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Teratoma

Case: A 31 year old woman has had dull, constant, abdominal pain for 6 months. On physical examination, the only finding is the right adnexal mass. CT scan of the pelvis shows a 7cm circumscribed mass that involves the right ovary and contains irregular calcifications. The right fallopian tube and ovary are surgically excised. Microscopic appearance of the mass is shown in the figure below:

[pic]

Id points:

1) Cyst wall is composed of stratified squamous epithelium and other skin adnexal structures.

2) Different tissues derived from various germ layers (intestinal glands, cartilage, adipose tissue, and thyroid) are present.

Seminoma

Case: A 29 year old man complains of a vague feeling of heaviness in the scrotum, but he has had no increase in pain for the past 5 months. He is otherwise healthy. Physical examination shows that the right testis is slightly larger than the left testis. An ultrasound scan shows the presence of a solid circumscribed, 1.5cm mass in the body of the right testis. A biopsy is performed and the microscopic appearance is shown below:

[pic]

Id points:

1) Uniform sheet of cells, divided into lobules by fibrous septa

2) Classic large seminoma cells with pale nuclei and prominent nucleoli

3) Lymphocytic infiltrate.

Fibroadenoma

Case: A 28 year old woman in the 3rd trimester of her pregnancy discovered a lump in her right breast. The physician palpated a 2 cm discrete, freely movable mass beneath he nipple. After the birth of a term infant, the mass appears to decrease slightly in size. The infant breast feeds without difficulty. Core needle biopsy was done and the microscopic picture is given below:

[pic]

Id points:

1) Proliferation of intralobular stroma

2) Stroma compresses and distorts the ducts

Invasive ductal carcinoma of the breast

Case: A 44 year old woman sees her physician because she felt a lump in her left breast 1week ago. The physician palpates a firm, irregular mass in the upper outer quadrant of the left breast. Axillary lymph nodes are also enlarged. There are no overlying skin lesions. An excision biopsy was done and the microscopic appearance is shown below:

[pic]

Well-differentiated

Id points:

1) Prominent tubule formation

2) Small round nuclei

3) Desmoplastic stroma

*invasive ductal carcinoma has, broadly, 3 histological appearances:

1) Well-differentiated

2) Moderately differentiated

3) Poorly differentiated

[pic]

Moderately differentiated

Id points:

1) Shows less tubule formation

2) More solid nests of cells and pleomorphic nuclei

[pic]

Poorly differentiated

Id points:

1) Ragged nests or solid sheets of pleomorphic cells

2) Enlarged irregular nuclei with mitotic figures

3) Central areas of tumor necrosis

Papillary Ca

A 30 years old female presented to the OPD with a painless mass in the neck. O/H patient revealed that she was exposed to radiation sometime in her life. O/E the mass moved upward as the patient swallowed some water and painless enlarged cervical lymph nodes were also found. On microscopy Clear "Orphan Annie eye" nuclei and pseudoinclusions were found.

ID points:

-Papillae with fibrovascular core.

-Psammoma bodies.

Multinodular Goiter (Nontoxic goiter)

A female presented to the OPD with an asymmetric enlargement of the thyroid gland. She was asymptomatic. O/E the swelling was found to be multilobulated.Lab tests showed normal T3, T4 and TSH. 

ID points:

-Nodules of varying sizes composed of colloid follicles.

-Calcification and hemorrhage.

Graves Disease

A 30 years old female presented to the OPD with an enlarged thyroid gland, exophthalmos and pretibial myxedema. The gland was diffusely enlarged,symmetrical and non tender. O/E signs of hyperthyroidism were present. Lab tests revealed increased T4 and decreased TSH.

ID points:

-Hyperplastic follicles with papillary infoldings. (due to crowding of the follicular epithelium, papillae are formed that project into the follicular lumen)

-Scant colloid with scalloped margins.

Ca Prostate

A 60 years old male presented to the OPD with lower back pain and complaints of hesitancy, dribbling and a feeling of incomplete emptying of bladder. On DREhard and fixed prostate was found. Serum PSA levels were elevated. Lumbar spine X-ray showed Osteoblastic Metastasis.

ID Points:

-Neoplastic Glands lie back to back.

-Glands lined by a single layer of cuboidal cells.

-Basal cell layer is absent. 

BPH

A 55 years old male came to the OPD with burning micturation, increased frequency of urine and urgency for the last 7 days. He did not have fever. For the last one year he had to strain to begin urination, stream had gradually become weaker and he had a sense that he could not empty his bladder completely. Recently he had to wake up at night 3 times to void. O/E Prostrate is 50g with rubbery feeling, mucosa is mobile, no nodule or indurated area. Some suprapubic tenderness was also present.

ID points:

-Corpora Amylacea.

-Papillary projections in some glands. (due to crowding of the proliferating epithelium)

-Hyperplastic glands are lined by columnar epithelial cells and peripheral layer of flattened basal cells.

-Fibromuscular stroma.

CNS Tumors

Glioblastoma multiforme:

o Densely cellular (highly malignant tumor cells around necrosis)

o Necrosis/vascular or endothelial cell proliferation

o Very poor prognosis, age > 50, probably male, seizures, nausea, vomiting, headache, progressive memory, personality, or neurological deficit

Astrocytoma:

o Increased number of glial cell nuclei

o Nuclear pleomorphism

o Mitotically active cells

o Any age, may progress slowly initially, then speed up when cells become anaplastic. Mean survival > 5 years. Headaches, seizures, focal neurological deficits 

Medulloblastoa

o Extremely cellular (sheets of anaplastic cells)

o Small cells with little cytoplasm and hyperchromatic nuclei

o Child, most likely male, initially: listless, morning headache, vomiting (blockage of fourth ventricle) 

§ later: stumbling gait, frequent falls, diplopia, papilledema, VI nerve palsy (cerebellar involvement)

§ very radiosensitive (if radiation given, 5 year survival is more than 75%), 

Little cytoplasm and hyperchromatic nuclei (elongated/crescent)

schwanoma:

o antoniA: elongated cells + cytoplasmic processes in fascicles + little stromal matrix

o antoni B: lesss densely cellular + oose meshwork of cells + microcysts + myxoid changes

o 40-50 years, both genders equal, CN VIII usually involved (tinnitus and hearing loss), sensory branches of CN V, and dorsal roots. 

meningioma:

whorled pattern of cells growth and psomoma bodies

• focal seizures, progressive spastic weakness in legs and incontinence, increased ICP symptoms

Renal Cell Carcinoma

Case: A 52 years old male who is a known smoker for the last 30 years, presents to clinic with painless appearance of blood in the urine. He complains of easy fatigue, paleness and flank pain. He is worried about the recent weight loss. He has a history of joint pains for the past 15 years for which he has been taking large doses acetaminophen for pain relief. O/E the patient has right sided abdominal mass along with a bruit. Lab findings revealed elevated ESR, normocytic anemia. Urinalysis shows Gross hematuria with vermiform clots. On biopsy:

[pic]

Microscopically, a) clear cells with a cytoplasm rich in lipids and glycogen b) cellular atypia

Transitional cell carcinoma

Case: A 67 years old male, known smoker for last forty years, presents to the clinic with gross blood in his urine. He complains of dull suprapubic pain, fatigue and shortness of breath. He was employed in a plastic industry and recently got retired. OE:: Patient is afebrile, normotensive. Urinanalysis shows hematuria

[pic]

1. Muclear anaplasia

2. Central fibrovascular core

3. Hyperchromatic nuclei and mitotic figures

Membranous glomerulonephritis

Case: A 45 years old Caucasian, hypertensive, male experiences malaise, fatigue and anoxeia for the last 6 months. OE patient had swelling (edema) of the eyelids and of the legs. Urinalysis: Protein +++ >3.5g/day.hypercholestrolemia, Kidney functions abnormal.

[pic]

This renal biopsy shows membranous nephropathy. Light (hematoxylin and eosin) stain shows thickened capillary loops via electron microscopy, with subepithelial deposits.

-Diffusely thickened glomerular basement membrane without a hypercellular glomerulus.

-The basement membrane may completely surround the granular deposits, forming a "spike and dome" pattern.

Cresentric GN

A 45 year old woman with a history of systemic lupus erythematosus presents in clinic with blood in her urine. She also complains of fatigue, body aches and swelling of legs. Recently she has developed nausea which is sometimes associated with episodes of vomiting. On examination she has pallor, peripheral and periorbital edema and her blood pressure is 150/90 mmHg. On blood examination, she is anemic and ESR, BUN and creatinine, potassium levels are elevated. Anti neutrophilic antibody is present. On urine analysis, proteinuria of 2.5 g/day is seen with microscopic hematuria. Renal biopsy was eventually performed to confirm the diagnosis.

[pic]

Id points

1. Prominent fibrocellular crescent formation

2. moderate mesangial proliferation in a glomerulus.

FOCAL SEGMENTAL

A 35 year old male, who is a known drug addict, presents to the clinic with generalized body swelling, fatigue and shortness of breath. He complains that his urine appears cloudy. On examination there is anasarca, signs of pleural effusion and ascities. Urinalysis reveals large amounts of protein, along with hyaline and broad waxy casts, whereas RBC casts are generally absent. Serum creatinine is normal, along with hypoalbuminemia and hyperlipidemia. Patient is initially treated with corticosteroids but proteinuria persisted. Eventually kidney biopsy was done.

[pic]

Id points

1. perihilar sclerosis with hyalinosis

2. capillaries are segmentally obliterated by accumulation of acellular matrix and hyaline deposits, along with adhesion to the Bowman capsule. Diffuse effacement of foot processes

3. lipid droplets and foam cells

Hydatidiform Mole

Case: A 22 year old woman, G 2, P 1 is in her early second trimester. She has noticed a small amount of vaginal bleeding for the past week and has had marked nausea and vomiting for several weeks. On physical examination, the uterus measures large for dates. Ultrasound shows intrauterine contents with a “snowstorm appearance” and no fetus identified.

-Common age for moles is under 20 and above 40, but it can occur between these ages during reproductive life. (age not a big factor)

- G 2 P 1 signifies she conceived twice before, but only 1 fetus made it to viable maturation age (20 weeks). In hydatidiform mole, if a mole is diagnosed then the risk of the subsequent pregnancy resulting in a mole is increased. Although we don’t know why 1 fetus did not survive, it is still an indicator that we should keep in mind. (it is possible her previous conception resulted in a mole)

- HM is usually diagnosed around the 14th week, which is the early second trimester.

-Vaginal bleeding is a clinical presentation (not a differentiating factor)

-Nausea and vomiting- HM mimics pregnancy symptoms

-Uterus often measures large for date in HM as the mole grows rapidly

-Snowstorm appearance is classical appearance of HM- because of hydropic villi and proliferation of trophoblasts.

-No fetus in “pregnancy” – major sign of HM! (most likely a complete HM)

ID Points:

1). Hydropic (swollen) chorionic villi present

2). Trophoblastic proliferation

Leiomyoma

Case: A healthy 40 year old woman has had a feeling of pelvic heaviness for the past 11 months. There is no history of abnormal bleeding. Her physician palpates an enlarged nodular uterus on bimanual pelvic examination. A pap smear shows no abnormalities. Pelvic CT imaging shows multiple solid, firm uterine masses that are tan-white; there is no evidence of necrosis or hemorrhage. A total abdominal hysterectomy is performed. A sample of the mass was taken, the histological section is shown below:

*case may also be that a patient is diagnosed with ________ (unrelated- maybe something like adenocarcinoma or endometrial carcinoma), patient has a hysterectomy done and a tan-white, well circumscribed mass is found. What is most like diagnosis?*

-Leiomyomas are often asymptomatic and grow silently, that is why the patient is still healthy, however a patient may or may not present with uterine bleeding (usually not)

-Can occur at any age during reproductive life, however are most common 20-40 yrs- when estrogen levels are highest or fluctuating (often during menopause)

-Causes uterus to increase in size

-can be singular, but usually multiple masses occur

-they are solid, well-circumscribed, and firm

-tan-white in color (grossly)

-ischemia and hemorrhage only occur if the mass grows large in size

ID Points:

1). Whorling bundles of smooth muscle cells

2). Foci of fibrosis

3). Foci of calcification

Leiyomyosarcoma

Generally not as important as some other slides, VERY uncommon

Case: Same as leiyomyoma except----

Age: 52 (above 50 commonly)

Hysterectomy shows: a single bulky polypoid mass, centers of necrosis and hemorrhage

ID Points:

1). Cytological atypia (depending on severity of leiomyosarcoma)

2). Increased mitotic activity

Endometrial CA

Case: A 62 year old childless woman notice a blood-tinged vaginal discharge twice during the past month. Her last menstrual period was 14 years ago. Bimannual pelvic examination shows that the uterus is normal in size, with no palpable adnexal masses. There are no cervical erosions or masses. Her BMI is 33. Her medical history indicates that for the past 30 years she has had hypertension and type 2 diabetes mellitus. An endometrial biopsy is done:

-Endometrial CA is most common between 55-65 years

-post-menopausal bleeding is a red flag for endometrial CA

-uterus does not always increase in size, but it can if there is metastasis

-Obesity, Hypertension, DM, and Nulliparity (she is childless) are all risk factors for endometrial CA.

ID Points:

Endometriod:

1). Cribriform architecture

2). Loss of polarity and nuclear atypia

Serious:

1). Papillae formation

2). Marked cytologic atypia

Cervical intraepithelial neoplasia

A 30 year old female can to the hospital for routine screening which included a Pap smear. The doctor told her that the results are positive for a precancerous lesion. She said she has multiple sexual partners and she had an early onset of intercourse.

CIN I:

• Apical koilocytosis (hyperchromatic nuclei with perinuclear halo of clear cytoplasm)

• Intact basement membrane

• Loss of polarity of cells

CIN II:

• Mitoses above the basal layer

• Loss of polarity

• Intact basement membrane

CIN III (CIS):

• Loss of polarity affecting entire thickness of epithelium

• Loss of progression of maturation from basal to apical layers

• Intact basement membrane

Ca cervix

A 45 year old woman presents with abnormal uterine bleeding and dyspareunia. She has also noticed difficulty urinating (cancer can obstruct the ureters and cause renal failure). She tells the doctor that she has multiple sexual partners. She never had a Pap smear done.

• Invasion of basement membrane

• Pleomorphic cells with high N/C ratio and loss of polarity

Cystic endometrial hyperplasia

50 year old female; either with abnormal perimenopausal bleeding/ anovulation/hormone replacement with estrogen only or any other cause of abnormal uterine bleeding.

• Cystic dilation of endometrial glands

• Gland crowding

• Maybe epithelial stratification

Serous cystadenocarcinoma of ovary

A 40 year old woman presents with unexplained weight loss, anorexia, lower abdominal pain, ascites and dysuria. On USG, there were bilateral masses in the ovaries. CA-125 tumor marker was positive. On biopsy, the tissue showed many papillae and psamomma bodies.

• Papillary pattern and stratified epithelium

• Psammoma bodies

• Invasion of stroma

Mucinous cystadenocarcinoma of ovary

A 45 year old woman presents with unexplained weight loss, anorexia, lower abdominal pain, ascites and dysuria. On USG, there was a single mass in the right ovary. The mass was removed. When cut, the tissue was multilocular and cystic. On histological exam, the tissue looked similar to a colon cancer.

*This can also manifest as pseudomyxoma peritonei which is characterized by ascites, adhesions and cystic tumor implants in the peritoneal cavity.

• Complex mucinous glands in stroma

• Epithelial stratification and necrosis

• Loss of gland architecture

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