Clinical History: A 50-year-old female had a slowly growing mass in the anterior cervical area for two years. Shortly before admission she developed hoarseness and difficulty swallowing. No thyrotoxic manifestations were noted. A subtotal thyroidectomy was performed.
The thyroid was nodular and weighed 250 grams. The capsule was intact. The cut surface revealed large and small honeycombed structures filled with yellow-brown colloid material. Focal hemorrhages and fibrosis were present in the nodules.
The nodules consist of small and large follicles up to 3 mm in diameter. The epithelium is low cuboidal, and the colloid is rich. In some sections there is scalloping at the periphery of the colloid. There is fibrosis as well as focal recent and old hemorrhages. A small amount of atrophic, compressed thyroid tissue may be seen in some sections.
Thyroid tissue consists of variably-sized, colloid-filled follicles. The colloid is eosinophilic and homogeneous. The glandular thyroid cells are cuboidal. The capsule is intact.
Clinical History: A 38-year-old white female complained of a mass in the neck of several months duration. At the time of examination the right lobe of the thyroid was enlarged and somewhat nodular. The opposite lobe was questionably enlarged. She had no symptoms of hypothyroidism or hyperthyroidism.
At the time of surgery the entire thyroid was enlarged, with an estimated weight of 60 grams. The tissue was pale and lobulated. A subtotal thyroidectomy was performed. The excised tissue weighed 30 grams.
The architecture of the gland is destroyed. A few acini are present. These vary in size. There is abundant lymphoid tissue in which are germinal centers. There are collections of rather large cells which do not form acini.
Thyroid tissue consists of variably-sized, colloid-filled follicles. The colloid is eosinophilic and homogeneous. The glandular thyroid cells are cuboidal. The capsule is intact.
Sectioning through a lobe of excised thyroid gland reveals a papillary carcinoma. This neoplasm can be multifocal, as seen here, because of the propensity of this neoplasm to invade lymphatics within thyroid, and lymph node metastases are common. The larger mass shown here is cystic and contains papillary excresences.
The tumor is composed of papillae covered by closely packed cells with bland, sometimes optically-clear ("Orphan-Annie eye") nuclei. Nuclear grooves are also present. A few round purplish calcifications, termed psammoma bodies, are also seen.
Thyroid tissue consists of variably-sized, colloid-filled follicles. The colloid is eosinophilic and homogeneous. The glandular thyroid cells are cuboidal. The capsule is intact.
430-1. What is the histological diagnosis of this thyroid neoplasm?
Clinical History: A 45-year-old male entered the hospital two days prior to death for evaluation of hyperglycemia and elevated serum cortisol. He died unexpectedly.
Within the nodule of tissue at one end of the section, the cells are mostly in a fascicular arrangement. They are vacuolated and histologically appear identical to normal cortical cells.
Adrenal tissue is composed of a central medulla and outer cortex. The medulla contains large polygonal neuroendocrine cells. The cortex contains cells with foamy cytoplasm. There is no evidence of hemorrhage or necrosis.
79-3. A female infant was referred to the neonatologist with signs of virilization. The doctor ordered a panel of tests to assess adrenal function. He/she is MOST concerned about:
Clinical History: A 78-year-old male was admitted with headache and bitemporal hemianopsia of several years duration. No endocrine disturbances were noted. He expired shortly after admission due to pneumonia.
The pituitary gland, weighing 3 gms and measuring 2 cms in greatest diameter, contained a large pink-gray soft tumor mass in the anterior lobe. The optic chiasm was slightly atrophic due to the compression of the tumor.
The tumor occupies nearly the entire anterior lobe, so that only a thin rim of normal hypophyseal tissue is present in the subcapsular area. The tumor is composed of uniform cells arranged in a trabecular or sinusoidal pattern. The stroma is highly vascular. Some of the tumor cells contain fine eosinophilic granules, but most of them are chromophobes with special stains.
The pituitary is an endocrine gland with neurohypophysis and adenohypophysis. The neurohypophysis is composed of spindle cells that are derived from neural crest. These are neurosecretory cells. The adenohypophysis is an endocrine gland which is composed of three histological cell types, acidophils, basophils and chromophobes. The staining properties vary with the hormonal product. For example, growth hormone secreting cells are acidophils.
427-1. This is a benign neoplasm that is thought to have arisen from the endocrine cells of the pituitary gland. Which of the following is the BEST histological diagnosis?
Clinical History: A 50-year-old female had recurrent bouts of severe abdominal pain accompanied by elevated serum amylase. After one of these episodes, she developed refractory shock, peritonitis and expired.
Hemorrhage is seen in the head of the pancreas. The stomach is reflected superiorly and the spleen can be seen at the far upper right. The pancreas is swollen and does not show the typical tan, lobulated architecture. Instead, it has areas of hemorrhagic necrosis that appear as black.
Several areas of fat necrosis with adjacent neutrophil infiltrate are seen, evidence of acute pancreatitis. In addition, some lobules of the pancreas show fibrosis and loss acini, evidence of chronic pancreatitis. In these areas, islets of Langerhans appear larger and more abundant. This is partly because they are resistant to injury and persist when acini are destroyed and partly because they undergo reactive hyperplasia.
The pancreas is comprised of glandular tissue with endocrine and exocrine function. The exocrine pancreas contains lobular arrays of acini. The acinar secretions of the exocrine pancreas are collected by the pancreatic ducts. The ducts are surrounded by a small amount of connective tissue without inflammation or fibrosis (scarring).The endocrine pancreas resides in the islets which are regularly arranged and present within the pancreatic lobules.
Clinical History: An 80-year-old white male had a three week history of chalky and greasy stools, a 20 pound weight loss, and a progressive obstructive jaundice. A cholangiogram revealed an obstruction in the common bile duct.
The head of the pancreas was enlarged with yellow-gray firm tissue, in which no normal lobular structures were seen. About 4 cm proximal to the ampulla there was a stenosis of the common bile duct. Proximal to this stenosis the bile ducts were markedly dilated with bile. The peripancreatic lymph nodes and the celiac axis were gray and firm with metastastic tumor.
The tumor is composed of duct-like structures, which are irregularly arranged and infiltrate into the dense connective stroma and perivascular or perineural lymphatics. Occasionally both ducts and individual tumor cells contain mucin. There is a small amount of pancreatic tissue which shows marked atrophy and fibrosis. The small ducts are distended and may show focal squamous metaplasia of the epithelium in some sections.
The pancreas is comprised of glandular tissue with endocrine and exocrine function. The exocrine pancreas contains lobular arrays of acini. The acinar secretions of the exocrine pancreas are collected by the pancreatic ducts. The ducts are surrounded by a small amount of connective tissue without inflammation or fibrosis (scarring).The endocrine pancreas resides in the islets which are regularly arranged and present within the pancreatic lobules.
189-1. Which is the MOST LIKELY diagnosis of this pancreatic tumor?
Clinical History: A 43-year-old white female had a four-month history of intermittent bloody stools. Sigmoidoscopy revealed pedunculated polyps 15 cm above the sphincter. She had a family history of colon cancer and the colon was removed prophylactically.
The resected tissue contained several polps. The largest polyp was 1.5 cm in diameter. The stalk was 2 cm in length. The base of the stalk and the adjacent mucosa showed no induration.
The exophytic structure of the polyp can be seen with the naked eye. There is a short stalk lined by normal colon mucosa with blood vessels in the submucosa. The finger-like villi of the polyp are lined by adenomatous mucosa, the hallmark of a neoplastic polyp. Compared to the nearby normal mucosa, the nuclei are elongated, hyperchromatic and stratified. There is increased nuclear to cytoplasmic ratio and decreased cytoplasmic mucin.
The colon is lined by glandular epithelium with numerous mucin secreting goblet cells. The epithelium is infolded into straight tubular glands of uniform diameter to increase the surface area available for secretion and absorption.
166-2. The polyp is lined by epithelium that features stratified hyperchromatic nuclei, increased nuclear-cytoplasmic ratio and reduced cytoplasmic mucin. This appearance of the lining epithelium is BEST described as:
Clinical History: A 70-year-old white male had an insidious onset of dysphagia of six months duration. X-ray revealed a filling defect and stenosis in the lower esophagus. An esophageal resection was performed.
The resected esophagus contained a firm, raised, pink-gray, friable and necrotic 3.5 x 4.5 cm tumor mass, completely encircling the esophagus and producing a marked stenosis.
At one end of the section the squamous epithelium of the esophagus shows marked atypia, pleomorphism and loss of polarity, but no submucosal invasion. These changes represent carcinoma in situ. By following the mucosal lining, one comes upon an area where the cords and nests of poorly differentiated squamous cells are seen to invade the mucosa and submucosa reaching the muscular layer. At one margin of the section the tumor cells are better differentiated with production of keratin and formation of so-called epithelial pearls. Associated with the tumor are marked fibrous proliferation and intense chronic inflammatory infiltration in the stroma. The tumor invades into, but not through the muscularis propria.
For the purpose of histological descriptions, the esophagus is subdivided into upper (entirely skeletal muscle in the muscularis externa), middle (mixed smooth and skeletal muscle) and lower (entirely smooth muscle) portions. Slide UCSF 226 is from the upper 1/3; slides 126 and 153 are from the middle 1/3; and slide 155 is from the lower 1/3 (at the esophageal-cardiac junction). The esophageal epithelium[example] is the non-keratinized stratified squamous type and is supported by a connective tissue lamina propria. Note the presence of isolated lymphoid nodules[example] and scattered leukocytes in the lamina propria. A rather thick layer of longitudinally arranged smooth muscle fibers form the muscularis mucosae [example]. The connective tissue of the submucosa consists of mostly collagenous fibers with some elastic fibers and varying amounts of fat as well as submucosal sero-mucous glands which can be readily observed in both slide 126 [example] and slide 153 [example] (those in slide 155 are not very well preserved).
In the upper esophagus, as shown in Slide UCSF 226, the muscularis externa consists of both inner and outer layers of skeletal muscle only. In the middle esophagus, the muscularis externa contains a mixture of skeletal and smooth muscle as seen in slide 126[example], whereas in the lower esophagus only smooth muscle is found as seen in slide 155[example]. Present in all regions of the esophagus (upper, mid, and lower) is the myenteric (Auerbach’s) plexus[example] between the two layers of the muscularis externa (W pg 267, 14.3). For most of its extent, the esophagus is retroperitoneal, so its outermost layer consists of a connective tissue adventitia which merges with the adjacent connective tissue associated with nearby structures (such as the trachea as shown in slide 126). Below the diaphragm, however, the esophagus is suspended within abdominal cavity and is therefore covered by a connective tissue serosa as shown in slide 155.
Clinical History: A 60-year-old female had a one year history of weight loss and upper gastro-intestinal obstruction for three months prior to surgery.
The resected portion of the stomach showed a large fungating, partially ulcerated tumor mass in the antrum. Regional lymph nodes and a liver biopsy were free of tumor.
There is a rather abrupt change of the normal stomach mucosa to malignant tumor tissue, projecting into the lumen as a cauliflower-like mass. The tumor forms abundant irregular acini, lined by one or more layers of atypical cells with mostly large irregular nuclei and poorly defined eosinophilic cytoplasm. Atypical mitoses are moderately frequent. The tumor has infiltrated through the muscularis mucosa and the edematous submucosa and has invaded the muscle layers. The invading tumor had elicited a rather marked neutrophilic and plasma cell response.
The normal gastric mucosa of the fundus contains superficial fovea arranged in leaf like fronds and deeper gastric glands. The foveolar cells secrete mucin. The gastric glands include mucous cells, parietal cells, chief cells and enteroendocrine cells.
253-1. Under the Lauren’s classification, this tumor of the stomach would be considered:
253-2. In a form of hereditary gastric cancer, patients have germline mutation and loss of E-cadherin and develop signet ring cell carcinoma. E-cadherin plays a role in maintaining cellular adhesion and is BEST considered a type of:
Clinical History: A 57-year-old female had early satiety, deep epigastric pain, nausea and vomiting for two months. An upper GI series revealed a small ulcer in the stomach. The free gastric acidity was low, and there was occult blood in the stool. A total gastrectomy was performed after the diagnosis of malignancy was made from a frozen section.
A shallow ulcer 1 cm in diameter was in the anterior wall of the stomach, 7 cm proximal to the pylorus. There was a broad zone of induration and thickening of the gastric mucosa which surrounded the ulcer. The section showed a diffuse gray-white mucosa tightly adherent to its submucosa. The submucosa is considerably thickened.
The ulcer is covered by a thin layer of inflammatory exudate. Granulation tissue and lymphocytic infiltration are present at the ulcer base. There is extensive fibrosis throughout the entire wall of the stomach with scattered tumor cells arranged in small clusters and in chains. These tumors cells are often hard to distinguish from the inflammatory cells.
The normal gastric mucosa of the fundus contains superficial fovea arranged in leaf like fronds and deeper gastric glands. The foveolar cells secrete mucin. The gastric glands include mucous cells, parietal cells, chief cells and enteroendocrine cells.
Clinical History: This 84-year-old female developed weakness and weight loss six months prior to death. She saw a physician twelve days prior to death with signs and symptoms of intestinal obstruction. A tumor mass was palpated in the rectum. The colon was resected.
A tumor was present 4 cm from the anus. It was hard and had completely surrounded the bowel, reducing the lumen to less than 0.5 cm in diameter. Small tumor implants were present over the peritoneum and mesentery nearby. No distant metastases were noted.
The the lumen of the bowel can be recognized. Note the thickened bowel wall and masses of tumor surrounding fat. Under low power note the tendency in some areas toward a gland-like structure. There is considerable variation in nuclear staining, size and shape. In some areas clumps of tumor cells are in the midst of mucus which the tumor cells are producing. Note the relatively large amount of dense collagen which accompanies the tumor cells in the fat.
The colon is lined by glandular epithelium with numerous mucin secreting goblet cells. The epithelium is infolded into straight tubular glands of uniform diameter to increase the surface area available for secretion and absorption.
84-1. In what section of the colon do MOST adenocarcinomas arise?
84-4. If this patient’s neoplasm were found to have penetrated into the subserosa and to have spread to one regional lymph node but NOT to distant sites, its stage is:
Clinical History: An 81-year-old, asymptomatic female was found to have guaiac positive stool on routine examination. Flexible sigmoidoscopy revealed a rectal mass.
This section, which includes the edge of the tumor shows invasive adenocarcinoma arising in a villous adenoma. Tall villi lined by neoplastic epithelium replace the normal mucosa at the edge of the mass. Centrally, where the lesion was ulcerated, tumor infiltrates through the muscularis propria and in some sections, enters the subserosal adipose tissue. Irregular glandular spaces are lined by tumor cells and large pools of mucin are seen, as well as desmoplastic (fibrotic) stroma. Although the nuclei of the carcinoma are anaplastic when compared to the normal colon mucosa, the neoplastic epithelium retains a columnar appearance, typically seen in colon carcinoma.
The colon is lined by glandular epithelium with numerous mucin secreting goblet cells. The epithelium is infolded into straight tubular glands of uniform diameter to increase the surface area available for secretion and absorption.
Clinical history: This 45-year-old man complained of flushing, diarrhea, nausea and vomiting. Elevated levels of serotonin and its metabolite, 5-hydroxyindoleacetic acid were found in the blood. An appendectomy was performed.
The tumor cells are relatively small with a round to oval stippled nucleus. There is minimal variation in size and shape. By electron microscopy, the cells contain secretory granules.
The appendix is a tubular organ with a lumen which is lined by mucin secreting columnar epithelium. There is no evidence of acute inflammation. The submucosa and muscle layers are unremarkable. There is no inflammation of the serosa.
Absolutely critical information you must know to practice medicine is in bold font. Important information that will be needed for routine patient care is in regular font. Information about less common diseases that you may encounter in clinical practice and that will probably appear on examinations is in italics
Name tests used in evaluating plasma glucocorticoids, indications, and
interpretation.
Discuss how plasma concentrations of cortisol and aldosterone are controlled.
Name the tests for evaluating adrenal androgens, their indications, and their interpretation.
Discuss the biosynthesis of the adrenal catecholamines and their urinary metabolites.
Discuss the use of growth hormone stimulation tests.
Describe the clinical and pathologic features of including hormonal changes and clinical
laboratory values in these hyperfunctional and hypofunctional conditions:
Contrast and compare the clinical and pathologic features of type 1 and 2 diabetes mellitus.
Outline methods of screening and following patients with diabetes mellitus using laboratory tests:
blood glucose concentration
glucose tolerance test
blood insulin concentration
glycosylated (glycated) hemoglobin level
urine glucose concentration
urine protein concentration
urine and blood ketones
Describe the clinical and pathologic features of including hormonal changes and clinical
laboratory values in these hyperfunctional and hypofunctional conditions:
Describe the various types of multiple endocrine neoplasia (MEN) syndromes, in terms of clinical, laboratory, and morphologic features, as well as prognosis.
Absolutely critical information you must know to practice medicine is in bold font. Important information that will be needed for routine patient care is in regular font. Information about less common diseases that you may encounter in clinical practice and that will probably appear on examinations is in italics
Compare and contrast the clinical and pathologic features of:
Absolutely critical information you must know to practice medicine is in bold font. Important information that will be needed for routine patient care is in regular font. Information about less common diseases that you may encounter in clinical practice and that will probably appear on examinations is in italics
Describe the clinical and pathologic features of disorders of the esophagus:
pathogenesis, including genetic and molecular factors
morphology, including grading and staging criteria
clinical features and course
Contrast and compare clinical and pathologic features of carcinoma of right and left colon.
Discuss carcinoid tumors of the colon, rectum, and appendix, in terms of:
pathogenesis
morphology
clinical features (including extra-colonic manifestations)
course and prognosis
Describe the etiology, pathogenesis, and morphology of appendicitis
actinomycotic appendicitis. chronic suppurative appendicitis resulting from infection by Actinomyces israelii. acute appendicitis. acute inflammation of the appendix, usually resulting from bacterial infection, which may be precipitated by obstruction of the lumen by a fecalith; variable symptoms often consisting of periumbilical, colicky pain and vomiting may be followed by fever, leukocytosis, persistent pain, and signs of peritoneal inflammation in the right lower quadrant of the abdomen; perforation or abscess formation is a frequent complication of delayed surgical intervention. bilharzial appendicitis. appendicitis caused by deposition of the eggs of the blood fluke Schistosoma mansoni in the vermiform appendix. chronic appendicitis. fibrous adhesions, scarring, or deformity of the appendix following subsidence of acute appendicitis; fibrous obliteration of the distal lumen is not abnormal in older persons; term frequently used to refer to repeated mild attacks of acute appendicitis. focal appendicitis. acute appendicitis involving only part of the appendix, sometimes at the site of, or distal to, an obstruction of the lumen. foreign-body appendicitis. appendicitis caused by obstruction of the lumen of the appendix by a foreign substance, such as a particulate foreign body. gangrenous appendicitis. acute appendicitis with necrosis of the wall of the appendix, most commonly developing in obstructive appendicitis and frequently causing perforation and acute peritonitis. left-sided appendicitis. appendicitis occurring on the left side of the abdomen, usually the left lower quadrant, due to abnormal rotation of the gut (e.g., situs inversus). lumbar appendicitis. acute appendicitis in a retrodisplaced appendix in the lumbar region. obstructive appendicitis. acute appendicitis due to infection of retained secretion behind an obstruction of the lumen by a fecalith or some other cause, including carcinoma of the cecum. perforating appendicitis. inflammation of the appendix leading to perforation of the wall of the appendix into the peritoneal cavity, resulting in peritonitis. recurrent appendicitis. repeated episodes of right lower quadrant abdominal pain attributed to recurrence of inflammation of the appendix in a person who did not have an appendectomy for prior episodes. SYN: relapsing appendicitis. relapsing appendicitis. SYN: recurrent appendicitis. stercoral appendicitis. appendicitis following a lodgment of fecal material in the appendix. subperitoneal appendicitis. appendicitis of a subperitoneally displaced appendix. suppurative appendicitis. acute appendicitis with purulent exudate in the lumen and wall of the appendix. verminous appendicitis. appendicitis caused by obstruction or in response to the presence of parasitic worms such as Ascaris lumbricoides, Strongyloides stercoralis, or the pinworm Enterobius vermicularis.
and list the most common complications.
Compare and contrast the clinical and pathologic features of
