Ditzels

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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 System Comment
Hernia sac Gastrointestinal pathology hernia
Stoma Gastrointestinal pathology stoma reversal
Sleeve gastrectomy Gastrointestinal pathology obesity
Vertebral disc Neuropathology herniated disc
Bands of Ladd Paediatric pathology
Cholesteatoma Paediatric pathology
Femoral head Orthopaedic hip fracture, hip OA
Bone reamings Orthopaedic
Tonsil Head and neck pathology tonsilitis
Leg amputation Cardiovascular pathology atherosclerosis
Lipoma Soft tissue pathology
Heterotopic ossification Soft tissue pathology contractures
Tubal ligation Gynecologic pathology completed family
Pressure ulcer (AKA decubitus ulcer) Dermatopathology
Vasectomy Genitourinary pathology completed family
Uvula Head and neck pathology obstructive sleep apnea

Gastrointestinal pathology

Hernia sac

General

  • Hernia repair.
  • 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

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.

Stoma

See: Colon and Small intestine.

General

  • Reversal of ileostomy or colostomy.

Stomas are done 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 REVERSAL:
- LARGE 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.[4]

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.

Cholesteatoma

General

  • Squamous epithelium in the middle ear - leading to accumulation of keratinaceous debris.[6]
    • Keratosis obturans - accumulation in the external ear canal - is considered to be a different process;[7] though some consider it a synonym.[8]

Microscopic

Features:[9]

  • Keratinaceous debris - key feature.
  • Squamous epithelium.
  • Macrophages +/- giant cell (containing keratinceous debris).
  • Chronic inflammation (lymphocytes).

DDx:

  • Cholesterol granuloma.[10]

Genitourinary pathology

Foreskin

Main article: Penis

General

Indications:

Main considerations:

Microscopic

Features:

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

DDx:

Paraurethral cyst

General

  • Rare.
  • Benign.

Clinical:[11]

  • Presentation: mass lesion, dyspareunia or dysuria.
  • Multipareous.

Microscopic

Features:

  • Cystic space with epithelial lining - diagnosis based on epithelial lining.

Subclassification:[12][13]

Head and neck pathology

Tonsillitis

Tonsil redirects here.

General

  • Commonly removed (tonsillectomy) when enlarged.
  • Very low probability of malignancy (<0.2%) in tonsilectomies in individuals <19 years old if no clinical suspicion.[15]

Gross

  • Symmetrical and equal size.

Note:

  • Gross exam is considered sufficient if there is no asymmetry.[16]

Microscopic

Features:

DDx:

Sign out

A. TONSIL, LEFT, TONSILLECTOMY:
- REACTIVE FOLLICULAR HYPERPLASIA.
- REACTIVE SQUAMOUS MUCOSA.

B. TONSIL, RIGHT, TONSILLECTOMY:
- REACTIVE FOLLICULAR HYPERPLASIA.
- REACTIVE SQUAMOUS MUCOSA.

Without squamous mucosa

A. TONSIL, LEFT, TONSILLECTOMY:
- REACTIVE FOLLICULAR HYPERPLASIA.

B. TONSIL, RIGHT, TONSILLECTOMY:
- REACTIVE FOLLICULAR HYPERPLASIA.

Obstructive sleep apnea

Uvula redirects here.
  • Abbreviated OSA.

General

  • Clinical diagnosis.
  • May be treated with a resection of the uvula.[18]
  • Associated with obesity.[19]

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

Venous thrombus and arterial thrombus redirect here.

General

  • Uncommonly comes to pathology.

Risk factors - think Virchow's triad:

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.[20]

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.
  • Thromboembolus.
  • Fat embolism.
  • Amniotic fluid embolus.
  • Foreign body.

Images:

Sign out

BLOOD CLOT, LEFT ILIAC ARTERY, THROMBECTOMY:
- THROMBUS.
- NEGATIVE FOR MALIGNANCY.

Micro

The sections show layers of red blood cells alternating with fibrin and white blood cells (Lines of Zahn).

Leg amputation

Overview

Comes in two basic flavours:

  • Above the knee ampuation (AKA).
  • Below the knee ampuation (BKA).

Etiology:

Toe amputation

  • Like leg ampuations.

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

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.

Atherosclerotic 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

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.

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.

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.[22]
    • Hassan et al.[23] advocate against their use, suggesting the yield is low and a biopsy should be preferred.

Microscopic

Features:[24]

  • 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.

General

  • Definition of heterotopic ossification: bone formation in soft tissue.[25]
  • Injury at site.
  • May be seen in the context of tetraplegia.

Clinical:[25]

  • +/-Joint stiffness.
  • +/-Swelling.
  • +/-Pain.

Microscopic

Features:

  • Lamellar bone - has layering/lines (best seen with polarized light).
  • +/-Skeletal muscle (within the marrow space).

DDx:

Sign out

LESION ("HETEROTOPIC OSSIFICATION"), RIGHT FEMUR, EXCISION:
- BONE -- CONSISTENT WITH MUSCLE HETEROTOPIC OSSIFICATION.
- NEGATIVE FOR MALIGNANCY.

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.

Other

De Quervain syndrome

Should not be confused with De Quervain's thyroiditis (subacute granulomatous thryoiditis).
  • AKA de Quervain disease.

General

  • Benign.
  • Clinical diagnosis.[26]

Clinical:

  • Pain.

Treatment:[26]

  • Steroid.
  • Surgery.

Microscopic

Features:

  • Dense connective tissue consistent with tendon.

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

Tenosynovitis

General

  • Uncommon pathology specimen.

Microscopic

Features:[27]

DDx:

IHC

Features:

  • CD68 +ve.
  • Beta-catenin -ve.

Note:

  • Immunostains are usually not required for the diagnosis.

Sign out

TENOSYNOVIUM, LEFT MIDDLE FINGER, EXCISION:
- DENSE CONNECTIVE TISSUE (CONSISTENT WITH TENDON) WITH LYMPHOHISTOCYTIC INFILTRATE.
- NEGATIVE FOR GIANT CELLS. 
- NEGATIVE FOR MALIGNANCY.

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.

Otosclerosis

General

  • Clinical diagnosis.
  • Causes conductive hearing loss.[28]
  • Etiology - genetic.
    • Over half a dozen genes have been identified.[29][30]
    • Classically described as autosomal dominant.

Treatment:

  • Stapedectomy (removal of the stapes).[31]

Microscopic

Features (temporal bone):[32]

  • 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:

Images:

Sign out

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

Missed stapes

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

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. ↑ 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.
  5. ↑ 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.
  6. ↑ URL: http://www.harrisonspractice.com/practice/ub/view/Harrisons%20Practice/141015/all/otitis_media_and_mastoiditis. Accessed on: 16 March 2011.
  7. ↑ Piepergerdes MC, Kramer BM, Behnke EE (March 1980). "Keratosis obturans and external auditory canal cholesteatoma". Laryngoscope 90 (3): 383–91. PMID 7359960.
  8. ↑ Shire JR, Donegan JO (September 1986). "Cholesteatoma of the external auditory canal and keratosis obturans". Am J Otol 7 (5): 361–4. PMID 3538893.
  9. ↑ Iino Y, Toriyama M, Ohmi S, Kanegasaki S (1990). "Activation of peritoneal macrophages with human cholesteatoma debris and alpha-keratin". Acta Otolaryngol. 109 (5-6): 444–9. PMID 1694387.
  10. ↑ URL: http://path.upmc.edu/cases/case273/dx.html. Accessed on: 14 January 2012.
  11. ↑ Isen, K.; Utku, V.; Atilgan, I.; Kutun, Y. (Aug 2008). "Experience with the diagnosis and management of paraurethral cysts in adult women.". Can J Urol 15 (4): 4169-73. PMID 18706145.
  12. ↑ Satani, H.; Yoshimura, N.; Hayashi, N.; Arima, K.; Yanagawa, M.; Kawamura, J. (Mar 2000). "[A case of female paraurethral cyst diagnosed as epithelial inclusion cyst].". Hinyokika Kiyo 46 (3): 205-7. PMID 10806582.
  13. ↑ Das, SP. (Jul 1981). "Paraurethral cysts in women.". J Urol 126 (1): 41-3. PMID 7195943.
  14. ↑ URL: http://webpathology.com/image.asp?n=3&Case=540. Accessed on: 5 February 2012.
  15. ↑ Erdag, TK.; Ecevit, MC.; Guneri, EA.; Dogan, E.; Ikiz, AO.; Sutay, S. (Oct 2005). "Pathologic evaluation of routine tonsillectomy and adenoidectomy specimens in the pediatric population: is it really necessary?". Int J Pediatr Otorhinolaryngol 69 (10): 1321-5. doi:10.1016/j.ijporl.2005.05.005. PMID 15963574.
  16. ↑ Williams, MD.; Brown, HM. (Oct 2003). "The adequacy of gross pathological examination of routine tonsils and adenoids in patients 21 years old and younger.". Hum Pathol 34 (10): 1053-7. PMID 14608541.
  17. ↑ Wang, XY.; Wu, N.; Zhu, Z.; Zhao, YF. (May 2010). "Computed tomography features of enlarged tonsils as a first symptom of non-Hodgkin's lymphoma.". Chin J Cancer 29 (5): 556-60. PMID 20426908.
  18. ↑ 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.
  19. ↑ 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.
  20. ↑ Kumar, Vinay; Abbas, Abul K.; Fausto, Nelson; Aster, Jon (2009). Robbins and Cotran pathologic basis of disease (8th ed.). Elsevier Saunders. pp. 124. ISBN 978-1416031215.
  21. ↑ 21.0 21.1 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.
  22. ↑ 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.
  23. ↑ 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.
  24. ↑ 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.
  25. ↑ 25.0 25.1 Leblanc, E.; Trensz, F.; Haroun, S.; Drouin, G.; Bergeron, E.; Penton, CM.; Montanaro, F.; Roux, S. et al. (Jun 2011). "BMP-9-induced muscle heterotopic ossification requires changes to the skeletal muscle microenvironment.". J Bone Miner Res 26 (6): 1166-77. doi:10.1002/jbmr.311. PMID 21611960.
  26. ↑ 26.0 26.1 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.
  27. ↑ Shon, W.; Folpe, AL. (Jun 2010). "Tenosynovitis with psammomatous calcification: a poorly recognized pseudotumor related to repetitive tendinous injury.". Am J Surg Pathol 34 (6): 892-5. doi:10.1097/PAS.0b013e3181d95a36. PMID 20442645.
  28. ↑ 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.
  29. ↑ Online 'Mendelian Inheritance in Man' (OMIM) 166800
  30. ↑ Online 'Mendelian Inheritance in Man' (OMIM) 605727
  31. ↑ 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.
  32. ↑ 32.0 32.1 "Otosclerosis.". Br Med J 1 (6105): 63-4. Jan 1978. PMC 1602666. PMID 620199. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1602666/.
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