Difference between revisions of "Ditzels"

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[[Image:Tonsillectomy tonsils.JPEG|thumb|right|220px|Tonsils (at [[cut-up]]) are a common ditzel. ([[WC]]/Katotomichelakis ''et al.'')]]
This article collects '''ditzels''', which are, in the context of [[pathology]], little specimens that are typically one or two slides and usually of little interest.<ref>{{Ref TPoSP|37}}</ref>
This article collects '''ditzels''', which are, in the context of [[pathology]], little specimens that are typically one or two slides and usually of little interest.<ref>{{Ref TPoSP|37}}</ref>


The challenge in ditzels is not falling asleep... so one misses the unexpected (subtle) tumour.
The challenge in ditzels is not falling asleep... so one misses the unexpected (subtle) tumour.  


=The big table of ditzels=
=The big table of ditzels=
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| [[Soft tissue pathology]]
| [[Soft tissue pathology]]
|-
|-
| [[Tubal ligation]]
| Uterine tubes ([[tubal ligation]])
| completed family
| completed family
| [[Gynecologic pathology]]
| [[Gynecologic pathology]]
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| [[Dermatopathology]]
| [[Dermatopathology]]
|-
|-
| [[Vasectomy]]
| Vas deferens ([[vasectomy]])
| completed family
| completed family
| [[Genitourinary pathology]]
| [[Genitourinary pathology]]
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| decortication for [[pneumonia]]
| decortication for [[pneumonia]]
| [[Pulmonary pathology]]
| [[Pulmonary pathology]]
|-
| [[Bursa]]
| [[bursitis]]
| Orthopaedic
|-
| [[Gastric band]]
| [[obesity]]
| [[Gastrointestinal pathology]]
|-
| Small bowel excised during [[Roux-en-Y gastric bypass]]
| [[obesity]]
| [[Gastrointestinal pathology]]
|-
| [[Uterine isthmocele]]/cesarean scar defect
| post-cesarean section
| [[Gynecologic pathology]]
|-
| [[Distal interosseous nerve]] (''[[posterior interosseous nerve]] of wrist'' and ''[[anterior interosseous nerve]] of wrist'')
| chronic hand pain, as may be seen in [[rheumatoid arthritis]]
| [[Neuropathology]]
|-
| [[Palmar fascia]]
| [[palmar fibromatosis]] (Dupuytren's contracture)
| Plastic surgery
|-
| Soft tissue of hand or wrist
| [[Ganglion cyst]]
| Plastic surgery
|- <!--
| Specimen
| Typical context (diagnosis)
| System -->
|}
|}


=Gastrointestinal pathology=
=Gastrointestinal pathology=
==Hernia sac==
==Hernia sac==
:''Inguinal hernia'' redirects here.
===General===
===General===
*Hernia repair (herniorrhaphy).
*Hernia repair (herniorrhaphy).
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====Mesothelial lining present====
====Mesothelial lining present====
<pre>
Submitted as "Hernia Sac", Excision:
- Benign fibroadipose tissue partially covered by mesothelium, consistent
  with hernia sac.
- NEGATIVE for malignancy.
</pre>
======Block letters======
<pre>
<pre>
SOFT TISSUE ("HERNIA SAC"), RESECTION/HERNIA REPAIR:  
SOFT TISSUE ("HERNIA SAC"), RESECTION/HERNIA REPAIR:  
Line 139: Line 181:
=====Gross only=====
=====Gross only=====
<pre>
<pre>
SOFT TISSUE, RIGHT INGUINAL, HERNIORRHAPHY:
SOFT TISSUE, RIGHT INGUINAL, HERNIA REPAIR:
- HERNIA SAC (GROSS ONLY).
- HERNIA SAC (GROSS ONLY).
</pre>
</pre>


<pre>
<pre>
SOFT TISSUE, LEFT INGUINAL, HERNIORRHAPHY:
SOFT TISSUE, LEFT INGUINAL, HERNIA REPAIR:
- HERNIA SAC (GROSS ONLY).
- HERNIA SAC (GROSS ONLY).
</pre>
</pre>
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====Ileostomy====
====Ileostomy====
<pre>
Submitted as "Ileostomy", Excision:
- Small bowel with submucosal fibrosis, otherwise within normal limits.
- Skin without significant pathology.
- NEGATIVE for dysplasia and NEGATIVE for malignancy.
</pre>
=====Alternate=====
<pre>
Submitted As "Ileostomy", Excision:
    - Consistent with ileostomy (small bowel, skin) without significant pathology.
    - NEGATIVE for dysplasia and NEGATIVE for malignancy.
</pre>
=====Block letters=====
<pre>
<pre>
ILEOSTOMY, ILEOSTOMY REVERSAL:
ILEOSTOMY, ILEOSTOMY REVERSAL:
Line 252: Line 309:


==Cholesteatoma==
==Cholesteatoma==
===General===
{{Main|Cholesteatoma}}
*Squamous epithelium in the middle ear - leading to accumulation of keratinaceous debris.<ref>URL: [http://www.harrisonspractice.com/practice/ub/view/Harrisons%20Practice/141015/all/otitis_media_and_mastoiditis http://www.harrisonspractice.com/practice/ub/view/Harrisons%20Practice/141015/all/otitis_media_and_mastoiditis]. Accessed on: 16 March 2011.</ref>
**''Keratosis obturans'' - accumulation in the external ear canal - is considered to be a different process;<ref>{{cite journal |author=Piepergerdes MC, Kramer BM, Behnke EE |title=Keratosis obturans and external auditory canal cholesteatoma |journal=Laryngoscope |volume=90 |issue=3 |pages=383–91 |year=1980 |month=March |pmid=7359960 |doi= |url=}}</ref> though some consider it a synonym.<ref>{{cite journal |author=Shire JR, Donegan JO |title=Cholesteatoma of the external auditory canal and keratosis obturans |journal=Am J Otol |volume=7 |issue=5 |pages=361–4 |year=1986 |month=September |pmid=3538893 |doi= |url=}}</ref>
*The etiology is ''not'' well understood.<ref name=pmid20860924>{{Cite journal  | last1 = Nevoux | first1 = J. | last2 = Lenoir | first2 = M. | last3 = Roger | first3 = G. | last4 = Denoyelle | first4 = F. | last5 = Ducou Le Pointe | first5 = H. | last6 = Garabédian | first6 = EN. | title = Childhood cholesteatoma. | journal = Eur Ann Otorhinolaryngol Head Neck Dis | volume = 127 | issue = 4 | pages = 143-50 | month = Sep | year = 2010 | doi = 10.1016/j.anorl.2010.07.001 | PMID = 20860924 }}</ref><ref name=pmid20156369>{{Cite journal  | last1 = Louw | first1 = L. | title = Acquired cholesteatoma pathogenesis: stepwise explanations. | journal = J Laryngol Otol | volume = 124 | issue = 6 | pages = 587-93 | month = Jun | year = 2010 | doi = 10.1017/S0022215109992763 | PMID = 20156369 }}</ref>
**Theories include migration/hyperplasia, and metaplasia.<ref name=pmid20156369/>
*Rarely transforms into [[squamous cell carcinoma]].<ref name=pmid19563937>{{Cite journal  | last1 = Rothschild | first1 = S. | last2 = Ciernik | first2 = IF. | last3 = Hartmann | first3 = M. | last4 = Schuknecht | first4 = B. | last5 = Lütolf | first5 = UM. | last6 = Huber | first6 = AM. | title = Cholesteatoma triggering squamous cell carcinoma: case report and literature review of a rare tumor. | journal = Am J Otolaryngol | volume = 30 | issue = 4 | pages = 256-60 | month =  | year =  | doi = 10.1016/j.amjoto.2008.06.011 | PMID = 19563937 }}</ref><ref name=pmid15699729>{{Cite journal  | last1 = Takahashi | first1 = K. | last2 = Yamamoto | first2 = Y. | last3 = Sato | first3 = K. | last4 = Sato | first4 = Y. | last5 = Takahashi | first5 = S. | title = Middle ear carcinoma originating from a primary acquired cholesteatoma: a case report. | journal = Otol Neurotol | volume = 26 | issue = 1 | pages = 105-8 | month = Jan | year = 2005 | doi =  | PMID = 15699729 }}</ref>
 
====Classification====
May be subdivided into:<ref name=pmid20860924/>
*Acquired - due to trauma, surgery or infection.
*Congenital.
 
===Gross===
*Whitish mass in the middle ear.<ref name=pmid23217274>{{Cite journal  | last1 = Al Balushi | first1 = T. | last2 = Naik | first2 = JZ. | last3 = Al Khabori | first3 = M. | title = Congenital cholesteatoma in identical twins. | journal = J Laryngol Otol | volume = 127 | issue = 1 | pages = 67-9 | month = Jan | year = 2013 | doi = 10.1017/S0022215112002757 | PMID = 23217274 }}</ref>
 
Image:
<gallery>
Image:Cholesteatom_kuppelraum_1a.jpg | Cholesteatoma. (WC)
</gallery>
 
===Microscopic===
Features:<ref name=pmid1694387>{{cite journal |author=Iino Y, Toriyama M, Ohmi S, Kanegasaki S |title=Activation of peritoneal macrophages with human cholesteatoma debris and alpha-keratin |journal=Acta Otolaryngol. |volume=109 |issue=5-6 |pages=444–9 |year=1990 |pmid=1694387 |doi= |url=}}</ref>
*Keratinaceous debris - '''key feature'''.
*Squamous epithelium.
*Macrophages +/- giant cell (containing keratinceous debris).
*Chronic inflammation (lymphocytes).
 
DDx:
*Cholesterol granuloma.<ref>URL: [http://path.upmc.edu/cases/case273/dx.html http://path.upmc.edu/cases/case273/dx.html]. Accessed on: 14 January 2012.</ref>
*[[Squamous cell carcinoma]].<ref name=pmid19563937/>
 
===Sign out===
<pre>
SOFT TISSUE (CHOLESTEATOMA), SITE NOT FURTHER SPECIFIED, REMOVAL:
- KERATINACEOUS DEBRIS, COMPATIBLE WITH CHOLESTEATOMA.
</pre>
 
<pre>
Soft tissue, left ear ("left ear keratosis"), excision:
- Keratinaceous debris, squamous epithelium and bone (consistent with cholesteatoma).
</pre>


=Genitourinary pathology=
=Genitourinary pathology=
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*[[Lichen planus]].
*[[Lichen planus]].
*Infection, e.g. [[syphilis]], [[candidiasis]].
*Infection, e.g. [[syphilis]], [[candidiasis]].
*[[Zoon balantitis]] - abundant plasma cells.
*[[Zoon balanitis]] - abundant [[plasma cell]]s.


===Microscopic===
===Microscopic===
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*See ''[[Penis]].
*See ''[[Penis]].


==Paraurethral cyst==
===Sign out===
===General===
<pre>
*Rare.  
Foreskin, Circumcision:
*Benign.
- Benign squamous mucosa within normal limits, consistent with foreskin.
</pre>
 
<pre>
A. Foreskin, Circumcision:
- Benign squamous mucosa without significant histopathology, consistent with foreskin.
</pre>
 
<pre>
Foreskin, Circumcision:
- Benign squamous mucosa with mild patchy chronic inflammation at the epidermal-dermal interface.
- NEGATIVE for dysplasia and NEGATIVE for malignancy.
</pre>
 
<pre>
Foreskin, Circumcision:
- Squamous mucosa with mild-to-moderate acute and chronic
  (lymphocytic) lichenoid inflammation.
- NEGATIVE for evidence of lichen sclerosus.
- NEGATIVE for dysplasia and NEGATIVE for malignancy.  


Clinical:<ref>{{Cite journal  | last1 = Isen | first1 = K. | last2 = Utku | first2 = V. | last3 = Atilgan | first3 = I. | last4 = Kutun | first4 = Y. | title = Experience with the diagnosis and management of paraurethral cysts in adult women. | journal = Can J Urol | volume = 15 | issue = 4 | pages = 4169-73 | month = Aug | year = 2008 | doi =  | PMID = 18706145 }}</ref>
Comment:  
*Presentation: mass lesion, dyspareunia or dysuria.
A PASD stain is NEGATIVE for micro-organisms.  
*Multipareous.
</pre>


===Microscopic===
====Micro====
Features:
The section shows squamous mucosa with mild basal pigmentation and subepithelial fibrous tissue. The epithelium matures to the surface. Significant inflammation is ABSENT. Atypia is ABSENT.
*Cystic space with epithelial lining - diagnosis based on epithelial lining.


Subclassification:<ref>{{Cite journal  | last1 = Satani | first1 = H. | last2 = Yoshimura | first2 = N. | last3 = Hayashi | first3 = N. | last4 = Arima | first4 = K. | last5 = Yanagawa | first5 = M. | last6 = Kawamura | first6 = J. | title = [A case of female paraurethral cyst diagnosed as epithelial inclusion cyst]. | journal = Hinyokika Kiyo | volume = 46 | issue = 3 | pages = 205-7 | month = Mar | year = 2000 | doi =  | PMID = 10806582 }}</ref><ref name=pmid7195943>{{Cite journal  | last1 = Das | first1 = SP. | title = Paraurethral cysts in women. | journal = J Urol | volume = 126 | issue = 1 | pages = 41-3 | month = Jul | year = 1981 | doi =  | PMID = 7195943 }}</ref>
==Paraurethral cyst==
*[[Epithelial inclusion cyst]].
{{Main|Paraurethral cyst}}
*Müllerian cyst.
*[[Gartner duct cyst]] ([[AKA]] [[mesonephric duct cyst]] [[AKA]] Wolffian duct cyst).<ref>URL: [http://webpathology.com/image.asp?n=3&Case=540 http://webpathology.com/image.asp?n=3&Case=540]. Accessed on: 5 February 2012.</ref>
*Skene duct cyst.


==Labia==
==Labia==
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=Head and neck pathology=
=Head and neck pathology=
==Tonsillitis==
==Tonsillitis==
:''Tonsil'' redirects here.
{{Main|Tonsillitis}}
===General===
{{Main|Tonsil}}
*Commonly removed (tonsillectomy) when enlarged.
*Very low probability of malignancy (<0.2%) in tonsilectomies in individuals <19 years old if no clinical suspicion.<ref name=pmid15963574>{{Cite journal  | last1 = Erdag | first1 = TK. | last2 = Ecevit | first2 = MC. | last3 = Guneri | first3 = EA. | last4 = Dogan | first4 = E. | last5 = Ikiz | first5 = AO. | last6 = Sutay | first6 = S. | title = Pathologic evaluation of routine tonsillectomy and adenoidectomy specimens in the pediatric population: is it really necessary? | journal = Int J Pediatr Otorhinolaryngol | volume = 69 | issue = 10 | pages = 1321-5 | month = Oct | year = 2005 | doi = 10.1016/j.ijporl.2005.05.005 | PMID = 15963574 }}</ref>
 
===Gross===
*Symmetrical and equal size.
 
Note:
*Gross exam is considered sufficient if there is no asymmetry.<ref name=pmid14608541>{{Cite journal  | last1 = Williams | first1 = MD. | last2 = Brown | first2 = HM. | title = The adequacy of gross pathological examination of routine tonsils and adenoids in patients 21 years old and younger. | journal = Hum Pathol | volume = 34 | issue = 10 | pages = 1053-7 | month = Oct | year = 2003 | doi =  | PMID = 14608541 }}</ref>
 
===Microscopic===
Features:
*Follicular hyperplasia - see ''[[lymph node pathology]]''.
*+/-Colonies (clusters) of [[actinomycetes]] in the tonsillar crypts.
 
DDx:
*Non-Hodgkin [[lymphoma]].<ref name=pmid20426908>{{Cite journal  | last1 = Wang | first1 = XY. | last2 = Wu | first2 = N. | last3 = Zhu | first3 = Z. | last4 = Zhao | first4 = YF. | title = Computed tomography features of enlarged tonsils as a first symptom of non-Hodgkin's lymphoma. | journal = Chin J Cancer | volume = 29 | issue = 5 | pages = 556-60 | month = May | year = 2010 | doi =  | PMID = 20426908 }}</ref>
 
===IHC===
If there is a clinical suspicion - a panel to exclude (small cell) non-Hodgkin lymphomas:
*CD3.
*CD20.
*CD5.
*CD10.
*CD23.
*Cyclin D1.
 
===Sign out===
<pre>
A. TONSIL, LEFT, TONSILLECTOMY:
- REACTIVE FOLLICULAR HYPERPLASIA.
- REACTIVE SQUAMOUS MUCOSA.
 
B. TONSIL, RIGHT, TONSILLECTOMY:
- REACTIVE FOLLICULAR HYPERPLASIA.
- REACTIVE SQUAMOUS MUCOSA.
</pre>
 
====Without squamous mucosa====
<pre>
A. TONSIL, LEFT, TONSILLECTOMY:
- REACTIVE FOLLICULAR HYPERPLASIA.
 
B. TONSIL, RIGHT, TONSILLECTOMY:
- REACTIVE FOLLICULAR HYPERPLASIA.
</pre>


==Obstructive sleep apnea==
==Obstructive sleep apnea==
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{{Main|Cardiovascular pathology}}
{{Main|Cardiovascular pathology}}
==Vascular thrombus==
==Vascular thrombus==
:''Venous thrombus'' and ''arterial thrombus'' redirect here.
{{Main|Vascular thrombus}}
===General===
*Uncommonly comes to pathology.
 
Risk factors - think [[Virchow's triad]]:
*Stasis, e.g. atrial fibrillation.
*Hypercoagulable states, e.g. cancer - see ''[[risks factors venous thromboembolism]]''.
*Endothelial injury.
 
===Gross===
: See ''[[pulmonary embolism]]''.
Features:
*Dull appearance.
*Laminations.
 
===Microscopic===
Features:
*Layers consisting of platelets and fibrin.
**Classically alternating with layers of RBCs - known as ''Lines of Zahn''.<ref name=Ref_PBoD8_124>{{Ref PBoD8|124}}</ref>
 
Note:
*Multiple laminations (layers), in general, suggest that clot was formed in a dynamic environment, i.e. in the context of blood flow.
 
DDx:
*Tumour embolus - malignant cells.
*Thromboembolus - may require [[clinical history]].
*[[Fat embolism]].
*Amniotic fluid embolus - in the context of pregnancy/postpartum.
*Foreign body.
 
Images:
*www:
**[http://library.med.utah.edu/WebPath/ATHHTML/ATH031.html Lines of Zahn (utah.edu)].
**[http://pathhsw5m54.ucsf.edu/case9/image94.html Lines of Zahn (ucsf.edu)].
*[[WC]]:
**[http://commons.wikimedia.org/wiki/File:Laminations_in_a_thrombus_-_low_mag.jpg Laminated thrombus - low mag. (WC)].
**[http://commons.wikimedia.org/wiki/File:Laminations_in_a_thrombus_-_high_mag.jpg Laminated thrombus - high mag. (WC)].
 
===Sign out===
<pre>
BLOOD CLOT, LEFT ILIAC ARTERY, THROMBECTOMY:
- THROMBUS.
- NEGATIVE FOR MALIGNANCY.
</pre>
 
====Micro====
The sections show layers of red blood cells alternating with fibrin and white blood cells (Lines of Zahn).


==Leg amputation==
==Leg amputation==
===General - overview===
{{Main|Leg amputation}}
Comes in two basic flavours:
*Above the knee ampuation (AKA).
*Below the knee ampuation (BKA).
 
Etiology:
*[[Diabetes mellitus]] - most common - see ''[[atherosclerotic peripheral vascular disease]]''.
*Trauma.
*Infection - see ''[[chronic osteomyelitis]]''.
*Drug use, e.g. [[cocaine]].<ref name=pmid17059855/>
 
===Sign out===
:See ''[[Ditzels#Atherosclerotic peripheral vascular disease]]''.


==Toe amputation==
==Toe amputation==
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*Drug use, e.g. [[cocaine]].<ref name=pmid17059855>{{Cite journal  | last1 = Dhawan | first1 = SS. | last2 = Wang | first2 = BW. | title = Four-extremity gangrene associated with crack cocaine abuse. | journal = Ann Emerg Med | volume = 49 | issue = 2 | pages = 186-9 | month = Feb | year = 2007 | doi = 10.1016/j.annemergmed.2006.08.001 | PMID = 17059855 }}</ref>
*Drug use, e.g. [[cocaine]].<ref name=pmid17059855>{{Cite journal  | last1 = Dhawan | first1 = SS. | last2 = Wang | first2 = BW. | title = Four-extremity gangrene associated with crack cocaine abuse. | journal = Ann Emerg Med | volume = 49 | issue = 2 | pages = 186-9 | month = Feb | year = 2007 | doi = 10.1016/j.annemergmed.2006.08.001 | PMID = 17059855 }}</ref>
*[[Chronic osteomyelitis]].
*[[Chronic osteomyelitis]].
*[[Cholesterol embolism]].


===Sign out===
===Sign out===
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LOWER EXTREMITY, LEFT, BELOW THE KNEE AMPUTATION:
LOWER EXTREMITY, LEFT, BELOW THE KNEE AMPUTATION:
- ULCERS AND ISCHEMIC CHANGES WITH FOCAL COMPLETE ARTERIAL OCCLUSION (GROSS ONLY).
- ULCERS AND ISCHEMIC CHANGES WITH FOCAL COMPLETE ARTERIAL OCCLUSION (GROSS ONLY).
</pre>
<pre>
LEG, RIGHT, ABOVE THE KNEE AMPUTATION:
- ULCERS AND ISCHEMIC CHANGES WITH EXTENSIVE ARTERIAL DISEASE (GROSS ONLY).
</pre>
<pre>
LEG, RIGHT, ABOVE THE KNEE AMPUTATION:
- EXTENSIVE ISCHEMIC CHANGES WITH SEVERE ARTERIAL DISEASE (GROSS ONLY).
</pre>
</pre>


Line 633: Line 573:
- ULCERATED SKIN AND CHRONIC ISCHEMIC CHANGES.
- ULCERATED SKIN AND CHRONIC ISCHEMIC CHANGES.
- BONE WITH NO SIGNIFICANT PATHOLOGY.
- BONE WITH NO SIGNIFICANT PATHOLOGY.
- NEGATIVE FOR MALIGNANCY.
</pre>
<pre>
GREAT TOE, RIGHT, AMPUTATION:
- GANGRENE.
- ATHEROSCLEROSIS.
- NECROTIC BONE WITH ABUNDANT COCCI ORGANISMS AND NEUTROPHILS
  WITHIN THE MARROW CAVITY.
- NEGATIVE FOR MALIGNANCY.
- NEGATIVE FOR MALIGNANCY.
</pre>
</pre>
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==Heterotopic ossification==
==Heterotopic ossification==
*Abbreviated ''HO''.
*Abbreviated ''HO''.
===General===
{{Main|Heterotopic ossification}}
*Definition of ''heterotopic ossification'': bone formation in soft tissue.<ref name=pmid21611960>{{Cite journal  | last1 = Leblanc | first1 = E. | last2 = Trensz | first2 = F. | last3 = Haroun | first3 = S. | last4 = Drouin | first4 = G. | last5 = Bergeron | first5 = E. | last6 = Penton | first6 = CM. | last7 = Montanaro | first7 = F. | last8 = Roux | first8 = S. | last9 = Faucheux | first9 = N. | title = BMP-9-induced muscle heterotopic ossification requires changes to the skeletal muscle microenvironment. | journal = J Bone Miner Res | volume = 26 | issue = 6 | pages = 1166-77 | month = Jun | year = 2011 | doi = 10.1002/jbmr.311 | PMID = 21611960 }}
</ref>
*Injury at site.
*May be seen in the context of tetraplegia.
 
Clinical:<ref name=pmid21611960/>
*+/-Joint stiffness.
*+/-Swelling.
*+/-Pain.
 
===Microscopic===
Features:
*[[Lamellar bone]] - has layering/lines (best seen with polarized light).
*+/-Skeletal muscle (within the marrow space).
 
DDx:
*[[Myositis ossificans]] - inflammation, cellular.
*[[Osteosarcoma]], extraskeletal.
 
===Sign out===
<pre>
LESION ("HETEROTOPIC OSSIFICATION"), RIGHT FEMUR, EXCISION:
- BONE -- CONSISTENT WITH MUSCLE HETEROTOPIC OSSIFICATION.
- NEGATIVE FOR MALIGNANCY.
</pre>
 
====Micro====
The sections show laminar bone with a marrow space containing adipose tissue and benign skeletal muscle. The osteocytes show no nuclear atypia. No mitotic activity is appreciated.


==Lumbar bone==
==Lumbar bone==
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*Uncommon specimen.
*Uncommon specimen.
*Septic bursitis is usually due to ''S. aureus''.<ref name=pmid23933823>{{Cite journal  | last1 = Hanrahan | first1 = JA. | title = Recent developments in septic bursitis. | journal = Curr Infect Dis Rep | volume = 15 | issue = 5 | pages = 421-5 | month = Oct | year = 2013 | doi = 10.1007/s11908-013-0353-1 | PMID = 23933823 }}</ref>
*Septic bursitis is usually due to ''S. aureus''.<ref name=pmid23933823>{{Cite journal  | last1 = Hanrahan | first1 = JA. | title = Recent developments in septic bursitis. | journal = Curr Infect Dis Rep | volume = 15 | issue = 5 | pages = 421-5 | month = Oct | year = 2013 | doi = 10.1007/s11908-013-0353-1 | PMID = 23933823 }}</ref>
**Usually associated with trauma to the overlying skin.<ref name=pmid439118>{{Cite journal  | last1 = Canoso | first1 = JJ. | last2 = Sheckman | first2 = PR. | title = Septic subcutaneous bursitis. Report of sixteen cases. | journal = J Rheumatol | volume = 6 | issue = 1 | pages = 96-102 | month =  | year =  | doi =  | PMID = 439118 }}</ref>


Indication:
Indication:
Line 749: Line 671:
<pre>
<pre>
BURSA, LEFT TROCHANTERIC, BURSECTOMY:
BURSA, LEFT TROCHANTERIC, BURSECTOMY:
- BENIGN DENSE CONNECTIVE AND FIBROADIPOSE TISSUE.
- BENIGN DENSE CONNECTIVE TISSUE AND BENIGN FIBROADIPOSE TISSUE.
- NO SIGNIFICANT INFLAMMATION.
- NO SIGNIFICANT INFLAMMATION.
- NEGATIVE FOR MALIGNANCY.
- NEGATIVE FOR MALIGNANCY.
</pre>
</pre>


=Other=
==Rotator cuff tear==
==Breast prosthesis==
:''Breast expander'' redirects here.
===General===
===General===
*Commonly used for cosmesis in the context of [[breast cancer]].
*Surgically repaired.
*[[Clinical diagnosis]].


===Gross===
===Microscopic===
''Specimen received in formalin labelled "right breast prosthesis" consists of a breast prosthesis measuring 13.5 x 12.5 x 4.5 cm. Seen on one side the number 356 is seen. The prosthesis is intact. No tissue is identified. No sections are submitted.''
Features:<ref>{{Cite journal  | last1 = Longo | first1 = UG. | last2 = Berton | first2 = A. | last3 = Khan | first3 = WS. | last4 = Maffulli | first4 = N. | last5 = Denaro | first5 = V. | title = Histopathology of rotator cuff tears. | journal = Sports Med Arthrosc | volume = 19 | issue = 3 | pages = 227-36 | month = Sep | year = 2011 | doi = 10.1097/JSA.0b013e318213bccb | PMID = 21822106 }}</ref>
 
*Collagen degeneration.
====Images====
*Disordered arrangement of collagen fibres.
<gallery>
**Wavy fibres.
Image:Saline-filled_breast_implants.jpeg | Breast implants. (WC)
**Separation of the fibres.
</gallery>
*+/-Inflammation - associated with smaller tears.
WP:
*+/-Decreased cellularity - associated with larger tears.
*[http://en.wikipedia.org/wiki/File:Ruptured_implant.JPG Ruptured breast implant (WP)].
*+/-Fatty replacement.<ref name=pmid24084435>{{Cite journal  | last1 = Kuzel | first1 = BR. | last2 = Grindel | first2 = S. | last3 = Papandrea | first3 = R. | last4 = Ziegler | first4 = D. | title = Fatty infiltration and rotator cuff atrophy. | journal = J Am Acad Orthop Surg | volume = 21 | issue = 10 | pages = 613-23 | month = Oct | year = 2013 | doi = 10.5435/JAAOS-21-10-613 | PMID = 24084435 }}</ref>


===Sign out===
===Sign out===
<pre>
<pre>
BREAST PROSTHESIS, RIGHT, REMOVAL:
RIGHT SHOULDER ACROMIOM AND BURSAE, EXCISION:
- INTACT BREAST PROSTHESIS (GROSS ONLY).
- UNREMARKABLE BONE (GROSS ONLY).
- BENIGN SOFT TISSUE.
</pre>
</pre>


====Not intact====
<pre>
<pre>
BREAST PROSTHESIS, LEFT, REMOVAL:
"BURSA AND ACROMION", LEFT SHOULDER, ROTATOR CUFF REPAIR:
- BREAST PROSTHESIS WITH EVIDENCE OF PERFORATION AND LEAKAGE (GROSS ONLY).
- BENIGN DENSE CONNECTIVE TISSUE AND BENIGN FIBROADIPOSE TISSUE.
- NO SIGNIFICANT INFLAMMATION.
- NO BONE IDENTIFIED.
- NEGATIVE FOR MALIGNANCY.
</pre>
</pre>
<pre>
"BURSA AND ACROMION", LEFT SHOULDER, ROTATOR CUFF REPAIR:
- BENIGN DENSE WAVY CONNECTIVE TISSUE WITH FIBRE SEPARATION.
- BENIGN FIBROADIPOSE TISSUE.
- NO SIGNIFICANT INFLAMMATION.
- NO BONE IDENTIFIED.
- NEGATIVE FOR MALIGNANCY.
</pre>
=Other=
==Breast prosthesis==
*[[AKA]] ''breast implants''.
{{Main|Breast prostheses}}


==De Quervain syndrome==
==De Quervain syndrome==
:Should ''not'' be confused with ''[[De Quervain's thyroiditis]]'' (subacute granulomatous thryoiditis).
:Should ''not'' be confused with ''[[De Quervain's thyroiditis]]'' (subacute granulomatous thryoiditis).
*[[AKA]] ''de Quervain disease''.
*[[AKA]] ''de Quervain tenosynovitis'',<ref name=pmid23405595>{{Cite journal  | last1 = Gigante | first1 = MR. | last2 = Martinotti | first2 = I. | last3 = Cirla | first3 = PE. | title = [Computer work and De Quervain's tenosynovitis: an evidence based approach]. | journal = G Ital Med Lav Ergon | volume = 34 | issue = 3 Suppl | pages = 116-8 | month =  | year =  | doi =  | PMID = 23405595 }}</ref> and ''de Quervain disease''.
===General===
===General===
*Benign.
*Benign.
*[[Tenosynovitis]] of the thumb.
*Clinical diagnosis.<ref name=pmid18063716>{{Cite journal  | last1 = Ilyas | first1 = AM. | last2 = Ilyas | first2 = A. | last3 = Ast | first3 = M. | last4 = Schaffer | first4 = AA. | last5 = Thoder | first5 = J. | title = De quervain tenosynovitis of the wrist. | journal = J Am Acad Orthop Surg | volume = 15 | issue = 12 | pages = 757-64 | month = Dec | year = 2007 | doi =  | PMID = 18063716 }}</ref>
*Clinical diagnosis.<ref name=pmid18063716>{{Cite journal  | last1 = Ilyas | first1 = AM. | last2 = Ilyas | first2 = A. | last3 = Ast | first3 = M. | last4 = Schaffer | first4 = AA. | last5 = Thoder | first5 = J. | title = De quervain tenosynovitis of the wrist. | journal = J Am Acad Orthop Surg | volume = 15 | issue = 12 | pages = 757-64 | month = Dec | year = 2007 | doi =  | PMID = 18063716 }}</ref>


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===Sign out===
===Sign out===
====Not apparent====
<pre>
<pre>
FIRST EXTENSOR COMPARTMENT, RIGHT HAND, BIOPSY:
FIRST EXTENSOR COMPARTMENT, RIGHT HAND, BIOPSY:
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==Tenosynovitis==
==Tenosynovitis==
:''Stenosing tenosynovitis'' directs here.
{{Main|Tenosynovitis}}
===General===
*Uncommon pathology specimen.
*May cause ''trigger finger''.<ref name=pmid23396894>{{Cite journal  | last1 = Vuillemin | first1 = V. | last2 = Guerini | first2 = H. | last3 = Bard | first3 = H. | last4 = Morvan | first4 = G. | title = Stenosing tenosynovitis. | journal = J Ultrasound | volume = 15 | issue = 1 | pages = 20-8 | month = Feb | year = 2012 | doi = 10.1016/j.jus.2012.02.002 | PMID = 23396894 }}</ref>
 
===Microscopic===
Features:<ref name=pmid20442645>{{Cite journal  | last1 = Shon | first1 = W. | last2 = Folpe | first2 = AL. | title = Tenosynovitis with psammomatous calcification: a poorly recognized pseudotumor related to repetitive tendinous injury. | journal = Am J Surg Pathol | volume = 34 | issue = 6 | pages = 892-5 | month = Jun | year = 2010 | doi = 10.1097/PAS.0b013e3181d95a36 | PMID = 20442645 }}</ref>
*Dense connective tissue (tendon).
*Histiocytes.
*+/-[[Psammoma bodies]].
 
DDx:
*Calcific tendinitis.
*[[Giant cell tumour of the tendon sheath]].
*[[Palmar fibromatosis]].
 
===IHC===
Features:
*CD68 +ve.
*Beta-catenin -ve.
 
Note:
*Immunostains are usually not required for the diagnosis.
 
===Sign out===
<pre>
TENOSYNOVIUM, LEFT MIDDLE FINGER, EXCISION:
- DENSE CONNECTIVE TISSUE (CONSISTENT WITH TENDON) WITH LYMPHOHISTIOCYTIC INFILTRATE.
- NEGATIVE FOR GIANT CELLS.
- NEGATIVE FOR MALIGNANCY.
</pre>
 
====Micro====
The sections show dense connective tissue (tendon) containing a cluster of cells with
indistinct cellular borders, abundant foamy grey cytoplasm, and round/oval
pale-staining nuclei with small nucleoli (histiocytes).  The cell cluster has a small
number of interspersed lymphocytes, and the centre of the cell cluster has acellular
hyaline material (degenerative tendon).
 
No calcification is identified. No giant cells are seen.
 
No nuclear atypia is apparent and no mitotic activity is appreciated.
 
=====Alternate=====
The sections show dense connective tissue (tendon) containing rare histiocytes and
lymphocytes. No calcification is identified. No giant cells are seen.  No nuclear atypia
is apparent and no mitotic activity is appreciated.


==Otosclerosis==
==Otosclerosis==
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==Abdominal pannus==
==Abdominal pannus==
{{Main|Obesity}}
*[[AKA]] ''pannus'', ''panniculus'' and ''pannona''.
:''Pannus'' redirects here.
{{Main|Abdominal pannus}}
===General===
*An apron-like excess of skin - following weight loss.<ref>URL: [http://plasticsurgery.about.com/od/glossary/g/panniculectomy.htm http://plasticsurgery.about.com/od/glossary/g/panniculectomy.htm]. Accessed on: 18 July 2012.</ref>
*Seen in [[obesity]].
 
===Gross===
*Skin with abundant fat.
**Pieces usually triangular.
**Stretch marks (striae) are very common. 
 
===Microscopic===
Features:
*Adipose tissue.
 
DDx:
*[[Lipoma]].
*[[Liposarcoma]].
 
===Sign out===
<pre>
ABDOMINAL PANNUS, EXCISION:
- BENIGN SKIN AND ADIPOSE TISSUE.
</pre>
 
<pre>
ABDOMINAL PANNUS, EXCISION:
- DERMAL SCAR, BENIGN SKIN AND ADIPOSE TISSUE.
</pre>
 
====Gross only====
<pre>
ABDOMINAL PANNUS, EXCISION:
- BENIGN SKIN AND ADIPOSE TISSUE (GROSS ONLY).
</pre>


==Empyema==
==Empyema==
:''Empyema peel'' redirects here.
:''Empyema peel'' and ''pleural peel'' redirect here.
===General===
===General===
*Empyemas are often managed surgically.<ref name=pmid10197399>{{Cite journal  | last1 = Ferguson | first1 = MK. | title = Surgical management of intrapleural infections. | journal = Semin Respir Infect | volume = 14 | issue = 1 | pages = 73-81 | month = Mar | year = 1999 | doi =  | PMID = 10197399 }}</ref>
*Empyemas are often managed surgically.<ref name=pmid10197399>{{Cite journal  | last1 = Ferguson | first1 = MK. | title = Surgical management of intrapleural infections. | journal = Semin Respir Infect | volume = 14 | issue = 1 | pages = 73-81 | month = Mar | year = 1999 | doi =  | PMID = 10197399 }}</ref>
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DDx:
DDx:
*[[Malignant mesothelioma]].
*[[Malignant mesothelioma]] - should have infiltrative growth.
*[[Fibrosing pleuritis]].
*[[Fibrosing pleuritis]].


===Sign out===
===Sign out===
<pre>
A. Right Pleural, Pleural Peel:
    - Proliferative fibroblasts with marked reactive changes.
    - Necro-inflammatory debris.
    - NEGATIVE for evidence of malignancy.
B. Right Lung, Biopsy:
    - Necro-inflammatory debris and reactive pleural changes.
    - Infarcted lung parenchyma.
    - NEGATIVE for evidence of malignancy.
</pre>
====Block letters====
<pre>
<pre>
PLEURA, LEFT, DECORTICATION:
PLEURA, LEFT, DECORTICATION:
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- NO MICROORGANISMS APPARENT WITH H&E STAINING.
- NO MICROORGANISMS APPARENT WITH H&E STAINING.
- NEGATIVE FOR MALIGNANCY.
- NEGATIVE FOR MALIGNANCY.
</pre>
====Not labelled as a peel====
<pre>
Left Lung, Biopsy:
- Fibrin, neutrophils, necrotic tissue and a fibroblastic
  response, compatible with empyema peel.
- NO viable lung parenchyma identified.
- NEGATIVE for evidence of malignancy.
</pre>
</pre>


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*Trauma.
*Trauma.
*[[Fungus|Fungal infection]] ([[candidiasis]]).
*[[Fungus|Fungal infection]] ([[candidiasis]]).
*Bacteria infection, e.g. [[Pseudomonas]] (causes green nails).


===Stains===
===Stains===
Line 1,051: Line 935:
- NO EVIDENCE OF MALIGNANCY.
- NO EVIDENCE OF MALIGNANCY.
</pre>
</pre>
==Canal of Nuck cyst==
===General===
*Canal of Nuck is the female equivalent of the male ''processus vaginalis''.<ref name=pmid36295514/>
*Women/girls only pathology - can be thought of as inguinal hernia in women.
*Very rare pathology.<ref name=pmid36295514>{{cite journal |authors=Kohlhauser M, Pirsch JV, Maier T, Viertler C, Fegerl R |title=The Cyst of the Canal of Nuck: Anatomy, Diagnostic and Treatment of a Very Rare Diagnosis-A Case Report of an Adult Woman and Narrative Review of the Literature |journal=Medicina (Kaunas) |volume=58 |issue=10 |pages= |date=September 2022 |pmid=36295514 |pmc=9609622 |doi=10.3390/medicina58101353 |url=}}</ref>
===Sign out===
<pre>
A. Submitted as "Canal of Nuck Cyst", Excision::
- Benign fibroadipose tissue partially covered by mesothelium with inflammation,
  compatible with clinical impression of canal of Nuck cyst.
- NEGATIVE for malignancy.
</pre>
==Palmar fascia==
{{Main|Palmar fascia}}


=See also=
=See also=
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[[Category:Basics]]
[[Category:Basics]]
[[Category:Ditzels]]

Latest revision as of 17:02, 2 July 2024

Tonsils (at cut-up) are a common ditzel. (WC/Katotomichelakis et al.)

This article collects ditzels, which are, in the context of pathology, little specimens that are typically one or two slides and usually of little interest.[1]

The challenge in ditzels is not falling asleep... so one misses the unexpected (subtle) tumour.

The big table of ditzels

Specimen Typical context (diagnosis) System
Hernia sac hernia Gastrointestinal pathology
Stoma (reversal) bowel obstruction, perforated viscus (peritonitis) Gastrointestinal pathology
Sleeve gastrectomy obesity Gastrointestinal pathology
Vertebral disc herniated disc Neuropathology
Bands of Ladd bands of Ladd Paediatric pathology
Cholesteatoma cholesteatoma Paediatric pathology
Femoral head hip fracture, hip OA Orthopaedic
Bone reamings hip fracture Orthopaedic
Tonsil tonsillitis Head and neck pathology
Leg amputation atherosclerotic peripheral vascular disease, trauma Cardiovascular pathology
Lipoma lipoma Soft tissue pathology
Heterotopic ossification contractures Soft tissue pathology
Uterine tubes (tubal ligation) completed family Gynecologic pathology
Pressure ulcer (AKA decubitus ulcer) ulcer, immobility Dermatopathology
Vas deferens (vasectomy) completed family Genitourinary pathology
Uvula obstructive sleep apnea Head and neck pathology
Stapes otosclerosis Head and neck pathology
Abdominal pannus obesity Dermatopathology (?)
Abdominal fat query amyloidosis Haematopathology (?)
Breast prosthesis breast cancer/cosmesis Breast pathology
Empyema peel decortication for pneumonia Pulmonary pathology
Bursa bursitis Orthopaedic
Gastric band obesity Gastrointestinal pathology
Small bowel excised during Roux-en-Y gastric bypass obesity Gastrointestinal pathology
Uterine isthmocele/cesarean scar defect post-cesarean section Gynecologic pathology
Distal interosseous nerve (posterior interosseous nerve of wrist and anterior interosseous nerve of wrist) chronic hand pain, as may be seen in rheumatoid arthritis Neuropathology
Palmar fascia palmar fibromatosis (Dupuytren's contracture) Plastic surgery
Soft tissue of hand or wrist Ganglion cyst Plastic surgery

Gastrointestinal pathology

Hernia sac

Inguinal hernia redirects here.

General

  • Hernia repair (herniorrhaphy).
  • Pathologic findings are very unusual and if present known to the surgeon.
    • Thus, it has been advocated that one ought not examine 'em.[2][3]

Microscopic

Features:

  • Fibrous tissue.
  • +/-Adipose tissue.
  • +/-Mesothelial cells.

Notes:

  • One should not see vas deferens.
  • Things worthy of some comment: granulation tissue, inflammation.

Sign out

Incarcerated without mesothelium

SOFT TISSUE ("HERNIA SAC"), RESECTION/HERNIA REPAIR: 
- FIBROADIPOSE TISSUE WITH FAT NECROSIS -- CONSISTENT WITH HERNIA SAC. 
- NEGATIVE FOR MALIGNANCY.
Micro

The sections show fibrofatty tissue with hemosiderin-laden macrophages, plump activated fibroblasts with pale staining nuclei, histiocytes with small nuclei and abundant grey vacuolated cytoplasm, fat necrosis and focal necrosis of the fibrous tissue.

Mesothelial lining present

Submitted as "Hernia Sac", Excision:
- Benign fibroadipose tissue partially covered by mesothelium, consistent 
  with hernia sac.
- NEGATIVE for malignancy.
Block letters
SOFT TISSUE ("HERNIA SAC"), RESECTION/HERNIA REPAIR: 
- FIBROADIPOSE TISSUE PARTIALLY COVERED BY MESOTHELIUM -- CONSISTENT WITH HERNIA SAC. 
- NEGATIVE FOR MALIGNANCY.
Inflamed
SOFT TISSUE ("HERNIA SAC"), LEFT, RESECTION/HERNIA REPAIR:
- FIBROADIPOSE TISSUE PARTIALLY COVERED BY MESOTHELIUM WITH FOCAL CHRONIC
  INFLAMMATION AND REACTIVE CHANGES -- CONSISTENT WITH HERNIA SAC.
- NEGATIVE FOR MALIGNANCY.
Gross only
SOFT TISSUE, RIGHT INGUINAL, HERNIA REPAIR:
- HERNIA SAC (GROSS ONLY).

SOFT TISSUE, LEFT INGUINAL, HERNIA REPAIR:
- HERNIA SAC (GROSS ONLY).

Stoma

Ostomy, ileostomy and colostomy redirect here.

General

See: Colon and Small intestine.
  • Reversal of ileostomy or colostomy.
    • The (generic) encompassing term for ileostomy and colostomy is ostomy.[4]

Stomas are created for a number of reasons:

Microscopic

Features:

  • Colonic-type or small intestinal-type bowel wall.
    • Lymphoid hyperplasia (abundant lymphocytes) - very common.
    • +/-Fibromuscular hyperplasia of the lamina propria and submucosa.
  • Skin.

Notes:

DDx:

Sign out

Colostomy

COLOSTOMY, COLOSTOMY REVERSAL:
- LARGE BOWEL WALL WITH SUBMUCOSAL FIBROSIS -- OTHERWISE WITHIN NORMAL LIMITS.
- SKIN WITHOUT SIGNIFICANT PATHOLOGY.
- NEGATIVE FOR DYSPLASIA AND NEGATIVE FOR MALIGNANCY.

Ileostomy

Submitted as "Ileostomy", Excision:
- Small bowel with submucosal fibrosis, otherwise within normal limits.
- Skin without significant pathology.
- NEGATIVE for dysplasia and NEGATIVE for malignancy.
Alternate
Submitted As "Ileostomy", Excision:
     - Consistent with ileostomy (small bowel, skin) without significant pathology.
     - NEGATIVE for dysplasia and NEGATIVE for malignancy.
Block letters
ILEOSTOMY, ILEOSTOMY REVERSAL:
- SMALL BOWEL WALL WITH SUBMUCOSAL FIBROSIS -- OTHERWISE WITHIN NORMAL LIMITS.
- SKIN WITHOUT SIGNIFICANT PATHOLOGY.
- NEGATIVE FOR DYSPLASIA AND NEGATIVE FOR MALIGNANCY.

Vagus nerve

General

  • Seen from vagotomy.

Typical indication:

  • Gastric outlet obstruction.[5]

Notes:

  • Left vagus nerve -> anterior vagal trunk.
  • Right vagus nerve -> posterior vagal trunk.

Microscopic

Features:

  • Peripheral nerve.

DDx:

  • Smooth muscle.

IHC

  • S-100 +ve.
  • Desmin -ve.

Sign out

A. VAGUS NERVE, POSTERIOR, VAGOTOMY:
- PERIPHERAL NERVE WITHIN NORMAL LIMITS.

B. VAGUS NERVE, ANTERIOR, VAGOTOMY:
- SMOOTH MUSCLE WITHIN NORMAL LIMITS.
- PERIPHERAL NERVE NOT IDENTIFIED, SEE COMMENT.

COMMENT:
The tissue was stained with desmin and S-100; it is positive for desmin. S-100 marks only 
small nerves fibres that innervate the muscle.

Pediatric

Bands of Ladd

General

Microscopic

Features:

  • Benign fibrous tissue.

Sign out

Adhesive band, Ladd's procedure:
- Vascular fibrous tissue consistent with bands of Ladd.

Cholesteatoma

Main article: Cholesteatoma

Genitourinary pathology

Foreskin

Main article: Penis

General

Indications:

Main considerations:

Microscopic

Features:

  • Usu. fibrotic dermis.
  • +/-Inflammation.

DDx:

Sign out

Foreskin, Circumcision: 
- Benign squamous mucosa within normal limits, consistent with foreskin. 

A. Foreskin, Circumcision: 
- Benign squamous mucosa without significant histopathology, consistent with foreskin. 

Foreskin, Circumcision: 
- Benign squamous mucosa with mild patchy chronic inflammation at the epidermal-dermal interface.
- NEGATIVE for dysplasia and NEGATIVE for malignancy.

Foreskin, Circumcision: 
- Squamous mucosa with mild-to-moderate acute and chronic 
  (lymphocytic) lichenoid inflammation. 
- NEGATIVE for evidence of lichen sclerosus. 
- NEGATIVE for dysplasia and NEGATIVE for malignancy. 

Comment: 
A PASD stain is NEGATIVE for micro-organisms.

Micro

The section shows squamous mucosa with mild basal pigmentation and subepithelial fibrous tissue. The epithelium matures to the surface. Significant inflammation is ABSENT. Atypia is ABSENT.

Paraurethral cyst

Main article: Paraurethral cyst

Labia

General

  • Operation labioplasty.

Microscopic

Features:

  • Squamous epithelium with compact keratin.
  • Fibrous stroma.

Sign out

LABIA MINORA, RIGHT, LABIOPLASTY:
- BENIGN SKIN WITH A THIN LAYER OF COMPACT KERATIN FIBROTIC STROMA -- CONSISTENT
  WITH LABIA MINORA.

Head and neck pathology

Tonsillitis

Main article: Tonsillitis
Main article: Tonsil

Obstructive sleep apnea

Uvula redirects here.
  • Abbreviated OSA.

General

  • Clinical diagnosis.
  • May be treated with a resection of the uvula.[7]
  • Associated with obesity.[8]

Microscopic

Features:

  • Benign oropharyneal mucosa (stratified squamous epithelium).
  • +/-Skeletal muscle.
  • +/-Salivary glands (minor) - mucinous.

Sign out

UVULA, RESECTION:
- OROPHARYNGEAL MUCOSA, CONSISTENT WITH UVULA.

Cardiovascular pathology

Main article: Cardiovascular pathology

Vascular thrombus

Main article: Vascular thrombus

Leg amputation

Main article: Leg amputation

Toe amputation

General - overview

  • Like leg ampuations.

Sign out

See Ditzels#Atherosclerotic peripheral vascular disease.

Finger amputation

General - overview

May be done due to:

  • Contractures leading to ulcerations.
  • Scleroderma - leading to ischemia.[9]

Sign out

See Ditzels#Atherosclerotic peripheral vascular disease.

Atherosclerotic peripheral vascular disease

Diabetic foot redirects here.
  • AKA peripheral vascular disease.
Main article: Atherosclerosis

General

Gross

  • +/-Ulceration.
  • +/-Gangrene - black skin - subclassified:
    • "Wet" = moist/oozing fluid.
    • "Dry" = shriveled, no moisture apparent.
  • +/-Loss of hair.

DDx - gross:

Image:

Sections - grossing:

  • Resection margin (check for viability).
  • Gangrenous area.
  • Blood vessels.
  • Bone (check for osteomyelitis).

Microscopic

Features:

Note:

  • Ischemia may be associated with marked nuclear changes. Uninitiated eyes may think they are seeing a sarcoma.

DDx:

Sign out

Forefoot amputation

RIGHT FOREFOOT, AMPUTATION:
- ULCERATED SKIN. 
- MODERATE-TO-SEVERE ATHEROSCLEROSIS.
- BLOOD VESSEL WITH RECANALIZATION.
- NEGATIVE FOR MALIGNANCY.

Leg amputation

LEFT LEG, BELOW KNEE AMPUTATION:
- MODERATE-TO-SEVERE ATHEROSCLEROSIS.
- COAGULATIVE NECROSIS OF SOFT TISSUE.
- NECROTIC BONE.
- MARROW CAVITY FIBROSIS WITH SIDEROPHAGES.
- RESECTION MARGIN WITH VIABLE TISSUE.
Revision
SKIN AND SOFT TISSUE, RIGHT UPPER LEG, REVISION OF AMPUTATION:
- ULCERATED SKIN WITH NECROTIC SOFT TISSUE WITH IMPETIGINIZATION, AND MICROABSCESS
  FORMATION.
- SEVERE ATHEROSCLEROSIS.
- NEGATIVE FOR MALIGNANCY.
Leg amputation - gross only
LOWER EXTREMITY, LEFT, BELOW THE KNEE AMPUTATION:
- ULCERS AND ISCHEMIC CHANGES WITH FOCAL COMPLETE ARTERIAL OCCLUSION (GROSS ONLY).

LEG, RIGHT, ABOVE THE KNEE AMPUTATION:
- ULCERS AND ISCHEMIC CHANGES WITH EXTENSIVE ARTERIAL DISEASE (GROSS ONLY).

LEG, RIGHT, ABOVE THE KNEE AMPUTATION:
- EXTENSIVE ISCHEMIC CHANGES WITH SEVERE ARTERIAL DISEASE (GROSS ONLY).

Toe amputation

Mild
THIRD TOE, RIGHT, AMPUTATION:
- SKIN WITH MARKED DERMAL FIBROSIS.
- MILD ATHEROSCLEROSIS.
- NEGATIVE FOR MALIGNANCY.

SECOND TOE, RIGHT, AMPUTATION:
- SKIN WITH MARKED DERMAL FIBROSIS AND ULCERATION WITH IMPETIGINIZATION.
- MILD ATHEROSCLEROSIS.
- NEGATIVE FOR MALIGNANCY.
Moderate
SECOND TOE, LEFT, AMPUTATION:
- MODERATE ATHEROSCLEROSIS.
- BONE WITH A FATTY BONE MARROW CAVITY WITH FOCAL FAT NECROSIS AND RARE PLASMA CELLS.
- SKIN WITH FIBROUS DERMIS AND A NON-SPECIFIC DERMAL PERIVASCULAR LYMPHOPLASMACYTIC 
INFILTRATE.

SECOND TOE, LEFT, AMPUTATION:
- MODERATE ATHEROSCLEROSIS.
- BONE WITH A FATTY BONE MARROW CAVITY WITH FOCAL FAT NECROSIS AND RARE PLASMA CELLS.
- SKIN WITH FIBROUS DERMIS AND NON-SPECIFIC PERIVASCULAR LYMPHOPLASMACYTIC DERMAL INFILTRATE.
Severe
SECOND AND THIRD TOE, LEFT, AMPUTATION:
- SEVERE ATHEROSCLEROSIS.
- ACUTE AND CHRONIC OSTEOMYELITIS.
- GANGRENE.

GREAT TOE, LEFT, AMPUTATION:
- GANGRENE.
- SEVERE ATHEROSCLEROSIS.
- ULCERATED SKIN AND CHRONIC ISCHEMIC CHANGES.
- BONE WITH NO SIGNIFICANT PATHOLOGY.
- NEGATIVE FOR MALIGNANCY.

GREAT TOE, RIGHT, AMPUTATION:
- GANGRENE.
- ATHEROSCLEROSIS.
- NECROTIC BONE WITH ABUNDANT COCCI ORGANISMS AND NEUTROPHILS 
  WITHIN THE MARROW CAVITY.
- NEGATIVE FOR MALIGNANCY.

Orthopaedic

Femoral head

Main article: Femoral head

Bone reamings

General

  • Taken during the surgical repair of a fracture, e.g. intramedullary nail placement.
  • Done to rule-out a pathologic fracture; considered reliable for detecting malignancy.[11]
    • Hassan et al.[12] advocate against their use, suggesting the yield is low and a biopsy should be preferred.

Microscopic

Features:[13]

  • Fragments of bone (scattered trabeculae).
    • Necrotic bone = bone with empty lacunae, i.e. lacunae missing osteocytes.
  • Bone marrow.
    • Megakaryocytes - large cells, multinucleated, eosinophilic cytoplasm.
    • Nucleated RBCs - perfectly round, dense nucleus, bright red cytoplasm.
    • Myeloid cells and precursors.
    • Adipocytes.

DDx:

Sign out

BONE, LEFT FEMUR, REAMINGS:
- FEATURES CONSISTENT WITH A RECENT FRACTURE.
- NEGATIVE FOR MALIGNANCY.

Heterotopic ossification

  • Abbreviated HO.
Main article: Heterotopic ossification

Lumbar bone

General

  • May be seen in the context of laminectomies to treat cauda equina syndrome.

Microscopic

Features:

  • Degenerative fibrocartilage:
    • Multiple chondrocytes in one pocket (lacuna) - regenerative change.
    • Degenerative cartilage.
  • Non-vital bone:
    • Empty lacuna.

DDx:

  • Occult malignancy.

Sign out

LUMBAR BONE, DECOMPRESSION:
- BONE AND VERTEBRAL DISC FRAGMENTS WITH DEGENERATIVE CHANGES.
- UNREMARKABLE BONE MARROW.
- NEGATIVE FOR MALIGNANCY.

Bursa

Bursitis redirects here.

General

  • Uncommon specimen.
  • Septic bursitis is usually due to S. aureus.[14]
    • Usually associated with trauma to the overlying skin.[15]

Indication:

  • Bursitis - may be treated with bursectomy.[16]

Note:

  • Most bursitis is managed conservatively.[17]

Microscopic

Features:

  • Dense connective tissue.
  • Fibroadipose tissue.

Sign out

No apparent inflammation

BURSA, RIGHT HIP, BURSECTOMY:
- BENIGN DENSE CONNECTIVE TISSUE WITH CALCIFICATIONS, AND FIBROADIPOSE TISSUE.
- NO SIGNIFICANT INFLAMMATION.
- NEGATIVE FOR MALIGNANCY.

BURSA, LEFT TROCHANTERIC, BURSECTOMY:
- BENIGN DENSE CONNECTIVE TISSUE AND BENIGN FIBROADIPOSE TISSUE.
- NO SIGNIFICANT INFLAMMATION.
- NEGATIVE FOR MALIGNANCY.

Rotator cuff tear

General

Microscopic

Features:[18]

  • Collagen degeneration.
  • Disordered arrangement of collagen fibres.
    • Wavy fibres.
    • Separation of the fibres.
  • +/-Inflammation - associated with smaller tears.
  • +/-Decreased cellularity - associated with larger tears.
  • +/-Fatty replacement.[19]

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RIGHT SHOULDER ACROMIOM AND BURSAE, EXCISION:
- UNREMARKABLE BONE (GROSS ONLY).
- BENIGN SOFT TISSUE.

"BURSA AND ACROMION", LEFT SHOULDER, ROTATOR CUFF REPAIR:
- BENIGN DENSE CONNECTIVE TISSUE AND BENIGN FIBROADIPOSE TISSUE.
- NO SIGNIFICANT INFLAMMATION.
- NO BONE IDENTIFIED.
- NEGATIVE FOR MALIGNANCY.

"BURSA AND ACROMION", LEFT SHOULDER, ROTATOR CUFF REPAIR:
- BENIGN DENSE WAVY CONNECTIVE TISSUE WITH FIBRE SEPARATION.
- BENIGN FIBROADIPOSE TISSUE.
- NO SIGNIFICANT INFLAMMATION.
- NO BONE IDENTIFIED.
- NEGATIVE FOR MALIGNANCY.

Other

Breast prosthesis

  • AKA breast implants.
Main article: Breast prostheses

De Quervain syndrome

Should not be confused with De Quervain's thyroiditis (subacute granulomatous thryoiditis).
  • AKA de Quervain tenosynovitis,[20] and de Quervain disease.

General

Clinical:

  • Pain.

Treatment:[21]

  • Steroid.
  • Surgery.

Microscopic

Features:

  • Dense connective tissue consistent with tendon.

Sign out

Not apparent

FIRST EXTENSOR COMPARTMENT, RIGHT HAND, BIOPSY:
- DENSE CONNECTIVE TISSUE CONSISTENT WITH TENDON.
- FIBROUS TISSUE.

Tenosynovitis

Main article: Tenosynovitis

Otosclerosis

Stapes redirects here.

General

  • Clinical diagnosis.
  • Causes conductive hearing loss.[22]
  • Etiology - genetic.
    • Over half a dozen genes have been identified.[23][24]
    • Classically described as autosomal dominant.

Treatment:

  • Stapedectomy (removal of the stapes).[25]

Microscopic

Features (temporal bone):[26]

  • Classically divided into four phases:
    1. Osteoclastic phase:
      • Large spaces form in bone marrow.
    2. Replacement phase:
      • Bone replaced by basophilic web-like tissue.
    3. Fibril phase:
      • Fibrils deposited.
    4. Lamellar phase:

Features - (stapes):

DDx:

Note:

  • Avascular necrosis of the stapes crura and otosclerosis together is considered rare.[27]

Images:

Sign out

STAPES, RIGHT, STAPEDECTOMY:
- BENIGN BONE CONSISTENT WITH STAPES.

STAPES, RIGHT, STAPEDECTOMY:
- UNREMARKABLE BONE CONSISTENT WITH STAPES.

Missed stapes

STAPES, RIGHT, STAPEDECTOMY:
- BENIGN FIBROFATTY TISSUE.
- NO BONE IDENTIFIED.

External links

Abdominal pannus

  • AKA pannus, panniculus and pannona.
Main article: Abdominal pannus

Empyema

Empyema peel and pleural peel redirect here.

General

  • Empyemas are often managed surgically.[28]
  • Classically, divided into three stages.[29][30]
    • I - exudative stage (acute).
    • II - fibropurulent stage (acute).
    • III - organizational stage (chronic).

Etiologies - common:

Microscopic

Features:

  • Neutrophils (pus) - key feature.
  • Lymphocytes.
  • Plasma cells.
  • Reactive fibroblasts.
  • Reactive mesothelial cells - not common.

DDx:

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A. Right Pleural, Pleural Peel:
     - Proliferative fibroblasts with marked reactive changes.
     - Necro-inflammatory debris.
     - NEGATIVE for evidence of malignancy.

B. Right Lung, Biopsy:
     - Necro-inflammatory debris and reactive pleural changes.
     - Infarcted lung parenchyma.
     - NEGATIVE for evidence of malignancy.

Block letters

PLEURA, LEFT, DECORTICATION:
- MIXED INFLAMMATORY INFILTRATE WITH ABUNDANT NEUTROPHILS.
- REACTIVE FIBROBLASTS AND FIBRIN.
- NO MICROORGANISMS APPARENT WITH H&E STAINING.
- NEGATIVE FOR MALIGNANCY.

Not labelled as a peel

Left Lung, Biopsy:
- Fibrin, neutrophils, necrotic tissue and a fibroblastic 
  response, compatible with empyema peel.
- NO viable lung parenchyma identified.
- NEGATIVE for evidence of malignancy.

Toenail

General

  • Relatively common.

Indications for removal:

  • Ingrown[31] - typically great toe.[32]
  • Onychomycosis - fungal infection.[33]
  • Pigmented lesion.
    • Exclude melanoma.[34]

Microscopic

Features:

  • Nail plate - paucicellular, dense connective tissue.
  • Keratinized squamous epithelium.
  • +/-Cocci organisms.

DDx:

Stains

For pigmented lesion:

Query fungal infection:

Sign out

Pigmented nail

PARTIAL NAIL PLATE, RIGHT THIRD TOE, SCISSOR EXCISION:
- NAIL PLATE AND THIN LAYER OF KERATINIZED SQUAMOUS EPITHELIUM WITH
  PARAKERATOSIS AND FIBRIN.
- NO APPARENT PIGMENT.
- NO EVIDENCE OF MALIGNANCY.
Micro

The sections show a paucicellular nail plate, and a thin layer of squamous epithelium with keratinization and partial retention of the nuclei (parakeratosis). There is also a small amount of fibrin. No pigmentation is apparent with Prussian blue and Fontana-Masson staining. No melanocytes are apparent. No nuclear atypia is apparent. No mitotic activity is identified. No microorganisms are apparent. No significant inflammation is apparent.

Query infection

GREAT TOENAIL, RIGHT, EXCISION:
- NAIL PLATE AND THIN LAYER OF KERATINIZED SQUAMOUS EPITHELIUM.
- SMALL CLUSTERS OF COCCI, FOCAL.
- NO APPARENT FUNGAL ORGANISMS WITH PASF STAIN.
- NO EVIDENCE OF MALIGNANCY.

Fungal organisms present

GREAT TOE NAIL, RIGHT, REMOVAL:
- NAIL PLATE AND THIN LAYER OF KERATINIZED SQUAMOUS EPITHELIUM WITH
  PARAKERATOSIS AND SCANT SUBEPITHELIAL TISSUE.
- FUNGAL ORGANISMS CONSISTENT WITH CANDIDA, DEMONSTRATED WITH PASF STAIN.
- SMALL CLUSTERS OF COCCI, FOCAL.
- NO EVIDENCE OF MALIGNANCY.

Canal of Nuck cyst

General

  • Canal of Nuck is the female equivalent of the male processus vaginalis.[35]
  • Women/girls only pathology - can be thought of as inguinal hernia in women.
  • Very rare pathology.[35]

Sign out

A. Submitted as "Canal of Nuck Cyst", Excision::
- Benign fibroadipose tissue partially covered by mesothelium with inflammation, 
  compatible with clinical impression of canal of Nuck cyst.
- NEGATIVE for malignancy.

Palmar fascia

Main article: Palmar fascia

See also

References

  1. ↑ Weedman Molavi, Diana (2008). The Practice of Surgical Pathology: A Beginner's Guide to the Diagnostic Process (1st ed.). Springer. pp. 37. ISBN 978-0387744858.
  2. ↑ Siddiqui K, Nazir Z, Ali SS, Pervaiz S (February 2004). "Is routine histological evaluation of pediatric hernial sac necessary?". Pediatr. Surg. Int. 20 (2): 133–5. doi:10.1007/s00383-003-1106-2. PMID 14986035.
  3. ↑ Partrick DA, Bensard DD, Karrer FM, Ruyle SZ (July 1998). "Is routine pathological evaluation of pediatric hernia sacs justified?". J. Pediatr. Surg. 33 (7): 1090–2; discussion 1093–4. PMID 9694100.
  4. ↑ URL: http://www.nlm.nih.gov/medlineplus/ostomy.html. Accessed on: 27 January 2013.
  5. ↑ Okawada, M.; Okazaki, T.; Takahashi, T.; Lane, GJ.; Yamataka, A. (2009). "Gastric outlet obstruction possibly secondary to ulceration in a 2-year-old girl: a case report.". Cases J 2 (1): 8. doi:10.1186/1757-1626-2-8. PMID 19123936.
  6. ↑ Raphaeli, T.; Parimi, C.; Mattix, K.; Javid, PJ. (Mar 2010). "Acute colonic obstruction from Ladd bands: a unique complication from intestinal malrotation.". J Pediatr Surg 45 (3): 630-1. doi:10.1016/j.jpedsurg.2009.12.026. PMID 20223332.
  7. ↑ Shin, SH.; Ye, MK.; Kim, CG. (Jun 2009). "Modified uvulopalatopharyngoplasty for the treatment of obstructive sleep apnea-hypopnea syndrome: resection of the musculus uvulae.". Otolaryngol Head Neck Surg 140 (6): 924-9. doi:10.1016/j.otohns.2009.01.020. PMID 19467416.
  8. ↑ Sarkhosh, K.; Switzer, NJ.; El-Hadi, M.; Birch, DW.; Shi, X.; Karmali, S. (Jan 2013). "The Impact of Bariatric Surgery on Obstructive Sleep Apnea: A Systematic Review.". Obes Surg. doi:10.1007/s11695-012-0862-2. PMID 23299507.
  9. ↑ Jones, NF.; Imbriglia, JE.; Steen, VD.; Medsger, TA. (May 1987). "Surgery for scleroderma of the hand.". J Hand Surg Am 12 (3): 391-400. PMID 3584887.
  10. ↑ Dhawan, SS.; Wang, BW. (Feb 2007). "Four-extremity gangrene associated with crack cocaine abuse.". Ann Emerg Med 49 (2): 186-9. doi:10.1016/j.annemergmed.2006.08.001. PMID 17059855.
  11. ↑ Clarke, AM.; Rogers, S.; Douglas, DL. (Dec 1993). "Closed intramedullary biopsy for metastatic disease.". J R Coll Surg Edinb 38 (6): 368-9. PMID 7509409.
  12. ↑ Hassan, K.; Kalra, S.; Moran, C. (Aug 2007). "Intramedullary reamings for the histological diagnosis of suspected pathological fractures.". Surgeon 5 (4): 202-4. PMID 17849954.
  13. ↑ Tydings, JD.; Martino, LJ.; Kircher, M.; Alfred, RH.; Lozman, J. (Mar 1987). "Viability of intramedullary canal bone reamings for continued calcification.". Am J Surg 153 (3): 306-9. PMID 3548454.
  14. ↑ Hanrahan, JA. (Oct 2013). "Recent developments in septic bursitis.". Curr Infect Dis Rep 15 (5): 421-5. doi:10.1007/s11908-013-0353-1. PMID 23933823.
  15. ↑ Canoso, JJ.; Sheckman, PR.. "Septic subcutaneous bursitis. Report of sixteen cases.". J Rheumatol 6 (1): 96-102. PMID 439118.
  16. ↑ Dillon, JP.; Freedman, I.; Tan, JS.; Mitchell, D.; English, S. (Jul 2012). "Endoscopic bursectomy for the treatment of septic pre-patellar bursitis: a case series.". Arch Orthop Trauma Surg 132 (7): 921-5. doi:10.1007/s00402-012-1494-7. PMID 22426936.
  17. ↑ Lustenberger, DP.; Ng, VY.; Best, TM.; Ellis, TJ. (Sep 2011). "Efficacy of treatment of trochanteric bursitis: a systematic review.". Clin J Sport Med 21 (5): 447-53. doi:10.1097/JSM.0b013e318221299c. PMID 21814140.
  18. ↑ Longo, UG.; Berton, A.; Khan, WS.; Maffulli, N.; Denaro, V. (Sep 2011). "Histopathology of rotator cuff tears.". Sports Med Arthrosc 19 (3): 227-36. doi:10.1097/JSA.0b013e318213bccb. PMID 21822106.
  19. ↑ Kuzel, BR.; Grindel, S.; Papandrea, R.; Ziegler, D. (Oct 2013). "Fatty infiltration and rotator cuff atrophy.". J Am Acad Orthop Surg 21 (10): 613-23. doi:10.5435/JAAOS-21-10-613. PMID 24084435.
  20. ↑ Gigante, MR.; Martinotti, I.; Cirla, PE.. "[Computer work and De Quervain's tenosynovitis: an evidence based approach].". G Ital Med Lav Ergon 34 (3 Suppl): 116-8. PMID 23405595.
  21. ↑ 21.0 21.1 Ilyas, AM.; Ilyas, A.; Ast, M.; Schaffer, AA.; Thoder, J. (Dec 2007). "De quervain tenosynovitis of the wrist.". J Am Acad Orthop Surg 15 (12): 757-64. PMID 18063716.
  22. ↑ Declau, F.; van Spaendonck, M.; Timmermans, JP.; Michaels, L.; Liang, J.; Qiu, JP.; van de Heyning, P. (2007). "Prevalence of histologic otosclerosis: an unbiased temporal bone study in Caucasians.". Adv Otorhinolaryngol 65: 6-16. doi:10.1159/000098663. PMID 17245017.
  23. ↑ Online 'Mendelian Inheritance in Man' (OMIM) 166800
  24. ↑ Online 'Mendelian Inheritance in Man' (OMIM) 605727
  25. ↑ Redfors, YD.; Gröndahl, HG.; Hellgren, J.; Lindfors, N.; Nilsson, I.; Möller, C. (Aug 2012). "Otosclerosis: anatomy and pathology in the temporal bone assessed by multi-slice and cone-beam CT.". Otol Neurotol 33 (6): 922-7. doi:10.1097/MAO.0b013e318259b38c. PMID 22771999.
  26. ↑ 26.0 26.1 "Otosclerosis.". Br Med J 1 (6105): 63-4. Jan 1978. PMC 1602666. PMID 620199. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1602666/.
  27. ↑ Erdoglija, M.; Sotirovic, J.; Jacimovic, V.; Vukomanovic, B. (2012). "Avascular necrosis of stapes crura in one case of operated otosclerosis.". Acta Medica (Hradec Kralove) 55 (4): 193-7. PMID 23631292.
  28. ↑ Ferguson, MK. (Mar 1999). "Surgical management of intrapleural infections.". Semin Respir Infect 14 (1): 73-81. PMID 10197399.
  29. ↑ Shiraishi, Y. (Jul 2010). "Surgical treatment of chronic empyema.". Gen Thorac Cardiovasc Surg 58 (7): 311-6. doi:10.1007/s11748-010-0599-6. PMID 20628845.
  30. ↑ Hamm, H.; Light, RW. (May 1997). "Parapneumonic effusion and empyema.". Eur Respir J 10 (5): 1150-6. PMID 9163661. http://erj.ersjournals.com/content/10/5/1150.long.
  31. ↑ Küçüktaş, M.; Kutlubay, Z.; Yardimci, G.; Khatib, R.; Tüzün, Y. (Feb 2013). "Comparison of effectiveness of electrocautery and cryotherapy in partial matrixectomy after partial nail extraction in the treatment of ingrown nails.". Dermatol Surg 39 (2): 274-80. doi:10.1111/dsu.12068. PMID 23227941.
  32. ↑ Jia, C.; Li, P.; Wu, Y.; Qiu, Y.; Cao, L.; Chang, C.; Zhang, Y. (Jul 2013). "[Modified surgical repair of severe ingrown toenail].". Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 27 (7): 869-71. PMID 24063180.
  33. ↑ 33.0 33.1 Reisberger, EM.; Abels, C.; Landthaler, M.; Szeimies, RM. (Apr 2003). "Histopathological diagnosis of onychomycosis by periodic acid-Schiff-stained nail clippings.". Br J Dermatol 148 (4): 749-54. PMID 12752134.
  34. ↑ Fanti, PA.; Dika, E.; Misciali, C.; Vaccari, S.; Barisani, A.; Piraccini, BM.; Cavrin, G.; Maibach, HI. et al. (Jun 2013). "Nail apparatus melanoma: is trauma a coincidence? Is this peculiar tumor a real acral melanoma?". Cutan Ocul Toxicol 32 (2): 150-3. doi:10.3109/15569527.2012.740118. PMID 23153047.
  35. ↑ 35.0 35.1 Kohlhauser M, Pirsch JV, Maier T, Viertler C, Fegerl R (September 2022). "The Cyst of the Canal of Nuck: Anatomy, Diagnostic and Treatment of a Very Rare Diagnosis-A Case Report of an Adult Woman and Narrative Review of the Literature". Medicina (Kaunas) 58 (10). doi:10.3390/medicina58101353. PMC 9609622. PMID 36295514. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9609622/.
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