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Pathology can be boiled down to:
Pathology can be boiled down to:
#What is it?
#What is it?
#*Biopsies.
#Did I get it all?
#Did I get it all?
#*Resections.
#Did I get the right thing?
#Did I get the right thing?
#*Most other things.


==Terms==
==Terms==
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*''Argyrophilic'' means has an affinity for silver<ref>URL: [http://www.merriam-webster.com/medical/argyrophilic http://www.merriam-webster.com/medical/argyrophilic]. Accessed on: 29 August 2011.</ref><ref>URL: [http://en.wiktionary.org/wiki/argyrophilic http://en.wiktionary.org/wiki/argyrophilic]. Accessed on: 29 August 2011.</ref>/loves silver/stains with silver.
*''Argyrophilic'' means has an affinity for silver<ref>URL: [http://www.merriam-webster.com/medical/argyrophilic http://www.merriam-webster.com/medical/argyrophilic]. Accessed on: 29 August 2011.</ref><ref>URL: [http://en.wiktionary.org/wiki/argyrophilic http://en.wiktionary.org/wiki/argyrophilic]. Accessed on: 29 August 2011.</ref>/loves silver/stains with silver.
===Morphologic patterns===
===Morphologic patterns===
{| class="wikitable sortable" style="margin-left:auto;margin-right:auto"
{{Main|Morphologic patterns}}
! Name of pattern
This covers things like ''cribriform'', ''hobnail'', ''herring bone'' and many others.
! Meaning
! DDx (incomplete/abbrev. list)
! Image
|-
| Hobnail
| basement membrane area < area exposed to luminal surface
| [[angiosarcoma]], clear cell carcinoma
| [[Image:Epithelioid_angiosarcoma_-_very_high_mag.jpg |thumb|center|150px| [[Angiosarcoma]] - very high mag. (WC/Nephron)]]
|-
| Storiform
| spiral appearance ''or'' cartwhell pattern<ref>Storiform. dictionary.com. URL: [http://dictionary.reference.com/browse/storiform http://dictionary.reference.com/browse/storiform]. Accessed on: April 24, 2009.</ref>
| [[solitary fibrous tumour]], [[DFSP]], [[dermatofibroma]], [[UPS]]
| [[Image:Storiform_pattern_-_very_high_mag.jpg | thumb| center|150px| [[DFSP]] - very high mag. (WC/Nephron)]]
|-
| Fascicular
| the long axis of the (spindle) cells are perpendicular to one another in adjacent bundles of cells
| [[leiomyoma]], [[leiomyosarcoma]]
| [[Image:Cutaneous_leiomyosarcoma_-_very_high_mag.jpg| thumb | center | 150px | [[Leiomyosarcoma]] - very high mag. (WC/Nephron)]]
|-
| Plexiform
| web-like formation<ref>URL: [http://www.mondofacto.com/facts/dictionary?plexiform http://www.mondofacto.com/facts/dictionary?plexiform]. Accessed on: March 9, 2010.</ref>
| [[plexiform neurofibroma]], [[MPNST]], plexiform lesion of [[pulmonary hypertension]]
| [http://www.flickr.com/photos/bc_the_path/1715728630/ plexiform lesion of Pulm. HTn (flickr.com)]
|-
| Cribriform
| pierced with small holes<ref>URL: [http://dictionary.reference.com/browse/cribriform http://dictionary.reference.com/browse/cribriform]. Accessed on: 8 August 2011.</ref>
| cribriform [[DCIS]], cribriform [[HGPIN]], cribriforming in a [[tubular adenoma of the gastrointestinal tract|tubular adenoma]] with high-grade dysplasia, endometrioid endometrial carcinoma
| [[Image:Atypical_ductal_hyperplasia_-_very_high_mag.jpg|thumb|center|150px|Cribriform architecure ([[ADH]]) - very high mag. (WC/Nephron)]]
|-
| Solid ''or'' Sheeting
| no architecture - back-to-back cells with no pattern apparent / no spaces between cells
| solid DCIS, poorly-differentiated malignancy (carcinoma, sarcoma, lymphoma)
| [[Image:Merkel_cell_carcinoma_-_high_mag.jpg|thumb|center|150px|Sheeting in a [[Merkel cell carcinoma]] - high mag. (WC/Nephron)]]
|-
| Micropapillary
| nipple like projections without a fibrovascular core (papillary = nipple-like<ref>URL: [http://dictionary.reference.com/browse/papillary http://dictionary.reference.com/browse/papillary]. Accessed on: 8 August 2011.</ref>)
| micropapillary [[DCIS]], micropapillary [[HGPIN]]
| [[File:Invasive_micropapillary_carcinoma_of_the_breast.jpg|thumb|center|150px|Micropapillary carcinoma. (WC)]]
|-
| Papillary
| nipple-like projection with a fibrovascular core
| [[papillary thyroid carcinoma]]
| [[Image:Papillary_renal_cell_carcinoma_high_mag.jpg| thumb|center|150px|[[Papillary RCC]] - high mag. (WC/Nephron)]]
|-
| Flat
| board-like, does not have a projection above the surface
| flat DCIS
| [http://www.breastpathology.info/Sloane/Images/dcis/flat1-400.jpg flat DCIS 1 (breastpathology.info)],<ref name=sloane/> [http://www.breastpathology.info/Sloane/Images/dcis/flat2-400.jpg flat DCIS 2 (breastpathology.info)]<ref name=sloane>URL: [http://www.breastpathology.info/Sloane/dcis.html http://www.breastpathology.info/Sloane/dcis.html]. Accessed on: 8 August 2011.</ref>
|-
| Herring bone
| like herring bone (technique) for climbing a hill in cross country skiing; books on a shelf, where they have partially fallen over -- on the one shelf to the left and the one below to the right
| [[fibrosarcoma]], [[synovial sarcoma]], [[MPNST]]
| [[Image:Malignant_peripheral_nerve_sheath_tumour_-_high_mag.jpg|thumb|center|150px| [[MPNST]] - high mag.(WC/Nephron)]]
|-
| [[Trabecular]] ''or'' cords
| trabecula = ''little beam''<ref>URL: [http://dictionary.reference.com/browse/trabecula http://dictionary.reference.com/browse/trabecula]. Accessed on: 26 December 2010.</ref>; quasi-linear arrangement of cells
| normal liver lobule, [[Sertoli cell tumour]]
| [[Image:Papillary thyroid carcinoma tall cell var high mag.jpg|thumb|center|150px|[[PTC]] tall cell variant - high mag. (WC/Nephron)]]
|-
| Nested (nesting)
| islands of cells with a circular outline
| neuroendocrine tumours
| [[Image:Small_intestine_neuroendocrine_tumour_high_mag_cropped.jpg |thumb|center|150px|[[Neuroendocrine tumour]] - low mag. (WC/Nephron)]]
|-
| Biphasic / multiple patterns
| multiple patterns or cell types; e.g. spindle cells and epithelioid cells
| [[synovial sarcoma]], [[malignant melanoma]], [[pleomorphic adenoma]], [[angiomyolipoma]], [[chondroid syringoma]]
| [[Image:Desmoplastic_small_round_cell_tumour_-_high_mag.jpg |thumb|center|150px| [[DSRCT]] - high mag. (WC/Nephron)]]
|}


===Nuclear destruction words===
===Nuclear destruction words===
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#Cytoplasm - abundance (scant, moderate, abundant).
#Cytoplasm - abundance (scant, moderate, abundant).
#*Eosinophilic cytoplasm disfavours lymphoma.
#*Eosinophilic cytoplasm disfavours lymphoma.
#*Oncocytic - possessing copious eosinophilic granular cytoplasm.
#**Benign lesions composed of oncocytes - oncocytoma
#**Oncocytic metaplasia (alteration of cytoplasm) can effect all or a part of a lesion.
#**Oncocytic neoplasms are common in the kidneys, thyroid and salivary glands.
#**Oncocytic change increases with age
#**May represent senescent accumulation of mitochondria in secretory epithelial.
#Chromatin - coarseness (fine, granular).
#Chromatin - coarseness (fine, granular).
#Nucleoli - number (absent, present, multiple).
#Nucleoli - number (absent, present, multiple).
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*A collection of PMNs... think about ''necrosis'' and ''abscess''.
*A collection of PMNs... think about ''necrosis'' and ''abscess''.


===Lymph node metstatsis===
===Lymph node metastasis===
{{Main|Lymph node metastasis}}
{{Main|Lymph node metastasis}}
*Take a good to look at the tumour first.
*Take a good to look at the tumour first.
*Tumour in a node is often better differentiated than the most poorly differentiated part in the primary site.
*Tumour in a node is often better differentiated than the most poorly differentiated part in the primary site.
*Subcapsular space - the first place to look for mets.
*Subcapsular space - the first place to look for mets.
*Lymph node metstasis are usually obvious.
*Lymph node metastasis are usually obvious.
**There are of course exceptions, e.g. [[small cell carcinoma]], [[invasive lobular carcinoma]].
**There are of course exceptions, e.g. [[small cell carcinoma]], [[invasive lobular carcinoma]].
*Histiocytes may be difficult to separate from tumour - especially for the novice.
*Histiocytes may be difficult to separate from tumour - especially for the novice.
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==Granulomas==
==Granulomas==
*Granulomas can be elusive to the novice.
{{Main|Granuloma}}
*Plural of ''granuloma'' was ''granulomata''; ''granulomas'' (an anglicized version) is, however, now generally accepted.
 
===Definition of granuloma===
*Many definitions exist.
*The term is used rather loosely by clinicans.
**Radiologists occasionally call small lung nodules "granulomas".
 
====Strict pathologic definition====
Robbins definition:
*Chronic inflammatory reaction characterized by the focal accumulation of activated macrophages, often with an epithelioid appearance.<ref name=Ref_PBoD82>{{Ref PBoD|82}}</ref>
**"Epithelioid" cells = cells whose morphology resembles that of epithelial cells; the cells appear to adhere to one another.
 
Adams definition - it's short & sweet:
*A compact collection of macrophages.<ref name=pmid937513>{{cite journal |author=Adams DO |title=The granulomatous inflammatory response. A review.  |journal=American Journal of Pathology |volume=84 |issue=1 |pages=164&ndash;191 |year=1976 |pmid=937513 |doi= |url=http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2032357/?tool=pubmed}}</ref>
**The macrophages must form a small ball/cluster of cells, i.e. touch one another.
 
Other pathologic definitions include the presence of:<ref name=pmid937513/>
*Plasma cells.
*Lymphocytes.
*Epithelioid macrophages.
 
Notes:
*The textbook answer for what is a granuloma is: "A collection of epitheliod macrophages."
**Granulomas are often associated with lymphocytes.
 
===Features that assist one in finding granulomas===
#Collection of cells that have abundant bubbly cytoplasm - '''most useful feature'''.
#'''Multinucleated [[giant cells]]''' - these are easy to identify if you've seen some before.
#*Individual/singular multinucleated giant cells are not diagnostic of a granuloma... but should raise one's suspicion of one being present.
#Necrosis - too much pink (on H&E stained sections).
 
Notes:
*Small round collection of lymphocytes - without a capsule (as seen in lymph nodes).
**If there are no macrophages... it's a ''lymphoid nodule''.
 
Images:
<gallery>
Image:Granuloma_20x.jpg |Granulomas showing abundant bubbly cytoplasm. (WC)
Image:Asteroid_body_intermed_mag.jpg |Granulomas with multinucleated giant cells in sarcoidosis. (WC)
Image:Necrogran10x.jpg|Granuloma with necrosis. (WC)
</gallery>
====As a list====
Features:<ref>Santos, G. 26 January 2010.</ref>
#Foamy/bubbly cytoplasm, abundant - '''low power'''.
#Epithelioid morphology - cell borders ''near'' indistinct - '''key feature'''.
#"Footprint" pattern nuclei/bean-shaped nuclei - '''key feature'''.
#*Macrophages usu. have an ovoid nucleus.
#+/-Nucleoli, small.
#+/-Fibrosis.
#+/-Palisading at edge.
 
====DDx====
*Reactive germinal centre - especially if there are abundant surrounding lymphocytes.<ref name=Ref_GLP170>{{Ref GLP|170}}</ref>
 
===Classification of granuloma===
====Histologic classification====
#Necrosing (also ''caseating'').
#*More likely to be infectious.
#*Examples: [[Tuberculosis]] (TB).
#Non-necrosing.
#*Less likely to be infectious.
#*Examples: Crohn's disease, sarcoidosis, drug reaction.
 
Whether necrosis is present in a granuloma is affected by the immune function, e.g. a [[HIV]]/AIDS patient may have non-necrosing granulomata due to TB.
 
Notes:
*A few people differentiate between ''caseating'' (fragments of recognizable tissue) and ''necrosing'' (dead debris only).<ref name=pmid17257125>{{Cite journal  | last1 = El-Zammar | first1 = OA. | last2 = Katzenstein | first2 = AL. | title = Pathological diagnosis of granulomatous lung disease: a review. | journal = Histopathology | volume = 50 | issue = 3 | pages = 289-310 | month = Feb | year = 2007 | doi = 10.1111/j.1365-2559.2006.02546.x | PMID = 17257125 }}</ref>
*Infectious non-necrosing infections: [[Mycobacterium avium complex]] (MAC), [[cryptococcus]], infections in immunosuppressed individuals.<ref name=pmid17257125/>
 
====Etiologic classification====
#Infectious, e.g. [[tuberculosis]], [[MAC]], [[leprosy]], [[syphilis]], [[cat-scratch disease]], schistosomiasis,<ref name=Ref_PCPBoD8_47>{{Ref PCPBoD8|47}}</ref> fungal infection.
#Neoplastic, e.g. [[seminoma]], Lennert lymphoma,<ref name=pmid19775391>{{Cite journal  | last1 = Summers | first1 = TA. | last2 = Rush | first2 = W. | last3 = Aguilera | first3 = N. | last4 = Lupton | first4 = G. | title = Cutaneous involvement in the lymphoepithelioid variant of peripheral T-cell lymphoma, unspecified (Lennert lymphoma). Report of a case and review of the literature. | journal = J Cutan Pathol | volume = 36 Suppl 1 | issue =  | pages = 25-30 | month = Oct | year = 2009 | doi = 10.1111/j.1600-0560.2008.01203.x | PMID = 19775391 }}</ref> ruptured ovarian teratoma.<ref name=pmid15526210>{{Cite journal  | last1 = Phupong | first1 = V. | last2 = Sueblinvong | first2 = T. | last3 = Triratanachat | first3 = S. | title = Ovarian teratoma with diffused peritoneal reactions mimicking advanced ovarian malignancy. | journal = Arch Gynecol Obstet | volume = 270 | issue = 3 | pages = 189-91 | month = Nov | year = 2004 | doi = 10.1007/s00404-003-0479-8 | PMID = 15526210 }}</ref>
#Autoimmune/inflammatory, e.g. [[Wegener's granulomatosis]], [[Churg-Strauss syndrome]].
#Allergic, e.g. [[hypersensitivity pneumonitis]].
#Foreign body, e.g. pulmonary talcosis, silicosis, berylliosis.<ref name=Ref_PCPBoD8_47>{{Ref PCPBoD8|47}}</ref>
#Drug reaction.
#Idiopathic, e.g. [[sarcoidosis]].
 
Notes:
*Memory device: ''DNF AAII'' = drug reaction, neoplasm, foreign body, allergy, autoimmune, idiopathic, infection.
*A long [[DDx]] for granulomas is complied by ''James''.<ref name=pmid10908370>{{Cite journal  | last1 = James | first1 = DG. | title = A clinicopathological classification of granulomatous disorders. | journal = Postgrad Med J | volume = 76 | issue = 898 | pages = 457-65 | month = Aug | year = 2000 | doi =  | PMID = 10908370 }}</ref>
 
===Lung granulomata===
There are many causes.<ref name=pmid17257125/>
 
Infectious:
*Myocbacterial: [[Tuberculosis]], [[MAC]], other.
*Fungal: [[Histoplasmosis]], [[Cryptococcosis]], [[Blastomycosis]], [[Coccidioidomycosis]].
*[[Aspiration pneumonia]].
Non-infectious:
*Pneumoconioses/[[hypersensitivity pneumonitis]]: Talcosis, Berylliosis.
Idiopathic/autoimmune:
*[[Sarcoidosis]].
*[[Wegener's granulomatosis]].
*[[Churg-Strauss disease]].
*[[Rheumatoid nodules]].
 
===Special granulomas===
====Fibrin ring granuloma====
*Classically associated with ''[[Q fever]]''.
**DDx:<ref name=pmid11881318>{{cite journal |author=Tjwa M, De Hertogh G, Neuville B, Roskams T, Nevens F, Van Steenbergen W |title=Hepatic fibrin-ring granulomas in granulomatous hepatitis: report of four cases and review of the literature |journal=Acta Clin Belg |volume=56 |issue=6 |pages=341–8 |year=2001 |pmid=11881318 |doi= |url=}}</ref> infections (Coxiella burnetii (causes [[Q fever]]), [[CMV]], [[EBV]] + others), drug reaction, malignancy (e.g. Hodgkin lymphoma<ref name=pmid8514044>{{cite journal |author=de Bayser L, Roblot P, Ramassamy A, Silvain C, Levillain P, Becq-Giraudon B |title=Hepatic fibrin-ring granulomas in giant cell arteritis |journal=Gastroenterology |volume=105 |issue=1 |pages=272–3 |year=1993 |month=July |pmid=8514044 |doi= |url=}}</ref>).
*Appearance:
**Epithelioid macrophages (i.e. a granuloma) surrounding a fibrin ring with a clear (lipid-filled) vacuole at its center.
***Images:
****[http://en.gooword.com/picture/864449/ FRG (gooword.com)].
====Naked granuloma====
*Minimal (lymphoid) inflammation.
**Classically [[sarcoidosis]] <ref name=pmid18948765>{{Cite journal  | last1 = Brinster | first1 = NK. | title = Dermatopathology for the surgical pathologist: a pattern-based approach to the diagnosis of inflammatory skin disorders (part II). | journal = Adv Anat Pathol | volume = 15 | issue = 6 | pages = 350-69 | month = Nov | year = 2008 | doi = 10.1097/PAP.0b013e31818b1ac6 | PMID = 18948765 }}</ref><ref name=pmid24138972>{{Cite journal  | last1 = Noiles | first1 = K. | last2 = Beleznay | first2 = K. | last3 = Crawford | first3 = RI. | last4 = Au | first4 = S. | title = Sarcoidosis can present with necrotizing granulomas histologically: two cases of ulcerated sarcoidosis and review of the literature. | journal = J Cutan Med Surg | volume = 17 | issue = 6 | pages = 377-83 | month =  | year =  | doi =  | PMID = 24138972 }}</ref> - DDx large.


==Common morphologic problems==
==Common morphologic problems==
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Note:
Note:
*Most of the resident [[microscope]]s, at U of T, have an eye piece diameter of 22 mm. Therefore, the field diameter at 40 X is approximately 22 mm / 40 X ~= 0.55 mm and the field of view is pi/4*(0.55 mm)^2 = 0.2376 mm^2.
*Most modern [[microscope]]s, have an eye piece diameter of 22 mm. Therefore, the field diameter at 40 X is approximately 22 mm / 40 X ~= 0.55 mm and the field of view is pi/4*(0.55 mm)^2 = 0.2376 mm^2.


==Pathology reports==
==Pathology reports==
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==Lab talk==
==Lab talk==
{{Main|Cutting}}
Tissue cutting terms - these often vary from lab-to-lab:<ref>URL: [http://www.mailman.srv.ualberta.ca/pipermail/patho-l/2002-July/016955.html http://www.mailman.srv.ualberta.ca/pipermail/patho-l/2002-July/016955.html]. Accessed on: 18 October 2011.</ref>
Tissue cutting terms - these often vary from lab-to-lab:<ref>URL: [http://www.mailman.srv.ualberta.ca/pipermail/patho-l/2002-July/016955.html http://www.mailman.srv.ualberta.ca/pipermail/patho-l/2002-July/016955.html]. Accessed on: 18 October 2011.</ref>
*Recut = cut off the top of the block.
*Recut = cut off the top of the block.
Michael
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