MULTIFORME
(GBM). This is a variety of astrocytoma. It has the
worst prognosis.

It is a high grade astrocytoma. With a palisading

arrangement.

The cells of a GBM can infiltrate widely, particularly

along white matter tracts, and even through the CSF.

Area of NECROSIS.
An early astrocytoma is a benign proliferation, but when
get to grade 4, which is GBM ! malignant
23) **Exam: Glioblastoma Multiforme
 The oligodendroglioma shown here as
round blue cells with clear
cytoplasm. This type of glioma
tends to be well circumscribed,
with cystic areas and focal
calcification.

The OLIGODENDROGLIOMA shown here as round

blue cells with clear cytoplasm ! fried egg
appearance.

This type of glioma tends to be well circumscribed,

with cystic areas and focal CALCIFICATION.

• For brain tumors, focus on Astrocytomas, Oligodendglioma and Meningoma.

This is a MALIGNANT MELANOMA.
Can ID by looking for a brown pigment in the cells.

CLARK staging is used to stage these tumors.

Clark level 1 ! very superficial ! 95% survival
Clark level 5! very deep with metastasis ! bad
prognosis.

This is kaposi sarcoma, a malignant

vascular tumor that occurs in several
forms:
Classic KS: Mediterranean origin
Endemic KS: Young African men
Epidemic KS: AIDS patients

Psoriasis also looks like this, but to a

lesser extent.
24) **Exam: Kaposi Sarcoma

A microscopic view of kaposi sarcoma.

Remember these scaly lesions are caused

by proliferation of blood vessels

You can get these lesions not only on the

skin, but anywhere (GI tract, liver,
spleen, lung, anywhere) and it can
produce a lot of hemorrhage.
ANGIOSARCOMA!!!!! Chronic lymphedema of the arm ends up being a malignant condition.
25) **Exam: Angiosarcoma

Here is a seminoma that is larger yet. Normal testis appears to the left of the mass, and the
spermatic cord extends to the left of that. The size of this neoplasm demonstrates the
factors of fear and denial that occur in many patients, delaying detection and therapy.
26) **Exam: ID seminoma
The enlarged parotid gland seen here at low power has extensive lymphoid infiltrates and
even a germinal center just left of center. Such an intense mononuclear infiltrate could be
seen early in Sjogren's syndrome, an autoimmune disease that involves salivary glands
(with xerostomia) and lacrimal glands (with xerophthalmia).

The large hemorrhage in this adult brain arose in the basal ganglia region of a patient with
hypertension. This is one cause for a "stroke".

This is an intermediate to remote infarct in the distribution of the middle cerebral artery.
This intermediate infarct of the frontal lobe shows liquefactive necrosis with formation of
cystic spaces as resolution begins.

Smooth muscle tumors of the uterus are often multiple. Seen here are submucosal,
intramural, and subserosal leiomyomata of the uterus.

The cholesteatoma can elicit an inflammatory reaction,

since the keratinaceous debris acts as a foreign body,
with foreign body giant cells and mononuclear cells.
Hemorrhage and necrosis leads to formation of
cholesterol clefts. Cholesteatomas require surgical
removal. (desctructive and expanding mass in the middle
ear behind or in the mastoid process)! hearing loss
27)**Exam: Cholesteatoma
At the center and to the right is a medullary
carcinoma of thyroid. At the far right is pink
hyaline material with the appearance of amyloid.
These neoplasms are derived from the thyroid "C"
cells and, therefore, have neuroendocrine
features such as secretion of calcitonin.
28) ** Exam Question: Cell of origin is C Cell
MEDULLARY CARCINOMA= C Cells secreting
CALCITONIN & AMYLOID

Here the amyloid stroma of the medullary thyroid

carcinoma has been stained with Congo red.
Medullary carcinomas can be sporadic or familial.
The familial kind can be multifocal and are
associated with multiple endocrine neoplasia
syndrome. (MEN SYND)

28) ** Exam Question: Cell of origin is C Cell

C CELLS secrete CALCITONIN & AMYLOID

This immunofluorescence micrograph of a

glomerulus demonstrates positivity with antibody
to fibrinogen. With a rapidly progressive GN, the
glomerular damage is so severe that fibrinogen
leaks into Bowman's space, leading to proliferation
of the epithelial cells and formation of a crescent.

29) **Exam question: Rapidly Progessive

Glomerulonephritis (CRESCENT FORMATION)

This is the gross appearance of fibrocystic changes

in the breast. A 1.5 cm cyst is noted here. This can
lead to palpation of an ill-defined "lump" in the
breast. Sometimes, fibrocystic changes produce a
more diffusely lumpy breast.

30)**Exam question: malignant when see atypical

epithelial hyperplasia
Another example of microscopic fibrocystic changes
of the breast are shown here. Fibrocystic changes
account for the majority of "breast lumps" that are
found in women of reproductive years, particularly
between age 30 and menopause.

30) On exam w/ above slide