THE SKILFUL PATHOLOGIST

Histopathology Diagnosis
and Exam Tips

Third Edition
Dr. Osama Sharaf Eldin, PhD, FRCPath

2017/2018
 Histopathology Diagnosis

Copyright © 2017 by Osama Sharaf Eldin, PhD, FRCPath

All Rights Reserved. No part of this publication may be reproduced or

transmitted in any form or by any means without the permission of the copyright
owner

ISBN: 978-0-244-02910-4

Preface
Histopathology diagnosis is the surest diagnostic test employed for detection of a
disease compared to the other laboratory and clinical investigations. Hence, the
precise learning of the particular diagnostic guidelines in histopathology is crucial
for the appropriate patient management. Considering this, the current book is
solely designed to deliver tips and tricks in macroscopic and microscopic
evaluation of specimens and with the aid of ancillary studies including special
stains, immunohistochemistry, immunofluorescence and electron microscopy. In
the light of the new changes in TNM staging, the gross “macroscopic”
examination of the specimen is illustrated

Pathology report is a comprehensive description of morphologic details,

diagnosis and management recommendations. The report aims to communicate
scientifically with the referring clinician.

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 The Skilful Pathologist Series

Value of Pathology report

 Diagnosis (including pathologic staging)

 Prognosis
 Efficacy of current treatment
 Guide for further treatment
 Data for research and quality control
 Warning for the presence of an underlying lesion, e.g., precancerous,
hereditary or familial lesion
 Medico-legal importance
 Reference for probable progress in the lesion

INPUT (Request +specimen)……….OUTPUT (Report + slides)

Report components

 Demographic data of the patient: name, age,…etc

 Clinical History: including investigations, previous treatments, clinical
differential diagnosis
 Macroscopic (Gross) examination: including cassettes numbers and
labelling
 Microscopic examination: detailed description of the pathologic process,
pattern, cell characteristic and diagnostic clues
 Diagnosis statement: includes the category, subcategory and subtyping,
ancillary studies requested and their results, pathologic staging and grading,
recommendations to the clinician

Osama Sharaf Eldin, South Wales, 2017

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 Histopathology Diagnosis

Dedication
I dedicate this work to the soul of my father, my mother, my wife and to my lovely
kids

Acknowledgments
I would like to thank my supervisors, colleagues and friends who inspired me
with ideas and knowledge and for their continuous encouragement:

Disclaimer:
This is a study guidebook, designed in the Power Point (bullet) format, employing
the least possible number of words to convey the meaning. It does not follow the
classical complex textbook or the grammatical English writing roles. As a self-
published book, this book may contain spelling or grammatical errors. In self-
publishing, the author writes, edits and designs his own book aiming to reduce
the costs and to provide a cheaper book for the buyers.

Abbreviations
(L) Left
(R) Right
AD Autosomal Dominant
adca Adenocarcinoma
ADH Atypical Ductal Hyperplasia
ALCL Anaplastic Large Cell Lymphoma
ANCA Anti-Neutrophil Cytoplasmic Antibodies
APC Adenomatous Polyposis Coli
AR Autosomal Recessive
ASAP Atypical small acinar proliferation, prostate
BBB Blood brain barrier
Bg Benign
Bx Biopsy
C/P Clinical Picture
CAP College of American Pathologists
CCC Clear cell carcinoma, or clear cell change
CD Cluster Of Differentiation
CGIN Cervical glandular intraepithelial neoplasia
CHI Commission For Health Improvement
CIN Cervical Intraepithelial Neoplasia
CIS Carcinoma in situ
CJD Creutzfeldt-Jakob disease
CK Cytokeratin

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CLL Chronic Lymphocytic Leukaemia

CME Continuous Medical Education
CML Chronic Myeloid Leukaemia
COD Cause of Death
CRC Colorectal carcinoma
DCIS Ductal Carcinoma In Situ
DDx Differential Diagnosis
DE Duct ectasia
DFSP Dermatofibrosarcoma Protuberans
DLE Discoid Lupus Erythematosus
Dx Diagnosis
EBV Epstein Barr Virus
EGF Epidermal Growth Factor
EMQ Extended Matching Question
EQA External Quality Assurance
FAP Familial Adenomatous Polyposis
FNAB Fine Needle Aspiration Biopsy
FNAC Fine Needle Aspiration Cytology
GCT Giant Cell Tumour
GFAP Glial Fibrillary Acidic Protein
GIST Gastrointestinal Stromal Tumour
GWI Guide wire in situ
HBV Hepatitis B Virus
HCC Hepatocellular Carcinoma
HCV Hepatitis C Virus
HNPCC Hereditary Non Polyposis Colorectal Carcinoma
HPV Human Papilloma Virus
HSV Herpes Simplex Virus
HTA Human Tissue Act
Hx History
IDC Infiltrating Duct Carcinoma
IHC Immunohistochemistry
IL Interleukin
ILC Infiltrating Lobular Carcinoma
IQA Internal Quality Assurance
ITGCN Intratubular Germ Cell Neoplasia
LAD Left Anterior Descending coronary
LAM Lymphangioleiomyomatosis
LAP Leukocyte Alkaline Phosphatase
LCIS Lobular carcinoma in situ
LHC Langerhans’ Cell Histiocytosis
LMN Lower Motor Neuron
LN Lymph node
LP Lamina propria
MALT Mucosa Associated Lymphoid Tissue
MCL Mantle Cell Lymphoma
MDM Multidisciplinary Team Meeting
ME Medical Examiner (US), equal to Coroner (UK)

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 Histopathology Diagnosis

mets Metastasis
MFH Malignant Fibrous Histiocytoma
Mg Malignant
mi Micromets
MM Muscularis mucosa
MMMT Malignant mixed Mullerian tumour
MN Motor Neuron
MP Muscularis propria
MPO Myeloperoxidase
MZL Marginal Zone Lymphoma
NHL Non-Hodgkin’s Lymphoma
NHS National Health Service (UK)
NSCC Non-Small Cell Carcinoma
OSPE Objective Structured Practical Exam
PAN Poly Arteritis Nodosa
PanIN Pancreatic intraepithelial neoplasia
PAS Periodic Acid Schiff
PASD PAS-Diastase
PCV Polycythaemia Vera
PIN Prostatic intraepithelial neoplasia
PLAP Placental Alkaline Phosphatase
PNET Peripheral Neuroectodermal Tumour
PSA Prostatic Specific Antigen
QA Quality Assurance
QC Quality Control
-R Receptor
RA Refractory Anaemia or Rheumatoid Arthritis
RCC Renal Cell Carcinoma
RCT Randomized Clinical Trial
SADS Sudden Adult Death Syndrome
SCC Small Cell Carcinoma
SE Skin ellipse
SE Skin ellipse
SIDS Sudden Infant Death Syndrome
SLE Systemic Lupus Erythematosus
SLL Small Lymphocytic Lymphoma
SLNB Sentinel lymph node biopsy
SM submucosa
Sq.CC Squamous Cell Carcinoma
SS Subserosa
T Tumour
TB Tuberculosis
TCC Transitional Cell Carcinoma
TNF Tumour Necrosis Factor
TNM Tumour, Node, Metastasis Classification
TNM Tumour, Node, Metastasis Classification
Tx Treatment
UDH Usual ductal hyperplasia, breast

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 The Skilful Pathologist Series

UMN Upper Motor Neuron

VAIN Vaginal intraepithelial neoplasia
VIN Vulval intraepithelial neoplasia
WLE Wide Local Excision
WT Wilms’ Tumour Antigen

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CHAPTER1: MACROSCOPIC (GROSS)

EXAMINATION

Macroscopic features are the first lesion-morphology to be described in the

Pathology Report and should supply important information that links the clinical
data to the microscopic picture, diagnosis, staging and management. Grossing is
the process of non-random selection of diagnostically relevant parts of the
referred tissue. This would be achieved by selecting the lesion representative
blocks from the whole specimen. The tissue block dimension should fit in the
tissue cassette; it is a selection of 2D tissue blocks from the 3D tissue specimen.
Any 3D specimen has 6 margins that should be sampled perpendicular to the
surface, when there is a malignant lesion plus one of the following:
3
 At least 3 sections from the tumour if < 10cm
 1 section/ 1cm if large
 1 section/ 3cm if huge
Note: The whole tumour may be embedded if small

Tumour resection margins: include

 Circumferential margin (e.g., oesophagus, rectum)
 En face margin
 Lateral margins
 Doughnut margin (rectum)
 Base of a polyp
 Mucosal margin

The margins should be inked using a special dye (India ink, Methylene
blue…etc). Different colours can be used for different margins. The distance
between the tumour and the resection margin should be measured and reported.

Specimen Nomination
This is the first link in the report between the pathologist and the clinician and
this necessitates a good understanding of the surgical technique and the
imagination of the resulting specimen.
Examples:
 Any site/lesion:
o Tru cut/core biopsy
o Incision (–otomy)
o Excision (–ectomy)
o Re- excision: for either previously involved margin or
previously non-representative sampling
 Lesion-specific:
o Wide local excision & Radical excision (including LNs)
o Explants : in transplantation
 Site –specific:
o Skin: Ellipse, shave, punch bx, Moh’s

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 Histopathology Diagnosis
o Cervix: Loop excision, cone excision, LLETZ
o Uterus: Hysterectomy, Whertieme, TAH-BSO: total abdominal
hysterectomy and bilateral salpingoophrectomy
o Breast: Tylectomy, Modified radical mastectomy (MRM)
o Colorectal: anterior resection, transanal excision, colectomy
o Lymph nodes: sentinel lymph node bx, block dissection,
clearance, Cherry picking
o Ampulla/pancreatic head: whipple’s
(pancreaticoduodenectomy)
Facts to be considered in cut up/ gross description

TNM
TNM parameters are the bases of dissection and all parameters mentioned in
the TNM staging for a certain tumour should be commented upon in the gross
description (e.g., tumour size, tumour extension, number of lymph nodes and
their size....etc)
Anatomical Consideration
 Organ anatomy: proximal /distal, lobes, hilum structures, anatomical
relationships..etc
 Arterial supply and venous drainage
 Lymphatic drainage of the area
 Lymph node distribution : axillary vs. internal mammary, superior
mesenteric vs. peripancreatic,

PROFORMA FOR MOST OF PATHOLOGY SPECIMENS

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Lesion Gross description

in solid organ
•Benign
•Malignant
•Cyst
•Cavity

in hollow organ/skin
•Ulcer
•Polypoid
•Diffuse infiltrating

Other non-preform lesions: e.g., liver explants, diffuse organ lesion, remnants
of conception...etc. Free text description is recommended taking into
consideration the measurements, lesion extension and severity

Description of a lesion differs if it occurs in solid organ (L; breast carcinoma) or in

hollow organ/surface (R; malignant ulcer, skin)

ANY LESION IN SOLID ORGAN

6S

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 Histopathology Diagnosis
SITE: ORGAN (e.g., liver), SUBSITE (e.g., Right lobe), TYPE OF
OPERATION/BX
SIZE: ...X …X… (3D measurements e.g., longitudinal and transverse axes +
depth) or maximum dimension
SHAPE: rounded, oval or irregular
SURFACE: of lesion/ or organ: smooth/rough, elevations/depressions or
granular/nodular/ /lobulated
SURROUNDINGS: compressed/infiltrated, perforated or hyperaemic
SPECIAL CHARACTERS: one word can diagnose a lesion!!!
 Waxy amyloid
 Greasy to touch  fatty (lipogenic) tumours or fatty change liver
 Caseation TB
 Necrosis large malignant tumours (central necrosis)
 Putrefied gangrenous limb or organ
 India rubbery consistencyamyloid in solid organ
 Motor-oil fluid content Adamantinoma
 Whorly cut section  fibroid (myoma), neurilemmoma, meningioma
 Mural nodule cerebellar (pilocytic) astrocytoma
 Blue dome cysts fibrocystic disease, breast
 Mummificationdry gangrene
 Dermoid ridge dermoid cyst of the ovary (benign cystic teratoma)
 Gritty sensation on cuttinginfiltrating duct carcinoma with excess
desmoplasia (fibrosis) or any other lesion with excess fibrosis (sclerosis).
 Phyllode (leaf)-like structures Phyllode tumour, breast
 Nutmeg liver  congested liver
 Tigroid “thrush-breast” heart toxic myocarditis
 Sago spleen amyloid spleen
4C

COLOUR:
 Red: fresh blood or fresh myoglobin
 Orange: carotene, bilirubin, lipid tumour of the ovary
 Yellow: lipid (fatty tissue, fatty change, adrenal, lipid tumour of the ovary);
elastic tissues, caseation (in tuberculosis), necrosis, pus, sebaceous
material (in dermoid cysts, sebaceous tumours)
 Green: bilivirdin, putrefaction, fungi, bile, biliary stones
 Blue: blood inside a cyst e.g., blue-dome cysts in fibrocystic disease of the
breast, veins through the skin, blue nevus, cartilaginous/mucinous tumours,
carbon pigment under pleura; blue sclera in osteogenesis imperfecta.
 Grey-White: most of tumours (benign or malignant), fibrosis
 Dull white (Chalk-like): calcification.
 Grey-black: lung tissue
 Brown: acid haematin (digested blood as in hematemesis), hemosiderin,
lipofuscin, melanin, haemoglobin/myoglobin.
 Black: Carbon pigment, excess melanin, homogentisic acid (alkapton)

Materials that have different colours

 Blood (red when fresh, blue when seized in a space, brown when old,
green-yellow when decomposed)

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 The Skilful Pathologist Series

 Melanin (pale brown when near epidermis (lentigo), deep brown when in
dermis (dermal nevus), blue when below dermis (Blue nevus), black when
condensed (melanoma).
 Carbon pigment: black or blue (under pleura)
 Lipid tumours: yellow, orange
 Placenta: mottled

CONSISTENCY:
 Soft: fat filled (lipid tumours, lipoma, loose connective tissue, or fatty
change), blood filled (sarcomas), air-filled (lung), or fluid filled (oedema,
abscess)
 Firm: benign tumours
 Hard: bones, calcified organs, malignant tumours, excess fibrosis.

COVERING:
 Capsule: Capsulated organs include kidney, spleen, and liver.
 Serosal coverings: e.g., peritoneum, pleura, pericardium, tunica,
meninges. Organs are either totally covered (lung) or partially covered
(bladder, rectum).
-The covering shows the same form of the underlying lesion. In both acute
and chronic inflammation, the covering appears thick, dull-opaque, white
and lustreless. In acute inflammation, this is due to fibrin deposition, while in
chronic inflammation, due to fibrosis.
CUT SECTION (C/S)
Depends on the consistency of the tumour or organ content
C/EDGE:
 Sharp (firm or hard consistency): e.g., amyloid liver
 Rounded (soft consistency): e.g., fatty change, lipoma
C/SURFACE:
 Bulging: congested liver, lipoma
 Retracted: infiltrating duct carcinoma of breast
MALIGNANT TUMOUR

Examples: Hypernephroma (renal cell carcinoma), Wilms', osteosarcoma, Ewing

sarcoma, bronchogenic carcinoma, cancer cervix, infiltrating duct carcinoma of
the breast

Carcinomas are characterised grossly by:

 ill-defined borders, not well circumscribed
 Infiltrates the surrounding tissue
 Greyish white in colour
 Hard in consistency
 Haemorrhage (brown) & Necrosis (yellow & friable)

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 Histopathology Diagnosis

Breast invasive ductal carcinoma, ill-defined, irregular whitish tumour tissue

invading the surrounding breast fat

Sarcomas are characterised grossly by:

 Huge size
 ill-defined borders, infiltrates the surrounding
 Grey pink in colour (high vascularity)
 Soft & fleshy in consistency
 Excess haemorrhage and necrosis

Soft tissue Sarcoma. Vascular necrotic tumour destroying the subcutaneous

tissue and muscle
BENIGN TUMOUR
Examples: leiomyoma of the uterus, thyroid adenoma, lipoma

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 The Skilful Pathologist Series

Thyroid adenoma. Well-circumscribed, capsulated mass. No haemorrhage or

necrosis

Lipoma. Well-circumscribed, capsulated, lobulated mass of fat compressing the

surrounding tissue

Benign tumours are characterised grossly by:

 Well circumscribed (may be capsulated)
 Compresses the surrounding (not infiltrate)
 Homogenous colour: e.g., greyish- white (leiomyoma, thyroid adenoma),
yellow (lipoma, lipid tumour)
 Firm, except lipoma and lipid tumour of the ovary (soft).
 Secondary changes: hyaline (in Leiomyoma), myxoid (in Lipoma),
haemorrhage, calcification, ossification
 Papillomas and adenoma of the colon should be freely mobile and not fixed
to the underlying tissue (no infiltration)
CYST
True cyst = wall + contents + lining + outer surface
Examples: dermoid cyst, serous & mucinous tumours of the ovary, hydatid cyst,
cerebellar astrocytoma, Adamantinoma of the mandible, polycystic kidney,
hydronephrosis, pyonephrosis

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 Histopathology Diagnosis

Ovarian papillary cystadenoma. Cystic mass lined by multiple variable sized

papillary structures

Benign cystic teratoma, ovary. Cystic mass containing variable tissue including
sebaceous/fatty material, cartilage and hair

The report should include the following:

 Wall: thick fibrous or thin translucent
 Lining: smooth/rough, papillae or dermoid ridge
 Content: serous fluid, mucus, sebaceous material, hair, bone, motor oil-like
fluid, haemorrhage
 Outer surface: smooth, attached to tissue (e.g., ovarian tissue)
 Locules: the cyst cavity may be divided by septa into smaller cavities
(locules). According to the number of locules, a cyst may be:
 Multilocular: e.g., mucinous cystadenoma or
 Unilocular: e.g., serous cystadenoma.
The locules may communicate with each other & with renal pelvis as in
hydronephrosis or not connected as in polycystic kidney

Pseudocyst: when there is no lining, e.g., pancreatic pseudocyst, aneurysmal

bone cyst
CAVITY

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 The Skilful Pathologist Series

Cavity = wall + contents + lining + surrounding

Examples: chronic lung abscess, cavitary pulmonary TB, Amoebic liver
abscess.

Lung abscess. Cavity surrounded by hyperaemic (pink) rim, with ragged lining
and suppurative contents

The report should include the following:

 Wall: thick/thin, fibrous
 Lining: pus, caseation, irregular, remnants of bl. vessels & bronchi
 Contents: pus (abscess), caseation (TB), chocolate pus (Amoebic)
 Surrounding: hyperaemia (abscess), no hyperaemia (TB), compressed

LESION IN HOLLOW ORGAN/SURFACE

ULCER

Def.: Discontinuation of surface or lining epithelium, leaving a raw area

Examples: Typhoid ulcer, TB ulcer, malignant ulcer of the skin (originates either
from skin structures like BCC, Sq.CC and melanoma or from other malignant
tumours under the skin and then destroys the above skin), amoebic ulcer,
aphthus ulcer, traumatic ulcer and malignant ulcers in the GIT or genito-urinary
tract

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 Histopathology Diagnosis

Malignant skin ulcer. The ulcer is large, usually solitary, has a raised everted
edge, necrotic floor and hard base.

The report should include the following:

 Site: exact anatomical site and its proximity to an anatomical landmark (e.g.,
medial malleolus, costal margin, ileo-caecal valve)
 Size: …X….small (aphthus), large (malignant)
 Shape: irregular, oval, rounded
 Longitudinal axis: parallel to that of the intestine (typhoid) or perpendicular
(TB)
 Number: solitary (malignant), multiple (typhoid)
 Relation to mesentery: anti-mesenteric (typhoid)
 Overlying serosal membrane (thickened over typhoid ulcer)
 Edge: raised & everted (malignant), undermined (typhoid, amoebic,
ulcerative colitis), punched out (traumatic), sloping, deep (peptic)
 Base: hard & indurated (malignant, peptic ulcer, syphilis)
 Floor: clean (peptic, syphilis), fibrinous exudate (typhoid), haemorrhage &
necrosis (malignant)
Description of common ulcers:
Malignant ulcer: solitary, large, raised everted edge, necrotic floor and hard
base.
TB ulcer: solitary or multiple, small, usually small intestine, non-hyperaemic
margin (blue), perpendicular to the longitudinal axis of the intestine

MULTIPLE LESIONS
Multiple Nodules

Examples: cirrhosis, multiple secondaries, multiple caseous foci of TB

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 The Skilful Pathologist Series

Multiple liver metastasis of colonic origin

The report should include the following:
 Multiple
 Variable in size (from….. to....) & shape (from… to……)
 Intervening tissue : compressed, fibrous
 Each nodule: C/S, Consistency, Colour

Multiple Cysts

Examples: polycystic kidney, hydronephrosis, pyonephrosis, bronchiectasis,

vesicular mole

Multilocular ovarian mucinous cyst

The report should include the following:

 Multiple
 Variable in size (from …. To….. ) & shape (from …. to …..)
 Intervening tissue : compressed, fibrous

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 Histopathology Diagnosis
 Each cyst: Wall, Lining, Content

Multiple Polypi

Examples: familial polyposis coli, pigmented villonodular synovitis, multiple

Bilharzial polyps of large intestine, multiple skin warts

Multiple colonic polyps

The report should include the following:

 Multiple
 Variable in size: from..... to……..
 Variable in shape: pedunculated/ sessile, simple/branched
 Tissue in between: dirty yellowish due to ova deposition (Bilharziasis),
brownish due to hemosiderin deposits (synovitis)
 Tips of polyp: intact/ ulcerated
 Base of polyp: movable/fixed (invasive cancer transformation)

Polyp vs. papilloma

Polyp is a general term that implies the presence of a finger like projection
protruding into a cavity (usually). The term polyp is an anatomical description, it
does not point to the underlying Pathology. The polyp could be sessile (no neck)
or pedunculated (has a neck) and could be simple or branched. Conversely,
papilloma is a pathologic term and it indicates a benign tumour that has a finger
like projection(s), covered by benign protective epithelial cells (transitional or
squamous), if multiple = papillomatosis. Both polyp and papilloma have a core of
connective tissue.

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CHAPTER 2: MICROSCOPIC EXAMINATION

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 Histopathology Diagnosis
Diagnosis is to recognize a specific disease and nominate it scientifically using
clinically relevant expressions or biologically significant terms. The policy of
configuring an accurate diagnosis in Pathology, compared to other clinical
subspecialties is not well defined. In surgery, for example, a complete guide of
operative procedures with illustrations including different kinds of knots,
instruments and techniques are found in textbooks, atlases, videotapes, DVDs
and other sources. The same applies for most of other medical specialties.
Unfortunately, in Pathology, the methodology for lesion recognition is not well
characterised, resulting in the false impression that Pathology is a hidden
science that is exclusive for few Pathology experts. In this chapter, there are
more details about the mysterious diagnostic Pathology methods and skills.

Final pathological diagnosis (DIAGNOSTIC STATEMENT) includes:

 The Lesion Name (category, subcategory and subtype)
 The Lesion Stage (pathological stage)
 The Auxiliary Studies required to confirm a specific diagnosis
 The Prognosis (e.g., ER/PR, HER-2, effect of treatment)
 The Recommendations to the clinician

The following should be specified for any lesion:

1. Lesion category = Process recognition (e.g., inflammatory, neoplastic,
traumatic, toxic, hypersensitivity, transplant rejection).
2. Lesion subcategory (e.g., acute vs. chronic inflammation, benign vs.
malignant lesion, acute vs. subacute rejection, carcinoma vs.
sarcoma….etc)
3. Lesion subtype: exact diagnosis after which no subdivision (e.g., low grade
papillary serous cystadenocarcinoma of the ovary)
STEPS OF SLIDE RECOGNITION-DIAGNOSIS
1. Visualisation: proper slide movement, using and switching between
magnifications and intentional searching for a lesion
2. Lesion pickup by the pathologist’s eye/visual cortex, which require an intact
visual pathway
3. Lesion analysis by cerebral cortex, which entails complex processing of
gained images
4. Memorization: filming and comparison with bank of stored images
5. Differential diagnosis postulation, based on clinical and morphologic data
(gross and microscopic)
6. Decision making after brainstorming. A final diagnosis is issued, an
auxiliary study is requested or appeal for a second opinion
7. Reporting: morphologic description and diagnosis statement (lesion name,
grading, pathologic staging, recommendations)
8. Communication with the clinician

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 The Skilful Pathologist Series

Image  perceived  analysed (divided, grouped and linked)  compared with

stored images (strong memory, database and experience)  recognised, Or
compared with known or expected information  correlated  category
recognition  differential diagnosis  lesion described and initial diagnosis
issued. Further auxiliary aids may be requested to confirm or subclassify the
lesion

Visualisation Requirements

 Movement of the eye: ability to focus, ability to sustain focusing, intact

neuromuscular coordination of the neck
 Movement of the slide: proper movement of the slide is essential for lesion
pickup. Concentrate on tissue periphery, count the number of fragments and
ensure that you have examined all. For cytology, move the slide in
horizontal parallel lines or in a continuous Z-line from side to side; focus on
crowded cells in a hypocellular smear or on individual cells in a clumpy
smear. Slide movement requires a proper hand movement to adjust the
stage, change the powers and light alignment by fine-tuning the light source,
diaphragm and condenser
 Healthy eyes: colour blindness decreases the quality of the image
perception. Take care of blind spots.
 Intact visual pathways including visual cortex
 Awareness and attention (intact limbic system)
 Clear mind; no emotional stress
Lesion Pickup
In addition to pattern/cell type recognition, two opposing skills are needed for
lesion pickup. First, the capacity to join small images together like Jigsaw puzzle
to get a large complete image, e.g., when examining a fragmented small biopsy.
Second, the ability to divide a large image into small images in your mind, e.g.,
when counting the % of score 1+ stained cells among a tumour that contains, in
addition, score 2+ and 3+ staining intensities.

The pathologist should examine the slide with a list of diagnostic clues in his
mind (see diagnostic clues below)
YOU CAN RECOGNISE ONLY WHAT YOU KNOW. For example, if you do not
know what coccidiomycosis look-like, you will not pick it up

Note: emotional stress can affect all the above-mentioned stages

Descriptive Skills Requirements

 Attention to details
 For gross description, see later in reporting chapter

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 Histopathology Diagnosis
 Quantitative measurements using appropriate tools (ruler, graticule..etc). For
example, the number of tissue fragments on the slide, the number / length of
the tissue core(s), the percentage of the length of the lesion to the total core
length, the number of glomeruli in a renal core biopsy, the percentage of
positive cells (PP) when assessing nuclear staining (IHC), the exact depth of
invasion in melanoma (Breslow staging), the number of mitotic figures per
hpf (high power field).
 Appropriate sequence of sentences when describing the morphologic data.
This should start with the process (neoplastic, inflammatory,
traumatic…etc), followed by the pattern (arrangement of the lesion units
and their relationship to each other and the surrounding including
compression, invasion, infiltration...etc), then cellular details within the
pattern, diagnostic clues and finally, the auxiliary studies required to
confirm the diagnosis (if applicable), respectively.
 The use of the appropriate pathologic descriptive terms
 The presence of associated or related other lesions should be described
Decision Making Requirements
 Correlate the clinical situation with the pathologic data
 Configure a differential diagnosis
 Match the picked up lesion with the memory-stored images
 Request the appropriate auxiliary technique, if indicated
DIAGNOSTIC CLUES
Must-Find Elements
 Pathognomonic: e.g., Reed-Sternberg cell in Hodgkin’s lymphoma,
lymphoepithelial lesion in gastric low grade MALT lymphoma, Call-Exner
bodies in granulosa cell tumour, Schiller-Duval bodies (endodermal sinus) in
Yolk Sac tumour

Schiller Duval (glomeruloid structure) is pathognomonic for Yolk sac tumour

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 The Skilful Pathologist Series

Call-Exner bodies. small gland like "follicles" filled with acidophilic material, in
ovarian granulosa cell tumour
 Diagnostic: e.g., lymphoglandular bodies in metastatic NHL effusion
cytology stained by Diff-Quick, cleaved cells in follicular lymphoma, snouts in
tubular carcinoma, Skeinoid fibres in GIST

Tubular carcinoma of the breast. Diagnostic snouts, projecting from the luminal
border are seen

Skeinoid fibres in GIST of the duodenum

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 Histopathology Diagnosis
 Characteristic: e.g., follicular pattern in follicular lymphoma. Follicular
pattern is not diagnostic for follicular lymphoma, because lymphomas with
follicular/nodular pattern include, in addition to follicular lymphoma, SLL,
Hodgkin’s and Mantle cell lymphoma. Furthermore, follicular hyperplasia is
an important DD. Therefore, in order to diagnose follicular lymphoma, you
should see follicles formed of cleaved cell pattern. More confirmative is to
see invasion of perinodal fat (important differentiation from follicular
hyperplasia), CD10 positivity inside the follicles and in the interfollicular cells
....etc, for proper diagnosis of follicular lymphoma.
Helpful Elements

 Special nuclear features: papillary carcinoma, endometrial carcinoma,

melanoma
 Storiform pattern in fibrous histiocytoid tumours
 Neuroendocrine tumours: monotonous, plasmacytoid, organoid, salt and
pepper chromatin pattern
 Lipid vacuolisation or lipid-rich tubules in testicular Sertoli cell tumour
(remember the morphologic similarities between subtypes of testicular
Sertoli cell tumour and RCC, also similarity between malignant Sertoli and
seminoma)
 Sustentacular cells in paraganglioma (& pheochromocytoma)

Sertoli cell tumour. Characteristic lipid vacuoles.

 Inflammatory cells as a guide: Sometimes the inflammatory cells can guide
to tumour site, e.g., CIS (carcinoma in situ), intraductal lesions, micro-
invasions, and micro-metastasis. This is true especially when associated
with desmoplastic reaction (fibrosis).

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 The Skilful Pathologist Series

Desmoplasia; excess fibrosis around the sheets of invasive carcinoma, merges

with tumour cells

 Lymphocytes are the guide to tumour cells in desmoplastic melanoma.

Lymphocytes are part of the tumour in thymoma, lymphoepithelial
carcinoma, seminoma and medullary carcinoma. Mixed inflammatory cells
are part of Hodgkin’s lymphoma (lymphocytes, eosinophils), MFH (malignant
fibrous histiocytoma) has an inflammatory variant. Eosinophils are part of
granulocytic sarcoma

Seminoma. Groups of large tumour cells separated by fibrous tissue infiltrated by

prominent lymphocytes

 Organ-specific lesions (unique to certain organs): tubular carcinoid and

signet ring carcinoid in appendix, gangliocytic paraganglioma in duodenum

27
 Histopathology Diagnosis

Deceiving Elements

 Non-specific changes that can occur in any lesion include calcification,

ossification, hyalinization and giant cells.

Calcification in normal breast ducts. This may be confused with breast

carcinoma, mammographically

Ossification (bone formation) in synovial sarcoma

 Pathologic calcification, where calcium is deposited in non-bony tissues due

to change in pH or due to the presence of calcium attractors like
phosphates. Calcium crystals could be diagnostic in some diseases (breast
carcinoma may show microcalcifications formed of Calcium oxalate).
 Calcium oxalate is birefringent, colourless, while Calcium carbonate gives a
bluish colouration by H&E. Alizard stains calcium, while von Kossa stains
phosphates. Severe pathologic calcification associated with parathyroid
carcinoma and it is diagnostic

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 The Skilful Pathologist Series

Bilharzial (Schistosomal) cystitis. The calcified Bilharzial ova are seen in the
submucosa

 Giant cells (osteoclasts) are common in any bone lesion where there is
destruction and repair. Giant cells could be diagnostic in some lesions
(e.g., Giant cell tumour of bone, if they are diffusely distributed). Foreign
body giant cells can be present in any lesion including post-surgical changes
(iatrogenic).

Giant cell tumour of bone (osteoclastoma). Evenly /diffusely distributed giant

cells in a spindle cell stroma is diagnostic for the tumour. Focal osteoclast like-
cells can be found in Aneurysmal bone cyst, osteosarcoma and other lesions

 Active fibroblasts in early granulation tissue formation may show atypical

features similar to malignancy.

 Reactive and inflammatory atypia in cytology may be confused with

malignancy
 Granulomas associated with tumours, e.g., Hodgkin’s, T-cell lymphoma,
seminoma, squamous cell carcinoma may attract the eyes of non-expert and
distract him from the main lesion

29
 Histopathology Diagnosis

Epithelioid granuloma (arrow) associated with adenocarcinoma.

 Excess inflammation may hide the neoplastic process

 The presence of high pleomorphism and other atypical features may

mislead junior pathologists for malignancy. To avoid confusion, if you see
pleomorphism always search for mitosis (excess and or atypical). Of these
tricky lesions, fasciitis, oesophageal leiomyoma, symplastic leiomyoma, .etc
(see pleomorphic pattern in pattern recognition)
Non-specific elements

These include infarction, fibrosis, biopsy technique-related haemorrhage,

granulation tissue, patchy scattered inflammatory cells, and anthracotic pigments
in the lung.

30
The Skilful Pathologist Series

31
 Histopathology Diagnosis

CHAPTER 3: PATTERN AND CELL TYPE

RECOGNITION

NORMAL PATTERNS

Normal tissue categories comprise epithelial tissues and mesenchymal tissues,

which include the hematopoietic system.
Epithelial tissues consist of cells + special pattern

An epithelial cell is polygonal or columnar with abundant cytoplasm and single

round or oval nucleus
The epithelial cells may be:
 Glands: formed of secretory part (acini) + ducts
 Protective tissue: A layer or multiple layers of tightly adherent cells
supported by basement membrane: transitional, squamous, mesothelial
cells...etc

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 The Skilful Pathologist Series

Normal colonic crypts (L), show regular roundish crypts, regularly spaced and
lined by goblet cells compared to colorectal adenocarcinoma (R) formed of
irregular, pleomorphic glands lined by darkly stained cells (hyperchromatism)

Mesenchymal tissues consist of cells + matrix

A mesenchymal cell is matrix producer, usually spindle-shaped with little

cytoplasm (except fat cells), frequently with spindle nucleus. The mesenchymal
tissues are subtyped according to the matrix into:
 Ordinary connective tissue: fibroblasts + fibrous matrix
 Specialised connective tissue: Cartilage, Bone, Muscles & Nervous
tissue
Haematopoietic and lymphoreticular system are categorised differently.

Normal cartilage (L) formed of regularly spaced chondrocytes that matures from
the surface chondrogenic layer downwards in chondroid matrix vs. immature,
irregularly spaced chondrocytes in chondroid matrix with bone destruction (R)

Normal vs. Pathological pattern

33
 Histopathology Diagnosis
In the above-mentioned normal tissues, cell type and pattern/ or matrix should
match each other. Normal mesenchymal tissues, for example, bone, composed
of osteoid matrix and osteocytes. Epithelial examples include colonic glands,
which constitute regular acinar structures formed of epithelial cells.
Pathologically, in malignant tumours there is Cell type-Pattern dissociation,
which could be explained by abnormal differentiation.
Tumours may often defined as backward or reversed differentiation in which
normal cells turn into primitive or stem cell-like (neoplastic cells). Neoplastic cells
have the capacity to produce different types of tissues as can be seen in Wilms’
tumour (pleuri-potent cells) and Teratoma (toti-potent cells).
Epithelial glandular tumours consist of epithelial cells (roundish nucleus,
abundant cytoplasm and defined borders), arranged in acinar structures, cords
or nests. An osteogenic matrix could be found in carcinoma, e.g., metaplastic
carcinoma of the breast. In mesenchymal tumours, different types of tissues or
matrices can be seen, for example in osteosarcoma, a cartilaginous or fibrous
matrix may be produced as well as osteoid matrix.
Examples of Cell Type/Matrix or Pattern Dissociation

Features Examples
Epithelial cells + osteoid Metaplastic carcinoma of the breast
Sarcoma with epithelioid features Many, e.g., epithelioid angiosarcoma
Benign muscle tumour with epithelioid Epithelioid leiomyoma
features
Bone tumour producing cartilage Osteosarcoma
Blood vessel tumour with epithelioid epithelioid angiosarcoma, epithelioid
features haemangioma
Epithelial tumour with sarcomatoid Sarcomatoid squamous cell carcinoma
features
Tumour of epithelial origin containing Mesothelioma (biphasic)
sarcomatoid component as well as
glandular component
Tumour of unknown origin containing Synovial sarcoma (biphasic)
sarcomatoid + epithelioid component
Tumour containing all types of tissue Teratoma
Sarcomas expressing epithelial Epithelioid sarcoma, anaplastic large
markers cell lymphoma
Carcinomas expressing mesenchymal Renal cell carcinoma
markers (Vimentin)
Epithelial tumour containing myxoid Mixed salivary gland tumour
and cartilaginous matrix
Tumour containing epithelial cells, Nephroblastoma (Wilms’)
muscles and bone
Nerve tumour containing muscle Malignant triton tumour (plump
rhabdomyoblasts in MPNST)

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 The Skilful Pathologist Series

A lesion pattern constitutes the units forming the lesion and their interaction
with each other and with the surrounding tissue. Cell type points to the lineage
of the tumour (epithelial, endocrine, apocrine, eccrine...etc). In inflammation, cell
type points to the duration e.g., chronicity is associated with plasma cells or type,
e.g., eosinophils seen in allergic reactions.

Pattern recognition is one of the most important skills required for proper
diagnosis. It entails the combination of knowledge, experience, memory and
imagination. Pattern recognition facilitates the configuration of differential
diagnosis (DDx).

In certain instances, reaching a differential diagnosis is the ultimate goal of

pattern recognition. A subsequent step of confirmation could be essential. The
confirmation includes:
 Correlation with other data (clinical, macroscopic…etc)
 Auxiliary studies (e.g., immunohistochemistry)
 Second opinion/Peer review
 Text book/ Atlas review

Image analysis programmers are struggling to create software that is able to

recognise lesion patterns. The main idea is to compare the examined tissue with
a database of stored patterns similar to finger prints or iris recognition
programmes used in Forensic science.
The pattern of a lesion is determined at the low power (4X objective) and
intermediate power (10X objective), while cell type is recognised at high power
(20X -40X objectives)

PATHOLOGICAL CATEGORIES “THE PROCESS”

Inflammation
 Acute inflammation: suppurative, non suppurative
 Chronic inflammation: non-specific or specific (granuloma)
Infections:
Viral, fungal, bacterial, or parasitic
Immune disorders:
Immunodeficiency or overactive immunity (hypersensitivity/ autoimmunity)
Cell injury
 Irreversible injury = Cell death (necrosis & apoptosis)
 Reversible injury
Circulatory / Vascular disturbance
(e.g., ischemia, thrombosis, hypertension
Traumatic:
Tissue loss, traumatic ulcers, traumatic fat necrosis…etc
Iatrogenic:
Chemotherapy, radiotherapy or surgery complication
Foreign body reaction
Talc, pneumoconiosis…etc
Growth disorders

35
 Histopathology Diagnosis
 Non neoplastic : atrophy, hypertrophy, atresia
 Pre-neoplastic : dysplasia, metaplasia
 Neoplastic: benign or malignant tumours
Combined lesions:
 Toxins may produce inflammation + cell injury
 Iatrogenic lesions may be traumatic + inflammation + cell injury
 Tumour secondary effects include haemorrhage, perforation, infection,
calcification, anti-tumour immune reaction, necrosis, or inflammation.

INFLAMMATORY PATTERN
Inflammation may associate trauma, foreign body reaction, bacterial, fungal, viral
or parasitic infection as well neoplasia. Inflammation itself can cause further
injury to organs as in viral hepatitis or it can cause further damage and necrosis
to nearby tissue as in necrotizing inflammation. Therefore, diagnosis of
inflammation may not be straightforward. Inflammation will be assigned as clear-
cut diagnosis when there is no underlying other lesion (e.g., malignancy). The
causative agent may be included in Pathology diagnosis as well as the timing of
inflammation (acute vs. chronic).
Acute: 3 criteria

 Acute inflammatory cells: polymorphs (neutrophils)

 Oedema (exudate)-FIBRIN
 Blood vessels : dilated and congested
Acute suppurative: Def.: inflammation characterised by pus formation.
Characterised by excess necrosis + excess polymorphs (either dead = pus cells
or alive) + pyogenic microorganism + congested dilated blood vessels +/-
macrophages +/- fibrosis. Pus is defective of fibrin (does not clot on standing)
due to proteolytic enzyme digestion. Localised form includes ABC (Abscess,
Boil, and Carbuncle). Diffuse form includes Cellulitis.

Breast abscess, cytology (Pap stained), shows neutrophils + histiocytes

Acute non-suppurative: Includes pseudo-membranous, allergic, fibrinous and
serous types. Exudate (protein-rich, contains fibrin clots on standing) +
polymorphs +/- eosinophils + congested dilated blood vessels +/-macrophages

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 The Skilful Pathologist Series

-In viral and typhoid, no polymorphs but instead there are T-lymphocytes. In viral
infection, there may be viral inclusions and viral changes in certain types of cells
Chronic: 3 criteria

 Chronic inflammatory cells : plasma cells (most important as they need at

least 2 wks to develop), lymphocytes, histiocytes (macrophages), fibroblasts
 FIBROSIS
 blood vessels: thick walled arterioles (endarteritis obliterans-EAO)

Chronic non-specific: It follows a complicated acute inflammation. Causes

include persistence of an irritant e.g., incomplete evacuation of an abscess,
chronic irritation or autoimmunity.

Plasma cells are typical feature of chronic inflammation, frozen section

Chronic Specific =Granulomatous:

Granulomas

Def.: grouping of epithelioid histiocytes. Granulomas could be classified based

on aetiology or microscopic features. Low-turnover granulomas stimulate the
proliferation of local tissue macrophages while, High turnover granulomas
recruit macrophages from circulating monocytes (blood) to settle in the tissues as
histiocytes.
Classification of granulomas based on aetiology:
INFECTIVE
 Bacterial
 Fungal
 Viral
NON INFECTIVE
-Allergic:
 Rheumatic
 Collagen vascular diseases: Rheumatoid, SLE,
 Drug-induced
-Foreign body granuloma:
 Talc powder/suture granuloma
 Pneumoconiosis

37
 Histopathology Diagnosis
UNKNOWN CAUSE
 Sarcoidosis
 Crohn’s

Classification of granulomas based on microscopic features:

 Allergic granuloma collagen vascular diseases as Rheumatic fever,
Rheumatoid & SLE
 Giant cell reparative granuloma, in the gum, also called giant cell epulis.
 Granuloma + Asteroid bodies: Sarcoidosis
 Granuloma + excess eosinophils: parasitic and drug-induced
 Granuloma + Langhan’s-like giant cells: TB, sarcoidosis
 Granuloma containing caseation TB & Syphilis (rare)
 Granuloma containing foreign bodies: foreign body granuloma
 Granuloma containing neutrophils (suppurative granuloma) actinomycosis
and fungal granulomas (e.g., Histoplasmosis)
 Granuloma containing parasites: Bilharziasis, Filariasis
 Granuloma with fibrinoid necrosis: Rheumatoid, SLE
 Granuloma with metastatic (not dystrophic) calcification Sarcoidosis
 Granulomas associated with tumours: non-specific granulomas may
associate Hodgkin’s, T-cell lymphoma, seminoma, squamous cell carcinoma
 Lipoid granuloma= xanthoma.
 Lipophagic granuloma: granulomas associated with loss of subcutaneous
fat.
 Naked granuloma (no lymphocytes)  Sarcoidosis
 Necrotizing granuloma: TB, fungal (Histoplasmosis, blastomycosis) &
Wegener’s granulomatosis of upper respiratory tract
 Non-caseating granuloma Sarcoidosis
 Non-infective granuloma allergic & foreign body granulomas
 Palisaded granuloma: Rheumatoid, granuloma annulare
 Ring-shape (doughnut) granuloma due to central clearing (Q-fever)

Bilharzial granuloma. Bilharzial ovum, containing living miracidium (nuclei),

surrounded by epithelioid histiocytes and eosinophils

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 The Skilful Pathologist Series

Talc granuloma. Talc granules (gloves) seeding, surrounded by giant cells and
fibrosis

Foreign body granuloma. Stitch material surrounded by FB giant cells,

histiocytes and extensive fibrosis.

Tuberculous granuloma formed of epithelioid histiocytes + central caseation +

Langhan’s giant cells

39
 Histopathology Diagnosis

CELL INJURY PATTERN

Pattern of injury depends on:

The irritant: Type, duration and strength of irritant
The tissue:
 Regenerative capacity of cells: labile, stable or permanent
 Sensitivity to irritant: brain is highly sensitive to hypoxia
 Vascularity: organs with double blood supply are more resistant to
decreased blood flow
Injury Patterns:
Non-lethal injury (degenerative) pattern

Parenchymatous organs including liver, kidney and heart are more sensitive than
other tissue because they are metabolically active organs (high number of
mitochondria) that require high blood glucose and oxygen.
Cloudy swelling: The affected cells swell + pink granular cytoplasm
Hydropic degeneration: The cells swell + water clear cytoplasm
Fatty change: cells distended by multiple or a single fat globule, which may push
the nucleus aside and indent it (signet ring)
Hyalinosis: Intra or extracellular deposition of glassy pink, non-granular material.
Russell (cytoplasmic) bodies and Dutcher bodies (nuclear) are examples of
intracellular hyalinosis.
Amyloidosis: amyloid is an abnormal protein that is deposited only extracellularly
compressing the surrounding cells and replaces them. Structural subtypes are
similar morphologically, but different chemically. Congo red + polarised light give
a green-apple birefringence.
Inclusions: abnormal proteins, excess glycogen, or excess lipid can be seen in
certain hereditary deficiency of enzymes. Viral inclusions (nuclear vs.
cytoplasmic) are another example
Pigmentation: abnormal pigmentations may be seen intra or extracellularly. The
pigment could be delivered by injection, ingestion, or inhalation. Pigments
include melanin (brown or black, Fontana (+), lipofuscin (golden yellow/brown,
Lipid stains (+), iron (haemosiderosis or haemochromatosis, Prussian blue stain
(+), bilirubin (cholestasis), Cupper, Lead, Carbon…etc. Formalin pigment should
be excluded (bleached by sodium thiosulphate)
Lethal injury pattern:

Apoptosis: single cell death. Early apoptosis shows chromatin condensation

and shrinkage of the cell with membrane blebbing. Late apoptosis shows nuclear
fragmentation, apoptotic bodies’ formation, and phagocytosis. Seen in viral
hepatitis (Councilman bodies), autoimmune diseases and chemotherapy-
induced.

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 The Skilful Pathologist Series

Necrosis: death of group of cells, part of an organ or a limb in a living body. It

includes fat necrosis –traumatic or enzymatic- (ghosts of fat cells + foreign body
giant cells), coagulative necrosis (preserved tissue architecture, e.g.,
myocardial infarction), liquefactive necrosis (lost tissue architecture, e.g.,
abscess, brain infarction), caseation necrosis (cheese-like, inflammation-
induced, e.g., TB), and gangrene (necrosis + putrefaction), which may be wet or
dry, ischemia-induced or infection induced (gas gangrene). Infarction is an
ischemic necrosis that could be red or pale, arterial or venous infarction.
Myocardial and brain infarctions are famous examples. In general,
morphologically the necrotic tissue appears pink granular (sometimes,
homogenous) material with ghosts of swollen cells.

Coagulative necrosis, also described as “Ghosts of a city”, where there is loss of

the parenchyma (cells), while the tissue frame work and blood vessel out line
remains. vs liquefactive
Nuclear changes include pyknosis, karyorrhyxis and karyolysis. The architecture
of the tissue is preserved in coagulative, lost in liquefactive and caseation. The
necrosis could be inter-vascular with preservation of the perivascular zone,
geographic (Glioblastoma Multiforme) or haphazard. In the liver, it could be
zonal, focal, or diffuse. In tumours, it could be central (ischemic) or intraductal as
in comedo type of DCIS. In Kikuchi lymphadenitis, the necrosis is massive and
may obscure the lymph node architecture. Necrosis by itself is an irritant that can
evoke an inflammation subtype named necrotizing inflammation.
Superimposed putrefaction by saccharolytic or proteolytic saprophytes (e.g.,
clostridia) creates gangrene. Therefore, gangrene by definition is a putrefied
necrosis.
Necrosis in tumours indicates inadequacy of the vascular supply to cope with the
highly proliferating tumour cells. For that reason, it is commoner in sarcomas.
Infarction is an ischemic necrosis that is coagulative in the heart and liquefactive
in the brain. Necrosis of a tumour following radio/or chemotherapy is a sign of
tumour response to treatment (e.g., osteosarcoma) and % of necrotic tumour
tissue to the rest of the tumour should be defined in the report.

41
 Histopathology Diagnosis

NEOPLASTIC PATTERN

Tumours composed of cells (parenchyma) + stroma (epithelial tumours,

lymphoma, leukaemia, embryonal tumours) or cells + matrix + stroma
(mesenchymal tumours)
BENIGN MALIGNANT

SCANNING Epithelial (e.g., adenoma, Epithelial (carcinoma):

POWER (2x) papilloma): Three forms: Ulcer (over a
Adenoma (capsulated, in solid surface or in a hollow organ),
organ, well circumscribed) or polypoid mass or infiltrating
papilloma (finger-like in hollow (annular stenosing) that invades
organs, its base and core are free of deeply in the surrounding tissue
invasion)
Mesenchymal (sarcoma):
Mesenchymal: (e.g., lipoma) Huge, rapidly growing, lobulated,
Small, lobulated haemorrhagic
LOW POWER
(4x- 10x)

Circumscription Epith & Mesench: Epith & Mesench:

Well-circumscribed, compress rather Poorly- circumscribed, invade
than invade

Tumour units Epithelial: Epithelial (carcinoma):

Regular acini, cords or nests. GIT Irregular acini, sheets, cords or
adenomas associated with single cells which invade the
dysplasia, but no invasion of the surrounding tissue, often induces
base (stalk) desmoplasia (fibrosis)

Mesenchymal (sarcoma):
Mesenchymal: Pleomorphic single cells
Monomorphic cells arranged singly, haphazardly arranged or in swirls,
but often within lobules separated by fascicles, whorls, lobules +
fibrous septa, fascicles or whorls + abnormal matrix
normal looking matrix (abnormal cells + abnormal
(normal looking cells + normal matrix)
matrix)

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 The Skilful Pathologist Series

HIGH POWER
20x- 40x)

Parenchyma Epithelial: Epithelial (carcinoma):

Monotonous cells arranged Atypical cells arranged in irregular
In regular units (acini, nests, cords) tumour units (sheets, cords,
with preserved relationships acini..etc). See morphologic
between the cells. Myoepithelial criteria of malignancy
cells are present in breast (except
microglandular adenosis) and
salivary gland, basal cells are
present in benign prostatic lesions
and basement membranes should
be intact. The capsule should be
intact in adenomas, e.g., follicular
thyroid adenoma, with exception of
mixed salivary gland tumour. 2D flat
sheets and honeycombing are
common in cytology.

Mesenchymal: Mesenchymal (sarcoma):

Monotonous cells arranged singly Atypical cells (more atypical than
carcinoma) arranged singly

Stroma Epithelial: Epithelial (carcinoma):

Delicate stroma composed of either Thick irregular stroma composed
regular cores of connective tissue as of excess fibrosis (desmoplasia),
in papilloma or regular trabeculae no capsule or the capsule may be
extending downwards form the infiltrated (follicular thyroid
fibrous capsule as in adenoma. Few carcinoma) immature blood
mature blood vessels are present vessels may bleed, necrosis may
occur in the centre due to
ischemia.

Mesenchymal: Mesenchymal (sarcoma):

Delicate stroma is the rule Variable stroma, very immature
blood vessels with excess
haemorrhage

Matrix Epithelial: Epithelial (carcinoma):

No matrix No matrix except in rare cases,
e.g., amyloid matrix in Medullary
carcinoma, thyroid

Mesenchymal Mesenchymal (sarcoma):

Matrix differentiates subtypes Matrix differentiates sarcoma
subtypes

43
 Histopathology Diagnosis
CARCINOMA PATTERNS (GENERAL)
o Unique carcinoma patterns, e.g., true glands
o Shared patterns, e.g., diffuse pattern
o Uncommon patterns, e.g., fascicles
SARCOMA PATTERNS (GENERAL)
o Unique sarcoma pattern: fascicles, swirls
o Shared patterns, e.g., diffuse pattern
o Uncommon patterns, e.g., nests
Grey zone between sarcoma and carcinoma
 Carcinosarcomas and other mixed tumours
 Carcinoma with sarcomatoid features e.g., metaplastic carcinoma of the
breast
 Sarcomas with epithelioid features, e.g., epithelioid sarcoma
Grey zone between benign and malignant
 Low-grade chondrosarcoma looks like benign cartilage microscopically.
Gross (huge, lobulated), radiologic (destructive) and clinical features (axial)
are highly important to determine the diagnosis.
 Lipoblastoma (benign lesion in infants, around scapula) is histologically
similar to liposarcoma subtype, but clinically the former occurs in infants
around the scapula while the latter occurs in adults in retroperitoneum, thigh
or scrotum
 Minimal deviation adenocarcinoma (adenoma malignum) of the cervix, looks
benign cytologically, but has an invasive front
 Non-malignant invasion, e.g., peritoneal implants associated with
borderline serous tumours of the ovary
 Metastasis described in some benign tumours as in benign
metastasizing leiomyoma, benign metastasizing meningioma, benign
metastasizing giant cell tumour of bone or angiomyolipoma (could be
synchronous tumours) and sclerosing haemangioma (pneumocytoma) of the
lung may show nodal metastasis that has no effect on prognosis.
 Benign bizarre tumours, e.g., Pheochromocytoma, cerebellar
haemangioblastoma, Histiocytomas, Spitz nevus, bizarre leiomyoma

 Non-invasive malignant lesions, e.g., Intraepithelial neoplasias, e.g.,

DCIS, Paget’s disease of the nipple, extramammary Paget’s, Bowen’s
disease, Superficial spreading malignant melanoma (above the basement
membrane)

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 The Skilful Pathologist Series

Epithelial tumours vs. Mesenchymal tumours. Epithelial tumours (L) formed of

closely related (stacked) cells (usually polyhedral in shape) with prominent
intercellular boundaries, arranged in sheets, acini, cords, nests...etc, while
mesenchymal tumours (R) composed of individually arranged (non-stacked)
cells (usually spindled) within a matrix (fibrous, neurofibrillary, cartilaginous...etc).

TUMOUR CLASSIFICATION
Although -theoretically- tumours are monoclonal, a single tumour subtype can
exhibit variable morphologic patterns. The tumour cells can range between
highly differentiated (similar to the tissue of origin) and anaplastic
(undifferentiated). Mixed tumours show a blend of tissues within the same
tumour all arising from the same tissue of origin.
Tumour classification based on behaviour/tissue type:
EPITHELIAL
Benign
o Adenoma (tubular or villous, solid or cystic. The cyst may be mucinous,
serous or other contents)
o Papilloma (transitional or squamous)
Malignant
 Carcinoma (according to pattern; Adenocarcinoma, squamous, transitional,
ductal, lobular, adenoid cystic, mucoepidermoid…etc)

MESENCHYMAL
Benign
o Named according to tissue of origin e.g., fibroma, osteoma
Malignant
 Sarcoma (according to matrix; fibro, osteo, chondro..etc)
 Lymphoma (classified according to the presence of Reed-Sternberg cell
into HL or NHL. The latter divided according to the lineage into B- or T-)
 Leukaemia (lymphoid vs. myeloid, then according to clinical course, age
and blast cells into acute or chronic)

MIXED TUMOURS: (true or false), examples

 Two or more benign epithelium, e.g., mixed salivary gland tumour
 Two Carcinomas, e.g., Adenosquamous carcinoma

45
 Histopathology Diagnosis

 Carcinoma + benign epithelium, e.g., Adenoacanthoma

 Carcinoma + sarcoma, e.g., Carcinosarcoma,
 Sarcoma + benign component, e.g., Hodgkin’s lymphoma, Seminoma

COMPOSITE TUMOURS
 Embryonal tumours -blastomas- (according to origin; neuro-, retino-,
medullo-, nephroblastoma and rhabdomyosarcoma)
 Teratoma and Teratocarcinoma
 Composite lymphoma

MIXED AND COMPOSITE TUMOURS

The mixed tumours could be:
 True mixed tumours: e.g., teratoma. The components are different tissues
with distinctive staining features
 False mixed tumour: e.g., benign pleomorphic salivary gland tumour where
there is pseudocartilage, all the tumour components are of myoepithelial
origin and they stain with myoepithelial markers.
Head and neck
 Adenomatoid odontogenic tumour
 Odontoma
 Ameloblastic fibroma/ fibrosarcoma
Salivary gland
 Benign & malignant mixed salivary gland tumour
 Mixed epithelial-myoepithelial tumour
Lung and pleura
 Bronchogenic carcinoma (mixed small/large, adeno/squamous)
 Carcinosarcoma
 Mesothelioma
 Pulmonary blastoma (embryoma)
Bl.vessels
 Angiomyxoma
 Glomangioma
 Glomangiomyoma
Soft tissue
 Angiomyolipoma: renal /extrarenal
 Chondroid lipoma
 Myxoid liposarcoma
 Synovial sarcoma
Skin
 Chondroid syringoma
 Eccrine spiradenoma
Genitourinary
 Non Seminomatous germ cell tumour, testis
 Mixed Mullerian tumour
 Nephroblastoma
 Rhabdoid Tumour

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 The Skilful Pathologist Series

 Teratoma
Breast
 Myoepithelioma
 Metaplastic carcinoma
Miscellaneous tissues
 Adenosarcoma
 Adenosquamous
 Carcinosarcoma
 Hepatoblastoma
 Mesenchymoma
 Ectomesenchymoma: tumour of immature neural crest, formed of
Neuroectoderm (ganglioneuroma, neuroblastoma or PNET) +
Mesenchyme (rhabdomyosarcoma)
 Thymoma

Mixed choriocarcinoma formed of solid sheets of cyto- and syncytiotrophoblasta

(L) and teratoma formed of glands and stroma of muscle and fibrous tissue (R) of
the testis.

Epithelial-Myoepithelial carcinoma of the breast. Malignant glands surrounded by

malignant myoepithelial cells

47
 Histopathology Diagnosis

Adenocarcinoma of the lung that produces metaplastic cartilage and bone

Biphasic mesothelioma formed of malignant glands and sarcomatoid stroma.

TUMOUR ARCHITECTURE (PATTERN)

Glandular
Stacked
Non-
Glandular
TUMOUR Non-Stacked
PATTERNS
Matrix Patterns
Special
Patterns

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 The Skilful Pathologist Series

STACKED

The tumour cells tend to form groups or tumour units (e.g., acini, sheets, cords,
nests...etc) rather than individually arranged. The cells may have distinct borders
and special inter-cellular relationships like intercellular bridges or desmosomes.
GLANDULAR (PSEUDO, TRUE or MIXED GLANDULAR)

Def: Epithelial or epithelial like (epithelioid) cells arranged around a space.

Metastatic adenocarcinoma in pleural effusion, glandular pattern is preserved

True glandular: If the space is a gland lumen

Pseudo glandular: if the space is not a gland lumen (e.g., mucin, vessel lumen
or necrosis).

A- PSEUDO-GLANDULAR PATTERN

Glands around necrosis or mucin, seen mostly in tumours of non-glandular

origin, but can be seen in few tumours of glandular origin

Examples: according to the luminal material:

Mucin
 Basal cell carcinoma (adenoid cystic type)
 Liposarcoma (Myxoid).
Blood
 Angiosarcoma
 Hemangioendothelioma (Epithelioid)
Necrosis
Non-Comedo necrosis:
 Squamous cell carcinoma (acantholytic subtype)
Comedo necrosis:
Comedo = Large ducts or cell nests + central pink necrosis as in:
 DCIS, comedo type of the breast
 Infiltrating ductal carcinoma (IDC), breast
 Salivary duct carcinoma (invasive)

49
 Histopathology Diagnosis
 CIN III (cervix) affecting metaplastic glands with impending
invasion
 Basaloid carcinoma, lung and ano-genital

Comedo necrosis in basaloid carcinoma created pseudoglands

B- TRUE GLANDULAR PATTERNS SUBCATEGORIES
CATS ………FEAR……. ACID (mnemonic)
Cystic

Acinar

Tubular

Sinusoidal

Follicular

TRUE Endometrioid
GLANDULAR Adenoid
cystic
Retiform

Adenomatoid

Cribriform
Incomplete
glands
Ductal

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 The Skilful Pathologist Series

Cystic pattern

Dilated glands could form large (macro) or small (micro) cysts.

Examples
 Benign serous/mucinous cystadenoma
 Malignant serous/mucinous cystadenocarcinoma
Acinar pattern

Acinus is the secretory part of the gland, formed of single layer of cells with no
myoepithelial cells.
Examples:
 Acinic cell carcinoma (pancreas & salivary gland)
 Carcinoid
 Endometrial carcinoma (subtype)
 Granulosa cell tumour
 Prostatic adenocarcinoma

Classical carcinoid tumour, acinar pattern

Tubular pattern

Renal tubules-like + single cuboidal lining (usually) as in Tubular carcinoma,

breast

51
 Histopathology Diagnosis
Tubular pattern in tubular carcinoma of the breast, with fat invasion
Sinusoidal pattern

Thin walled channels, similar to splenic and hepatic sinusoids.

Examples:
 Vascular lesions: angiosarcoma, Hemangiopericytoma
 Non vascular: parathyroid & adrenal adenomas

Follicular pattern

Thyroid-follicles-like (Glands + pink materials in the lumen)

Examples:
Follicular (colloid content): thyroid lesions
Follicle-like (Non-colloid):
o Parathyroid adenoma & carcinoma
o Mesonephroid carcinoma, ovary
o Secretory carcinoma, breast
Endometrioid pattern

Endometrial glands-like (Glands + clear lumen + smooth luminal border +

stratified lining without mucin)
Examples:
 Endometrial carcinoma, uterus
 Endometrioid carcinoma, ovary, cervix & colon
 Endometrioid Yolk sac tumour, testis
 Duct carcinoma, prostate (remember Utricle!)

Adenoid cystic pattern

Sheets with irregular borders composed of two cell types (dense myoepithelial +
epithelial) arranged around irregular spaces containing basement membrane
materials (PAS (+)
Examples:
 Adenoid cystic carcinoma, breast & salivary
 Adenoid cystic basal cell carcinoma

Retiform pattern

Rete testis-like (elongated channels lined by epithelial/endothelial cells)

Examples:
 Sertoli-Leydig cell tumour, ovary & testis
 Synovial sarcoma

Adenomatoid pattern

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 The Skilful Pathologist Series

Bland looking glands lined by cuboidal cells, separated by fibrous stroma

Examples:
 Adenomatoid tumour, adrenal, peritoneum (DDx benign Mesothelioma)
& uterus. All should be Cytokeratin (+)
 Adenomatoid hyperplasia, salivary, parathyroid & stomach
 Adenomatoid malformation (congenital cystic) of the lung

Cribriform (sieve) pattern

Sheets with regular well-defined borders of uniform epithelial cells of one cell
type arranged around regular round spaces containing mucin
Examples:
 Cribriform carcinoma, breast
 Prostate (high grade PIN, adenocarcinoma Gleason grade3 & 4)

Invasive cribriform carcinoma, breast

Incomplete glands

Cells form arcs or incomplete circles around a deficient lumen. Nuclei usually
pleomorphic with some of them are 4:1 or more in size. Pancreatic ductal
carcinoma is an example

Ductal pattern

Tubule like + stratified or simple lining + myoepithelial cells (unlike acini), if

benign
Examples
o Ductal carcinoma. breast (In situ & invasive)
o Ductal carcinoma, pancreas & salivary

53
 Histopathology Diagnosis

Ductal carcinoma of pancreas shows close resemblance to normal pancreatic

ducts, but they have irregular angulated outline, invaded the surrounding tissue
with prominent desmoplastic reaction

MIXED GLANDULAR PATTERN (ADDITIONAL ELEMENT PRESENT)

He Must Clearly Sign the Paper ….mnemonic

Glandular + extracellular
Mucin (mucinous)

Glandular + Papillae Glandular + intracellular

Mucin (signet ring)

Glandular + Clear cells Glandular + Hobnail

Glandular + extracellular mucin (Mucinous)

Large glands lined by mucin secreting cells with basal nuclei.

Examples:
 Female genitals & breast
1. Mucinous tumours in ovary

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 The Skilful Pathologist Series

2. Endocervical adenocarcinoma, cervix

3. Endometrial carcinoma (mucinous variant), uterus
4. Ductal carcinoma (mucinous type), breast …..good prognosis
 GIT mucinous carcinomas …… poor prognosis

Mucinous adenocarcinoma of the colon, epithelial cells in a sea of mucin

Glandular + intracellular mucin (Signet ring cells)

Cytoplasmic mucin pushes the nucleus aside (signet ring), seen also in cytology.
Examples:
 Gastric signet ring cell carcinoma is the typical example, which is quite tricky
in frozen section, and lymph node metastasis where mucin stains or IHC
may be required.
 Krukenberg tumour of the ovaries
 Signet ring (mucinous) carcinoid of the appendix
 Other signet ring cell lesions without glandular configuration: see under
signet ring cell pattern (in cell type recognition)

Signet ring cell carcinoma, stomach

55
 Histopathology Diagnosis

Signet ring (mucinous, goblet cell) carcinoid of the appendix (CK7+, PASD+,
CEA+)

Glandular + Hobnail pattern

Nail heads-like (large nuclei protruding inside the lumen). Examples:

o Ovarian tumours (Clear cell carcinoma, Juvenile granulosa cell tumour,
Sertoli-Leydig cell tumour, Yolk sac tumour) and breast lactating adenoma
o Angiosarcoma

Clear cell carcinoma of the ovary, with prominent hobnailing

Glandular + clear cells

Clear cells = blank-looking but swollen cytoplasm + round uncompressed
nucleus (vs. signet ring)
Examples:
o Renal cell carcinoma (clear cell type)
o Clear cell carcinoma, ovary
o Endometrial carcinoma (secretory type)

Glandular +Papillary

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 The Skilful Pathologist Series

Papillae = connective tissue (CT) core + epithelial cover. Examples:

o Papillary carcinoma, thyroid
o Villous adenoma, colon
o Ovary: papillary serous tumours, endodermal sinus tumour (glomeruloid
papillae) and clear cell carcinoma (hyalinised papillae),
o Cervix: endocervical carcinoma (Villoglandular type)
o Breast : Micropapillary DCIS, papillary carcinoma, ductal papilloma
o Papillary mesothelioma (hyalinised papillae)

Ductal papilloma, breast FNA

Papillary serous cystadenocarcinoma, ovary

Papilla in mesothelioma, pleural cytology (L) and biopsy (R)

57
 Histopathology Diagnosis

MISCELLANEOUS PATTERNS

Diffuse pattern

Cells arranged diffusely without a specific organisation. Examples

 Lymphoma & Leukaemia
 Small cell carcinoma
 PNET, Ewing's sarcoma & Merkel cell tumour

Diffuse large B cell lymphoma

Small cell carcinoma of the lung

Rosettes

Rosettes are radially arranged cells around a core. Types of rosettes (according
to the core) include:
 Flexner-Wintersteiner = true rosette, with a lumen in the centre. e.g.,
retinoblastoma
 Homer-Wright rosettes (false rosettes), centre formed of neurites. e.g.,
Neuroblastoma, medulloblastoma

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 The Skilful Pathologist Series

Medulloblastoma shows pseudorosettes

2. NON-GLANDULAR EPITHELIAL PATTERNS

Basaloid pattern

Indian-file pattern

Trabecular pattern

Squamous pattern

Alveolar Pattern

Basaloid pattern

Basal layer-like (cohesive small, uniform, oval cells + dark blue nuclei +
peripheral palisading)
Examples:
 Basal cell carcinoma, Trichoepithelioma, Pilomatrixoma & Cylindroma,
skin (BASIC TRICKS in PATHOLOGY & CYTOLOGY)..mnemonic
 Basal cell adenoma, salivary
 Adamantinoma

59
 Histopathology Diagnosis

Indian-file pattern
Single queue of tumour cells
Examples: 3L
 Lobular carcinoma, invasive, breast
 Liposarcoma (myxoid)
 Leiomyomas (vascular)

Indian file pattern in invasive lobular carcinoma

Trabecular pattern

Trabecular = thick/thin strands of cells separated by fibrous tissue, seen also in

cytology

Examples:
Endocrine tumours, tumours in endocrine organs or in liver where normally the
cells are arranged in trabeculae
 Hyalinising trabecular adenoma & Hurthle cell carcinoma, thyroid
 Merkel cell tumour & Intra-abdominal desmoplastic small round cell
tumour (DSRT)
 Carcinoid tumour (Insular)
 Granulosa cell tumour (Insular), ovary
 Hepatocellular adenoma & carcinoma

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 The Skilful Pathologist Series

Normal liver trabeculae (L) vs. trabeculae in hepatocellular carcinoma (R),

thickened, >2-3 cell thick
Squamoid pattern

Prickle cell-like (large cells with abundant, glassy cytoplasm +/- prominent
intercellular bridges)

Examples:
 Squamous cell carcinoma
 Squamoid change in melanoma & mesothelioma and in TCC of the
bladder
 Squamous morules in endometrial lesions

Squamous cell carcinoma, glassy pink cytoplasm + well-defined bridges

Alveolar pattern

Groups of discohesive cells, especially in the centre, separated by fibrous tissue,

giving an alveoli-like appearance.

Alveolar soft part sarcoma

61
 Histopathology Diagnosis
Examples:
Alveolar rhabdomyosarcoma
Alveolar soft part sarcoma
 Bronchiolo-alveolar carcinoma.
 Melanoma often shows alveolar pattern & some traumatised intradermal naevi.
Focal alveolar pattern is often seen in high-grade sarcomas & in anaplastic
tumours due to loss of cell cohesion.
NON-STACKED PATTERNS (Mesenchymal)

Fibromatosis pattern
Fibrosarcoma pattern
Pleomorphic pattern
Storiform pattern
Whorled pattern

The tumour cells are inter-related, but not dependent on each other. By other
means, there are no prominent intercellular bridges, borders, desmosomes, or
cellular moulding. The cells appear to be individually arranged but often within
proliferation centres and almost produce a specific matrix of cartilage, collagen,
osteoid…etc
Fibromatosis pattern

Monomorphic spindle cells with benign features + poorly cellular + fibrous or

myxoid matrix
Examples:
 Neurofibroma
 Fibromatosis

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 The Skilful Pathologist Series

Neurofibroma, monotonous spindle cells

Fibromatosis, monotonous cells infiltrating the fat and muscles

Fibrosarcoma-pattern
Monomorphic spindle cells with malignant features + highly cellular + fascicles
Examples:
 Fibrosarcoma: fascicles intersecting at acute angle (Herringbone)
 Leiomyosarcoma (fascicles intersect at right angles)
 Malignant peripheral nerve sheath tumour (MPNST)
 Monophasic synovial sarcoma (short fascicles)
 Spindle cell (embryonal) rhabdomyosarcoma

63
 Histopathology Diagnosis
Malignant peripheral nerve sheath tumour (MPNST)

Leiomyosarcoma, intersecting fascicles

Note: In congenital peribronchial myofibroblastic tumour (CPBMT)-also termed

congenital fibrosarcoma-, the lung parenchyma is replaced by nodules of bland
spindle cells arranged in herringbone pattern + immature cartilage.

Pleomorphic pattern
Pleomorphic spindle cells with malignant features
Examples: (PLEOMORPHIC SARCOMAS)
 MFH (storiform)
 Pleomorphic liposarcoma (lipoblasts)
 Pleomorphic leiomyosarcoma (paranuclear vacuoles)
 Pleomorphic osteosarcoma (osteoid)
 Pleomorphic rhabdomyosarcoma (straw cells, spider cells)

Pleomorphic liposarcoma, with prominent lipoblasts

Pleomorphic sarcomas DD
1- Non sarcomatous malignant tumours (metaplastic carcinoma of the
breast “Sarcomatoid carcinoma”, anaplastic large cell lymphoma, ...etc)
2- Benign lesions which mimic pleomorphic sarcomas (benign
Pseudosarcomas)
 Ancient schwannoma
 Atypical fibroxanthoma

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 The Skilful Pathologist Series

 Benign fibrous histiocytoma (atypical variant)

 Bizarre neurofibroma
 Giant cell tumour of soft tissue
 Giant cell tumour of tendon sheath
 Ischemic fasciitis
 Pleomorphic hyalinising angiectatic tumour
 Pleomorphic lipoma Diffuse-type
 Proliferative fasciitis / myositis (ganglion-like cells among plump
myofibroblasts background, excision is curative)
 Symplastic glomus tumour
 Symplastic haemangioma
 Pleomorphic xanthastrocytoma, brain (PXA)

Metaplastic breast carcinoma

Storiform pattern

Spindle cells radiating from a centre

Examples:
 Fibrohistiocytic tumours (MFH [Malignant fibrous histiocytoma], DFSP
[Dermatofibrosarcoma Protuberans] & DF [Dermatofibroma])
 Desmoplastic mesothelioma (the storiform pattern in this hypocellular,
bland-looking tumour differentiates it from fibrous pleurisy and pleural
plaque)

65
 Histopathology Diagnosis

Dermatofibroma, storiform pattern

Whorled pattern
Hurricane like or swirl arrangement
Examples:
 Meningioma
 Fibromyxoid sarcoma (FMS)
 Dedifferentiated liposarcoma

Meningioma, characteristic whorled pattern of meningothelial cells

MATRIX PATTERNS
Matrix pattern can differentiate certain lesions from each other. For example,
Eccrine Hydradenoma (Hyalinised matrix) from Chondroid syringoma (Myxo-
chondroid matrix)

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 The Skilful Pathologist Series

Myxoid

Amyloid

Chondroid Osteoid

Myxoid matrix
Loose, pale, poorly cellular matrix. this is exactly similar to what seen in the
Wharton jelly of the umbilical cord or core of chorionic villi/vesicular mole.
Examples:
 Aggressive angiomyxoma (small vascular spaces), vulva
 Cardiac & Intramuscular myxoma
 Chordoma (physalipherous cells)
 Embryonal rhabdomyosarcoma (small round cells)
 Myxoid chondrosarcoma and myxoid liposarcoma (small round cells)
 Myxosarcoma as a separate lesion or as a part of carcinosarcoma

Vesicular mole, core of villi. This is the prototypical myxoid tissue

Myxoid lesions of soft tissue:

Benign Intermediate malignancy
Lipoblastoma Aggressive angiomyxoma
Myxoid Chondroma/lipoma DFSP
Myxopapillary ependymoma Knuckle pad tumour
Myxoid leiomyoma Malignant
Myxomas Chondro/ lipo/ leiomyo-sarcoma

67
 Histopathology Diagnosis

Neurofibromas Embryonal rhabdomyosarcoma

Neurothekoma Metastatic carcinoma/melanoma
Nodular fasciitis MFH
Ossifying fibromyxoid tumour

Embryonal Rhabdomyosarcoma

Myxoid liposarcoma

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 The Skilful Pathologist Series

Myxopapillary ependymoma

Left atrial Myxoma, heart

Myxoid lesions of the skin:

Benign Intermediate malignancy
Angiomyxoma Aggressive angiomyxoma
Cutaneous focal mucinosis Myxoid DFSP
Cutaneous myxoid cyst Malignant
Dermal fasciitis Embryonal rhabdomyosarcoma
Myxoid dermatofibroma Low grade fibromyxoid sarcoma
Myxoid neurofibroma Metastatic carcinoma/melanoma
Myxoid schwannoma Myxofibrosarcoma
Superficial acral fibromyxoma Ossifying fibromyxoid tumour
Trichodiscoma

Myxoid lesions of the vulva:

• Aggressive angiomyxoma
• Cutaneous myxoma
• Cellular angiofibroma

69
 Histopathology Diagnosis
• Myofibroblastoma
• Nodular Fasciitis
• Other myxoid tumours of soft tissue

Myxoid tumours of retroperitoneum:

• Myxoid liposarcoma
• Myxoid rhabdomyosarcoma
• Myxoid MFH (myxofibrosarcoma)
• Myxoid change in MPNST
• Myxoid change may occur in other sarcomas more rarely
Osteoid matrix

Bone = Normal osteoid + calcium. Normal/benign osteoid = regular dense

collagen. Malignant tumour osteoid is thin, irregular, lace-like eosinophilic,
surrounded by tumour cells.
Examples:
Bony lesions producing osteoid
 Osteosarcoma
 Osteoma (normal osteoid)
Non-bony lesions producing osteoid
 Ossifying fibromyxoid tumour of soft tissue
 Calcifying apponeurotic fibroma
 Myositis ossificans
 Carcinosarcoma (osteosarcoma as a part of sarcomatous component)
 Nodular fasciitis
 Sarcomas (synovial sarcoma, liposarcoma, epithelioid sarcoma, MPNST)
 Hemangioendothelioma
 Mixed salivary gland tumour, salivary
 Wilms’ tumour
 Secondary change in many benign lesions: e.g., schwannoma...
 Metaplastic carcinoma of the breast

Osteosarcoma, malignant osteoblasts in osteoid matrix

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 The Skilful Pathologist Series

Well defined bone trabeculum (arrow) beside Verocay bodies (star) in

schwannoma. Ossification as a secondary change seen in many benign tumours
Amyloid matrix

Amyloid appears microscopically as homogenous, pink, structureless material

that is deposited extracellularly. Medullary carcinoma is the prototypical tumour
that secretes amyloid. Amyloid deposition can occur in parenchymatous organs
or muscles as a result of systemic disease or in specific organs due to localised
disease.
Chondroid matrix

Chondroid matrix is pale, bluish material, secreted in chondrogenic tumours.

Osteosarcoma can produce chondroid matrix. Cartilage can be seen in Wilms’
tumour and teratoma.
Carcinosarcoma (chondrosarcoma may represent the sarcomatous component)
Chondroid metaplasia can occur in both benign and malignant lesions
Pseudocartilage is produced in benign mixed salivary gland tumour (pleomorphic
adenoma)

Chondrosarcoma, malignant chondrocytes in chondroid matrix

71
 Histopathology Diagnosis

Adenocarcinoma, lung with chondroid metaplasia

SPECIAL TISSUES PATTERNS

VASCULAR PATTERNS

Vascular lesions are characterised by proliferating blood vessels (angiogenesis)

with variable forms of vascular maturations. Reticulin stain and vascular markers
including CD31, CD34 and FVIII-related can highlight these vascular patterns. A
blood vessel may contain all or some of the following: endothelial cells,
basement membrane, pericytes, elastic fibres and smooth muscles. Vascular
patterns include:
 Capillary haemangioma pattern
 Cavernous haemangioma pattern
 Granulation tissue pattern
 Hemangiopericytoma pattern: stag-horn blood vessels, seen in
hemangiopericytoma and hemangiopericytoma-like tumours (see before)
 Epithelioid haemangioma pattern
 Papillary vascular pattern, e.g., Masson haemangioma
 Plexiform capillary pattern, e.g., myxoid liposarcoma
 Slit-like pattern, e.g., angiosarcoma, Kaposi sarcoma
 Mixed pattern, e.g., arteriovenous haemangioma (all types of blood
vessels)

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 The Skilful Pathologist Series

Kaposi sarcoma, Composed of slit like vascular spaces + stroma + lymphocytes

and plasma cells + extravasated RBCs

Angiosarcoma, slit –like vascular spaces lined by atypical cells

Craw feet- like vascular spaces in myxoid liposarcoma

SKIN PATTERNS

73
 Histopathology Diagnosis
Epidermal Patterns

 Lichenoid pattern (interface dermatitis): band-like inflammation in the

papillary dermis + damage of basal cells + Grenz zone (clear area below
dermo-epidermal junction), e.g., lichen planus, erythema multiforme
 Psoriasiform pattern: epidermal hyperplasia + parallel elongated rete
ridges, e.g., psoriasis, mycosis fungoides
 Pseudoepitheliomatous hyperplasia: hyperplasia of epidermis + irregular
elongation of rete ridges, e.g., granular cell tumour
 Acanthoma pattern: increased layering of all epidermis components, e.g.,
acanthoma and acanthotic variant of many lesions
 Dysplastic pattern: atypical cells in partial or full thickness of epidermis,
e.g., actinic keratosis
 Pagetoid pattern: single, large, may be clear cells at dermo-epidermal
junction, e.g., mammary & extramammary Paget’s disease
 Verrucous pattern: hyperkeratosis + acanthosis, e.g., seborrhoeic
keratosis
 Spongiotic pattern : intercellular oedema between epidermal cells, e.g.,
IgA pemphigus
 Vesiculo-bullous pattern: blistering inside or below epidermis, e.g.,
impetigo (intra corneal blister), pemphigus vulgaris (intra epidermal blister),
epidermolysis bullosa (subepidermal blister)

Pemphigus Vulgaris, intraepidermal blister

Dermal Patterns

 Diffuse, e.g., lymphoma, drug reactions

 Granulomatous, e.g., leprosy
 Vascular /perivascular lesions, e.g., leukocytoclastic vasculitis

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 The Skilful Pathologist Series

Leukocytoclastic vasculitis, perivascular infiltrate of neutrophils

Dermal Inflammation
 Superficial, e.g., drug reactions (perivascular)
 Superficial & deep, e.g., lymphoma, light reaction
 Folliculitis & perifolliculitis, e.g., acne, impetigo
 Panniculitis, e.g., erythema nodosum (septal), erythema induratum (lobular)

Acne, perifollicular inflammation

75
 Histopathology Diagnosis
Erythema induratum, fat lobular inflammation (lobular panniculitis)

Mononuclear Cell Infiltrate

Epidermotropic
 Spongiotic: dermatitis
 Non spongiotic:
 CD4+: T-cell lymphoma, lymphomatoid papulosis
 CD1+: Langerhans’ cell histiocytosis
Non-Epidermotropic
Angiocentric
 Atypical: leukaemia cutis
 Non-atypical: dermatitis
Interstitial
 Mastocytosis, B-cell and late T-cell lymphoma
LIVER PATTERNS

Normal pattern

Trabecuale of one or two cells, acini may be seen in childhood but not in adult
life. The presence of acini is a clue for malignancy in adult liver as well as
trabeculae > two-cell thick.
Anatomical division:
Zones: 3 zones between the marginal vein (a portal vein tributary) and central
vein. Zone1 is periportal (peripheral lobular), Zone2 is mid lobular and zone3 is
pericentral. Zone1 is the first to be affected in toxic conditions (highest blood
flow) while Zone3 is the first to be affected in ischemic conditions (already the
least blood flow)
Lobules: hexagonal, composed of the hepatocytes trabeculae surrounding the
central vein, bounded by portal tracts
Acinus: rhomboid tissue between two central veins that is centred by the lobule
border (containing the marginal vein).
Lesion patterns

Non- lethal Injury pattern: ballooning degeneration, feathering, ground glass

nuclei, storage disease pattern (honeycomb hepatocytes), giant cell formation
Lethal injury pattern:
-Apoptosis: Councilman (acidophilic) bodies
-Necrosis: focal, zonal, bridging, submassive, massive
Hepatitis (Inflammatory) patterns: mononuclear inflammation (lobular,
interface, bridging), granulomas, viral inclusions

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 The Skilful Pathologist Series

Florid acute viral hepatitis with severe necrosis. The same pattern can be seen in
any acute liver injury, e.g., paracetamol-induced
Congestive pattern: heart failure (nutmeg liver), veno-occlusive disease, Budd-
Chiari syndrome (bilateral hepatic veins occlusion)
Bile duct injury pattern: ductopenia, polymorphs in the lumen (indicates
infection, e.g., ascending cholangitis), polymorphs around the ducts (e.g.,
alcoholic hepatitis), bile duct proliferation and cholestasis (bile plugs, bile lakes).
Vanishing bile syndrome is a group of lesions, associated with decreased bile
duct numbers. Langerhans’ cell histiocytosis affects mainly the bile ducts or
canaliculi  ductopenia &cholestatic features  cirrhosis. Main DDx is primary
sclerosing cholangitis (PSC). Ductular proliferation is characteristic for
extrahepatic biliary obstruction, however, in milder form, it is a part of HCV and
early stages of primary biliary cirrhosis (PBC)
Fibrosis: Bridging (portal-portal, portal-central, central-central), pericellular
(alcoholic hepatitis), periportal. If associated with regenerating nodules =
cirrhosis. Ito cell has a major role.
Neoplastic patterns:
Adenoma: well-circumscribed mass of hepatocyte trabeculae. Hepatocellular
carcinoma: darkly stained invasive nodules (vs. paler Well-circumscribed cirrhotic
nodules) destroying the liver architecture. The nodules composed of variable
sized acini and thick trabeculae of atypical hepatocytes.

Hepatocellular carcinoma (L), thickened irregular trabeculae > 2 cell thick,

invading non cirrhotic liver (R)

77
 Histopathology Diagnosis

Interface hepatitis. Erosion of the peripheral plate of hepatc lobule by portal

inflammatory cells leading to isolated hepatocytes

Metastasis: portal (lymphoid leukaemia) vs. sinusoidal (myeloid leukaemia).

Adenocarcinoma metastasis from GIT may follow subcapsular compartments,
vascular supply or haphazard distribution.
Cholangiocarcinoma: acini + mucin pools invading large portal tracts
Other patterns: Granulomatous pattern, Drug injury patterns

Cholestatic pattern. Excess bile pigments in hepatocytes

SPLEEN PATTERNS

Distribution:
 Red pulp distribution: myeloid leukaemias
 White pulp distribution: lymphoid leukaemias
Pattern:
 Diffuse
 Nodular (Follicular): Hodgkin’s (single or multiple), follicular lymphoma
(multiple)

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 The Skilful Pathologist Series

Amyloid deposits in central arterioles of white pulp and trabeculae (Sago

Spleen) or diffusely
LYMPH NODE PATTERNS
The lymph node patterns include Perinodal pattern: perinodal lymphatic emboli,
periadenitis, Subcapsular: the first site for homing of metastasis, Cortical
pattern: B cell lymphomas, Paracortical pattern: T-cell lymphoma, infectious
mononucleosis, and Sinus catarrh or sinus pattern: sinus histiocytosis and
ALCL & Interfollicular pattern: interfollicular Hodgkin’s. The effacement of nodal
architecture could be partial or complete.

Reactive follicular hyperplasia

Loss of nodal architecture. Partial (as in this case) or total replacement of nodal
architecture by an infiltrate of epithelial cells (metastatic carcinoma) or lymphoid infiltrate
(lymphoma) can be appreciated by low power examination.

79
 Histopathology Diagnosis

Subcapsular sinus full of malignant cells (Mets)

LYMPHOMA DIAGNOSIS


Lymphoma usually shows the following features

 Loss of nodal architecture by expansile mass inside the node
 One cell type predominates (usually) rather than mixture of cells
 Cellular atypia, for example, folded nuclear membrane, abnormal
chromatin or clear cytoplasm.
Distinction between reactive follicular hyperplasia and follicular lymphoma
Architectural arrangement of the follicles at low power magnification is the most
important differentiating feature.
Follicular lymphoma Follicular hyperplasia

Total effacement of normal architecture Preserved nodal architecture

Evenly distributed follicles throughout Cortical distribution

cortex and medulla

Slight variation in size and shape of follicles Marked variation in size and shape of
follicles + elongated or dumbbell-shaped
follicles

Follicles fade Follicles sharply demarcated

Infiltration of capsule and perinodal fat by No infiltration

follicles

The whole follicle formed of neoplastic Follicle centre formed of lymphoid cells +
cleaved cells histiocytes and Mantle zone formed of
smaller lymphocytes

Cell types inside and outside follicles are Follicle cells differ from interfollicular cells
the same (all are CD10+)

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 The Skilful Pathologist Series

Composite lymphoma characterized by more than one histologic pattern at a

solitary anatomic site, while discordant lymphoma means two different
lymphoma types at two anatomic sites.
LYMPHOMA GROWTH PATTERN
For nodal lymphomas

Microscopic features essential for diagnosis:

 Whether the effacement of nodal architecture is partial or complete
 The presence or absence of aggressive behaviour including perinodal
infiltration, vascular invasion…etc
 The pattern of growth, which may be:
(1) Diffuse pattern: when proliferating cells diffusely infiltrate the lymph node or
obliterate the architecture
(2) Follicular pattern: The presence of true follicles in which there is abrupt
transition between the cells of the centre and those of the mantle zone. The term
“predominantly follicular” pattern is used when the follicles occupy 75 to 100%
of the surface area of the lymph node. The term “follicular and diffuse” pattern
is employed when the follicles occupy from 25 to 75%. The term “minimally
follicular” pattern applies when the follicles occupy 25% or less of the surface
area
(3) Pseudo follicular pattern (proliferation centres) are true follicles (i.e. there
is gradual transition between the central and the peripheral cells regarding the
size and cytologic characters). Pseudo follicles are usually vague and may be
only focally present. Seen in SLL/CLL
(4) Mantle zone pattern: proliferation of lymphocytes that are located
immediately adjacent to the follicle centre. It is vaguely nodular and involves the
mantle zone of some reactive follicles.
(5) Marginal zone pattern: It means proliferation of lymphocytes just outer
to the mantle zone area, e.g., MALT lymphoma.
(6) Sinus pattern (sinus catarrh) when the pathologic process is found
predominantly in the sinuses causing their distension, e.g., anaplastic large cell
lymphoma

Sinusoidal growth of anaplastic large cell lymphoma in lymph node

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 Histopathology Diagnosis
(7) Interfollicular pattern: means expansion of the area between benign
follicles by the proliferating cells, e.g., interfollicular Hodgkin’s, T-cell
lymphoma.
(8) Lennert’s pattern: means diffusely scattered epithelioid histiocytic
population throughout the lymph node
(9) Starry-sky pattern in diffuse areas means the presence of numerous
benign histiocytes having abundant cytoplasm and showing phagocytosis of
surrounding cells. e.g., Burkitt’s lymphoma and lymphoblastic lymphoma

Starry sky pattern in lymphoblastic lymphoma. Note the characteristic nuclear

appearance of lymphoblastic lymphoma.

For Extranodal Lymphoma

 Follicular colonization (in which the neoplastic cells colonize the centre
of reactive follicles) and lymphoepithelial lesion (infiltration of epithelial
structures by groups of neoplastic cells) as in low-grade MALT
lymphoma.
 Angioinvasive pattern (infiltration of vascular walls and obliteration of the
lumens of blood vessels) as in angiocentric T-cell lymphoma affecting
upper airways
 Epidermotropism (tendency of neoplastic cells to invade the epidermis)
and Pautrier’s microabscess (invasion of the epidermis by groups of
atypical cells) as in mycosis fungoides
Morphologic Features for Lymphoma Subtyping & Reporting
 Proportion of large and small cells. This is important especially in
subclassification of follicular lymphoma, peripheral T-cell lymphoma, T-
cell rich-B cell lymphoma
 Mixture of reactive cells. In T-cell rich-B cell lymphoma, reactive T
cells may constitute up to 80% of the population. Hodgkin’s lymphoma
contains variable amount of reactive cells including eosinophils and
plasma cells
 Vascular proliferation is one of the features of peripheral T-cell
lymphoma and angioimmunoblastic lymphoma

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 The Skilful Pathologist Series

 Starry sky pattern is characteristic for Burkitt’s lymphoma, but not

specific and can be found in other high grade lymphomas
 Mitotic index and apoptosis are conspicuous in high grade
lymphomas
 Presence or absence of necrosis (following therapy or associated
with high-grade lymphomas) or fibrosis (certain anatomical sites show
tendency to fibrosis that may impart a nodular pattern even with diffuse
lymphoma, e.g., mediastinum, spleen, inguinal lymph nodes). Thick
collagenous bands are characteristic for nodular sclerosing Hodgkin’s
 Hemophagocytosis (seen in some T-cell lymphomas and histiocytic
tumours).
 Plasmacytoid differentiation (seen in MALT lymphoma, follicular
lymphoma, small lymphocytic lymphoma)
 Richter’s syndrome (transformation of low-grade lymphoma to high
grade).
 Composite tumours: presence of more than one type or grade of
lymphoma in the same anatomical site
 Cell type: immunoblasts, centroblasts, cleaved cells...etc (detailed in
cell type recognition)
CELL TYPE RECOGNITION
Cell type can be recognised by a combination of cell size, outline and type
criteria.
CELL SIZE CRITERIA

The size can be determined using an endogenous control as the size of a mature
lymphocytes, red blood cell, or nucleus of macrophage or endothelial cell.
Accordingly, the size of tumour cells divided into:
 Small, when a tumour cell equals the size of a mature lymphocyte (7-8
µm). Small round cell tumours are discussed below
 Large, when it is > 4-5x the size of a mature lymphocyte or larger than
the nucleus of an endothelial cell or macrophages (20-30µm). Examples
include large cell Neuroendocrine tumour and diffuse large B-cell
lymphoma
 Medium, when the size is intermediate between both (2-3x).
 Small and large cells: Mixture of small and large cells are seen in tumours
with dual population as in seminoma and Hodgkin’s lymphoma
 Pleomorphic lesions (Anisonucleosis): extremes of cell sizes can be
seen in such lesions as in anaplastic large cell lymphoma and Pleomorphic
Sarcomas.
Small cell pattern
Examples:
 Lobular carcinoma, breast
 Gastric carcinoma (signet ring)
 Small blue cell tumours*

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 Histopathology Diagnosis
*Small blue cell tumours characterised by small-sized cells + dark blue nuclei +
scant cytoplasm
Examples:
 Embryonal tumours “blastomas” (neuro-, medullo-, nephro-, retinoblastoma
& rhabdomyosarcoma)
 Small lymphocytic lymphoma (SLL)
 Small cell carcinoma, lung (SCC)
 Desmoplastic small round cell tumour (DSRT)
 Merkel cell tumour
 Undifferentiated tumours
 Small cell variant of many tumours

Small cell carcinoma of the lung

Large cell pattern
Examples:
 Large cell neuroendocrine tumours
 Large cell carcinoma, lung
 Diffuse large cell lymphoma
 Hepatocellular carcinoma (HCC)
 Renal Cell carcinoma (RCC)
 Mesothelial cells either reactive or mesothelioma
 Melanoma
 Squamous cell carcinoma

Large cell neuroendocrine tumour of the lung

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Pleomorphic cell pattern

Examples:
 Pleomorphic sarcomas (MFH, liposarcoma, leiomyosarcoma,
rhabdomyosarcoma, osteosarcoma),
 Anaplastic large cell lymphoma
 Melanoma
 Atypical fibroxanthoma (borderline), bizarre leiomyoma (Benign)

Pleomorphic sarcoma, atypical mitosis (arrow)

CELL OUTLINE CRITERIA

 Round cells: see above
 Spindle cells: Spindle cells are elongated cells with longer and shorter axes.
Cell poles could be tapering as in fibrocytes or rounded as in myocytes. The
nuclei could be rounded, oval or spindle with tapering ends (fibrocytes) or
rounded ends (myocytes) = cigar-shaped. The most slender spindle cells are
the neurogenic cells. Spindling usually refers to a “mesenchymal origin”
(connective tissue, nerve, muscle...etc). EMT (epithelial-mesenchymal
transition) is spindling of epithelial cells at the invasive front of the tumour.
Major DDx of spindle cell tumours
 Fibromatosis
 Myofibroblastic
 Smooth muscle
 Neural: neurofibroma, schwannoma, MPNST
 Synovial sarcoma
 GIST/GANT
 Solitary fibrous tumour
 Others: spindle cell carcinoma, spindle cell melanoma (desmoplastic)
 Polygonal (polyhedral): this term usually refers to cells of “epithelial origin”,
which preserves the polygonal shape by intercellular desmosomes. The cells
in cytology may lose this character and become roundish especially when
using cytospin, which disaggregates the cells.

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 Histopathology Diagnosis

CELL TYPE CRITERIA

Epithelioid Squamoid Basaloid Granular

Clear cells Blastoid Anaplastic Monocytoid

Xanthomatous Signet-ring Hobnail Physalipherous

Histiocytoid Plasmacytoid Rhabdoid Myogenic

Ganglion-like Neuroendocrine Endocrine Fibroblast-like

Neurogenic Sarcomatoid Oxyphilic Oncocytic

SOME EXAMPLES
Squamoid cell change

Squamoid = cells with abundant glassy, eosinophilic cytoplasm. Examples:

 Mesothelioma
 Melanoma & Spitz nevus
Anaplastic cells
Anaplastic cells = highly malignant cells with high degree of cellular atypia
Examples:
 Pleomorphic sarcomas: rhabdomyosarcoma, MFH, liposarcoma,
leiomyosarcoma
 Anaplastic lymphoma (ALCL) & anaplastic seminoma
 Anaplasia can be seen also in angiosarcoma & melanoma

Anaplastic large cell lymphoma

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 The Skilful Pathologist Series

Rhabdomyosarcoma. Rhabdomyoblasts with pink abundant cytoplasm.

Anaplastic Leydig cell tumour of the testis. The anaplastic cells exhibit high
degree of cellular atypia

Ganglion-like cells

Cells with ample cytoplasm, vesicular nuclei and prominent single nuclei. Seen
in Ganglioneuroma and proliferative fasciitis

Clear cells
Clear cells = cells with water-clear cytoplasm. The cause of cytoplasmic
clearance differs in different lesions. Fat, glycogen, large vacuoles, or artefacts
are the main causes of cytoplasmic clearance.

Always discriminate between clear cell change in tumours, clear cell variants and
clear cell tumours (last category usually contain the word “clear”)

Clear cell change in Tumours

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 Histopathology Diagnosis
 Oxyphilic adenoma (oncocytoma), clear cell change due to cystic dilatation
of mitochondria of salivary glands
 Steroid cell tumour, dysgerminoma (seminoma in testis) of the ovary
 Adrenal hyperplasia/adenoma/carcinoma
 Parathyroid hyperplasia/adenoma/carcinoma
 Ewing's sarcoma (Glycogen, PAS+, vs. lymphoma)
 Skin: sebaceous carcinoma, melanoma

Sebaceous carcinoma
 Ewing’s sarcoma/PNET: small round blue cell tumour, Nuclear chromatin is
stippled, cytoplasm is clear (glycogen, PAS+) or eosinophilic . may see
Homer-Wright rosettes. Positive for CD99, NSE, FLi-1

Ewing’s sarcoma, shows cytoplasmic vacuoles which are PAS+

Clear cell variants
 Kidney: renal cell carcinoma (clear cell variant): CD10+, Vim+, cytokeratin+
and EMA+. All other carcinomas are cytokeratin+ and vimentin (-)
 Salivary:
o Myoepithelioma (clear cell variant, glycogen)
o Acinic cell carcinoma (clear; hypernephroid variant)
o Myoepithelioma, clear cell type
o Epithelial-myoepithelial carcinoma

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o Clear cell adenocarcinoma (glycogen)

o Oncocytoma, clear cell type
DDx: Salivary onocytoma contains glycogen so it is PAS(+) and PTAH =blue
mitochondria, while metastatic RCC contains fat, so it is PAS (-).

Clear cell tumours

 Paget’s disease of the nipple and Pagetoid lesions of the skin
 Clear cell carcinoma of ovary
 Clear cell sarcoma of the kidney
 Clear cell sarcoma of soft tissue: S100+, HMB45+
 Clear cell chondrosarcoma of the bone
 Sugar tumour (benign clear cell tumour of the lung)
 Clear cell carcinoma (CCC), uterus: ER (Oestrogen Receptor) can
differentiate between clear cell carcinoma (-) and clear cell metaplasia (+) of
endometrium.
 Clear cell carcinoma, ovary: DDx include mesonephroid and
hypernephroid lesions and metastatic signet ring cell carcinoma
 Clear cell sarcoma: Spindle + epithelioid cells. 95% in the extremities.
Positive for S100P, Vimentin, HMB45 and Melan A (hence, called
amelanotic melanoma)

Clear cell sarcoma of soft tissue “ sarcoma of soft parts” invading muscles

Granular cells
Large cells + cytoplasmic granules (PASD (+)
Examples:
 Granular cell tumour
 Dermatofibrosarcoma Protuberans (DFSP)
 Synovial sarcoma

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 Histopathology Diagnosis
Oncocytic cells
Morphologically, Oncocytic = Oxyphilic = eosinophilic = apocrine = Hurthle cells
= polygonal large cells with abundant eosinophilic granular cytoplasm + central
nucleus + large nucleolus. Granularity and eosinophilia are due to ↑↑
mitochondria (highly active cells). Examples:
 Salivary: Warthin's tumour, oncocytoma (also renal) & oncocytic carcinoma
 Thyroid: Hurthle cell adenoma/ carcinoma

Oncocytoma of the kidney. Note the characteristic oncocytic cells arranges in

tubules, cysts and nests. The cells have large granular cytoplasm, round nuclei
and prominent nucleoli

Chromophobe RCC. Characteristic perinuclear halo, plant-like cells

Plasmacytoid cells
Plasmacytoid cell = oval/ rounded cells with eccentric round nucleus and pink
cytoplasm.
Examples:
 Myeloma
 Myoepithelioma, salivary and breast
 Neuroendocrine tumours (one of the morphologic features of
neuroendocrine differentiation)
 Pituitary adenoma
 Medullary carcinoma, thyroid
 Oligodendroglioma

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Rhabdoid cells
Round/polygonal large cells + pink cytoplasm (inclusions) + round nuclei + large
single nucleoli.
Examples:
 Renal /extrarenal Rhabdoid tumour
 Mesothelioma
 Leiomyosarcoma (epithelioid)
Signet-ring cells
Single vacuole pushing the nucleus aside
Examples:
 gastric signet ring carcinoma (Mucin)
 Liposarcoma (Fat)
 Lobular carcinoma (intracellular lumens)
 Mesothelial cells
 Sclerosing stromal tumour, ovary (Fat)
 Chordoma (physalipherous cells)
 Follicular lymphoma (variant)
 hemangioendothelioma (blood, intracellular lumens)
 Melanoma (artefact)

Foam cells
Multiple vacuoles + central or peripheral nuclei
Examples:
 Histiocytomas
 Xanthelasma
 Xanthogranuloma

Giant cells
Normal giant cells are osteoclasts (multinucleated) and megakaryocytes
(multilobed nucleus). Similarly, pathological Giant cells may be multinucleated or
have solitary multilobed/unilobed nucleus.
Lesions with predominant multinucleated giant cells include giant cell variant of
MFH and GCT of bone.
Examples of diagnostic giant cells in certain lesions include:
 foreign body giant cell in foreign body granulomas
 Langhan’s giant cells in TB
 Langhan’s-like giant cells in sarcoidosis and Crohn’s disease
 Malignant giant cells in high grade malignant tumours. Malignant giant
cells are characterised by pleomorphic overlapping & hyperchromatic
nuclei, seen in pleomorphic sarcomas
 Touton giant cell which shows peripheral vacuolated cytoplasm
around circle of nuclei, seen in fibrohistiocytic tumours
 Rhabdomyoblasts in rhabdomyosarcoma
 lipoblasts in liposarcoma

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 Histopathology Diagnosis

Lipoblast, diagnostic for liposarcoma

LYMPHOID CELLS

The nuclear and cytoplasmic features that determine the lymphoid cell type
include:
 Cytoplasmic basophilia and abundance of cytoplasm
 The presence or absence of coarse chromatin or folded nuclear
membrane
 The presence or absence of nucleoli, their number, position, and
relationship to nuclear membrane
 Cellular and nuclear pleomorphism
 Abnormal mitotic figures and apoptosis
 Inclusion bodies:
(1) Cytoplasmic: Russell bodies
(2) Nuclear: Dutcher bodies
Cell types include:
 Immunoblasts: large cells + abundant cytoplasm + rounded vesicular
nucleus + prominent central, basophilic single nucleolus, e.g., large cell
lymphoma
 Reed-Sternberg cell: Diagnostic for Hodgkin’s. Classical RS has two
large kidney-shaped mirror image nuclei + prominent eosinophilic
nucleoli surrounded by clear halos (Owl eye) + eosinophilic cytoplasm.
RS variants include Mono- (popcorn), Multi-nucleate RS and lacunar
cells in NSHL (nodular sclerosing HL). RS variants can differentiate HL
subtypes.

Lymphocyte-rich HL

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 RS-like cells: Binucleated immunoblast with basophilic nucleoli, seen

in anaplastic large cell lymphoma & peripheral T-cell lymphoma
 Centrocytes (Cleaved cells): compact basophilic nucleus with irregular
contour and twisted or angulated appearance + inconspicuous nucleoli
+ little cytoplasm, e.g., follicular lymphoma, diffuse large B-cell
lymphoma
 Centroblasts (Non-cleaved cells): large rounded vesicular nucleus +
1-3 prominent nucleoli related to nuclear membrane + little cytoplasm,
e.g., large cell lymphoma
 Lymphoblasts: size > small lymphocytes (10-20 µm), but < cells of
large B-cell lymphoma, with round or convoluted nuclei, fine chromatin
& inconspicuous nucleoli + scant, faintly basophilic cytoplasm, seen in
lymphoblastic lymphoma.
 Prolymphocyte: larger than small lymphocyte with more abundant
slightly basophilic cytoplasm and a prominent central nucleolus.
Paraimmunoblast: same size of immunoblast + prominent central
nucleolus but with a less basophilic cytoplasm. Both cell types present
in proliferation centres of small lymphocytic lymphoma (SLL)
 Small non-cleaved lymphocytes: medium-sized nucleus + small
inconspicuous nucleoli related to inner aspect of nuclear membrane +
small amount of highly basophilic cytoplasm, e.g., Burkitt’s
 Cells with cerebriform or convoluted nuclei: seen in mycosis
fungoides, Sezary syndrome
 Cells with Wreath-like nuclei: Large giant cells with nuclei arranged as
a circle or half a circle, e.g., anaplastic large cell lymphoma
 Hairy cells: small lymphoid cells + oval or bean-shaped nucleus +
abundant pale cytoplasm with “hairy” projections on smear
preparations, seen in Hairy cell leukaemia
 Villous lymphocytes: .In peripheral blood, cells have small surface
villous projections, seen in splenic marginal zone lymphoma
 Plasmacytoid lymphocytes : abundant basophilic cytoplasm +
eccentric lymphocyte-like nuclei, seen in plasmacytoid lymphoma and
MALT lymphoma
 Monocytoid B-cells: clear cytoplasm + nuclei with moderately
condensed chromatin, seen in marginal zone lymphoma

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 Histopathology Diagnosis

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 The Skilful Pathologist Series

CHAPTER 4: PATHOLOGICAL STAGING

1. Non tumour staging: e.g., fibrosis staging in liver

inflammation

2. Tumour staging: Detailed below

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 Histopathology Diagnosis

INTRODUCTION
Definition: Tumour Staging is the assessment of the degree of the spread of the
tumour. The staging could be clinical (cTNM) or pathological (pTNM).

Malignant tumours have the inherent ability to expand to nearby anatomical

planes (direct spread) and/ or to involve remote anatomical structures/organs
away from the original tumour (metastasis). This innate behaviour of malignant
tumours explains their deadly effect on the body.
The ability of the malignant tumour to metastasise has attracted a countless
research labour. The main purpose for these studies is to recognise the gears of
the tumour to metastasise and the ways to break those using genetic
modifications, short interference RNA, neutralizing antibodies….etc. Metastasis
promoters include mutant p53, S-100A4, CD44, WAVE3
angiogenesis factors, collagenases and metalloproteinases.

The assessment of tumour spread could be done by clinical examination,

intraoperative assessment, radiology or by pathological examination;
macroscopic and microscopic

Tumour staging is the most important prognostic factor. Therefore, the accuracy
of staging procedure is crucial for determining the treatment options of the
patient.
The American Joint Committee on Cancer (AJCC) has established a TNM
(tumour, node, and metastasis) classification system based on the same clinical
and pathological staging information

VALUE OF STAGING
Staging helps plan a person’s treatment.
The stage can be used to estimate the person’s prognosis
Linking the stage to histological grade
Knowing the stage is important in identifying clinical trials that may be suitable for
a particular patient.

AIDS TO TUMOUR STAGING

Pathological staging/ Invasive staging
Although pathological staging is the most accurate method of determining the
stage of the tumour, the materials provided for examination is limited because of
the lack of the accessibility of surgery to certain anatomical sites, limitation of
procedure, limitation of the patient condition.

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LIMITATIONS TO PATHOLOGICAL STAGING:

Anatomical site limitation:
Spleen: splenic biopsy is unknown in surgery. The only method to biopsy the
spleen is to do splenectomy, because of the extensive haemorrhage following
even a minute rupture of the capsule induced by the biopsy needle

Procedure limitation
Brain stem is non-accessible to surgery because the current procedure is highly
destructive in such location. The biopsy procedures have a high percentage of
complications, some of which could be fatal. Such complications are currently
hindered by the use of radiology-guided procedures

Patient condition limitation:

Critically-ill patients are not amenable for biopsy, which may contribute to
deterioration of the patient condition and therefore other non-invasive staging
procedures may be employed.

Based on the pathologic diagnosis, the clinician can follow up the tumour spread
by looking for masses or enlargement of the lymph nodes, expecting that the
enlargement represents tumour metastasis, which may not be true by histologic
examination.
Laparotomy staging for Hodgkin’s lymphoma (Ann Arbor) entails laparotomy,
splenectomy, liver wedge biopsy and lymph nodes biopsy

Clinical staging used in the following cases

No surgical treatment
Adjuvant treatment done before surgery
Deficient data to stage pathologically

Sites Usually Staged Clinically:

Cervix
Head and neck, tumours
Lymphomas

Discrepancy in tumour staging between pathologic,

clinical and radiologic staging:
In some instances, there is difference between the tumour size evaluated
clinically/radiologically and the pathologic macroscopic staging. The possible
causes include:
Time elapsed between the clinical/radiologic assessment and the sampling of the
lesion for pathologic. This is a true difference and the pathologic assessment
should be considered the most accurate
Measurement discrepancy: maximum dimension of the lesion is the most
important and hence, the comparison should be done at this level or the three
dimensions of the lesion should be mentioned

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 Histopathology Diagnosis
Reaction surrounding the tumour, including fibrosis, necrosis, inflammation ,
haemorrhage and calcification may hinder the accuracy of Clinical/ radiologic
assessment compared to pathologic examination

Discrepancy between macroscopic and microscopic

pathologic staging:
Microscopic measurements are the most accurate, because it can precisely
exclude the peritumoural tissues, including fibrosis and deduct it from the lesion
size. However, the shrinkage of tissue following formalin fixation, limitation of the
size of the cassette and being chiefly a 2D measurement implies some
modification to improve it. These modifications include:
Composite blocks
Combination of microscopic examination and macroscopic measurement (3D
measurements)
Addition of 10% to the microscopic measurement, which equal the percentage of
tissue shrinkage as a result of formalin fixation.

METHODS OF TUMOUR SPREAD

DIRECT SPREAD (T)

Direct spread means increase of the tumour size with subsequent invasion of the
surrounding normal structures. Direct spread is a preliminary step before
metastasis. The size of the tumour and the depth of invasion correlate with the
tumour ability to metastasise. A clear example of this is malignant melanoma,
where Breslow thickness and Clark levels staging correlates with prognosis. With
increasing tumour size the requirements of the tumour cells for oxygen and
nutrition increases and hence new vascular formation are required, the ability of
the tumour cells to stimulate new vascular formation (angiogenesis) correlates
with tumour survival and progression. In order for the tumour cells to invade the
surrounding tissues, they require secretion of certain enzymes to dissolve the
ground substance of the tissues. These enzymes include collagenase and
metalloproteinase.
Steps of direct spread:
 Detachment: the tumour cells start to lose the adhesive substances and
molecules, like E-cadherin. Therefore, the cells will set free to move away.
 Attachment: once the cells have lost their adhesive molecules, they attach
to the underlying basement membrane by new adhesion molecules that
recognises the basement membrane components including laminin and
collagen type IV.
 Penetration of basement membrane: the tumour cells start to secrete lytic
enzymes to destroy the basement membrane and underlying tissue, to
create more spaces for more free movements with the extracellular matrix.
 Motility: acquiring motility in epithelial cells is a behavioural sign of
malignancy, that can be better observed in tumour culture. The cells move
towards the lymphatic and blood vessels.

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Effects:
Direct spread of the tumour corresponds clinically to the local manifestations of
the tumour. These include:
 Perforation of a hollow organ wall, with subsequent loss of its content within
the nearby cavity, causing severe irritations like peritonitis, pleuritis and
effusions
 Penetration to the nearby organ, causing adhesions and fistulae formation
 Ulcer of the lining epithelium with subsequent haemorrhage. bleeding per
rectum in colorectal cancer or hematemesis in gastric cancer
 Haemorrhage: examples include fatal haemorrhage from lingual artery in
cancer tongue, haemoptysis in lung cancer due to erosion of peribronchial
vessels, haematuria in renal cancer and epistaxis in nasopharyngeal
tumours.
 Compression and Obstruction: examples include intestinal obstruction (Chin,
Wang et al.), superior vena cava (mediastinal) syndrome, Pancoast tumour
(apical lung carcinoma). Bilateral compression on both ureters by
retroperitoneal neoplasm or cervical carcinoma can lead to bilateral
hydronephrosis and renal failure

Mediastinal syndrome: compression of mediastinal structures by a growing

tumour mass, usually from central lung carcinoma. The manifestations are
summarised in Ds:
 Dysphagia: due to compression on the oesophagus
 Dyspepsia
 Dyspnoea: due to compression on the trachea
 Destruction of the Aorta
 Dysphonia/ Dysphasia: compression on the recurrent laryngeal nerve
 Dilated congested jugular veins, non-pulsating

Pancoast tumour: lung carcinoma affecting the apical portion of the lung
compressing the thoracic inlet structures. These include
Subclavian vessels, leading to unilateral ischemic pain in the upper limb and blue
colouration of the fingers
Sympathetic chain compression leading to anhydrosis, enophthalmos and ptosis

Primary tumour
TX Primary tumor cannot be evaluated
T0 No evidence of primary tumor
Tis Carcinoma in situ
Ta: malignant tumour that is exophytic like non invasive papillary carcinoma and
verrucal carcinoma
T1, T2, T3, T4 Size and/or extent of the primary tumor
Size does not matted in hollow organ tumours in general including GI
adenocarcinomas, urothelial carcinoma, uterine adenocarcinoma and ovarian
tumours in addition to thymic carcinoma

Size is crucial in carcinoid tumours, renal cell carcinoma, cervical carcinoma,

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 Histopathology Diagnosis

Maximum extension of all tumours is the main representative of the tumour

except in cervical carcinoma where both transverse and longitudinal diameters
are needed. In multiple tumours, some stagings consider the biggest tumour as
in breas carcinoma, while others require the total size of tumours as in
hepatocellular carcinoma.

Metastasis (N, M):

Metastasis (Greek = displacement, plural: metastases), occasionally shortened

as mets

Metastasis is the single most important difference between benign and malignant
tumours.
The ability of the malignant tumours to metastasise varies from one tumour type
to the other. Sarcomas in general are more frequently metastasise than
carcinomas. On the other hand, some malignant tumours do not have capacity to
metastasise and therefore recognised as “locally malignant tumours”. Examples
of the last category include gliomas, basal cell carcinoma, ameloblastoma, most
of giant cell tumours of bone and craniopharyngeoma.
o
When tumour cells metastasize, the new tumour is called a secondary, 2 ,
metastatic tumour implants, deposits, or mets, while the original tumour called
o
primary tumour or 1
Often, the primary origin is unknown. in such cases these are called mets
of unknown /hidden primary and assigned Tx in the TNM staging.

Methods of tumour metastasis

Lymphatic spread: the prefered method of metastasis by carcinoma. However,

some sarcomas may give lymph node deposits. Examples include synovial
sarcoma and rhabdomyosarcoma.
Tumour Emboli
Permeation: continuous cord of tumour cells travel through the lymphatics to LN
Retrograde lymphatic spread: tumour emboli travel to a common sharing tissue
like skin

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Permeation
Emboli

To venous
circulation

Diagram showing modes of spread of tumour cells to lymph node. The tumour
cells first reach the subcapsular sinuses ia afferent lymphatics, then to medullary
rays where the are transferred through the efferent lymphatic s to the venous
circulation

Metastatic carcinoma in lymph node

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 Histopathology Diagnosis
Haematogenous (blood) spread: the preferred method of metastasis by
sarcomas. However, some carcinomas are recognised by their propensity for
hematogenous spread. Of these, follicular thyroid carcinoma, choriocarcinoma,
hepatocellular carcinoma, renal cell carcinoma

Extensive lymphovascular invasion (LVI) in an ovarian mucinous

adenocarcinoma. Thbe presence of LVI in a tumour indicate the high potential of
the tumour to metastasis and is a negative progostic factor

Metastatic sarcoma in bone marrow. Such spread occurs by hematogenous

spread

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 The Skilful Pathologist Series

Perineural spread: preferred mean of spread in prostatic adenocarcinoma and

pancreatic adenocarcinoma

Perineural spred in pancreatic adenocarcinoma

Implantation: tract of fine needle biopsy, or dislodged malignant cells during

surgical operation
Inoculation (contact metastasis): a tumour of one labia or lip transmitted to the
normal facing side
Transluminal spread: tumour cells drop off and form another tumour in a
luminal structure like bronchus or intestine
Transcoelomic spread: tumour cells separate from the original tumour and
become lodged on the surface of another organ. Kruckenberg tumour of the
ovary is an example, however there is a debate that kruckenberg tumour may
represent a lymphatic spread

Note : mimics of metastasis in malignant tumours

Field effect: urothelial tumours are known to be multifocal, in the background of
multifocal CIS
Synchronous/ metachronous tumours: incidental two tumours arise
separately at same time (synchronous) or within a period of time (metachronous)

Effects of metastasis
Metastasis is the most important negative prognostic factor in tumours
Failure of vital organs
Pathological Fracture
All the local effects of the primary tumour but in other organs, examples:
In lymph nodes, a common symptom is lymphadenopathy
Lungs: cough, hemoptysis and dyspnea (shortness of breath)
Liver: hepatomegaly (enlarged liver) and jaundice
Bones: bone pain, fracture of affected bones
Brain: neurological symptoms such as headaches, seizures, and vertigo

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 Histopathology Diagnosis
The following is a summary of the TNM staging. Please refer to the UICC staging in:
“TNM Classification of Malignant Tumours”, Wiley-Blackwell; 7th edition (27 Nov 2009),
ISBN-10: 1444332414, and AJCC Cancer Staging Manual (Edge, AJCC Cancer
Staging Manual), Springer; 7th edition (October 6, 2009) ISBN-10: 0387884408 for full
details

GENERAL RULES OF PATHOLOGICAL TNM STAGING FOR CANCER

 For gynaecological tumours, there is in addition the FIGO classification

 For colon carcinoma there is Duke’s in addition to TNM
 Ipsilateral =same side
 Contra lateral = opposite side
 Midline nodes are considered ipsilateral nodes.
 Radical neck dissection specimen usually yield 10 or more LNs
 12 pericolic LNs is median number for colectomy specimen
 New staging following radio-chemotherapy will be assigned “ y”. This could be
pathological (yp) or clinical (yc) staging
 No TNM staging for thymic carcinoma, phyllodes or brain tumours in TNM7.
 No T1 or T2 in mucosal melanoma. Not T1, T2 or T3 in anaplastic thyroid
ca. No T1 in radical prostatectomy for adenocarcinoma as T1 is reserved for
prostatic biopsies
 Multiple synchronous tumours of same type in one organ, stage using
highest T stage and add (m) for multiple, e.g., T3 (m) or number of tumours
, e.g., T3 (3)
 Synchronous bilateral tumours, classify individually, e.g. in both ovaries,
both adrenals, both thyroid lobes or both liver lobes
 T4 generally (and specifically head and neck) indicates an advanced disease
where:
T4a: Moderately advanced local disease = deep local invasion or skin
over
T4b: Very advanced local disease = adjacent, vital or remote tissue
invasion
 Microscopic features included in staging in certain tumours, e.g., necrosis in
soft tissue, grade in soft tissue, bone and penile tumours, mitosis in
melanoma, histological subtype in thyroid carcinoma
 Regional LNs differ according to anatomical site.
 Size for pN is the size of metastatic deposit, not of the entire LN.
 Number of LNs is lower in post-neoadjuvant cancer resections
 No “MX” or “pM0” in in TNM7. If a biopsy is negative for metastasis, it is cM0
or consider no pM stage in this case.
 Completeness of Resection (R): this is required in many tumour resection
staging and considered an important prognostic factor; however, it is not
always possible to comment on. This is divided into:
R0: T completely excised locally
R1: microscopic involvement of margin by T (to within 1mm)
R2: macroscopic T left behind or gross involvement of margin

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Tumours and resection margins (dotted line)

Body after excision Body after excision

Complete resection (R0) Incomplete resection (R1/R2)

Completeness of resection also includes circumferential (non peritonealised)

margins of the oesophagus and rectum (also ascending and descending colon),
vascular and bronchial margins of the lung, vascular and ureteric margins of the
kidney.
Grossly the comment of total mesorectal excision (TME) grading in rectal cancer
and total mesocolic resection (TMC) in colon cancer are complementary to the
degree of perfection of removal of the tumour
Note: Completeness of resection is an independent prognostic factor.

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 Histopathology Diagnosis
 Perineural Invasion “Pn”, essential to be assessed in prostate and pancreas
 After radio/chemotherapy, new staging will be assigned yTNM. Retreatment
staging, following recurrence will be assigned rTNM. Tumour regression
grading (TRG) = tumour response to therapy.
 Stage grouping: different combinations of T+N+M that yield the final stage
of the disease. This varies according to tumour type. In all TNM stage
grouping, the final stage is IV, which indicates an advanced disease except
in nephroblastoma-Wilms tumour- where there is stage V in bilateral disease
 Micromets: diagnosed after SLNB and lymphadenectomy (clinically occult)
 Macromets: clinical LN mets confirmed by bx or LN mets + extensive ECE
(clinically apparent). Note: clinically detected = detected by imaging (not
lymphoscintigraphy) or by clinical exam.
 N1, N2, N3: Involvement of regional LNs (size, side, number or anatomical
site)
Abbreviations:
T: Tumour,
LN: Lymph node,
SLNB or (sn): sentinel LN Bx,
(i): LN metastasis detected by IHC,
LVI: lymphovascular invasion,
LP: Lamina propria,
SM: Submucosa,
MP: Muscularis propria,
MM: Muscularis mucosa,
SS: Subserosa,
ECE: extracapsular extension
Note:
 When M not mentioned in the text, M1= distant mets
 When N not mentioned in the text, N1= regional LNs mets

TNM grouping
Stage grouping:
• Anatomical extent of disease, composed of T, N, and M categories alone in
different combinations. Any M1= Stage IV
Prognostic Grouping:
• T, N, and M plus other prognostic factors, e.g., serum hormone level,
mutations…etc

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 The Skilful Pathologist Series

SUMMARY OF PATHOLOGICAL TNM, 7TH EDITION

HEAD AND NECK TUMOURS

 Head & neck carcinomas only included. Other tumours like lymphoma or soft
issue tumours staged differently.
 T size not considered in mucosal melanoma, nasal sinuses, nasopharynx
and larynx
 Extracapsular Extension (ECE), histologic grade, LVI and resection margins
status are important prognostic factors
 Carotid involvement is by encasing not by invading it
 Cervical LN dissection includes levels I-VII
 Cervical Lymph nodes (neck block dissection specimen):
Level 1: submental & submandibular , Level 2: Upper jugular , Level 3: Mid-jugular,
Level 4: Lower jugular, Level 5: Posterior triangle LNs, Level 6: Prelaryngeal ,
Pretracheal & Paratracheal, Level 7: Upper mediastinal

Lip, Oral Cavity, Oropharynx, Hypopharynx

T1: ≤2cm
T2: > 2 - 4 cm
T3: > 4cm
T4 differs according to the anatomical site:
 T4a (lip): skin of nose/chin, inferior alveolar nerve, mouth floor or through
cortical bone
 T4a (oral cavity): skin of face, deep tongue muscles, maxillary sinus or through
cortical bone.
 T4b (lip+oral): masticular space, pterygoid plates, skull base or carotid.
 T4a (oropharynx): larynx, medial pterygoid, deep tongue muscles
 T4b (oropharynx): lateral pterygoid muscle, skull base, carotid
 T4a (hypopharynx): cricoid, hyoid , thyroid cartilage, or central soft tissue
 T4b( hypopharynx): prevertebral fascia, carotid, or mediastinum
Notes:
Oral cavity involves the tongue, floor of the mouth
Superficial bone erosion ≠T4
Lip has three compartments, each staged differently:
-Vermilion surface and commissures, staged under the lip as above
-Hair bearing area of the lip is staged under skin cancer
-Inner mucosal surface of the lip, staged under oral cavity

Mucosal Melanoma
No T1 or T2 in mucosal melanoma staging, due to their aggressiveness
T3: Epithelium/ submucosa
T4a: Deep local invasion (soft tissue, cartilage, bone) or overlying skin
T4b: Adjacent (skull base, carotid, masticator or prevertebral space), vital (skull
contents: brain, dura or cranial nerves) or remote structures (mediastinum)

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 Histopathology Diagnosis

Nasal Cavity and Paranasal Sinuses

Nasal Cavity and Ethmoid Sinus
T1: 1 subsite
T2: 2 subsites
T3: orbit, maxillary sinus, palate, cribriform plate
Maxillary Sinus
T1: Mucosa
T2: Bones (inferior or medial wall, hard palate, middle nasal meatus)
T3: Posterior wall sinus, orbit (inferior /medial wall), subcutaneous
For All Nasal Cavity and paranasal sinuses
T4a: Anterior orbit, anterior cranial fossa or skin
T4b: Superior orbit, middle cranial fossa, brain
Larynx
Supraglottis
T1: 1 subsite, N mobility
T2: >1subsite , N mobility
T3: Cord fixation or deep invasion (post-cricoid, pre-epiglottic, thyroid)
Glottis
T1: vocal cord (s), N mobility
T1a: 1 cord
T1b: both cords
T2: Supra/ subglottis, impaired mobility
T3: cord fixation, paraglottic space, thyroid cartilage
Subglottis
T1: subglottis,
T2: vocal cord(s) + N/ impaired mobility
T3: Cord fixation
For All Larynx
T4a: deep local (Soft tissues, tongue, strap muscles, thyroid, oesophagus)
T4b: adjacent (Prevertebral space), vital (carotid), remote ( mediastinum)
Salivary gland
T1: ≤ 2 cm, inside gland
T2: >2 - 4 cm, inside gland
T3: >4 and/or outside gland (extraparenchymal extension)
T4a: Deep local invasion (mandible, ear, facial nerve) or overlying skin
T4b: Adjacent ( skull, pterygoid plates) or vital (carotid)
Note: extraparenchymal extension evaluated clinically or macroscopic NOT
microscopic.
N for all previous (lip, oro-hypopharynx, larynx, nose/paranasal salivary
and oesophagus:
N1: Ipsilateral single ≤3 cm
N2: ipsilateral 3 - 6 cm (single/multiple) or any size (bilateral/contralateral)
N2a: Ipsilateral single >3 - 6 cm
N2b: Ipsilateral multiple, any ≤6 cm
N2c: Bilateral or contralateral, any ≤6 cm

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 The Skilful Pathologist Series

N3: any >6 cm

Nasopharynx (separate because N is different)
T1: Nasopharynx, oropharynx or nasal Cavity. No parapharyngeal extension
T2: Parapharyngeal extension
T3: deep local invasion of bones structures of skull base and/or paranasal
sinuses
T4: deep local (hypopharynx), Adjacent (orbit, infratemporal fossa/masticator
space) or vital (Intracranial, cranial nerves)
N1: Unilat cervical, unilat/bilat retropharyngeal, above supraclavicular fossa; ≤ 6
cm
N2: Bilat cervical above supraclavicular fossa; ≤ 6 cm
N3a: >6 cm
N3b: Supraclavicular fossa
THYROID
Papillary/follicular/medullary/Hurthle:
T1: ≤ 2cm, intrathyroid
T2: >2-4cm, intrathyroid
T3: > 4cm or minimal extrathyroid extension
T4a: larynx, trachea, oesophagus, recurrent laryngeal nerve or subcutaneous
T4b: prevertebral fascia, carotid or mediastinal vessels
Anaplastic/undifferentiated: (no T1,T2 or T3. Any size)
T4a: intrathyroid
T4b: extrathyroid

N1a: cervical level VI (pre/paratracheal, prelaryngeal)

N1b: cervical other levels (uni-, bi-, or contralateral), retropharyngeal or
mediastinal
Stage grouping differs according to age (<45 or >45), histological type
(papillary/follicular vs. medullary vs. anaplastic). Note: follicular/papillary <45
staged I or II only, no stage III or IV, while anaplastic is stage IV by definition.
GASTROINTESTINAL TRACT
Oesophagus and OGJ
Tis: High-grade dysplasia/ CIS
T1: LP or SM (T1a: LP/MM, T1b: SM)
T2: MP
T3: Adventitia
T4: Adjacent
T4a: Pleura, pericardium, diaphragm
T4b: other; aorta, vertebral body, trachea
N1: 1-2 LN
N2: 3-6 LN
N3: ≥ 7 LN
Stomach
Tis: CIS/ high grade dysplasia

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 Histopathology Diagnosis
T1: LP or SM ( T1a: LP, T1b: SM )
T2: MP
T3: SS (also extension to lesser /greater omentum without perforation)
T4a: Perforates serosa
T4b: invades adjacent structures
N1: 1 - 2 LNs, N2: 3 -6 LNs, N3a: 7 - 15 LNs, N3b: ≥ 16 LNs
M1: distant mets, positive peritoneal cytology or peritoneal bx

(GIST)

T1: ≤ 2 cm, T2: > 2 – 5 cm, T3: > 5 – 10 cm, T4: > 10 cm
Grading:
 Low grade: mitosis ≤5/50hpf
 High grade: mitosis >5/50hpf. Hpf= 40x
Stage grouping includes mitotic rate and differs in according to site

Small Intestine
Non-ampullary duodenum, Jejunum and ileum
Tis: CIS, T1: LP/SM, T2: MP, T3: SS, non-peritonealized perimuscular tissues
(mesentery, retroperitoneum) ≤2 cm
T4: Visceral peritoneum, adjacent structures (incl. mesentery, retroperitoneum) >2
cm
N1:1-3LNs, N2: >3LNs

Ampulla of Vater

T1: ampulla /sphincter of Oddi

T2: duodenal wall
T3: pancreas
T4: peripancreatic or other adjacent structures
N1: Regional lymph node metastasis

Pancreas
Both exocrine (adenocarcinoma) and neuroendocrine tumours
Tis: CIS (high grade PanIN)
T1: limited to pancreas, ≤ 2cm
T2: limited to pancreas, >2cm
T3: beyond pancreas, but not T4
T4: celiac axis or SMA
Prognostic factors:
Exocrine: Preoperative CA 19-9 & CEA
Endocrine: Preoperative plasma chromogranin A level (CgA) + Mitotic count
N1: Regional lymph node metastasis

Colon-Rectum

T1: SM
T2: MP
T3: SS, non-peritonealized pericolic/perirectal tissues

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T4a: perforates visceral peritoneum

T4b: invades other organs
N1: 1 -3 LNs (N1a: 1 LN, N1b: 2 – 3 LNs, N1c: Satellites in SS, without LN mets)
N2: ≥ 4 LNs ( N2a: 4 – 6 LNs, N2b:≥ 7 LNs)
M1: Distant mets, 1 organ (M1a), > 1 organ or peritoneum (M1b)
Dukes' staging:
A: Inv. into but not through bowel wall
B: Inv. through bowel wall
C: LN mets
D: systemic mets
Modified Dukes' (Astler-Coller)
A: Limited to mucosa
B1: Inv into but not penetrating through MP
B2: Penetrating through MP
C1: B1+ LN mets
C2: B2 + LN mets
D: systemic mets
Tumour invaded
Staging example: through MP to SS fat

Muscularis Propria

LN metastasis

Tumour invaded subserosa and with LN metastatsis (confirmed histologically).

The staging of this tumour is pT3 N1a

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 Histopathology Diagnosis

Metastatic colorectal carcinoma to the liver (macroscopic; left and microscopic;

right). The stage for this tumour now is pT3N1aM1

Appendix

Adenocarcinoma (non mucinous and mucinous including goblet cell carcinoid):

Tis: CIS, T1: SM, T2: MP, T3: SS, or mesoappendix
T4a: Perforates visceral peritoneum (for mucinous tumours, peritoneal spread
within right lower quadrant “RLQ”)
T4b: other organs
N1: 1- 3 LN, N2: > 3 LN
M1a: Intraperitoneal mets beyond RLO
M1b: Non-peritoneal mets
Note: Appendix classic carcinoid staged differently.

Anal canal
Tis : CIS (Bowen’s, AIN 2-3)
T1: ≤2cm , T2: >2-5 cm, T3: >5 cm, T4: Adjacent organ(s)
N1: Perirectal, N2: unilat. internal iliac/inguinal, N3: Perirectal or bilat. internal
iliac/inguinal

Note: Neuroendocrine tumours (NET) Staging

GI tract:
• Carcinoid of stomach, SI, LI and appendix: individual staging according to site
• Mucinous (goblet) carcinoid staged as carcinoma
Pancreas and Lung: any NET staged as carcinoma
Skin: Merkel cell carcinoma staged differently from Non-Merkel
Small cell or large cell NET of any site: staged as carcinoma

Carcinoids (NET) of Gastrointestinal Tract

The ENETS and UICC TNM staging of neuroendocrine tumours
Appendix (classic carcinoid)
T1= ≤ 2 cm, (T1a: ≤1cm, T1b: >1-2cm)
T2= > 2 – 4 cm or involves caecum,
T3= > 4 cm or involves ileum,

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 The Skilful Pathologist Series

T4= Perforates peritoneum or other organs

Small intestine
T1: LP/SM & ≤1 cm, T2: MP or > 1 cm, T3: SS or pancreas/retroperitoneum
(ampullary), T4: Perforates serosa or other organs
Stomach
Tis: < 0.5 mm (in situ, confined to mucosa),
T1: LP/SM & ≤ 1 cm,
T2: MP or > 1 cm
T3: SS,
T4: Perforates serosa or other organs
Large intestine
T1: LP/SM & ≤2cm (T1a: < 1 cm, T1b: 1 - 2 cm)
T2: MP or > 2 cm
T3: SS
T4: Perforates serosa or other organs

ENETS introduced the grading of carcinoid (NET) based on the Ki-67 index. Ki-
67 index = % of Ki-67 (+) cells/2000 cells. Grade 1= <2%, Grade 2= 2-20%,
Grade 3= >20%
Liver, bile ducts & Gall bladder

HCC
T1: single, No LVI,
T2: single + LVI or multiple + any < 5 cm,
T3a: Multiple + any >5 cm T3b: invades major branch of portal/hepatic vein,
T4: other organs (not gall bladder) or perforation of visceral peritoneum
Intrahepatic cholangiocarcinoma
T1: single, No LVI,
T2a: single + LVI, T2b: multiple, No LVI,
T3: visceral peritoneum or adjacent structures, T: periductal invasion/growth
Proximal Extrahepatic bile ducts (hilar) ( including Rt, Lt and common
hepatic ducts)
T1: ductal wall,
T2a: beyond ductal wall, T2b: liver,
T3: unilat portal v/hepatic a branches,
T4: main portal vein, bilat branches /large bile radicals
Distal Extrahepatic bile ducts, (from cystic duct insertion to common
hepatic duct)
T1: Ductal wall,
T2: Beyond ductal wall,
T3: Adjacent organs (incl. G bladder),
T4: Celiac axis, or SMA (sup. mesenteric artery)
Gall bladder carcinoma:
Tis: CIS,
T1a: LP, T1b: MP,
T2: perimuscular CT,
T3: perforates serosa/ 1 organ/ or liver,
T4: portal v, hepatic a, or ≥2 extrahepatic organs

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 Histopathology Diagnosis

RESPIRATORY TRACT (lower)

Lung, NSCC, SCC and carcinoid

T1: ≤3 cm (T1a: ≤ 2 cm, T1b: > 2 - 3 cm) – not in main bronchus
T2: >3 -7cm or T in main bronchus ≥ 2 cm from carina or invades visceral pleura
or partial atelectasis
T2a: >3 - 5 cm
T2b: >5 -7 cm
T3: > 7 cm or T in main bronchus <2 cm from carina or invades parietal pleura,
chest wall, diaphragm, pericardium, mediastinal pleura or total atelectasis or
separate nodule(s) in same lobe
T4: Mediastinum (heart, carina...) or separate nodules in ipsilat lobe
N1: Ipsilateral peribronchial/ hilar nodes
N2: Ipsilateral mediastinal/ subcarinal
N3: Contralateral mediastinal, hilar, scalene or supraclav
Regional lymph nodes
N1 nodes: 10= Hilar, 11= Interlobar (peribronchial), Intrapulmonary including
12= Lobar, 13= Segmental, 14= Subsegmental)
N2 nodes: 1= Highest mediastinal, 2 =Upper paratracheal, 3 =Prevascular and
retrotracheal, 4 =Lower paratracheal, 5= Subaortic, 6= Para-aortic, 7=
Subcarinal, 8= Paraesophageal, 9= Pulmonary ligament
N3 nodes: any contralateral LNs

M1a: T nodule(s) in contralat lung, pleural nodules or malignant

pleural/pericardial effusion
M1b: Distant mets
Note: pleural invasion known after H&E combined with elastic stain

Pleural mesothelioma

T1a: parietal only, T1b: parietal + visceral

T2: ipsi. lung or diaphragm
T3: Endothoracic fascia, mediastinal fat, focal chest wall, non-transmural
pericardium (advanced, resectable)
T4: Contralateral pleura, peritoneum, mediastinum, myocardium, brachial plexus,
spine or malignant pericardial effusion (non-resectable)
N1: Ipsilateral bronchopulmonary or hilar
N2: Subcarinal, ipsilateral mediastinal or internal mammary
N3: Contralateral mediastinal or internal mammary or supraclav. ipsi/contra

FEMALE ORGANS

A-Breast

Tis (DCIS / LCIS/Paget’s)

T1: T in mm (T1mi :≤ 1mm, T1a: >1- 5mm, T1b: >5 -10mm, T1c: >10 -20mm)
T2: > 2-5cm,
T3: > 5cm

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 The Skilful Pathologist Series

T4a: Chest wall (not pectoralis), T4b: Skin (ulcer, nodules or edema “peau d’
orange”. Note: Dermis only ≠ T4), T4c: T4a + T4b, T4d: Inflammatory carcinoma
(clinically= erythema + oedema “peau d’ orange” ≥1/3 breast skin, pathologically
dermal lymphatic emboli + invasive tumour)
N1mi: micromets = >0.2 or >200cells, but any <2mm. Note: ITCs (isolated
tumour cells): < 0.2 mm or < 200 cells in one section (considered N0, or =N0(i+)
if detected only by IHC)

N1a: 1-3 axillary, >2mm (macromets)

N1b: int. mamm mets by SLNB, not clinically
N1c: 1-3 axillary + int. mamm mets by SLNB, occult clinically
N2a: 4-9 axillary
N2b: Int mamm, clinically
N3a: ≥10 axillary, or infraclav
N3b: int. mamm, clinically or >3 axillary + Int. mamm, by SLNB, occult clinically
N3c: supraclav
Breast regional LNs (all ipsilateral) :
1. Axillary (intramammary LNs counted as axillary):
Level1 (low axilla)
Level2 (mid axilla) include Rotter [interpectoral LN]
Level3 (apical axilla), include infraclav
2. Internal mammary LNs
3. Supraclav LN
Any other LNs, including cervical or contralateral LNs = M1
Definitions:
N1& N2: Level1& 2 axillary, N3: Level3, infraclav, supraclav, Internal mamm.
cM0(i+): Molecularly/micro-detected T cells in circulating blood, bone marrow or
other non-regional nodal tissue < 0.2 mm in patient without symptoms or signs of
metastases
M1: mets detected clinically/ radiographic or histologically > 0.2 mm
Intramammary LNs are staged under axillary

B- Female genital tract

 Staging is predominantly clinical

 FIGO staging also included in Latin numbers
 No FIGO 0
Vulva
Tis: CIS (VIN3)
T1: Confined to vulva/perineum
T1a: < 2 cm + invasion < 1.0 mm (IA), T1b: > 2 cm or invasion > 1.0 mm (IB)
Note: Invasion measured from nearest dermoepidermal (mucosal-submucosal)
junction
T2: Lower urethra/vagina/anus (II)
T3: Upper urethra/vagina, bladder, rectal/mucosa, bone, fixed to pelvic bone
(IVA)
N1a: 1-2 LNs, any < 5 mm
N1b: 1LN ≥ 5 mm

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 Histopathology Diagnosis
N2a: ≥3 LNs any < 5 mm
N2b: ≥2 LNs ≥ 5 mm
N2c: ECE (extracapsular extension)
N3: Fixed, ulcerated

Vagina
Tis: CIS (VAIN3)
T1: Vaginal wall (I), T2: Paravaginal tissue (II), T3: pelvic wall (III), T4: Mucosa of
bladder/rectum, beyond pelvis (IVA)
Cervix
Tis: In situ
T1: Confined to uterus
T1a: microscopic only (clinically occult)
T1a1: Depth <3 mm, horizontal <7 mm
T1a2: Depth >3-5 mm, horizontal <7mm
T1b: Depth> T1a2, or clinically detected
T1b1 <4cm
T1b2: >4 cm
T2: Beyond uterus but not pelvic wall or lower 1/3 vagina
T2a: No parametrium
T2b: Parametrium
T3: Lower 1/3 vagina/pelvic wall/hydronephrosis
T3a: Lower 1/3 vagina
T3b: Pelvic wall/hydronephrosis
T4: Mucosa of bladder/rectum; beyond true pelvis
Note: FIGO follows TNM exactly, e.g., T1b2 = IB2, except T4=IVA
IVB= M1

Corpus

Adenocarcinoma and carcinosarcoma

Tis: In situ
T1: within corpus
T1a: endometrium or < ½ myometrium
T1b: ≥ ½ myometrium
T2: cervical stroma (glandular invasion only = T1)
T3: Local or regional
T3a: serosa or adnexa
T3b: vagina or parametrium
T4: mucosa of bladder/rectum
N1: pelvic LNs
N2: para-aortic LNs
M1: Inguinal LNs, peritoneuml or distant organs e.g., lung, liver

Grading of Endometrioid adenocarcinomas:

 G1= ≤5% , G2= 6-50% , G3= > 50% (of non-squamous or non-morular -NS/NM- solid
growth pattern)
 Marked nuclear atypia increases the grade by 1.
 Serous, clear cell, and mixed mesodermal tumors = Grade 3.

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Leiomyosarcoma and Endometrial stromal sarcoma

T1: uterus only
T1a: ≤ 5 cm
T1b: > 5 cm
T2: beyond uterus, in pelvis
T2a: Adnexa,
T2b: Other pelvic tissues
T3: abdominal tissues
T3a: 1 site
T3b: > 1 site
T4: bladder or rectum
Adenosarcoma
T1: within corpus
T1a: endometrium or
T1b :< ½ myometrium
T1c: ≥ ½ myometrium
T2: beyond uterus, in pelvis
T2a: Adnexa,
T2b: Other pelvic tissues
T3: abdominal tissues
T3a: 1 site
T3b: > 1 site
T4: bladder/rectum
N1: pelvic LNs
Note: FIGO staging like cervix

Gestational Trophoblastic Tumours

T1: Confined to uterus
T2: Other genital structures
M1a: Mets to lung(s)
M1b: Other distant mets
Stage grouping includes prognostic score index; Low risk: ≤ 6, High risk: ≥ 7
Prognostic score involves age, site/no. of mets. Pre-Tx hCG level, size of T,
previous failed chemo, interval to pregnancy

Ovary
T1: Limited to the ovaries
T1a: 1 ovary, capsule intact
T1b: 2 ovaries, capsule intact
T1c: Capsule ruptured, T on surface, malignant cells in ascites/wash
T2: Pelvic extension
T2a: Uterus, tube(s)
T2b: Other pelvic tissues
T2c: Malignant cells in ascites or peritoneal washings
T3: Peritoneal mets outside pelvis
T3a: Microscopic mets
T3b: Macroscopic mets ≤2cm
T3c: Macroscopic mets >2 cm

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 Histopathology Diagnosis
N1: Regional LN mets
M1: Distant mets (excludes peritoneal mets)
Note: FIGO staging like cervix

Fallopian Tube

Tis: CIS
T1: limited to the fallopian tube(s)
T1a: 1 F.T only
T1b: 2 F.T only
T1c: 1or 2 F.T + extension onto or through the tubal serosa, or + positive ascites
or peritoneal washings
T2: pelvic extension
T2a: uterus and/or ovaries
T2b: other pelvic structures
T2c: Pelvic extension + malignant cells in ascites or peritoneal washings
T3: peritoneal implants outside pelvis
T3a: Microscopic mets
T3b: Macroscopic mets≤ 2 cm
T3c: macrscopic mets> 2 cm

Note: Liver capsule mets is T3 while liver parenchymal mets = M1. IV. Pleural
effusion positive cytology =M1.
Note: FIGO staging like cervix

MALE ORGANS

Prostate
T1: Not palpable or visible by imaging
T1a: incidental, ≤5% of tissue resected (prostate TURP)
T1b: incidental, >5% of tissue resected (prostate TURP)
T1c: detected by needle bx, after high PSA
T2: Confined within prostate (or apex involvement but intact capsule)
T2a: ≤ ½ of 1 lobe
T2b: > ½ of 1 lobe
T2c: Both lobes

T3: Extraprostatic extension (Note: Invasion into apex or into-but not beyond-
prostatic capsule = T2)
T3a: Extracapsular/bladder neck extension (base)
T3b: Seminal vesicle (SV)
T4: Fixed or invades adjacent structures, not SV
N1: Regional LN(s)
M1a: Non-regional LNs
M1b: Bone
M1c: Other sites
Note:
 Positive inked (intra/extracapsular) margin = R1
 Stage grouping involves PSA level and Gleason score

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 The Skilful Pathologist Series

 Clinically important parameters: Gleason 1ry, 2ry and 3ry patterns and No.
of (+) /examined bx cores
 Differentiation grade:
 Gleason ≤ 6 Well differentiated, G1
 Gleason 7 Moderately differentiated, G2
 Gleason 8-10 Poorly differentiated/undifferentiated, G3

Testis
Tis: Intratubular (ITGCN)
T1: within testis & epididymis, no LVI
T2: within testis & epididymis + LVI or T. vaginalis invasion (If T. albuginea only=
T1)
T3: Spermatic cord ± LVI
T4: Scrotum ± LVI
N1: ≤ 2 cm and or ≤ 5 LNs, none >2cm
N2: >2 -5 cm or >5 LNs, none >5cm or or extranodal extension
N3: > 5 cm
M1a: Non-regional LNs or lung
M1b: Other sites
Serum tumour markers level (S) included in the stage grouping.
Serum Tumour Markers (S)
S0 = normal
S1 : LDH < 1.5 X N and hCG : < 5K and AFP : < 1K
S2 : LDH 1.5 –10 x N or hCG: 5K–50K or AFP: 1K–10K
S3: LDH > 10 x N or hCG : > 50K or AFP : > 10K

Penis

Ta: Noninvasive verrucous carcinoma

T1a: subepithelial CT (No LVI, not poorly differentiated carcinoma)
T1b: subepithelial CT + LVI or poorly differentiated carcinoma
T2: corpus spongiosum or cavernosum.
T3: urethra
T4: other adjacent structures.
N1: inguinal, single
N2: inguinal, multiple/bilateral
N3: pelvic or inguinal + ECE
M1: distant mets + LN outside pelvis
Prognostic factors:
Invasion of C. spongiosum/ cavernosum, % of poorly differentiated component,
depth of verrucous ca invasion, size of largest LN mets, ECE, HPV Status

URINARY SYSTEM / ADRENAL

Adrenal Cortical Carcinoma

T1: < 5 cm, no extra-adrenal invasion

T2: > 5 cm, no extra-adrenal invasion

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 Histopathology Diagnosis
T3: Local invasion, but not T4
T4: Adjacent organs (great vessels, kidney, pancreas, liver, spleen, diaphragm)

Kidney
T1: ≤7 cm, within the kidney (T1a: ≤4 cm, T1b:>4cm)
T2: >7 cm, within the kidney (T2a: >7-10cm, T2b: >10cm)
T3: major veins or perinephric/peripelvic fat (grossly)
T3a: Renal vein or perinephric/peripelvic fat
T3b: extends to Vena cava < diaphragm
T3c: extends to Vena cava > diaphragm or invades vena cava wall
T4: Beyond Gerota fascia or adrenal (ipsilateral)
N1: 1 LN
N2: >1 LN
Clinically important:
Invasion beyond capsule into fat or perisinus tissues, Venous involvement, Adrenal
Extension, Fuhrman Grade, Sarcomatoid features, tumour necrosis
Fuhrman Grade :
Grade 1 : Nuclei: round, uniform. No nucleoli
Grade 2 : Nuclei: slightly irregular. Nucleoli : visible at high-power x400
Grade 3 : Nuclei: very irregular outlines. Nucleoli : visible at x 100
Grade 4 : Nuclei : Bizarre and multilobed, spindle. Nucleoli: Prominent

Renal Pelvis, Ureter TCC

Ta: Noninvasive papillary
Tis: In situ
T1: Subepithelial CT
T2: MP
T3: Beyond MP
T4: Adjacent organs/ perinephric fat
N1: Single ≤2 cm
N2: Single >2 - 5 cm or multiple, any <5 cm
N3: Any >5 cm

Urinary bladder TCC

Tis: In situ: "flat T"
Ta: Non-invasive papillary
T1: Subepithelial CT
T2: MP
T2a: Inner ½,
T2b: Outer ½
T3: perivesical (beyond muscularis)
T3a: microscopic
T3b: macroscopic
T4: Extravesical organs/structures
T4a: prostatic stroma, uterus, vagina
T4b: pelvic wall, abdominal wall
N1: 1 LN mets in true pelvis (hypogastric, obturator, external iliac or presacral
LN)
N2: >1 LN mets in the true pelvis

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N3: mets in common iliac LN

Urethra and Prostatic Urethra (pu)

Same like bladder for Ta, Tis and T1
T2: Corpus spongiosum, prostate, periurethral muscles
T3: Corpus cavernosum, beyond prostate capsule, anterior vagina ( , bladder
neck
T4: Other adjacent organs

SOFT TISSUE SARCOMA (STS)

As a part of the staging, histological diagnosis and grading into low/high grade is
essential. Some tumours are high grade by definition. Examples include MFH,
synovial sarcoma, soft part alveolar sarcoma
T1: ≤ cm (T1a: Superficial, T1b: Deep)
T2: >5 cm ( T2a: Superficial, T2b: Deep)
Notes:
 Superficial = all the tumour above superficial facia without invasion to the
fascia. Muscle involvement = deep location.
 Stage grouping includes grade.
 STS not included in TNM: Kaposi, angiosarcoma, DFSP, fibromatosis, GIST
and STS of viscra (hollow or parenchymatous) or brain
FNCLCC grading system for STS:
Tumour differentiation:
1 = STS resembling adult mesenchyme, e.g., lipo
2= STS where histologic type is certain, e.g., myxoid lipo
3= embryonal/undifferentiated/uncertain origin, e.g., osteo, Ewing, synovial,
PNET
Mitotic count: 1= 0-9/10hpf, 2= 10-19/10hpf, 3= ≥20/10hpf
Tumour necrosis: 1=No necrosis, 2=<50%, 3= ≥50%
Final Grade: Grade 1= 2, 3, Grade 2= 4, 5, Grade3= 6, 7, 8

BONE TUMOURS
The staging applies to all primary malignant bone tumours except lymphomas,
multiple myeloma, juxtacortical osteosarcoma/chondrosarcoma.
T1:≤ 8cm, T2: >8cm, T3: Discontinuous Ts in primary site
N1: Regional
M1a: Lung (no. of mets clinically important), M1b: Other sites
Grade: Low grade, High grade
Stage grouping includes grade (high grade tumours include Ewing’s)
Percentage of necrosis following Tx should be included in the report

HODGKIN’S AND NON HODGKIN’S (ANN ARBOR)

Stage I
1 LN region (I)
Localized 1 extralymphatic organ (IE)
Stage II
≥2 LN regions, same side of diaphragm (II)

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 Histopathology Diagnosis
Localized 1 extralymphatic organ + regional LN, ± other LN regions same side of
diaphragm (IIE)
Stage III
LN regions both sides of diaphragm ± Localized 1 extralymphatic organ (III E) or
Spleen (IIIS) or both (IIIE+S)
Stage IV
Multifocal ≥1 extralymphatic organ(s) ± regional nodes or localised 1
extralymphatic + non-regional LNs
All stages divided into:
A. No weight loss/fever/sweats
B.Weight loss/fever/sweats

SKIN TUMOURS
Vulva, penis and eyelid not included
Metastasis to non regional LNs= M1

Squamous cell carcinoma ‘SCC’

T1: ≤2 cm + <2 high-risk factors

T2: >2 cm or any size + ≥2 high-risk factors
T3: Deep structures (muscle, cartilage, bone)
T4: Skull base, axial skeleton
N1: 1 LN ≤ 3 cm
N2: 1 LN >3 -6 cm, or multiple ≤6 cm
N3: Any > 6 cm
High risk factors:
Depth/invasion: >2mm (AJCC) or >4mm (UICC), Clark IV, Perineural inv or LVI
Site: ear, hair-bearing lip
Differentiation: poorly or undiff

Merkel cell carcinoma

T1: ≤2 cm,
T2: > 2 -5 cm ,
T3: > 5 Cm,
T4: Deep extradermal structures (e.g., bone, muscle…)
N1a:Microscopic mets,
N1b: Macroscopic mets
N2: In transit mets only
M1a: Skin, subcut, non-regional LN,
M1b: Lung,
M1c: Other sites

Melanoma
Tis: in situ, lentigo maligna melanoma
T1: ≤1.0 mm in thickness
2
T1a: ≤ 1mm, Clark 2/3, no ulcer + mitosis <1/mm
2
T1b: ≤ 1mm Clark 4/ 5 + ulcer or mitoses ≥ 1/mm
T2: > 1-2mm (T2a: no ulcer, T2b: + ulcer)
T3: >2-4mm (T3a: no ulcer, T3b: + ulcer)

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 The Skilful Pathologist Series

T4: >4mm (T4a: no ulcer, T4b: + ulcer)

N1: 1LN (N1a: micro, N1b: macro)
N2: 2-3 LNs (N2a: micro, N2b: macro, N2c: satellite/in-transit + no LN mets)
N3: ≥4LN or matted or satellite/in-transit + LN mets
M1a: distant skin/subcutaneous tissues, or distant LNs
M1b: lung
M1c: other viscera or any site + elevated serum LDH
Prognostic factors:
Depth, ulcer, serum LDH, mitosis, tumour infiltrating lymphocytes (TIL), Clark
level, vertical growth pattern, regression

Primary cutaneous lymphoma

T1: patches/ plaques, <10% of skin (T1a: patches ,T1b: plaques).
T2: patches /plaques, > 10% of skin (T2a: patches, T2b: plaques).
T3: ≥ 1 tumour (s) (≥1cm)
T4: confluent erythema ≥80% skin surface

N1: Clinically abn. LNs, Dutch grade 1 (clone -/+). (T cell clonality is determined
by PCR or Southern blot analysis of receptor gene)
N2: Clinically abn LNs Dutch grade 2 (clone -/+)
N3: Clinically abn LNs, Dutch grades 3-4 (clone -/+)
M1: visceral involvement histologically

Peripheral blood involvement (B): included in stage grouping

B0: Not significant: ≤ 5% Sézary cells (clone -/+)
B1: Low blood tumour burden: > 5% Sézary cells but not B2 (clone -/+)
B2: High blood tumour burden: ≥1000/μL Sézary cells with clone+

Eye- Ophthalmic pathology

Eyelid carcinoma
T1: ≤5mm, not tarsal late or lid margin
T2a: >5-20mm or any size + tarsal plate/lid margin
T2b: >10-20 or full thickness eyelid
T3a: >20mm any size + orbital/ocular tissue or perineural
T3b: enucleation required
T4: extensive invasion

Conjunctival carcinoma
T1: ≤5 mm
T2: > 5 mm
T3: adjacent structures (Not orbit)
T4: orbit +/- further extension
T4a: orbit soft tissue
T4b: orbit bone
T4c: paranasal sinuses
T4d: brain

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 Histopathology Diagnosis

Conjunctival Melanoma
Tis: in situ and 1ry acquired melanosis with atypical epithelioid cells >75% of
epithelial thickness
T1: bulbar conj, substantia propria
T1a: ≤0.5mm, T1b: >5-1.5mm, T1c: >1.5mm
T2: palpebral conj, substantia propria
T2a: ≤0.5mm, T2b: >5-1.5mm, T2c: >1.5mm
T3: adjacent
T3a: eye, T3b: eyelid, T3c: orbit, T3d: sinus
T4: CNS

Uveal Melanoma

Iris
T1: within iris
T1a: ≤ 3 o’clock, T1b: > 3 o’clock, T1c: + glaucoma
T2: ciliray body/choroid:
T2a: +glaucoma
T3: sclera
T3a: +glaucoma
T4: extraocular
T4a: ≤5mm, T4b: >5mm

Ciliary body/choroid
T1: category 1
T1a: No extraocular, T1b: microscopic extraocular, T1c: macroscopic
extraocular
T2: category 2
T2a: No extraocular, T2b: microscopic extraocular, T2c: macroscopic
extraocular
T3: category3
T4: T3 + extraocular

Retinoblastoma
There are pTNM and cTNM. Only pTNM discussed
T1: within eye
T1a: ≤ 3mm, ≥1.5mm to optic n.
T1b: >3mm or <1.5mm to optic n.
T1c: >3mm or <1.5mm to optic n + Retinal detachment or subretinal fluid >5mm
from tumour
T2: minimal optic n/choroidal invasion
T2a: superficial inv to optic n
T2b: T2a + focal choroidal inv
T3: significant optic n/choroidal invasion
T3a: optic n. inv. beyond lamina cribrosa or massive choroidal haemorrhage
T3b: optic n. inv. beyond lamina cribrosa + massive choroidal haemorrhage
T4: extraocular
T4a: optic n. inv to resection margin or extraocular extension

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T4b: optic n. inv to resection margin + extraocular extension

T4c: intracranial prechiasmatic
T4d: intracranial postchiasmatic
M1a: single mets, outside CNS
M1b: multiple mets, outside CNS
M1c: CNS mets
M1d: Discrete masses, not M1e
M1e: Leptomeningeal or CSF mets
Note: T4 = direct extension from the tumour, while M= distant mets not
connected to 1ry tumour

Lacrimal gland carcinoma-Meibomian carcinoma

T1: ≤2 cm, +/- extension to orbital soft tissue
T2: > 2 - 4 cm
T3: > 4 cm
T4a: periosteum
T4b: orbital bone
T4c: adjacent structures (brain, sinus, pterygoid fossa, temporal fossa

Orbital sarcoma
T1: ≤15 mm
T2: >15 mm, not T3 or T4
T3: orbital tissues and/or bony walls
T4: globe or periorbital tissue (eyelids, temporal fossa, nose, sinuses, or CNS)

Ocular adnexal lymphoma

T1: within conjunctiva. No orbital involvement
T1a: bulbar conjunctiva
T1b: palpebral conjunctiva
T1c: extensive conjunctiva involvement
T2: orbit
T2a: anterior orbit
T2b: anterior orbit + lacrimal
T2c: posterior orbit
T2d: nasolacrimal drainage system
T3: pre-septal eyelid
T4: beyond orbit to adjacent structures
T4a: nasopharynx
T4b: bone (including periosteum)
T4c: sinuses (maxillofacial, ethmoidal or frontal)
T4d: Intracranial

Other organs/tumours staging not included in TNM7

Thymic carcinoma
Thymic carcinoma not included in TNM7, due to absence of good correlation
between the staging and the prognosis. Previously published TNM:

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 Histopathology Diagnosis
T1: tumour completely capsulated
T2: invades pericapsular CT
T3: invades nearby structures
T4: pleural or pericardial spread
N1: anterior mediastinal LNs
N2: other mediastina LNs not N1
N3: scalene and or supraclav LN.

Brain tumours

No staging of brain tumours in TNM7, because of inherent inability of brain

tumours to mets and lack of lymphatics in the brain. Previously published TNM:
Supratentorial
T1:<5 cm unilat, T2: >5 cm, unilat
Infratentorial
T1: <3 cm unilat, T2: >3 cm, unilat
For both
T3: Invades ventricular system
T4: crosses midline or invades infra- (or supra-) tentorially
Grading involved in stage grouping. Grading parameters: necrosis, mitosis and
cellularity

Phyllodes tumour of the breast

Phyllodes tumour of the breast is divided into benign, borderline or malignant

based on the stromal overgrowth (>40x without epithelium), mitosis (>10/10hpf),
stromal atypia or heterologous elements. Metastasis reported in regional lymph
nodes in 5% of cases and hematogenous spread occurs mainly to the lung. No
TNM staging for malignant or borderline tumours.

Haggitt levels for invasion in a pedunculated polyp:

 Level 1: inv within head of the polyp

 Level 2: inv. into junction of head and stalk
 Level 3: inv.into stalk
 Level 4: inv. in SM below stalk

Kikuchi levels for submucosal (sm) invasion in sessile polyp:

 Sm1: minor SM invasion from MM to depth of 300 µm

 Sm2: intermediate invasion.
 Sm3: invasion near inner surface of MP

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 The Skilful Pathologist Series

CHAPER5: PATHOLOGICAL GRADING

Pathological grading includes:

A. Tumour grading
B. Tumour responce grading (following radio, chemotherapy)
C. Non-Tumour grading: examples;
 Hepatitis activity index (HAI): grading of necoinflammatory reaction in
liver inflammation.
 Lupus nephritis grading
 Grading of graft (transplant) rejection

127
 Histopathology Diagnosis

TUMOUR GRADING

Grading of a tumour is done based on tumour differentiation (differentiation =

resmbelence of the tumour to tissue of origin)

Grading includes assessment of both the architectural and cytologic features of

the tumour.
Combined architecture and cytology: most of tumours
Pure architecture grading: Gleason’s in prostate
Nuclear grading: RCC, DCIS

Grading is included in tumour staging in brain tumours

High-grade tumours require wider excision, has high rate of recurrence and poor
prognosis
Low grade = well differentiated= grade 1
High grade = poorly differentiated= grade 3

ADENOCARCINOMA

Grade 1: >95% of tumour composed of glands

Grade 2: 50% to 95% of tumour composed of glands
Grade 3: 5% to 49% of tumour composed of glands
Grade 4: <5% of glands

SQUAMOUS CELL CARCINOMA

Sites: oral, skin, oesophagus

• G1, Well differentiated, low grade: nests of squamous + prominent cell

borders+ keratin pearl formation. (in keratinizing type)
• G2, Moderately diferentaiated, intermediate grade, small nests of squamous C.
+ moderate pleomorphism
• G3, Poorly differentiated, high grade: sheets of anaplastic cells + severe
pleomorphism+ ill-defined cell borders.

Variants of Squamous Cell Carcinoma

High-grade variants
Spindle /sarcomatoid
Basaloid
Small cell
Lymphoepithelioma-like
Low-grade variants
Verrucous
Papillary
Adenoid

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NEUROENDOCRINE TUMOURS

Neuroendocrine markers used to define neuroendocrine markers

(Synaptophysin, Chromogranin and CD56), however Ki67 proliferation index is
required for grading (in addition to morphology) for pancreatic and GI
neuroendocrine tumours (NETs)

G1: (well differentiated, low grade, carcinoid): Ki-67 index <2%

G2: (intermediate grade, atypical carcinoid): Ki-67 index 2- 20%
G3: (poorly differentiated, high grade, NE carcinoma): Ki-67 index >20%

ADENOID CYSTIC CARCINOMA

Low grade. Tubular pattern

Intermediate grade. Cribriform pattern
High grade. Solid pattern

PROSTATE GLEASON GRADING AND GLEASON SCORE

Gleason score is between 2 -10 and it is the sum of primary (most prevalent
grade) and secondary pattern (worst grade)

Gleason patterns (grades)

Gleason grade 1: well circumscribed nodules of single, separate glands. Not
diagnosed in needle biopsies
Gleason grade 2: as grade 1 but some variabilities in gland size. Not diagnosed
in needle biopsies
Gleason grade 3: Single, separate, variable glands, irregularly separated,
ragged, poorly defined edge.
Gleason grade 4 : fused/cribriform glands. Ductal carcinoma is grade 4
Gleason grade 5: either single cells with no glands or comedo pattern

BREAST CARCINOMA GRADING

Elston / Nottingham modification of Bloom-Richardson system. The system
assess three parameters:

Tumor tubule formation:

1 point: > 75% of tumor
2 points: 10 - 75% of tumor
3 points: < 10% of tumor

Mitotic count/10hpf
1 point: 0 - 9
2 points: 10 - 19
3 points: 20+

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 Histopathology Diagnosis

Nuclear pleomorphism:
1 point: mild
2 points: moderate
3 points: severe

Final Scoring
3 - 5 points: Grade 1
6 - 7 points; Grade 2
8 - 9 points: Grade 3

RENAL CELL CARCINOMA

Fuhrman grading system is a nuclear grading system uses the low magnification
power to grade the nuclei in the worst area of the tumour
Fuhrman’s grading system is used for clear cell and papillary renal cell
carcinomas
Grade 1: Nucleoli are absent or inconspicuous and basophilic at 400x
magnification
Grade 2: Nucleoli are conspicuous and eosinophilic at 400x and visible but not
prominent at 100x
Grade 3: Nucleoli are conspicuous and eosinophilic at 100x
Grade 4: Extreme nuclear pleomorphism, multinucleate giant cells, and/or
rhabdoid and/or sarcomatoid differentiation

HEPATOCELLULAR CARCINOMA

Classic HCC graded as

Well-differentiated HCC. Minimal cytologic atypia , trabecular or

pseudoglandular.
Moderately differentiated HCC. Moderate atypia, psudoglandular + well-
defined nucleoli.
Poorly differentiated HCC. Pleomorphic tumour cells +/- giant cells, solid nests.

FOLLICULAR LYMPHOMA

According to WHO classification, follicular lymphoma is graded ccording to

number of centroblasts in 10 neoplastic follicles, per hpf. Centroblasts are large
noncleaved cells with 1 to 3 nucleoli attached to the inner nuclear membrane
Grade 1. 0–5 centroblasts/hpf.
Grade 2. 6–15 centroblasts/hpf.
Grade 3. >15 centroblasts/hpf.

THYMUS
Thymic tumours are classified into
Well-Differentiated (Thymoma): Like normal thymus + No significant
cytological atypia in the tumour cells.

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Moderately Differentiated Thymic Epithelial Neoplasm (Atypical Thymoma):

Partial loss of normal thymus appearance , + moderate cytologic atypia.
Poorly Differentiated Thymic Epithelial Neoplasm (Thymic
Carcinoma): Prominent cytologic atypia present

ASTROCYTIC TUMOURS

WHO grading system

Grade1, fibrillary astrocytoma, pilocytic astrocytoma and subependymal giant
cell astrocytoma: mild cellularity, no necrosis, no vascular proliferation, no
mitoses.
Grade 2, well-differentiated/diffuse astrocytoma: moderate cellularity mild to
moderate atypia , rare mitoses, no vascular proliferation or necrosis.
Grade 3, anaplastic/malignant astrocytoma, moderate to high cellularity severe
atypia, frequent mitoses. e.g., gemistocytic astrocytoma.
Grade 4: Glioblastoma Multiforme: Necrosis and vascular proliferation + frequent
mitoses and severe pleomorphism.
OLFACTORY NEUROBLASTOMA
Hyams grading system :
Grade1: Prominent lobulation, prominent neurofibrillary background, high
number of rosettes, mild pleomorphism, few mitosis, no necrosis, calcification
Grade4: no lobulation, no neurofibrillary background, no rosettes, severe
pleomorphism, excess mitoses, excess necrosis, no rosettes, no calcification
Grade 2&3 intermediate between 1&4

SOFT TISSUE SARCOMA

FNCLCC grading system for soft tissue sarcoma (STS):

Tumour differentiation:
1 = STS resembling adult mesenchyme, e.g., liposarcoma
2 = STS where histologic type is certain, e.g., myxoid liposarcoma, alveolar soft
part
3 = embryonal/undifferentiated/uncertain origin, e.g., osteo, Ewing, synovial,
PNET
Mitotic count:
1 = 0-9/10hpf,
2 = 10-19/10hpf,
3 = ≥20/10hpf
Tumour necrosis:
1 = No necrosis,
2 = <50%,
3 = ≥50%
Final Tumour Grade:
Grade 1 = 2 or 3
Grade 2 = 4 or 5,
Grade 3 = 6, 7 or 8

131
 Histopathology Diagnosis

DUCTAL CARCINOMA IN SITU

This is a nuclear grading system

Grade 1. The nuclei are small, round, and uniform, less than 1.5 times the size
of an RBC.
Grade 2. Larger nuclei, 1.5- 2 times the size of an RBC, few mitoses
Grade 3. Large nuclei > 2.5 times the size of an RBC, prominent nucleoli,
frequent mitoses

CERVICAL INTRAEPITHELIAL NEOPLSIA (CIN)

CIN 1, mild squamous dysplasia, +/-HPV related changes (koilocytic changes,

arisainoid nuclei)
CIN 2, moderate squamous dysplasia, lower 2/3
CIN 3, severe squamous dysplasia, full thickness, may involve the squamous
metaplastic crypts.

VULVAL INTRAEPITHELIAL NEOPLASIA

VIN 1, mild squamous dysplasia, lower 1/3

VIN 2, moderate squamous dysplasia, lower 2/3
VIN 3, severe squamous dysplasia/carcinoma in situ, full thickness

TUMOUR RESPONCE GRADING

Tumour regression grading (TRG) evaluates the response of a malignant

tumour to preoperative chemo/radiotherapy in colorectal cancer
TRG4: total regression of the tumour, no viable tumour cells (tumour ablation).
The tumour mass becomes totally necrotic or fibrosed.
TRG3: fibrosis/necrosis occupies most of the residual tumour mass (>50%
tumour regression)
TRG2: dominant tumour with fibrosis/necrosis in 25-50% of the tumour mass
TRG1: minor regression, fibrosis/necrosis in <25% of the tumour mass
TRG0: no regression (chemo/radio-resistant tumour)

Pathological complete response (pCR) is a prognostic evaluation of patient

reponse to neoadjuvant chemotherapy in breast cancer. This includes
assessment of two parameters:

A.Tumour response
Complete response: either
(i) no residual tumour
(ii) no residual invasive tumour but DCIS present.
Partial response : either
(i) <10% of residual tumour
(ii) 10–50% of residual tumour
(iii) >50% of residual tumour
No response.

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B. Nodal response
No nodal mets
No mets, but fibrosis present (evidence of response)
Mets + fibrosis
Mets. No fibrosis.

Residual Cancer Burden (RCB) involves the cellularity of residual tumour cells
in tumour bed and number + size of LN mets,

The Miller-Payne system for grading response after neoadjuvant chemotherapy

treated breast cancers:
Grade 1: No change
Grade 2: <30% loss of tumour cells
Grade 3: 30% - 90% loss of tumour cells
Grade 4: > 90% loss of tumuor cells
Grade 5: No malignant cells, however, DCIS may be present

The Miller-Payne system does not include lymph nodes response.

NON TUMOUR GRADING

METHOTREXATE INDUCED LIVER DISEASE

Grade 1: mild fatty change + mild portal inflammation

Grade 2: G1 + focal necrosis
Grade 3a: G2 + Mild portal fibrosis
Grade 3b: interface hepatitis or bridging fibrosis
Grade 4: cirrhosis

BANFF SCORES FOR ACUTE HEPATIC CELLULAR REJECTION:

Portal inflammation:
Score 1: lymphocytes in some portal tracts
Score 2: lymphocytes+ neutrophils + eosinophils in most portal tracts
Score 3: Score 2 + spillover into peripotal hepatocytes
Bile duct:
Score1: few bile ducts inflitrated by inflammatory cells
Score 2: all bile ducts infiltrated by inflammatory cells + cellular atypia in some
bile ducts
Score 3: cellular atypis in all bile ducts

Endothelial inflammation:
Score 1: subendotheial lymphocytic infiltrate in venules in some portal tracts
Score 2: score 1 but in most portal tracts

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 Histopathology Diagnosis
Score 3: as score 2 + perivascular inflammation and necrosis

Final score
<3 not diagnostic of rejection
4-5 mild
6-7 moderate
8-9 severe

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CHAPTER 6: DIAGNOSTIC TIPS AND

TRICKS

TYPES OF THE EXAMINED SLIDES:

 Fragmented tissues
 Skin punch biopsy
 Tissue core/ tru cut biopsy
 Tissue section
 Cytology :
1. Fluid-based cytology (Thin prep, cytospin…etc)
2. Smears and imprints
 Frozen section
 IHC slides

1.Fragmented tissues:

Rule1: each fragment should be examined

Rule2: the most likely to be missed are the peripheral fragments
Rule3: mark the lesion using a permanent marker

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 Histopathology Diagnosis
Method: count the fragments by naked eye, pick up the general outline of the
fragments, better to draw them on a blank sheet and make a checklist for each
fragment. Start with the most peripheral fragment then go inward.

2.Tissue cores/ Tru cut

Rule1: careful processing is essential

Rule2: serial sections may be required
Rule3: number and length of the cores as well as the length of the lesion
compared to the total length should be reported.
Method: similar to fragmented tissue. In renal biopsies, there should be at least
7-8 glomeruli to be an adequate specimen
3.Skin punch biopsy

Rule1: careful processing is essential

Rule2: levels may be needed before you find the lesion
Rule3: the presence of parakeratosis always indicates a lesion
Rule4: If you see perifollicular inflammation, always do PAS for fungi
4.Tissue Section

Rule: The periphery of the section will show the type of tissue, the effect of the
lesion on the surrounding, the presence or absence of a capsule.
Method: screen the periphery of the section first, report the type of tissue and
the exact position of the lesion in the tissue.
You can notice if this lesion compressed or invaded the surrounding tissue
(infiltrating or pushing margin) and if the tissue surrounding the lesion contains a
precancerous lesion. The capsule; intact or breached (follicular thyroid
carcinoma). The centre of the tissue then examined for grading. The depth of
invasion in a malignant tumour is the base for pathologic staging (The graticule
can be used to measure distances).

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5.Cytology

GYNE CYTOLOGY
Criteria of colposcopy referral
 First CIN2/CIN3 smear (moderate/severe dyskaryosis)
 Second CIN1 smear (mild dyskaryosis)
 Third borderline smear
 Abn. smear following treatment
 Clinically suspicious lesions, even with negative smear

NON-GYNE CYTOLOGY
Contraindications to FNA
 Bleeding disorders
 Infection at FNA site
 uncooperative or irritable patient
 Absence of an obvious mass/cyst
A. Fluid-based cytology

Rule1: the representative lesion could be one cell.

Rule2: in clumpy cytology, examine the hypocellular areas primarily, while in a
poorly cellular cytology, look for cell sheets, nests first.
Method:
Primary screening: at low power (4x) or 10x objective, screen the slide, to find
areas of interest; mark them using a marker pen.
Secondary screening: Cellularity (high, low), Architecture (papillae, cell balls,
sheets, individual cells, matrix and secretions) and Cell types (malignant/benign
tumour cells, epithelial/mesenchymal cells, or inflammatory cells) are the main
components of cytology examination. Cellular details better identified by high
power (40x). Benign or malignant are the main categories of diagnosis.
B-Smears and imprints

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 Histopathology Diagnosis
Rule1: same rules of fluid cytology
Rule2: comment on adequacy of the specimen
Rule3: artefacts are common
Rule4: be careful when examining the periphery of the smear, as drying
artefacts and cell swelling are very common.
Method:
Primary screening: as in fluid cytology, but avoid clotted areas and search for
well smeared sheets/cells. Screen the whole slide in parallel lines or Z
configuration (from side to side), to find areas of interest; mark them using a
marker pen.
Secondary screening: same as fluid cytology
6.Frozen Section (intraoperative consultation)

Rule1: no emergency frozen section

Rule2: do not rush for diagnosis if there is uncertainty.
Rule3: Ice crystal artefacts are common and may be misleading.
Rule4: the presence of fat may hinder the quality of the section
Rule5: a paraffin section from same tissue should follow
Method: take care of the artefacts and remember that cell swelling is common
and hence many alerting appearances will appear normal when seen in paraffin
section. The tissue sections appear paler than paraffin sections due to high
water content (oedema-like appearance). Trimming artefacts are common due to
variability in tissue consistency (this is not the case in paraffin section where all
the tissues acquire the paraffin consistency). Support your diagnosis with other
methods when possible (tissue imprints, rapid cytology or special stains, e.g.,
PAS)
7.IHC slides

Score 0 Score 1 Score 3

Rule1: pathologist’s role is to comment on intensity/distribution of the stain, not

to diagnose a lesion (benign, malignant...etc). The nature of the lesion could only
be known using routinely stained slide (H&E, Giemsa...etc).
Rule2: image analysis software is supportive
Method: use a paper and pen, score the slide based on:
 The intensity (1+, 2+, or 3+)
 The localisation (nuclear, cytoplasmic or membranous)

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 The distribution (percentage of positive cells or percentage of each intensity

score among the whole tissue).

If the tissue shows variable staining intensities, the combined score would be the
most reproducible and scientifically correct.

The combined score = % of (1+) X1 + % of (2+) X2 + % of (3+) X3 = Result out

of 300

MICROSCOPIC MORPHOLOGIC PARAMETERS

Very Low power (2x objective), scanning power

This power gives you a panoramic view of the following:

 Nature of the specimen
 Tissue Fragments
 Core biopsy
 Tissue section
 Cellularity in cytology: hypo/hypercellular
 General symmetry of the lesion: this is generally important to differentiate
between benign and malignant lesions. Benign lesions are usually
symmetrical due to synchronous proliferation of the cells (e.g., nevus), while
malignant lesions are usually asymmetrical (e.g., melanoma). Asymmetry
seen in Squamous cell carcinoma vs. keratoacanthoma and seborrhoeic
keratosis.

Low power (4X objective)

 Type of tissue: normal tissue attached to the lesion best recognised by low
power
 Location of the lesion : bone (periosteum, cortex, medulla), Lymph node
(cortical, paracortical, medullary, interfollicular, sinuses), bone marrow
(paratrabecular, peritrabecular, intertrabecular), liver (portal vs. acinar, focal
vs. zonal or diffuse)
 Infiltrative vs. pushing edge
 Diffuse vs. nodular (lymphoma)
 Lobulated tumours

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 Histopathology Diagnosis
 Relation to surrounding tissue
 The affected layer of an organ
 Superficial or deep
 Architecture preservation/loss: architecture loss in lymph node (partial or
complete loss occur in lymphoma, metastasis or excess necrosis), in liver
(lost totally in cirrhosis, partially in hepatocellular carcinoma, metastasis)

Cirrhosis. Regenerating nodules replaced the normal liver architecture

Hepatocellular carcinoma. Irregular hypercellular nodules replaced the normal

liver architecture

 Pattern of growth:
 Diffuse vs. nodular pattern (e.g., follicular, granulomatous, lobulated like
thymoma, plexiform like neurofibroma subtype, multinodular like
endometrial stromal tumour)
 Lobulated vs. jigsaw puzzle pattern. Jigsaw Puzzle means moulding of
sheets borders, examples include cylindroma, thymoma, basal cell
adenoma of salivary gland

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Brenner tumour, ovary, nodules, cystic areas among fibrous stroma

Epithelioid sarcoma, nodules of sheets of cells with central necrosis

Sebaceous carcinoma, nodules of clear cells infiltrates the dermis

 Circumscription (well or poorly circumscribed)

 invaded (malignant, usually) or compressed the surrounding (benign,
usually). If invaded the surrounding tissue, the edge could be pushing (low
proliferation)

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 Histopathology Diagnosis

Spermatocytic seminoma, infiltrating normal seminiferous tubules

Gastric GIST, compresses rather than infiltrates the mucosa

 Capsule invasion (full thickness or partial thickness invasion)
 Necrosis: Necrosis could be coagulative where the architecture is
preserved (myocardial infarction) or liquefactive where the architecture is
lost (abscess or brain infarction). Necrosis distribution could be geographic
as in glioblastoma, comedo as in DCIS, necrosis with perivascular
preservation as in ischemic necrosis or following chemo-/radiotherapy.

Geographic necrosis in Glioblastoma Multiforme

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 Extent of the lesion: the lesion could be superficial (e.g. Ulcerative colitis)
or transmural (e.g., Crohn’s, signet ring cell carcinoma).

Transmural inflammation and granulomas is the hallmark of Crohn’s disease

 Assessment of depth of invasion is the basic of pathologic staging (e.g.,
Breslow staging for melanoma). This can be done microscopically by
inserting a graticule in one eye piece. Graticule is optimum for measuring
Breslow thickness in melanoma, depth of invasion in small tumours, cell
size, nuclear and nucleolar size

Ependymoma, unique vascular rosettes

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 Histopathology Diagnosis

Starry sky appearance in Burkitt’s lymphoma

Dark and pale areas of schwannoma = alternating hypo- and hypercellular areas

Rhabdomyosarcoma, alternating cellular and hypocellular area

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Meningioma whorls

RCC, clear cell type, formed of nests, replacing the normal kidney

Synovial sarcoma infiltrating the skeletal muscles

Intermediate power (10X objective)
This power provide more details and most of the lesions are diagnosed using this
power. The following parameters could be seen:
 Pattern recognition

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 Histopathology Diagnosis
 Vasculature pattern (arcades, slits, sinusoids, glomeruloid), vascular
invasion
 Stroma/matrix (cellular. Fibrous, osseous, cartilaginous, myxoid,
hyaline…etc)
 Interface between parenchyma and stroma
 Margins
 Level of invasion
Tumour edge
The edge is the merger between the tumour front and the non-tumoural /normal
tissue around. The tumour edge could be well or poorly-defined. The tumour
edge may be sharply demarcated (well-defined) when the tumour growth is slow,
while the poorly defined edge indicates an aggressive, rapidly growing tumour
that infiltrates the surrounding tissue. In more aggressive tumours, the tumour
edge may not be identified at all, especially in small biopsies.
Importance of tumour edge:
 It contains the tumour front (most active cells) and hence Ki-67 and other
proliferation markers should be assessed at such areas
 Tumours with poorly defined edge has worse prognosis
 It is the site of EMT (epithelial-mesenchymal transition)

Comment on Tumour Vasculature

 Hemangiopericytoma like pattern (staghorn pattern): seen in paraganglioma,
renal clear cell sarcoma, synovial sarcoma, clear cell chondrosarcoma,
solitary fibrous tumour, mesenchymal chondrosarcoma, infantile
fibrosarcoma and low grade endometrial stromal tumour.
Hemangiopericytoma is CD31(-) (vs. hemangioendothelioma, which is
CD31+), while both are CD34+.
 Ectatic vessels: uterine stromal nodule and low grade stromal sarcoma
 Craw-feet like: myxoid liposarcoma
 Thick, hyalinised blood vessels: Glomus, amyloid T, leiomyoma
 Perivascular rosettes of tumour cells: ependymoma, renal clear cell
sarcoma, endocrine pancreatic tumours

Craw-feet like blood vessels in myxoid liposarcoma

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Angiomyofibroblastoma of the testis, characteristic hyalinised blood vessels

 Glomeruloid bodies: Glioblastoma multiforme, Yolk sac tumour (Schiller

Duval bodies)
 Vascular invasion: hepatocellular carcinoma and renal cell carcinoma are
known for their predilection for vascular invasion
 Fibrin thrombi in blood vessels: adrenal cortical adenoma
High Power (40x Objective, some consider 20x )
Diffuse lesions and lesions defined based on cell types should be examined
using this power as well as cytology preparations. In addition, high power
confirms the diagnosis that was made using low/intermediate powers. The
following parameters must be reported:
 Evaluation of tumour cell size by comparing with an internal control
(denominator). Small cells = size of 1 Neutrophil/RBC, while large cells =
size of a histiocyte, fibroblast nucleus or 4-5x size of RBC. the pathologist
should measure the distance between structures and the sizes of cells and
nuclei
 Tumour Cells type (One /dual population, epithelioid, sarcomatoid..etc) and
Shape (rounded, spindled..etc)
 Relation of cells to each other (polarity, overlapping, regularly spaced,
Intercellular bridges, cell borders and outlines.....etc)
 Cellular details: Cytoplasm characteristics and inclusions and Nuclear
details: mitosis, apoptosis, nucleoli, chromatin pattern, nuclear membrane
..etc

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 Histopathology Diagnosis

Squamoid cells, prominent interceullar bridges, prominent nucleoli and absent

granular cell layers around keratin pearls are diagnostic for SqCC

Aggressive angiomyxoma of the vulva shows diagnostic collarette pattern of

muscle around a blood vessel

Mitotic count per hpf (arrows), usually refers to 40X field. This is used to evaluate
the aggressiveness of the tumour and should be supported by Ki-67 staining

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Oil Immersion (100x Objective) Lens

This power is reserved for delicate cellular details. For example, when examining
a blood film to differentiate between different cell types including myelocytes,
promyelocytes, lymphocytes...etc for leukaemia subtyping or to visualise the
nucleolar details, Auer bodies, viral inclusions

Motile malignant cell has elongated morphology with two poles. An advancing
broad pole (pseudopodia) where contraction of actin filaments will pull the cell
body forward and a passive thin pole (Cell culture)

Late apoptosis. Apoptotic bodies formed after packaging of nuclear fragments

and cytoplasmic fragments in membrane-bound vesicles. A nearby intact cell is
seen engulfing the apoptotic bodies (Cell culture)

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 Histopathology Diagnosis

Melanin pigment (arrow) within pleomorphic malignant cells in pleural effusion.

The presence of the pigment is a clue for diagnosing metastatic melanoma.

Progression of view and details with increasing magnification:

The following examples illustrate the amount of information gained by the use of
4x, 10x and 40x powers respectively:

Large cell neuroendocrine tumour of the lung

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 The Skilful Pathologist Series

Basaloid carcinoma, lung

151
 Histopathology Diagnosis

Meningioma

SOME TIPS

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 The Skilful Pathologist Series

Tricky Lesions That Require Careful Attention

 Acinic cell carcinoma, salivary (mimic normal glands especially in FS,
but without ducts)
 Epithelioid haemangioendothelioma (EH)
 Histiocytosis
 Infections : viral, fungal
 Inflammatory myofibroblastic tumour
 Intrapulmonary thymoma
 Kaposi Sarcoma (early stage), may mimic normal skin
 Lymphadenoma with solid squamous nests, salivary gland (mimic
SqCC)
 Peritoneal angiosarcoma
 Sertoli-Leydig cell tumour (ovary, testis) has a lot of mimicry to many
other tumours
 Signet ring cell carcinoma
 Systemic mastocytosis (cells with well-defined borders, clear or granular
cytoplasm, cell shape oval, rounded, fusiform or spindle, no nucleoli,
elicit fibrous reaction +/- eosinophils)
Easily Overlooked Tumours
 Adenofibroma
 Adenomyoma
 Adenosarcoma
 Aggressive angiomyxoma of the vulva
 Cystadenofibroma
 Cystic mesothelioma
 Desmoplastic mesothelioma (DDx pleural plaque and fibrous pleurisy)
 Epithelioid leiomyoma (Leiomyoblastoma)
 Fibromyoblastoma
 Fibromyoma
 Solitary fibrous tumour
Lesions That Can Occur Anywhere
 Crohn’s
 Fasciitis
 Fibromatosis
 Hemangioendothelioma
 Hemangiopericytoma
 Inflammation
 Kaposi sarcoma
 Lymphoma
 Malignant Fibrous histiocytoma
 Melanoma
 Myofibroblastoma- inflammatory pseudo-tumour
Tumours That May Occur In Unexpected Sites
Soft tissue osteosarcoma and mesenchymal chondrosarcoma

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 Histopathology Diagnosis
Lesions often Confused with Malignant Tumours
Bone
 ABC (aneurysmal bone cyst)
 Callus
 Fibrous dysplasia
 Myositis ossificans
 Osteoblastoma
Soft tissue
 Histiocytomas
 Nodular fasciitis
 Pleomorphic and spindle cell lipoma
 Pleomorphic xanthogranuloma (PXG)
Serous membranes
 Adenomatoid tumour
 Benign cystic mesothelioma
 Reactive mesothelial cells
Variable sites
 Pleomorphic xanthastrocytoma (PXA), brain
 Giant cell granuloma
 Inflammatory fibroid polyp
 Inflammatory pseudo-tumours
 Myofibroblastic tumour
 Plasma cell granuloma
 Post TURB spindle cell tumour of the bladder

Tricky Lesions By Naked Eye

Mesothelioma encases the lung in late stages. Adenocarcinoma arising from

lung periphery can encase the lung too. Hemangiopericytoma is similar grossly
and microscopically it mimics fibrous mesothelioma or may trap the alveoli to
mimic biphasic mesothelioma. LMWK and vascular markers can resolve the
problem.

HISTOPATHOLOGIC CLUES TO TUMOUR DIAGNOSIS

 Tumour units or pattern (tumour architecture): glandular, diffuse, cords,
sheets…etc
 Tumour cells features (size & shape): small/large, round, clear, spindle,
squamoid..etc
 Cellularity: hypo- or hypercellular
 Cell diversity: dual or single type
 Predominant component (important for tumour nomenclature)
 Predominant grade or the worst grade in a tumour (the latter is the
fundamental for Kloppel (WHO) grading of breast IDC)
 Cellular atypia: pleomorphism, nuclear to cytoplasmic ratio…etc
 Matrix production: mucinous, osteoid, fibrous…etc
 Pattern of damage to normal tissue: compression, infiltration
 Vascular pattern (see later)

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 Specific features: calcifications, psammoma bodies, Dutcher bodies, Russell

bodies, salt and pepper chromatin pattern…etc
 Diagnostic artefacts: easily crushed cells (delicate cells) of oat cell
carcinoma and PNET and separation artefacts in BCC
 Pattern of necrosis: comedo, geographic, extensive coagulative or
liquefactive
CRITERIA OF MALIGNANCY

MORPHOLOGIC CRITERIA BY ROUTINE STAINS

HISTOPATHOLOGY
Architectural criteria of malignancy
In any tumour
 Pleomorphism of tumour units (irregular acini, sheets, cords…etc)
 Invasion of the surrounding tissues (spiky tumour units or cells invading
normal structures due to motility and enzymes production)

Those bland-looking cells are malignant owing to their frank fat invasion, tubular
carcinoma, breast

 Necrosis - coagulative (central, geographic or inside the acini). Infarcts can

occur in benign/malignant tumours or inflammation

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 Histopathology Diagnosis
Central necrosis indicate ischemia of the central cells, which are away from the
poorly formed blood vessels, and due to rapid enlargement of the tumour mass

 Haemorrhage is more liable in rapidly growing tumours due to poorly formed

vessels, increased angiogenesis and necrosis of the vessel's wall. Therefore
it is commoner in sarcomas
 Loss of polarity: distorted alignment of the cells (epithelial tumours)
 Invasion of basement membrane (epithelial tumours)
Specific tumours
 Capsular invasion in follicular thyroid carcinoma (full thickness)
 Increased number of layers as in urothelial carcinoma (>8 layers)
 Endocrine tumours: specific patterns in pancreatic carcinoma and thick
fibrous bands in parathyroid carcinoma
 Malignancy in Meningioma: infiltration of Virchow-Robin’s space
Cellular criteria of malignancy= cellular atypia
In any tumour
 Pleomorphism (cellular and nuclear): variable in size and shape
 Increased nuclear to cytoplasmic ratio (N/C): N= 1:4 to 1:6
 Irregular thickening, angular nuclear membrane
 Malignant giant cells (with nuclear overlapping)
 Hyperchromatism or abnormal clearing of chromatin
 Coarse nuclear chromatin (clumps)
 Large, multiple, sometimes eosinophilic nucleoli
 Atypical (e.g., triple, quadruple) or excess mitoses

High degree of pleomorphism, nuclear features of malignancy and increased N/C

ratio are prominent. However, atypical/excess mitoses are essential to diagnose
malignancy
Specific tumours
 The presence of one cell type in lymphoma (vs. LN hyperplasia)
 The presence of Reed Sternberg cell in Hodgkin’s
 Nuclear features in papillary thyroid carcinoma

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Papillary thyroid carcinoma show abnormal nuclear clearing and overlapping

nuclear cleavage
CYTOLOGY
Architectural criteria of malignancy
 Irregular sheets, thick or complex papillae, cords, 3D (rather than 2D or flat
sheets), cell balls or morulae. Differentiation between three dimensional (3D)
and two dimensional (2D) structures is vital to discriminate between benign
and malignant process in cytology

3D configuration, seen in this malignant sheet of urine cytology.

 Cellular discohesion and frequent single cells
 Loss of polarity in cell sheet
 Cell- in- cell (pair cells)
 Tumour diathesis: necrotic tumour debris
 Lymphoepithelial bodies in lymphoma
 Papillae. In thyroid cytology, it is a definite sign of malignancy (papillary
carcinoma). In urine cytology, highly stratified papillae are malignant. In
breast, papillary carcinoma has complexly branched fronds and atypical
cells.
Cellular criteria of malignancy
As in histopathology cellular criteria above plus:
 Overlapping of the nuclei
 Enlarged nuclei (compared to size of RBCs or lymphocytes)

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 Histopathology Diagnosis
 Nuclear moulding: compressed side by side + deformed shape
 Coarse chromatin: chromatin clumps
 Nuclear membrane: irregular with grooves & angulations
 Azzoppardi effect: basophilic nuclear fragments (DNA) around blood
vessels in necrotic area of small cell carcinoma

Huge irregular nuclei (compare with the size of RBCs), and prominent nucleoli in
Large cell carcinoma, pleural effusion.

Irregular outline of sheets of atypical epithelial cells, with marked overlapping

indicates malignancy, breast FNA.
Criteria that favour Benign
 Flat 2D and cohesive sheets
 Honeycomb appearance of the cells in the sheet
 Regular spaces between the cells
 The presence of myoepithelial cells within ductal structures as in
fibroadenoma of the breast
 The presence of apocrine cells, stromal cells (naked nuclei) and fibro-fatty
tissue in the breast cytology

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 The Skilful Pathologist Series

2D group of monomorphic cells and nuclei, fixed relationships between cells in

the sheet and honeycomb appearance. Additionally, the presence of naked
nuclei of myoepithelial cells in the background confirms the benign nature,
breast FNA

Antler horn appearance of this branched breast duct is typical of fibroadenoma of

the breast, breast FNA

CELL CULTURE
Behavioural changes
 Loss of growth factor dependency
 Secretion of transforming growth factors (TGFs)
 Anchorage independent growth & Loss of contact inhibition
 Increased growth rate /decreased doubling time
 Immortalization (e.g., HELA cells) & loss of replicative senescence
 Motility
Morphology: Cellular criteria of malignancy as histopathology + flattened
morphology
Molecular changes: Cell surface markers (glycolipids and glycoproteins) and
adhesion molecule changes include reduction in surface fibronectin and increase
or loss of actin microfilaments.
Biochemical changes: Increased glucose transport & secretion of proteases,
e.g., plasminogen activator

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 Histopathology Diagnosis
The presence of some features of cellular atypia does not always mean
malignancy. Diagnosis of malignancy is dependent on the collective data of
morphology, in addition to, other factors including:
 Site (e.g., axial vs. peripheral chondrogenic tumour, deep peritoneal vs.
superficial subcutaneous lipogenic tumour)
 Tumour size (especially important in endocrine tumours, GIST, Phyllode
tumour of the breast)
 Clinical features (e.g., paraneoplastic syndrome, massive hypercalcaemia
in parathyroid carcinoma, evidence of multifocal invasive masses radiologically
as in hepatocellular carcinoma supported by ↑ AFP )
 IHC (e.g., absent myoepithelial cells) and molecular ( evidence of specific
mutation) auxiliary techniques

ELECTRON MICROSCOPIC FEATURES OF MALIGNANCY

 Basement membrane invasion
 Endocrine differentiation in certain tumours
 Loss of differentiation as in undifferentiated tumours
SPECIAL STAINS FEATURES OF MALIGNANCY
 PAS stain highlights the breached parts of basement membrane
 Mucin stain (e.g., Alcian, mucicarmine) positive cells in lymph node indicate
metastasis from mucin producing tumour
 PAS (+) cells in seminiferous tubules found in intratubular germ cell
neoplasia (ITGCN)
 Fontana-Masson stain can confirm melanoma diagnosis
 Reticulin stain can distinguish malignant tumour “invasion” from benign
tumour “compression”
IMMUNOHISTOCHEMICAL FEATURES OF MALIGNANCY

 Myoepithelial cells markers (p63+, SMM-HC, SMA+, S-100+, CK14+) are

absent in breast cancer (absent also in microglandular adenosis)
 Absence of basal cells (p63+) in prostatic adenocarcinoma differentiates it
from atypical small acinar proliferations (ASAP) and other benign lesions
 Proliferation markers (e.g., Ki-67): high percentage of positivity is associated
with malignancy

Ki-67 in normal colonic crypts (L) confined to the base of the crypt compared to
diffuse, intense staining in adenocarcinoma, colon (R)

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 Kappa/lambda light chain monotypia is associated with lymphoma rather

than reactive changes
 Loss of a pan-T cell marker (CD2, 3, 5, 7) is associated with T-cell
lymphoma
 Loss of E-cadherin protein
 Basement membrane staining can highlight the breached parts using
antibodies against basement membrane components, e.g., collagen IV and
laminin
MOLECULAR BIOLOGY FEATURES OF MALIGNANCY

 Malignancy associated mutations (translocations, amplifications and

deletions). Examples include t(9:22) in chronic myeloid leukaemia and del
22 in meningioma
 Receptor rearrangement in lymphoid neoplasms
 DNA methylation changes are associated with cancer
 Loss of imprinting
 Osteopontin is a marker for metastasis (CD44 is its receptor)
 Loss of E-cadherin gene
 Aneuploidy is associated with malignancy, but aneuploidy per se not
diagnostic for malignancy. Aneuploid malignant tumours are highly
aggressive
NON-MICROSCOPIC CRITERIA OF MALIGNANCY
Malignancy in some tumours can be proven by non-microscopic methods. These
include:
 Pituitary carcinoma: evidence of metastasis
 Adrenal cortical carcinoma: weight, size, metastasis
 Parathyroid carcinoma: high calcium level, pathologic calcification
 GIT cancer tumour markers: high serum level of CEA
 Prostate carcinoma: high serum level of PSA and acid phosphatase
 Rearrangement of heavy or light chains or T-cell receptor in Lymphoma

Clues for Malignancy in Certain Tumours

 Parathyroid carcinoma: thick fibrous bands, trabecular pattern, spindle cells,
excess mitoses, capsular/vascular invasion, high level of free calcium,
metastasis, loss of Rb

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 Histopathology Diagnosis

Calcification + thick fibrous bands in parathyroid carcinoma

 Adrenal carcinoma: invasion and mitoses

 Pituitary carcinoma: metastasis
 Malignant meningioma: infiltration of Virchow-Robin’s space
 papillary low grade TCC, bladder: increased multilayering (>8) in
 Prostatic adenocarcinoma: architecturally abnormal small acini + absent
basal cells. Gleason is architectural grading, nuclear features do not count

Prostatic adenocarcinoma, small, irregular single-layered glands with nerve

invasion, Gleason grade 3
 Renal cell carcinoma: clear cells arranged in trabeculae or nests, tumour
size. Cellular criteria of malignancy are not essential
 Papillary carcinoma, thyroid: papillary complexity, hyalinised cores, colloid
features plus nuclear features (coffee-bean, water-clear, overlapping,…etc)
 Follicular carcinoma, thyroid: full thickness invasion of the capsule is the
clue to malignancy and overexpression of p53. Cellular features do not
count
 Pancreatic endocrine carcinomas: architectural and cell type, secretion of
gastrin, somatostatin or ACTH instead of insulin
 Papillary mucinous/serous carcinoma of the ovary: multilayering
 GIST, GANT and Phyllode breast tumours: size > 5cm and mitotic count/hpf
(high power field)

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 Malignant transformation in Pilomatrixoma, skin: Invasive + high nuclear

atypia + abn mitoses + extensive necrosis
 Malignant transformation in benign mixed salivary gland tumour (ex-
pleomorphic ), include invasion beyond the capsule >0.8cm, cytological
atypia, excess mitoses, hyalinization fibrosis and focal calcifications
 Malignant transformation of a nevus (into melanoma): clinically itching,
ulceration, bleeding...etc, pathologically, Pagetoid spread, marked atypia,
invasion of the dermis, and positivity for HMB45/Melan-A
 Malignant transformation in leiomyoma: increased number of normal mitosis,
presence of atypical mitosis
TRICKS

Non-malignant lesions associated with atypia, include:

 Dysplasia, including adenomas of the colon
 Reactive atypia (or inflammatory atypia)
 Repair (active fibroblasts)
 Benign tumours: e.g., bizarre leiomyoma, pheochromocytoma
 Radio-/chemotherapy induced changes

Reactive/inflammatory atypia in gastritis, can be confused with carcinoma

Features, which could present in benign lesions include
 Invasion: invasive mole, adenomatoid tumour (false invasion)
 Metastasis: metastasizing leiomyoma, metastasizing mole
 Haemorrhage: thyroid adenoma
 Necrosis: calcifying epithelioma of Malherbe, Kikuchi lymphadenitis,
necrotizing granuloma, leiomyoma with necrosis
 Irregularity in size and shape of tumour units: adenomatoid tumour
 Capsular invasion and pseudo-invasion: mixed salivary gland tumour
(pleomorphic adenoma)
 Therefore, diagnosis of malignancy is dependent on the experience and
memory of the pathologist + gathering of the features in one lesion.
Non neoplastic proliferative lesions of the ovary
 Ectopic decidual reaction
 Endometriosis & Endosalpingiosis
 Stromal hyperplasia & Hilus cell hyperplasia

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 Histopathology Diagnosis

Tumours of Undetermined Malignant Potential

 STUMP (smooth muscle tumour of undetermined malignant potential),
uterus
 Granulosa tumour, ovary
 Brenner tumour, ovary
Non-gradable malignant tumours- all high grades by definition
 Endometrial serous adenocarcinoma
 Synovial sarcoma
 Alveolar soft part sarcoma
Tumours of intermediate malignancy (rare metastasis, good prognosis)
 Ameloblastoma (Adamantinoma), bone
 Adenoid cystic carcinoma (low grade subtype)
 Basal cell carcinoma, skin
 Craniopharyngioma, pituitary
 Dermatofibrosarcoma protuberance (DFSP)
 Endocrine tumours “some”, e.g., carcinoid, islet, medullary thyroid)
 Fibromatosis!!
 Giant cell tumour of bone (intermediate grade type)
 GIST and GANT tumours of GIT (intermediate grade type)
 Granulosa cell tumour, ovary (unpredictable prognosis?!)
 Mucoepidermoid carcinoma (low grade subtype)
 Phyllode tumour, breast (intermediate grade type)
Multiple primary tumours (not metastasis):
 Angiomyolipoma (sometimes named metastatic benign tumour)
 Breast: lobular carcinoma and fibroadenoma are commonly bilateral
 Colorectal carcinoma on top of FAP or HNPCC
 Epithelium of common embryonic origin like biliary tract, urinary tract and
cloacogenic tumours (tumours of vagina or anus)
 Hepatocellular carcinoma on top of cirrhosis
 Skin tumours on top of xerodermia pigmentosa
 Synchronous and metachronous colorectal carcinoma
 Transitional cell carcinoma of urinary tract: field effect
 Uterine leiomyomata
Comment on Some Microscopic parameters of Malignancy
Loss of polarity
See before
Pleomorphism

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 The Skilful Pathologist Series

Def.: differences in size and shape beyond maximal normal distortion of size and
shape of normal structures. Deformation (distortion) of structures may occur
during oblique cutting of the tissues, crystal formation in frozen section or
improper fixation. In malignant tumours, pleomorphism is due to non-
synchronous division of malignant cells, different subclones of tumour cells, the
presence of proliferation centres (most active cells) and abn mitoses combined
with abn division of the cytoplasm, which may result in either large undivided
nucleus (monster cell), or many small cells with small nuclei
Assessment of pleomorphism is more sensitive in cytology compared to
histology.
In cytology, pleomorphism is referred to as anisocytosis and anisonucleosis
Some non-neoplastic processes may show pleomorphism, e.g., reactive atypia.

Pleomorphism can occur at three levels:

Tumour Units: variability in acini, trabeculae or sheets is a discriminating feature
between malignant and benign (or normal)
Cells and Nuclei: Both cellular and nuclear pleomorphism is seen in malignant
tumours and few benign lesions. The nuclear pleomorphism may be more vivid
especially when combined with other nuclear features of malignancy (e.g.,
prominent multiple nucleoli).

Grading of pleomorphism
The classical grading is as follows:
Mild: minor deviation from normal size and shape of cells/nuclei
Moderate: a degree between mild and severe
Severe: considerable differences in size and shape of cells/nuclei
The above grading is subjective and needs to be standardised using
morphometric studies. This could be achieved by measuring the minimum and
maximum range of change in nuclear size and divide the whole spectrum into
three definite grades.

Mild Moderate Severe

Lesions characterised by severe pleomorphism:

Malignant pleomorphic lesions

Malignant fibrous histiocytoma; MFH (storiform)
Pleomorphic rhabdomyosarcoma
Pleomorphic liposarcoma

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 Histopathology Diagnosis
Pleomorphic leiomyosarcoma
Pleomorphic osteosarcoma
Melanoma
Benign Pleomorphic lesions
Pleomorphic lipoma
Pheochromocytoma
Bizarre (symplastic) leiomyoma
Cerebellar haemangioblastoma
Atypical fibroxanthoma (borderline)

Malignant lesions that exhibit low-grade pleomorphism:

Low-grade lymphoma (SLL, Mantle, follicular lymphoma)
Synovial sarcoma (but it is high grade by definition)
Pleomorphism vs. Polymorphism:
Pleomorphism indicates a change in size and shape of the same cell population,
while polymorphism denotes a mix of different cell types as in Hodgkin’s.
Peripheral T- cell lymphoma characterised by both pleomorphism and
polymorphism

Polymorphous low grade adenocarcinoma (PLGA) of salivary gland:

Being polymorphous means that the tumour formed of ducts, trabeculae, tubular
and solid pattern, while the tumour cells are almost monotonous and may be
bland-looking. PLGA may be confused with pleomorphic adenoma, especially in
fragmented biopsy. The tumour- normal tissue interface is essential to
distinguish between the two lesions.
Nuclear atypia

Nuclear chromatin
In Normal/benign cells, the chromatin is fine and evenly distributed in the
nucleus.
In malignancy, the chromatin turns into coarse, granular and irregularly
distributed in the nucleus, giving the characteristic hyperchromatism (more
bluish) of the malignant cell. A famous exception is papillary thyroid carcinoma.
Smudgy chromatin is a description of the decoy cells due to viral effect, in
cytology
Nuclear outline
In Normal/benign cells, the nuclear contour is smooth, usually regularly rounded,
oval or spindle. In malignancy, the nuclei become angulated with irregular
thickening of nuclear membrane and often-nuclear moulding
Nucleoli

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Nucleoli are the site of mRNA, responsible for protein synthesis in the cell.
Protein synthesis increases in reactive atypia, dysplasia and of course
malignancy. In malignant tumours, the nucleoli become, multiple, larger,
conspicuous = prominent, sometimes eosinophilic, pleomorphic and with
irregular shapes. These features are supportive for malignancy if associated
with nuclear features of malignancy including irregular nuclear membrane,
hyperchromatism, increased N/C ratio...etc. Reactive/inflammatory atypia may
show prominent nucleoli in an enlarged nucleus, but with small nuclear
membrane and preserved N/C ratio. Prominent eosinophilic single nucleoli are
characteristic for melanoma.
Size and prominence of the nucleoli is essential part of the nuclear grading of
RCC. In benign/normal, the nucleoli, usually small and inconspicuous. AgNOR is
a silver staining method used to detect the nucleoli (NORs= nucleolar organiser
regions). Malignant tumours express higher amount of AgNORs

Large prominent and irregular nucleoli in anaplastic seminoma (L) and high
grade breast carcinoma (R)

MITOSES

In malignancy, either see increased number of typical mitosis (bipolar) or

appearance of atypical mitosis (Tripolar, quadripolar ”H"- or cross-shaped”, star-
shaped or bizarre figures)

167
 Histopathology Diagnosis

Atypical mitosis (cross-shaped, centre) and tripolar (inset)

Mitotic count is to assess the number of cells in the metaphase of mitosis

(hypercondensed chromatin), taking care to discard apoptotic cells and cells with
indefinite features per 40x. Mitotic count should be done in the most active area
of the tumour, usually the tumour front (periphery).
The presence of mitosis in lower 1/3, lower 2/3 or the whole thickness of
epithelium determines CIN1, CIN2 and CIN3, respectively in the cervix.
Note: Numerous typical mitotic figures are seen in fasciitis, but still benign!

CHAPTER 7: DIFFERENTIAL DIAGNOSIS

IN PRACTICE

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 The Skilful Pathologist Series

Differential diagnosis (DDx) is a list of all diagnostic possibilities. DDx could be

Clinical-based or Pathology-based. In any DDx, there should be inclusion and
exclusion criteria.

Types of DDx Categories

• According to symptoms, signs ,anatomic

location or radiologic finding.
• Clinical DD is important for the pathologist, in
Clinical DDx order to focus on few numbers of possibilities for
first instance; however, he should not exclude
other possibilities

• According to morphology (gross or microscopic)

or immunohistochemistry.
Pathological DDx • Creation of a successful pathologic DD is highly
dependent on pathologist’s analytical power
and experience.

After you finish the list of DDx, you should start to configure a WITH and
AGAINST for each diagnostic possibility to reach the final diagnosis where all
parameters should be WITH and none AGAINST. You may request certain
investigations, stains or other clinical data to reach the ultimate diagnosis

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 Histopathology Diagnosis

CLINICAL DDx

Similar age group: (testicular mass in a child, enlarged axillary LN in a

child….etc)
Similar symptoms: (dyspepsia/dysphagia in middle aged male….etc)
Similar signs: (button like lesion on the penis of a young male, maculopapular
rash in a child or causes of hydrocele …etc)
Similar (same) anatomic site: e.g., mass in the right iliac fossa, mass in
anterior mediastinum, mass in lung hilum, causes of macroglossia (large
tongue).
Similar X-ray pattern: hilar shadow in the right lung, cannon ball metastasis in
the lung, fluffy cotton appearance, osteolytic lesion in the metaphysis/ diaphysis/
epiphysis of long bone.

EXAMPLES OF CLINICAL DDx

Common causes of primary and secondary headache
 Primary headaches: Migraine, Cluster, Tension-type
 Secondary headaches
o Intracranial space occupying lesions: tumour, arteriovenous
malformation, Abscess, Hematoma, Intracranial aneurysms,
Hydrocephalus, Pseudotumour cerebri
o Infection: Sinusitis, Meningitis, Encephalitis
o Inflammation: Vasculitis, Acute disseminated encephalomyelitis
Breast diseases of children and adolescents
 Fibroadenoma
 Virginal hypertrophy
 Intraductal papilloma
 Duct hyperplasia (epitheliosis)
 Juvenile papillomatosis
 Juvenile carcinoma
A disease that never occur in children breast
 Fibrocystic disease

DDx of Mass in Right Iliac Fossa (RIF)

Intestinal causes:
 Ileo-caecal Crohn’s
 Ileo-caecal intussusceptions: infants in weaning
 Ileo-caecal actinomycosis
 Ileo-caecal TB
 Ileo-caecal lymphoma
 Amoeboma (amoebic pericolic mass)
 Appendicular mass (ruptured appendix as a result of neglected severe
suppurative inflammation+ peritoneum + fibrosis + intestinal loops)
 Cancer caecum

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 The Skilful Pathologist Series

Extra-intestinal:
 Ptosed kidney: dropped kidney due to loss of peri-renal fat in starvation
or severe fat restriction in the diet
 Ovarian mass: tumour, cyst, abscess
 Huge splenomegaly: enlarged spleen can cross from left to right side of
the abdomen enforced by leino-gastric ligament. Huge spleen is seen in
leukaemia, leishmaniasis, Bilharziasis, storage diseases (Gaucher’s &
Neiman Peck)
DDx of Mass in Left Iliac Fossa (LIF)
Intestinal causes:
 Bilharzioma (Bilharzial pericolic mass)
 Cancer sigmoid
 Diverticulosis of the sigmoid
 Volvulus of the sigmoid colon
Extra-Intestinal causes:
The same as RIF.
The enlarged spleen may descend to the LIF instead of RIF induced by weak
Leino-gastric ligament. Weakness of this ligament occurs as a result of protein
malnutrition caused by multiple parasitic infestation. LIF splenomegaly named
“endemic or tropical splenomegaly”
DDx of Ulcers of Small Intestine
 Crohn’s: aphthus early, fissure ulcer late
 Malignant: mainly, lymphoma

st st
Peptic: can occur in duodenum (1 inch of 1 part), jejunum (following
gastro-jejunal anastomosis as a part of duodenal ulcer surgery) or ileum (if
there is gastric metaplasia in Meckle’s diverticulum). Ulcers are deep with
clean floor and indurated base
 TB, ileum: Early, the ulcers are transverse as they occur along lymphatics
(circular course). Later on, the ulcers become longitudinal when TB affects
lymphoid follicles -Peyer’s patches-
 Typhoid, ileum: longitudinal ulcers as they occur over the lymphoid follicles,
at the anti-mesenteric border
 Uraemic ulcers: as a result of chronic renal failure
DDx of Ulcers of Large Intestine
 Amoebic: small, multiple with undermined edge-flask shaped- due to
proteolytic digestion of deeper tissues by trophozoites), no hyperaemia at
the edge, mainly in right colon
 Bacillary: follows pseudomembrane sloughing, irregular, surrounded by
erythema at the edge, no skip lesions, left colon more affected
 Bilharzial: multiple, small, dirty yellowish mucosa, left colon
 Crohn’s: deep fissure ulcers, transmural, skip lesions, cobblestone
 Malignant: colorectal cancer
 Solitary rectal ulcer
 Stercoral: due to trauma by hard stool
 Traumatic: endoscopy-induced

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 Histopathology Diagnosis
 Ulcerative colitis: superficial with undermined edge due to hyperplasia of
colonic mucosa at the edges, left colon mainly
 Uraemic: in chronic renal failure, multiple, superficial, haemorrhagic

DDx of GIT Ulcers with Undermined Edges (Flask Shaped Ulcers)

These ulcers are larger in the depth than superficially. Mechanism of
undermining is different in different ulcers
S.I (small intestine):
 Typhoid (axis parallel to intestine)
 TB: lymphoid follicles are affected, so more destruction occurs
around (deeper layers)
L.I (large intestine):
 Amoebic: trophozoites destroy deeper tissue > superficial
 Ulcerative colitis: epithelium grows at the edges to constrict the
DDx of Multinodular Lesion in the Lung (Radiology)

 Multiple cysts: congenital, acquired

 Nodules+ necrosis: necrotizing granulomas
 Solid rounded lesions: pneumoconiosis, cannon-ball mets, TB, sarcoidosis,
lymphoma/lymphoid hyperplasia, leukaemia, histiocytosis (bilateral)

Benign Tumours of the Lung

 Epithelial
o Squamous papilloma
o Alveolar adenoma
o Adenomas- salivary gland type: pleomorphic adenoma
o Mucinous cystadenoma
o Clear cell tumour “sugar tumour”
 Mesenchymal
o Chondroma
o pulmonary hamartoma, sclerosing haemangioma
o Inflammatory myofibroblastic tumour
o Thymoma, meningioma
Localized Pleural Tumours
 Fibrous plaque
 Lipoma
 Localized mesothelioma
 Localized sarcoma
 Solitary fibrous tumour: patternless pattern, CD34(+)
 Malignant solitary fibrous tumour ( invasion, > 10 cm, haemorrhage +
necrosis, M/E: cellular, atypia, mitoses > 4/hpf, sarcomatous areas)
 Schwannoma
DDx of Paediatric Cystic Lung Lesions

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 The Skilful Pathologist Series

 Developmental: bronchogenic cyst, bronchial atresia, intralobar

sequestration, extralobar sequestration, CPAM (large cyst type) congenital lobar
overinflation, lymphatic cyst
 Neoplastic: Pleuropulmonary blastoma cystic (type I), solid and cystic (type
II)
 Acquired: persistent PIE, pneumatocele, abscess/necrotizing pneumonia
DDx of Abdominal Enlargement = Fs + Lumps + Megalys
 Fat
 Foetus
 Flatulence /Flatus as in cholecystitis
 Faecal impaction
 Full stomach
 Full bladder
 Fatigued muscles (weak abdominal muscles)
 False pancreatic cyst (pseudocyst)
 Fluid (ascites)
 Fibroid (leiomyomata)
 Fluid filled cavities (encysted effusion, ovarian cysts)
 Lumps (tumours of ovary, colon, liver, spleen, kidney, stomach, bladder,
neuroblastoma)
 Megalys (hepatomegaly, splenomegaly, megacolon)

DDx of Acute Abdomen (medical and surgical forms)

 Acute appendicitis, cholecystitis, diverticulitis, pancreatitis
 Intestinal obstruction (paralytic ileus, intussusception, strangulated hernia,
volvulus)
 Perforated peptic ulcer (leads to chemical peritonitis)
 Mesenteric infarction (thrombosis, embolism)
 Twisted ovarian cyst
 Ectopic pregnancy
 Peritonitis (chemical or infective)
 Meconium Ileus in neonates
 Necrotizing enterocolitis in neonates
 Ischemic colitis in elderly (often painless, associated with fresh blood and
mucous in the stool)
 Mediterranean fever (medical acute abdomen)

DDx of Leg Ulcers:

 Burn
 Fungus infection
 Ischemic : atherosclerosis, anterior tibial syndrome
 Malignant ulcer (Marjoline ulcer; a squamous cell carcinoma on top of
varicose ulcer or burn)
 Radiation

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 Histopathology Diagnosis
 Trauma and decubitus ulcer (prolonged immobilisation, bony prominences)
 Trophic ulcer (loss of sensation due to peripheral neuropathy as in DM,
leprosy): occur on bony prominences and toes bases.
 Necrobiosis lipoidica, pyoderma gangeronosum
 Varicose ulcer: on medial malleolus

CYSTS
A cyst is a hollow structure that is abnormally formed in the body because of
inflammation, injury, neoplasia or other causes. Congenital cysts could occur due
to developmental abnormalities like persistence of embryonic structures or failure
of connection of tubular rudiments
Cysts classification according to aetiology
 Degenerative: nodular goitre, leiomyoma
 Developmental : polycystic kidney, branchial
 Hyperplastic: fibrocystic disease (breast)
 Implantation: epidermoid
 Inflammatory: pancreatic pseudocyst
 Neoplastic : cystic ovarian tumours, e.g., teratoma
 Obstruction : hydronephrosis, bronchiectasis, cystic fibrosis
 Parasitic: hydatid
 Retention : ranula (in the mouth floor)

Examples
 Adrenal cyst: calcified fibrous wall + no lining + blood content
 Arachnoidal: Congenital/post-traumatic, fibrous wall
 Baker’s: cartilaginous /fibrous wall + synovial lining
 Bone cysts:
o Aneurysmal (ABC): osteoid and bony wall + No lining + blood
content
o Simple: fibrous wall + no lining + RBCs extravasation
 Branchial: newborn male, sternal skin, lymphoid follicles in the wall
 Breast: part of fibrocystic disease
 Bronchogenic: ciliated columnar or squamous lining + cartilage, glands,
muscles or nerves in the wall
 Chylus: mesenteric, lymph content + endothelial lining +muscle wall

rd
Colloid cyst: 3 ventricle, unilocular, clear content, cuboidal lining, thin
fibrous wall, a cause of sudden death
 Conjunctival cyst: Benign epithelial-lined due to trauma/surgery
 Dermoid/ epidermoid cyst
 Vaginal/ Vulval cysts

Epithelial Cysts of the Mandible

Odontogenic
 Dentigerous

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 The Skilful Pathologist Series

 Eruption
 Gingival (newborn)
 Keratinizing & calcifying
 Keratocyst: solitary or primordial, multiple (nevoid BCC syndrome)
 Lateral periodontal cyst
 Radicular or peri-apical
Fissural & non-odontogenic (named according to site)
 Dermoid /epidermoid
 Fissural cyst of tongue/mouth floor
 Naso-alveolar
 Naso-labial
 Naso-palatine
 Palatal (newborn)
Ovarian cysts
 Neoplastic : Dermoid cyst (benign cystic teatime), serous and mucinous
tumours, cystic granulosa cell tumour
 Non-neoplastic: Polycystic ovary (Stein-Leventhal syndrome), Theca lutein
and follicular cysts, Cystic corpus luteum, endometriosis, endosalpingiosis,
developmental cysts, surface inclusion cysts

Cutaneous cysts:

By definition, the cyst should be dermal and > 2mm in size. This excludes milia
(digital mucinous cyst) and microcavities seen in SqCC and SK (Seborrhoeic
Keratosis), all <2mm
Follicular
 Epidermal inclusion cyst (epidermoid): granular layer present (gradual
keratinisation)
 Tricholemmal cyst (pilar): no granular layer in pilar type keratinisation
(Abrupt Keratinisation) + cholesterol clefts. Proliferating variant show
palisading and refractile basement membrane
 Dermoid cyst
 Pigmented follicular cyst
 Eruptive hair cyst (Villous)
 Sebaceous duct cyst (Steatocytoma)
Ductal
 Apocrine hydrocystoma/cystadenoma
 Eccrine hydrocystoma/cystadenoma
Rare cysts
 Branchial cleft cyst
 Ciliated cyst
 Cystic teratoma
 Endometriosis/ endosalpingiosis
 Folliculo-sebaceous cystic hamartoma
 Median raphe cyst of the penis
 Metaplastic synovial cyst

175
 Histopathology Diagnosis
 Omphalo-mesenteric duct cyst (umbilical polyp)
 Orbital respiratory cyst
 Thymic cyst
 Thyroglossal duct cyst

Liver Cysts, radiologically or grossly

 Benign cystic mesothelioma

 Bile duct hamartoma (von Meyenburg’s complexes)
 Biliary cystadenoma and cystadenocarcinoma
 Caroli disease (= congenital communicating cavernous ectasia of the biliary
tract),
 Choledocal cyst (precancerous)
 Cystic change in HCC
 Giant cavernous haemangioma
 Hydatid cyst
 Polycystic liver disease (associated with autosomal dominant polycystic
kidney)
 Simple hepatic cysts, single or multiple, hamartomatous, lined by cuboidal
epithelium
 Undifferentiated Embryonal Sarcoma

PATHOLOGIC DDx

For a differential diagnosis, the following should be considered.

THE LESION: could be inflammatory, neoplastic, congenital, immune mediated,
traumatic….etc.
THE SITE: remember the anatomy (organs at the site and nearby organs) and
normal histology (layers including skin, fascia, peritoneum, muscles, nerves,
vessels, fat and connective tissue, capsule of organs….etc).
THE PATIENT: some lesions are common in certain ages, others are impossible
to occur in certain ages. Some lesions are commoner in females, some are
exclusive to males, e.g., haemophilia, angiofibroma of the nasopharynx (tumour
cells contain testosterone receptors).

Similar Gross picture

 Similar shape and site (colonic polypi, ulcers in large intestine, nodule at
the inner angle of the eye…etc)
 Similar colour: yellow mass in the ovary, hyperpigmented nodule in the
back of a middle aged man…..etc)
 Similar consistency (hard mass in the palate, lobulated mass in the parotid
region, alternating hard and soft mass in long bone…..),
 Similar cut section (whorly cut section in a uterine mass…etc)

Similar Histopathology features

 Similar pattern of cellular arrangements (e.g., storiform pattern)

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 The Skilful Pathologist Series

 Similar vascular pattern (lesions with vascular arcades, perithelial pattern,

haemangioma-like, stag-horn, stellate……etc)
 Similar necrotic tissue distribution (geographic, central….etc)
 Similar degree of pleomorphism (DDx of pleomorphic sarcomas)
 Generalised similarity: tumours containing benign giant cells, tumours
containing benign lymphocytes, tumours known of high necrosis, non-
neoplastic lesions containing diagnostic giant cells, tumours containing
cytoplasmic inclusions

Microscopically Alike but Clinically Different Lesions

 Lipoma & low grade liposarcoma

 Chondroma & low grade chondrosarcoma
 Salivary pleomorphic adenoma & skin counterpart
 Pyogenic granuloma & capillary haemangioma
 Sarcoidosis, early TB & tuberculoid leprosy
 Clear cell oncocytoma, salivary (glycogen +, PAS+ and PTAH+ 
stains mitochondria blue) and RCC, kidney (Lipid +, PAS(-).
Differentiation essential exclude metastatic RCC.
Clinically Alike but Pathologically Different Lesions
For example, intracranial space occupying lesions present with a common
clinical picture of increased intracranial pressure, but pathologically they include
varied lesions ranging from inflammatory to late stage metastatic tumour.
DDx GROUPS
Group of diseases that have a common morphologic feature
Examples
 Small round cell tumour
 Spindle cell tumours of the breast
 Spindle cell tumours of the lung
 Myxoid lesions of the skin
DDx TWINS
Two diseases which commonly occur in the same anatomic site, similar
morphology or clinical picture and their exact subtyping is essential for treatment
and prognosis
Examples:
 Adenocarcinoma, lung vs. Mesothelioma
 Hodgkin’s lymphoma vs. reactive hyperplasia (cytology)
 Follicular lymphoma vs. follicular hyperplasia
 Papillary thyroid carcinoma vs. papillary variant of follicular carcinoma
 Ovarian vs. peritoneal papillary serous tumour
 Low grade astrocytoma vs. reactive gliosis
 Microglandular adenosis vs. tubular carcinoma
 Atypical epitheliosis vs. ductal carcinoma in situ (DCIS), breast
 Meningioma vs. schwannoma, cerebello-pontine angle

177
 Histopathology Diagnosis
 Schwannoma vs. neurofibroma
 Primary adenocarcinoma of the bladder vs. secondary colonic carcinoma
 Low grade osteosarcoma vs. myositis ossificans
 Kaposi sarcoma vs. kaposiform hemangioendothelioma
 Epithelioid angiosarcoma vs. epithelioid hemangioendothelioma
 HCC vs. atypical adenomatous nodule
 Nodular lymphocyte predominance HL vs. Lymphocyte rich classical HL

EXAMPLES OF PATHOLOGIC DDx

DDx of Spindle Cell Tumours of the Breast

Metaplastic IDC:
Circumscribed, sarcomatoid (any sarcoma)
Subtypes: epidermoid, spindle cell, acantholytic and adenosquamous
Adeno-myoepithelioma
1 cm, circumscribed. Biphasic: nests of polygonal cells and spindle cells
Spindle cell myoepithelioma
No capsule, fascicular pattern, cellular
Phyllode tumour of the breast
Circumscribed, <5cm usually, biphasic: epithelial and spindle cells (metaplasia,
any mesenchymal tissue)
Stromal sarcoma
No epithelial component, fibrosarcoma-like
Fibromatosis
Nodular fasciitis

DDx of Spindle Cell Tumours of the Ovary

 Endometrioid stromal sarcoma of the ovary

 Fibromatosis
 Granulosa cell tumour
 Massive edema, stromal hyperplasia, and stromal hyperthecosis
 Sclerosing stromal tumour
 Sertoli-Leydig (Myer type III, poorly differentiated)
 Signet-ring stromal tumour
 Thecoma/ fibroma

Lymphomas with follicular /nodular pattern

1- B-cell lymphoma
 Follicular lymphoma
 Marginal zone lymphoma; MZL (MALT & splenic)
 Mantle cell lymphoma (MCL)
 Prolymphocytic leukaemia (vague nodules, proliferation centres)
2- T-cell lymphoma
 Angioimmunoblastic
3- HL (Hodgkin’s lymphoma)

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 Nodular LP (lymphocyte predominance)

 Classical HL, follicular type

Tumours containing cells with grooved (bean-shaped) nuclei

 Chondroblastoma
 Langerhans’ cell histiocytosis
 Papillary thyroid carcinoma
 Lymphomas of follicle centre origin (cleaved nuclei)
 Granulosa cell tumour, ovary

Tumours showing Indian file pattern

 Adamantinoma
 Invasive lobular carcinoma, breast
 Undifferentiated carcinoma
 Signet ring cell carcinoma when invading fibrous tissue or muscle
 Sclerosing epithelioid fibrosarcoma
Lesions Characterised by Excess Necrosis
Neoplastic
 Glioblastoma multiforme (geographic necrosis)
 Small cell carcinoma
 Ewing’s tumour
 High grade sarcomas
 Nasal angiocentric lymphoma
 Melanoma
Central necrosis (comedo type) is common in:
 Adenoid cystic carcinoma, salivary (Solid-type)
 Basaloid carcinoma, lung
 CIN3 in metaplastic gland, cervix
 Comedocarcinoma of the prostate (Gleason grade 5)
 Ductal carcinoma in situ (DCIS, comedo type), breast
 Epithelioid sarcoma of soft tissue (also geographic necrosis)
 Salivary duct carcinoma
 Sebaceous carcinoma

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 Histopathology Diagnosis

DCIS, solid type, showing central (comedo) necrosis

Extensive necrosis in Embryonal carcinoma of the ovary

Non-neoplastic lesions
 Calcifying epithelioma of Malerbe
 Late tuberculous lymphadenitis (Caseation necrosis)
 Necrotizing lymphadenitis (Kikuchi)
 Necrotising granulomatous dermatitis (geographic necrosis)
 Wegener's granulomatosis

Wegener’s granulomatosis of the lung show giant cells, polymorphs and necrosis

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Caseation necrosis (centre of granuloma) in late TB

Tumours with accentuated lobular pattern (low power)

 Chondroma
 Chondromyxoid fibroma
 Chondrosarcoma
 Chordoma
 Eccrine hydradenoma
 Haemangioma
 Malignant eccrine poroma
 Pheochromocytoma
 Paraganglioma
 Pilar tumour
 Thymoma

Tumours Containing Giant Cells with Wreath-Like Nuclei

 Atypical lipoma
 Anaplastic large cell lymphoma
 Clear cell sarcoma = Malignant melanoma of soft parts ( wreath giant cells are +
typically nested growth pattern)

Dimorphic/ Biphasic Tumours

 Adamantinoma
 Chondromyxoid fibroma
 Eccrine spiradenoma
 Foci of dedifferentiation in a tumour e.g., chondrosarcoma
 Mesenchymal chondrosarcoma
 Mesothelioma
 Metaplastic carcinoma of the breast
 Nephroblastoma (Wilms’)
 Synovial sarcoma

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 Histopathology Diagnosis

Lesions Containing Psammoma or Psammoma Like bodies

 Acinic cell carcinoma, salivary
 Bronchiolo-alveolar carcinoma, lung
 Calcifying epithelial odontogenic tumours (psammoma-like bodies called
“Leisgang rings”)
 Cementoma, mandible
 Cutaneous heterotopic meningeal nodules
 Delta cell tumour of pancreas
 Endometrial adenocarcinoma (SEROUS subtype…..the worst)
 Endosalpingiosis
 Fibrous dysplasia (Chinese letters look like psammoma bodies)
 Metanephric adenoma of the kidney
 Meningioma (especially Psammomatous type)
 Mesothelial hyperplasia (reactive) & Mesothelioma (epithelial type)
 Oncocytic adenoma (follicular variant) of thyroid may have psammoma-like (but
they are intra follicular and this differentiates it from papillary carcinoma)
 Papillary tumours of ovary & thyroid
 Peritoneal psammomatosis
 Primary papillary serous tumour of peritoneum
 Psammomatous melanocytic schwannoma
 Serous psammocarcinoma: a variant of serous carcinoma shows with immense
psammoma bodies + low grade atypia

Papillary serous cystadenocarcinoma, ovary with psammoma bodies

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Bronchioloalveolar carcinoma with psammoma-like bodies

Metanephric adenoma, kidney

Tumours Containing Excess Stromal Fibrosis

 Brenner's tumour, ovary
 Epithelioid leiomyoma / leiomyosarcoma
 Epithelioid sarcoma
 Hepatoblastoma
 Malignant mixed Mullerian tumour (MMMT)
 Malignant peripheral nerve sheath tumour (MPNST)
 Melanoma
 Mesothelioma (biphasic)
 Nephroblastoma (Wilms' tumour)
 Neuroendocrine tumours
 Phyllode tumour
 Synovial sarcoma

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 Histopathology Diagnosis

Brenner tumour, ovary shows extensive stromal fibrosis

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CHAPTER 8: STAINING AND SUPPORTIVE

TECHNIQUES

Auxiliary vs. ordinary techniques in diagnosis and differential diagnosis:

Unstained tissue and cells are non-visible and cannot be used for diagnosis.
However, some techniques use the unstained tissues, e.g., RAMAN
spectroscopy. In RAMAN spectroscopy, a laser beam is focused on the tissue
and the resultant signals are picked up and mapped to show the chemical
composition of the examined tissue.

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 Histopathology Diagnosis
Ordinary stains (for simple morphology)

These are used to show up the morphology of tissues and cells. These include
Haematoxylin and Eosin (H&E), Giemsa (Speedy Diff-Quick stain), Papanicaulou
(Pap)…etc. H&E is the most frequently used for tissue staining and rarely used
to stain smears. Haematoxylin stains the nuclei blue, while Eosin stains the
cytoplasm pink. Eosinophilic = pink, e.g., protein materials, necrosis, fibrous
tissue, while Basophilic = blue, e.g., nucleoproteins, calcifications. Eosinophils
and Basophils named according to their colour characters. Amphophilic refers
to neutral staining as seen in cytoplasm of plasma cells. Giemsa used almost
exclusively in cytology, bone marrow and blood films. It highlights the cytoplasm
and cell borders, but not perfect for fine nuclear details. As Giemsa exaggerates
the nuclear features, benign cells (e.g., fibroadenoma) stained with Giemsa can
look quite atypical for non-skilled.
Papanicaulou is used almost exclusively in cytology especially in cervical and
urine cytology to differentiate squamous from glandular lineage and to define cell
maturation. Pap may stain the cytoplasm orange (orangeophilic), green or blue
(cyanophilic), while the nuclei are constantly blue. Pap stain is ideal for nuclear
details especially nuclear membrane (unlike Giemsa).
FROZEN SECTION -FS- (INTRAOPERATIVE CONSULTATION)

FS can be considered as an ordinary technique where rapid diagnosis is the

main goal. The FS results will determine the further conduction of the surgical
procedure (hence named intraoperative consultation).
Rules
 No emergency frozen section. The pathologist should be notified 24h at
least before FS.
 Artefacts are common
 Paraffin section should follow, using the remaining tissue
Indications of FS
 Identification of tissue type, benign versus malignant nature of the lesion
 Type of malignancy
 Surgical margins
 Positivity of lymph nodes, or metastasis in other tissues
 Identification of normal tissue as parathyroid gland, ganglia
 Molecular techniques requires fresh tissue (e.g., PCR) and the pathologist
may be responsible for tissue sampling using FS
Advantages

 If the diagnosis is malignant, the mass can be removed immediately without

a need for another operation
 If more tissue is required for a precise diagnosis, the surgeon can obtain an
additional sample, avoiding a second operation.
 FS biopsy can ensure that the mass being removed is the intended tissue
for removal.

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 It can help ensure that the entire mass and its surrounding margins are
removed.
 FS is essential for surgery of congenital megacolon; multiple section levels
may be done to reach the ganglionic segment
 FS is essential for Moh’s technique in dermatopathology
 IHC for certain antibodies can be more accurate using FS
Problems

 Sampling error
 Lack of special studies
 Lack of consultation
 Artefacts: ice crystals, fat (does not freeze)
 Infection (risk of infection is high, no formalin)
 Experienced pathologists are always required

Contraindications of FS

 Suspected tuberculosis and other communicable diseases

 Small lesions that may be destroyed during preparation
Special circumstances

FS diagnosis can be enhanced by the use of :

1. Imprints (touch preparations)
2. IHC
3. special stains (e.g., PAS stain can highlight the ITGCN (glycogen rich) in
testes)
Common difficulties in FS
 Misinterpretation of mucoepidermoid carcinoma and acinic cell carcinoma of
salivary gland as benign or normal
 Invasive vs. in situ lesions is difficult to interpret in FS
 For any liver mass, AFP level should be known before examining the FS
 Parathyroid adenoma (no fat, one cell type, bizarre nuclei) has a rim of
compressed normal tissue vs. hyperplasia or normal (contain fat). Oil Red O
fat stain highlights normal gland
 Thyroid vs. Parathyroid tissue. Thyroid has birefringent calcium oxalate
crystals detectable by polarized light.
 Post-FNA alterations can mimic capsular or vascular invasion
 Difficult to distinguish thyroid goitre, adenoma and minimally invasive
follicular carcinoma. numerous sections required to diagnose minimally
invasive follicular carcinoma
 Freezing artifact can mimic nuclear features of papillary thyroid carcinoma
and parathyroid neoplasms

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 Histopathology Diagnosis

SPECIAL (AUXILIARY) TECHNIQUES IN DIAGNOSIS

These are used following the ordinary stain either to confirm the morphology
(EM) or to highlight the structure (special stain), antigenicity (IHC, IF) or genetic
profile (molecular). They could confirm/exclude a specific diagnosis from a list of
differential diagnosis.
The auxiliary techniques include:
 Special (histochemical) stains
 Immunofluorescence (IF)
 Immuno-histo/cyto- chemistry
 EM (electron microscope)
 Molecular techniques
SPECIAL STAINS (CHEMICAL DIFFERENTIATION METHODS)
Special stains employ the physical & chemical properties of the target organism,
cell molecules or tissue to make them selectively visible compared to the
background.
Target of staining Stain
Acid-Fast bacilli Fite stain, ZN
Bacteria Gram stain
Helicobacter pylori Warthin-Starry, Toulidine

Fungi Methenamine silver, PASF, Mucicarmine,

Groccott
Spirochetes Steiner, Warthin - Starry
Collagen type I Trichrome Stain
Elastic fibres Verhoeff - Van Gieson stain
Reticulin/ collagen type III Reticulin (Wilder's)
Fat Oil red O, Sudan Black
Glycogen PAS
Acid mucopolysaccharides Alcian blue 2.5 and PAS
Neutral mucopolysaccharides PAS
Sialomucin mucicarmine
Amyloid Congo Red stain, crystal violet method

Melanin Fontana- Masson

Melanin removal Permanganate
Charcott Leyden crystals Luna
Muscle striations PTAH
Myelin Luxol fast blue, PAS osmium
Axons Bodian, Bielschowsky, Silver
Calcium Von Kossa's
Iron Perl’s (blue) , Gomori's
Cupper Shikata

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Connective tissue stains

Masson trichrome stain; “MTC” (collagen type I stain) differentiates muscle
from collagen. It highlights the internodular fibrosis in cirrhosis, which
differentiates it from normal liver or liver fibrosis. After severe liver injury, Ito cells
respond by producing collagen type I (MTC (+), instead of the normal collagen
type III (reticulin stain (+) leading to cirrhosis. MTC is one of the routine stains for
renal bx to show glomerular sclerosis. MTC supportive for the diagnosis of
collagenous colitis, and old myocardial infarction.
Reticulin stain (collagen type III/IV stain) is useful in highlighting the reticular
framework of parenchymal organs, basement membrane and to differentiate
follicular lymphoma from follicular hyperplasia. It can highlight parenchymal
collapse as in massive liver necrosis and identify malignant tumour “invasion” vs.
benign tumour “compression”.
Reticulin invests every cells in hemangiopericytoma and hemangiopericytoma-
like tumours. In neuropathology, reticulin stain can discriminate between
hemangiopericytoma and schwannoma (pericellular distribution) vs. meningioma.
Pericellular in pleomorphic xanthastrocytoma (PXA) vs. gliomas. Abundant
around clusters in haemangioblastoma vs. Gliomas.
Van Giessen (elastic fibre stain) is useful to detect:
 Excess elastin (elastosis): elastofibroma, elastosis (heart)
 Destruction of elastin : actinic keratosis (sun damage)
 Loss of elastin: lichen sclerosus et atrophicus (loss of elastin and
homogenisation of papillary dermis)
Mucin stains

Mucins are mucopolysaccharides (sialic acid in epithelium, chondroitin/ keratan

sulphate in mesenchymal tissue). Mucin stains include: PAS (most sensitive),
Alcian blue, Mucicarmine (epithelial mucin specific) and Colloidal iron. IHC can
detect mucin too.
Types:
 Neutral: PAS (+), Alcian –ve. Found in GIT & Prostate
 Acidic :
o Simple, non-sulphated: PAS(+), Alcian(+) at pH=2.5
o Simple, mesenchymal: PAS(-), Alcian(+) at pH=2.5
o Complex, sulphated: PAS(+), Alcian(+) at pH=1
o Complex, mesenchymal: PAS(-)/ Alcian(+) at pH=0.5

General use of mucin stains in DD

 High grade Mucoepidermoid carcinoma vs. other non mucin secreting
tumours
 Signet ring cell carcinoma vs. foamy macrophages in gastric wall or LN
 Micrometastasis detection in lymph nodes in FS
 Intestinal vs. gastric metaplasia

PAS (Periodic Acid Schiff) Stain/With or Without Diastase

 PAS (+) materials: glycogen, mucous, fungi

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 Histopathology Diagnosis
 PAS (+) lesions:
1. Focal segmental Glomerulosclerosis (FSGS)
2. Alpha-1- antitrypsin (AAT) deficiency, liver
3. Ewing’s sarcoma (+), glycogen vs. lymphoma (-)
4. Cystic fibrosis
 PAS stains glycogens and glycoproteins. Diastase dissolves glycogen only,
so if a material is PAS+ but diastase resistant = non-glycogen, e.g., alpha-1-
antitrypsin
 PAS+ (Glycogen) discriminate Ewing sarcoma from all other morphologically
similar neoplasms including lymphoma
 PAS can detect ITGCN of the testes because of its high glycogen content.
 Alcian/PAS is used to differentiate acidic vs. neutral mucin, respectively. For
example, in gastric intestinal metaplasia, the metaplastic cells stain pink (PAS)
while Goblet cells stain magenta (Alcian)
 Any Apocrine metaplasia is PAS (+)
 PAS/diastase: to differentiate between glycogen (dissolve by diastase) and
other
 PAS/hyalurinidase: to differentiate between glycoproteins/ground
substances of mesothelioma and adenocarcinoma
 Salivary tumours: Acinic cell carcinoma granules are PAS+/D resistant while
Epithelial-Myoepithelial carcinoma, is PAS+/D sensitive (glycogen)

Hormone Stains

They give brown-black staining of silver. They include:

 Chromaffin (pheochromocytoma): Schmorl's
 Argentaffin (carcinoid) : Fontana-Masson and Schmorl's
 Argyrophil: Grimelius stain

Melanin stains

These include:
 DOPA-oxidase brown
 Fontana-Masson  black
 Schmorl's blue-green
 Bleaching using potassium permanganate or hydrogen peroxide
differentiates melanin from other pigment (e.g., carbon pigment)

True melanin is PAS –ve while pseudo-melanin in macrophages (e.g., melanosis

coli) is PAS (+)
Minerals
 Iron (hemosiderin): Perl's iron stain, Prussian blue (blue)
 Calcium: H&E (blue), Alizarin (red), Von Kossa stains phosphate

Fat stains
Sudan Black and oil red O. Frozen section, no alcohol

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Uses: used to stain:

o Fat emboli, lung
o Normal parathyroid (fat stain+) vs. parathyroid adenoma
o Renal cell carcinoma
o Lipogenic tumours
o Lipochrome (lipofuscin) pigments (e.g., brown atrophy of the heart)

IMMUNOFLUORESCENCE (IF)

It is simply a direct antigen-antibody reaction, where fluorochrome-tagged

antibodies are employed to bind to a specific antigen. Fluorescence microscope
should be used to pick up the signals.
IF Uses: can detect linear vs. granular deposits of complement, antibodies and
immune complexes as well as viruses in the following:
 Henoch-Schönlein purpura (IgA staining), helpful to differentiate it from other
causes of purpura (e.g., urticarial vasculitis)
 Glomerulonephritis subtypes
 Skin lesions: Pemphigus vulgaris and foliaceus (granular deposits of C3 or
IgM),
 Viruses: IF can detect measles in nasal secretion smears by a measles-
specific IgM enzyme immunoassay, Herpes (linear deposits of C3) and HIV

IMMUNOHISTOCHEMISTRY (IMMUNE DIFFERENTIATION METHOD)

IHC allows detection of antigens within a morphologic context.

IHC General Uses

• Finding the tissue of origin in ‘‘undifferentiated’’ neoplasms

• Detection of infectious agents
• Evaluation of prognostic markers including hormone receptors, oncogene
products, or proliferation markers

IHC resolution of diagnostic problems

• Undifferentiated neoplasms
• Small blue cell tumours
• Soft tissue tumours
• Classification of lymphoma
• Detection of micrometastasis in a lymph node
• Metastasis of unknown origin

IHC components: antigen, antibody, enzyme, dye

Antigen (Ag)

• The Ag is a protein component of a cell, virus or extracellular matrix for

which the IHC is employed to assess. The Ag has epitopes which combine
with determinants on Ab
• Localisation: nuclear, cytoplasmic, membranous

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 Histopathology Diagnosis
• Intensity of staining is directly proportional to the amount of the protein in the
cell (1+, 2+ or 3+), this is why IHC is considered as a semi-quantitative
method
• Distribution of the stain indicates the prevalence of such protein among a
population of cells and referred to as percentage of positive cells
Antibody (Ab)

• Affinity of the Ab to combine covalently (by determinants) with the antigenic

epitopes establishes the sensitivity of the IHC.
• The utilised antibody is developed in certain species and purified as
polyclonal or monoclonal
• Polyclonal Ab has high sensitivity + lower specificity
• Monoclonal Ab has high specificity + lower sensitivity
• A primary (1ry) Ab binds the antigen directly while secondary (2ry) Ab binds
the 1ry to amplify the reaction.

Antibodies as markers (functional classification of Abs)

• Markers to detect the tissue of origin (GCDPF-15 for breast tissue, TTF-1 for
thyroid and lung tissue, PSA for prostate tissue)
• Markers to detect the tumour aggressiveness
• Markers to prove/exclude malignancy, e.g., myoepithelial cells, basal cells
and basement membrane integrity
• Markers of suitability of specific treatment (e.g., Hormone receptors in breast
and prostate carcinoma)
• Markers of cure
• Markers of prognosis (e.g., p53, proliferation markers, ER/PR)
• Super-Specific markers: THIS IS A DREAM, a marker that can detect
specific tumour subtype

Is There A Marker Of Malignancy?

NO universal markers of malignancy, but there are markers for specific cancers:
• PSA positive metastases = prostate adenocarcinoma
• Loss of positivity of one of pan T-cell markers (CD2, 3, 5, 7) = T-cell
lymphoma
• Change in kappa/lambda ratio (monotypic) in a B- lymphocyte proliferation is
= B-cell lymphoma
• Inverted pattern of bcl-2 in lymphoid follicular neoplasm = follicular
lymphoma
• Increased percentage of positive cells of proliferation markers, like Ki-67 is a
marker of malignancy
• Loss of myoepithelial cells (e.g., negative p63) in breast (one exception!) or
basal cells in the prostate = malignancy
Enzyme
• Alkaline phosphatase or peroxidase
• The enzyme molecules used to amplify the Ag-Ab reaction by attaching to
different sites on a single antibody

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• An antienzyme should be attached

• Biotin/Avidin sometimes used
Dye (Chromogens)
• Different chromogens (colour-producing substrate systems) are used for
visualisation of the reaction
• For peroxidase, AEC (3-Amino-9-ethyl carbazol) or DAB (Diaminobenzidine)
giving a red or brown colour respectively
• For alkaline phosphatase, fast blue (blue) or fast red (red)
IHC Techniques
• Direct IHC: a fluorescent molecule conjugates to Ab for use as a label. The
detection system (i.e., the enzyme or fluorochrome) is linked directly to the
primary Ab
• Indirect technique: The primary Ab is not conjugated; the 2ry Ab
recognises the 1ry Ab as an Ag. The 2ry Ab is enzyme-conjugated
• Affinity-labelling: Avidin-Biotin method; the high affinity of avidin for biotin
is used as a substitute to the antigenic nature of immunoglobulins
• Antibody Bridge Techniques: (‘‘three-step method’’) is a further
modification of the indirect method. In addition to the 1ry and 2ry Abs, a
tertiary labelled antibody is used.

DIAGNOSTIC IHC
• PANEL APPROACH
• ALGORITHMIC APPROACH
Panel Approach
• Antibodies panel= group of Abs to specific Ags expected to be expressed by
the tumour under consideration and other tumours in the differential
diagnosis
• The panel will create an immunologic profile comprising both positive and
negative results
• The panel minimises the false negative/false positive results.
• It may be essential to make a staged panel. A primary panel to know the
lineage (e.g., to differentiate lymphoma from carcinoma) and a secondary
panel to know the subtype (e.g., anaplastic large T cell lymphoma)
Primary panel includes:
• Vimentin: (+) in mesenchymal tissue
• EMA: (+) in epithelial tissues
• S-100: (+) in melanoma, nervous tissue, cartilage
• Myeloperoxidase (MPO): (+) in myelocytes (leukaemia)
• CD45: (+) in lymphoid tissue
Secondary panel includes:
• Epithelial panel: e.g., CK7 and CK20 (see later)
• Lymphoid panel: using T- and B-cell markers
Algorithmic approach
• A single Ab is used (in pre-designed sequence) based on the results gained
from the previous Ab result
• It offers a reproducible scheme for solving frequent diagnostic problems

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 Histopathology Diagnosis
Antigen Retrieval (AR)
• Following formalin fixation, antigenic epitopes become masked due to
formation of cross-linkages. This leads to false negative results
• Retrieval of Ag epitopes can reverse the condition leading to change in
staining pattern
AR- Methods
• Heat-induced epitope retrieval’ or ‘unmasking’: cross-linkages could be
disrupted by high temperature heating (> 100°C) or by strong alkaline
treatment (PBS and citrate buffer).
• Enzymatic digestion: e.g., pepsin
Systemic use of Immunohistochemistry in Dx and DDx of lesions

Hematopoietic

Non-Hodgkin's lymphoma: Vim+, LCA+ (CD45)

NHL Primary panel: B (CD19, 20, 79a) or T (CD2, 5, 3, 7) = pan markers
 Malignancy confirmed as B-cell lymphoma if there is monotypic expression
of kappa /lambda
 Malignancy confirmed as T-cell lymphoma if there is loss of a pan-T cell
marker or T-cell receptor rearrangement by molecular study
B-cell subclassification: CD43, CD5, CD23 & CD10 are useful
CD10: positive in acute leukaemia, follicular lymphoma (both follicles and
interfollicular cells) & Burkitt’s
CD5: T cell marker (+) in mature T cells, but lost in T-cell lymphoma) that is
positive in certain B cell lymphoma including CLL/SLL, Mantle cell lymphoma.
CD5 is –ve in other low grade lymphomas
CD23: (+) in CLL/SLL, (-) in Mantle cell lymphoma
CD43: (+) in CLL/SLL & Mantle cell lymphoma, but –ve in follicular lymphoma
T cell lymphoma: (+) for CD2, 3, 5, 7, 45RO [loss of one of pan-T markers is a
sign of malignancy, but staining with a pan-T cell marker indicates the lineage (T
cell lineage)]
B cell lymphoma: CD19+, 20+, CD79a+, monotypic Kappa/Lambda
Natural killer cells (NK): CD16+, CD56+, CD57+
Classic Hodgkin’s lymphoma: Reed-Sternberg cells are CD15+, CD30+
Multiple Myeloma: (+) for CD79a, CD38, CD138, monotypic light chain (Kappa/
Lambda) positivity
TdT (terminal deoxy transferase)  (+) in precursor lymphoid cells and
lymphoblastic lymphoma
Myeloperoxidase “MPO”: positive in myeloid cells (Myeloid leukaemia)

DDx Histiocytosis vs. dendritic cell tumour

Langerhans’ cell histiocytosis Dendritic cell tumours
(+) for CD1a (+) for CD21, CD35, F XIIIa

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Bone marrow components:

 Megakaryocytes : positive for CD31, CD34, CD41(Glycoprotein IIb), CD42
(Glycoprotein Ib), CD61 (Glycoprotein IIIb) and VIII-related
 Myeloid cells : MPO+, lysozyme+
 Erythroid cells : positive for Glycophorin A and Hb
Extramedullary myeloid Tumour (chloroma) is positive for: MPO, CD117 and
Lysozyme
Mast cells are positive for Leder's stain (chloroacetate esterase), CD117 (c-kit)
and Tryptase. Mast cells are seen in mast cell tumours and seen scattered in
certain tumours, e.g., synovial sarcoma
Immunohistochemical profile of Histiocyte subsets
Macrophages Dendritic cells
Phagocytic Non-Phagocytic
Lysozymes No- Lysozymes

Positive for CD68, CD4, CD11c, CD68 (-) except when activated
CD14 and HLA-DR FDC IDC

Origin: CD34(-) Origin : CD34(+)

stem cells stem cells

FDC: follicular dendritic cells, IDC: interdigitating cells.

Breast

GCDFP-15 (gross cystic disease fluid protein): Unique to breast tissue, can
differentiate primary breast carcinoma (+) from metastasis to the breast (-).
Metastatic ovarian carcinoma to the breast should be WT-1(+) (non- mucinous)
and GCDF-P15 (-). Mammoglobin is more sensitive than GCDFP-15
CK7: Normal breast and breast carcinomas are (+). Can differentiate mammary
Paget’s (+) from melanoma (-)
Primary breast carcinoma should be –ve for CD20, TTF-1 and CDX-2. A
breast tumour that is positive to any of these markers is a metastasis.
(Remember CK20 ≠ breast)
AE1/E3 =pan-keratin for lymph node micrometastasis
Paget’s (PAS+, CEA+, CK7+, ER+, HER2+), Melanoma (HMB45+, not on
nipple), Extra-mammary Paget’s (PAS+, CK7+/CK20+, ER-)
Myoepithelial (ME) markers: p63 & smm-hc (smooth muscle heavy-chain
myosin) are the most specific, in addition to, SMA, ker903 (34βE12) & S-100.
Used to differentiate atypical ductal hyperplasia (ADH) (+) vs. DCIS (patchy) vs.
invasive carcinoma (-). All benign lesions should be (+) except microglandular
adenosis (the only benign breast lesion with no myoepithelial cells but has intact
basement membrane)
CK5/6: (+) in usual hyperplasia but –ve in atypical ductal hyperplasia
CD34: (+) in phyllode tumour
Basement membrane markers include laminin and type IV collagen.

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 Histopathology Diagnosis
Essential to differentiate microglandular adenosis (intact BM) from tubular
carcinoma (breached BM)
DCIS vs. LCIS: E-Cadherin is (+) in DCIS (linear, membranous). 34bE12 is (+) in
LCIS
Apocrine carcinoma: Androgen receptor (+) while, ER/PR double negative!
Salivary gland type carcinomas (all are ER –ve):
 Adenoid cystic: basaloid cells (+) for laminin, SMA, Vim, CK7,
CK14
 Acinic cell: (+) for amylase, lysozyme, α1-antitrypsin, EMA, S100

Soft tissue lesions

Soft tissue tumour panel

Spindle cell tumours: SMA, Desmin, S100, CK, CD34, EMA
Pleomorphic cell tumours: CK, S100, Actin, Desmin, CD30
Epithelioid tumours: CK, S100, CD34
Round cell tumours: CK, LCA, Desmin, CD99, S100
Immunoprofile of common Soft tissue lesions
 Angiosarcoma: Vim+, FVIII+, CD34+, CD31+
 Clear cell sarcoma : S100+, HMB45+
 Deep fibromatosis is beta catenin+ (superficial type is –ve)
 Dermatofibrosarcoma protuberans : CD34 +
 Desmoplastic small round cell: CK+, desmin+, NSE+
 Epithelioid angiosarcoma :CD31+, CD34+
 Epithelioid sarcoma :EMA+, CK+
 Glomus tumours and myopericytomas : SMA+, caldesmon+
 Granular cell tumour: S100+, Inhibin+
 Kaposi's sarcoma : Vim+, CD34+
 Leiomyosarcoma (actin +, desmin +/-, caldesmon +/-
 Liposarcoma: Vim+, S-100+, mdm2. Dedifferentiated liposarcoma is
mdm2 +, cdk4 +
 Malignant fibrous histiocytoma (MFH): Vim+, AAT+, Lysozyme+
 MPNST: S100 + in 50-60%
 Myoepitheliomas: CK/EMA+, S100+, desmin+, GFAP+
 Paraganglioma: chromogranin+, NSE+& “sustentacular” cells S100
 PEComas: HMB45+ and muscle markers+
 Reactive myofibroblastic lesions :SMA +/-, desmin +/-
 Rhabdomyosarcoma: Vim+, desmin+, myoglobin+, myogenin+
 Solitary fibrous tumour and spindle cell lipoma :CD34+
 Synovial sarcoma: Vim+, CK+, EMA+, CD99+

Muscle tumours
LESION SMA DESMIN H-caldesm myogenin
Myofibroblastic Focal + (-) (-) (-)
Smooth muscle + +/- +/- -
Skeletal muscle +/- + - +
(Rhabdomyosarcoma)

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Small Blue Cell Tumours (all are Vim+ except neuroblastoma)

 Embryonal rhabdomyosarcoma: NSE-, Desmin+, Actin+
 Ewing's sarcoma: NSE-, Desmin-, CD99+, WT-1+
 Neuroblastoma: Vim(-), NSE+, Desmin-, Actin-
 Wilms' tumour: NSE-, Desmin-, Actin-
 Desmoplastic small round cell tumour (DSRT): Desm+, WT-1+,
Fibrohistiocytic tumours, e.g., fibrous histiocytoma are positive for F XIIIa,
Lysozyme, Alpha-1-antitrypsin (AAT), alpha chemotrypsin. CD163 is a new
specific marker

Skin

Immunoprofile of Common lesions:

 Angiosarcoma: CD31+, CD34+, Factor VIIIRA+, CK+, D2-40+, CD30+
 Desmoplastic melanoma: only (+) for S-100 (has neuronal features)
and MAGE-1, but not (+) for other conventional melanoma markers.
 Eccrine spiradenoma: CK+, SMA+ in basal cells only.
 Glomus tumour: collagen type IV + ( around individual cells), laminin,
SMA+, CD34+
 Hidradenoma (solid type): CK+, CEA+, EMA+.
 Juvenile xanthogranuloma: CD68+, F XIIIa+, Ki-M1P+
 Melanoma: S-100+, Melan-A+, HMB45+, Tyrosinase+, MAGE-1,
CD117 (CD117 stains in situ but not deep dermis or invasive
component)
 Merkel cell carcinoma (1ry neuroendocrine cell carcinoma of the skin):
Monokeratin+ (dot-like), EMA+, Cam5.2+, AE1/AE3+, CK20+,
chromogranin+, synaptophysin+, Fli-1+, p53+, Ki-67+
 Naevi and melanoma: S-100+, HMB-45+
 P63 is (+) in Adnexal tumours (Bg/mg) and SqCC. P63 is (-) in
metastatic adenocarcinoma
 Papillary haemangioma: CD31+, CD34+, SMA+, D2-40-
 Primary mucinous carcinoma of the skin: ER+/PR+, mostly face of
elderly male
 Primitive (polypoidal) non-neural granular cell tumour of the skin:
S-100-, NKI-C3+ (non-specific)
Common DDx
 Angioleiomyoma: SMA+, Desmin+, Vimentin+, Collagen type IV+,
HMB45-) vs. Angiomyolipoma: HMB45+
 Compound nevus vs. Melanoma: Melan-A has no value in DDx.
Compound nevus: HMB45, Tyrosinase and Ki-67, diminished positivity
with increasing depth (diminished Ki-67 = maturation gradient). In
Melanoma: opposite, more staining in the deeper component + No
maturation gradient by Ki-67
 Dermatofibroma : AAT+, FXIIIa+, Tenascin+ at dermoepidermal
junction vs. DFSP: CD34+, ApoD+, Tenascin- at dermoepidermal
junction

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 Histopathology Diagnosis
 Paraganglioma-like dermal melanocytic tumour (PDMT): S100+,
HMB-45+, AE1/AE3-, SMA- Vs. PEComa: SMA+
 SqCC: BerEP4-, EMA+ vs. BCC: BerEP4+, EMA-

DDx of cutaneous and subcutaneous myxoid lesions

 Aggressive angiomyxoma: desmin+, SMA+
 Botryoid rhabdomyosarcoma: myoglobin+
 Extraskeletal myxoid chondrosarcoma: S-100 +
 Myxoid dermatofibroma: factor XIIIa+, SMA+
 Myxoid dermatofibrosarcoma protuberans: CD34+
 Myxoid leiomyosarcoma: desmin+, SMA+
 Myxoid malignant melanoma: S-100+, Melan-A+ and HMB-45+
 Myxoid Schwannoma: S-100+
 Superficial acral fibromyxoma: CD34+

DDx of sclerotic skin tumours

 Desmoplastic trichoepithelioma: CK7-, EMA-, SMA- (rare Ki-67)
 Microcystic adnexal carcinoma, MAC: CK7+, EMA, SMA+ (rare Ki-67,
deceptively bland looking tumour)
 Sclerosing type basal cell carcinoma: CK7-, EMA-, SMA- (high Ki-67)

Salivary

 All salivary tumours are CK7+/CK20- with few exceptions. Squamous

cell carcinoma is CK7/20 double negative
 CEA and EMA (+) in :
o Adenoid cystic carcinoma
o Pleomorphic adenoma vs. myoepithelioma (EMA-,CEA-)
o Epithelial-myoepithelial carcinoma
o BCC
 Myoepithelial markers (calponin, p63) highlights the in situ nature of
salivary duct carcinoma
 Anti-mitochondrial antibodies (+) in oncocytic tumours (important to
differentiate clear cell variant from other clear cell tumours of salivary
gland
 Primary salivary duct carcinoma (ER-, CEA+) vs. met breast duct
carcinoma (ER+, CEA-)
 Small cell carcinoma: neuroendocrine markers, CK20 and TTF-1 are
essential for subtyping and differentiation of primary from metastatic
tumours.
 Thyroglobulin to differentiate the follicular variant of acinic cell tumour (-)
from a metastatic thyroid carcinoma (+)
 Acinic cell carcinoma: CK+, CEA+, amylase-/+
 Adenoid cystic carcinoma :
o Ductal epithelial cells: CD117+, CEA+, EMA+
o Basaloid myoepithelial cells: S-100+, Calponin+,
CD43+(important, ? specific for ACC)

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 Basal cell adenocarcinoma : CEA+, CK+, CK5/6+, S-100+, SMA, Vim+

 Carcinoma ex pleomorphic adenoma, CXPA: CEA+, EMA+, cyclin-A+
(? specific), HER-2
 Epithelial-myoepithelial carcinoma:
o Ductal cells: CK+, CK7+, BCL-2, CD117+
o Clear cells: P63+, S-100+, Calponin+
Thyroid
• Medullary carcinoma shows amyloid and calcifications. Medullary carcinoma
is calcitonin+, CEA+, thyroglobulin (-) (IMPORTANT)
• Follicular and papillary subtypes of Medullary carcinoma are thyroglobulin –
ve, while papillary and follicular thyroid carcinomas are thyroglobulin+
• Papillary carcinoma is CK19+, CD44+ (differentiates it from other thyroid
tumours)
• Follicular carcinoma is positive for Galectin-3 and CD44v6,
• Follicular carcinoma vs. Adenoma: carcinoma has nucleoli that appear high
in number using AgNOR. In addition, follicular adenoma is positive for
Thyroperoxidase.
• Unknown primary: lung & thyroid tumours are TTF-1 positive
Nervous system

• GFAP (glial fibrillary acidic protein) is positive in gliomas, however, negative

GFAP doesn't exclude glioma (particularly if Vimentin +)
• Glioblastoma multiforme is GFAP+, AE1/AE3+, CK7/CK20 double negative
• Meningioma is CEA+, CK7+, EMA+
• Malignant meningioma; histologically, invades the Virchow-Robin’s space,
high cellularity, high mitoses, no whorls, prominent nucleoli. By IHC, high Ki-
67 and high % of PR positive nuclei
• Medulloblastoma is synaptophysin+
GIT

p63 is positive in normal oesophageal epithelium and negative in intestinal

metaplasia associated with Barrett’s metaplasia
p53 is a general marker of dysplasia (e.g., dysplasia associated with Barrett’s,
ulcerative colitis, colonic adenomas...etc)
Ki-67 can differentiate between serrate adenoma and pure adenoma (stains the
bottom glands)
CD10 stains absorptive cells (present in intestinal but not gastric metaplasia)
GIST is CD117+ (KIT) &CD34+, while leiomyoma is CD117(-). (IMPORTANT for
DD). Mast cells & melanocytes are CD117+
Liver
Hepatocellular carcinoma: CK7-/CK20-, polyclonal CEA+ (canalicular pattern) &
HepPar 1+
HCC is shows CD34+, loss of reticulin, and increased Ki-67 positivity compared
to normal or focal nodular hyperplasia (FNH). If metastic HCC use AFP or
HepPar1.

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 Histopathology Diagnosis
Cholangiocarcinoma: CK7+/CK20-/CK19+, CEA+, EMA+.
Angiomyolipoma: HMB45+
Solitary fibrous tumour: CD34+, Vimentin+
Epithelioid Haemangioendothelioma: CD31+, CD34+, FVIII+

Lung/pleura

 Lung primary is TTF-1+ vs. secondaries, which are TTF-1(-)

 Squamous cell carcinoma is TTF-1(-), CK5/6+, p63+
 Adenocarcinoma is Napsin-A+, TTF-1+. Enteric type adca is CDX-2+
 Small-cell carcinoma is TTF-1+, CK7-/CK20-, synaptophysin+

Stain/Marker Adenocarcinoma Mesothelioma Reactive

Mesoth. cells
Hyalurinidase - +
PAS/diastase PAS+/ Diastase+ PAS+/Diastase -
Calretinin - + (most specific)
CEA +++ +/-
WT-1 - +
Desmin - - ++
Ber-Ep4 + - -
E-cadherin + -
CD15 (LeuM-1) + -
EMA cytoplasmic membranous
Mucin + -
CK HMW -/LMW + HMW+/ LMW+
P63 (nuclear) - +
TABLE. Adenocarcinoma vs. Mesothelioma VS. Reactive
Urinary

In prostate, ker903 and p63 are (+) for basal cells. If small acini that are negative
for basal cell markers = adenocarcinoma
Prostatic adenocarcinoma (PSA+, CEA-) vs. TCC (CK7+/CK20+, PSA-, CEA+,
thrombomodulin+) vs. metastatic colorectal carcinoma (PSA-, CEA+, CK7-, β-
catenin+)
TCC: CK7/20 double (+)
Wilms’ tumour: WT-1+, Fli-1(-)
Angiomyoblastoma: HMB45+, Melan-A+, CD117+, EMA-, CK-
RCC has two immunoprofiles:
 Clear cell and granular cell: CD10+, Vim+, CK7-
 Chromophobe (also oncocytoma): CD10-, Vim-, CK7+
Adrenal

Adrenal tissue and tumours are EMA-, Vim +, CD10+

Pheochromocytoma: synaptic+, chrome+, NSE+, S100+ (sustentacular cells)
Adrenal cortical paediatric carcinoma: strong inhibin+

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 The Skilful Pathologist Series

Male genital

Leydig cell tumour: inhibin+, synaptophysin+, melan-A+ (!), CK-

Sertoli vs. Seminoma: remember that seminoma look like potato grossly and
the cells contain glycogen, hence PAS/D positive. Sertoli full of fat (Sterol), so
the tumour is yellowish and soft grossly and microscopically the cells are full of
fat, hence fat stains positive. In addition, they are positive to inhibin
Sertoli: EMA & inhibin double+, PLAP-, myxoid stroma
Seminoma: EMA & inhibin double –ve, PLAP+, no myxoid stroma
Intratubal germ cell neoplasia (ITGCN): OCT3/4+, CD117+, PLAP+, ferritin+
(also PAS/D special stain). In FS, PAS/D is highly helpful
Testicular tumours with high HCG (HCG ↑↑ estradiol  Gynaecomastia)
 Seminoma
 Choriocarcinoma
 Sertoli and Leydig cell tumours

Ovary

Germ cell Tumours

o Seminoma : PLAP+, Vim+
o Embryonal carcinoma : CK+, PLAP+, CD30+
o Choriocarcinoma: HCG+, CK+
o Yolk sac tumour: AFP+, CK+, AAT+, ER/PR double+, polyclonal CEA+
(canalicular pattern), like the liver (remember the hepatoid variant)
Granulosa cell tumour: calretinin+, inhibin+, CD99+, CD10+ , EMA-, Vim+,
S100+
Sertoli cell tumour: inhibin+
Endometrioid carcinoma: CK7+, EMA+
Carcinoid: CK+ (pan), synaptophysin, chromogranin+
Sarcomatoid sex cord stromal tumour (SSST): inhibin+, calretinin+
Small cell carcinoma of the ovary (hypercalcaemic and pulmonary types):
WT-1+ and EMA+ double+ (diagnostic), p16+, p53+. Negative for chromogranin,
CD99, CD117, Inhibin, Desmin, TTF-1 (DDx; metastatic scc of the lung)
CD10 & inhibin differentiate stromal sarcoma (CD10+) from granulosa cell
tumour (inhibin+)
CD10 & CD45 differentiate stromal sarcoma (CD10+) from lymphoma (CD45+)
Cadherin
• Endometrioid & serous subtypes: E/N-Cadherin double+
• Mucinous: E-Cadherin+, but N-Cadherin (-)
WT (Wilms’ tumour antigen) and origin of papillary serous tumour:
• Ovarian and peritoneal tumours are WT+
• Uterine tumours are WT(-)
Uroplakin: Brenner Tumour (+) while TCC ovary (-)
CD99 is (+) in both Granulosa and Sertoli cell tumours
CD30: (+) in Embryonal carcinoma
CD117: (+) in Dysgerminoma (seminoma counterpart)

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 Histopathology Diagnosis
Uterus

CD10 is general marker of the endometrial stroma. Therefore, it can highlight the
stroma in endometriosis (especially ovarian)
CD10 is (+) in stromal sarcoma and (-) in smooth muscle tumours.
Negative CD10 areas in endometrial carcinoma equal invasion in myometrium
H-Caldesmon is (+) (most specific) in smooth muscle tumours and –ve in
myofibroblastic tumours
PEComas: Perivascular epithelioid tumours of the uterus occur in Tuberous
sclerosis, e.g., lymphangioleiomyomatosis. They simulate stromal sarcomas but
perivascular. Positive for HMB45 & SMA
DDx of HMB45+ epithelioid mesenchymal tumour, uterus:
 Clear cell carcinoma (CCC)
 Endometrial stromal tumour (Low grade)
 Leiomyosarcoma (epithelioid)
 Melanoma (metastatic)
 PEComas
 Placental site trophoblastic tumour

Endometrial adenocarcinoma is Keratin and Vimentin (+)

ER (Oestrogen Receptor) can differentiate between clear cell carcinoma (-) and
clear cell metaplasia (+) of endometrium

SOME USEFUL MARKERS IN DIAGNOSIS

CK7/20
Double positive, CK7+/CK20+ TOP
 TCC (U. bladder) & adenocarcinoma (G. bladder)
 Ovary (mucinous)
 Pancreatic adenocarcinoma
Double negative CK7-/CK20- :
SMALL CELL, SMALL NUCLEI, SMALL ACINI, LARGE CYTOPLASM
 Small cells : small cell carcinoma (lung), small-cell neuroendocrine tumours
(lung)
 Small nuclei: carcinoid, RCC
 Small acini: prostatic adenocarcinoma
 Large cytoplasm: HCC (CEA+), RCC (CD10+), Adrenal cortical ca, Sq. CC,
Epithelioid sarcoma (EMA+), thymoma
CK20+: CSMC
 Colon adenocarcinoma
 Stomach [Gastric carcinoma (50%)]
 Merkel cell (CK20perinuclear spot, CD56+)
 Carcinoid (tubular type)
CK7+ (Female cancers): TO BE MR NHS
 Thyroid ca
 Ovarian ca (serous & endometrioid)

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 The Skilful Pathologist Series

 Breast cancer
 Endometrial adenocarcinoma
 Mesothelioma (Epithelial)
 Renal chromophobe RCC /oncocytoma
 NSCC lung (adenocarcinoma & bronchioloalveolar carcinoma)
 HCC, lamellar
 Salivary gland ca
CD99/CD34
CD99 is cell surface protein encoded by genes on X & Y chromosomes.
Expressed in immature B and T cells, high grade malignancies & others
CD99 and FLI-1 are useful in the diagnosis of Ewing sarcoma / PNET but as
they are their specificity (CD99 may be positive in a large variety of tumours
including poorly differentiated synovial sarcoma, desmoplastic small round cell
tumour, lymphoblastic leukaemia) or sensitivity (FLI-1 is only positive in 70% of
cases of Ewing sarcoma),
CD34 is myofibroblast and endothelial marker
• Solitary fibrous tumour: CD34+, CD99 +, bcl-2+
• Synovial Sarcoma: CD99+, CD34(-)
• Dermatofibrosarcoma protuberans (DFSP): CD34+
• Phyllode tumour, breast: CD34+
• Kaposi: CD34+
• GIST: CD34+, CD117+
• Ewing/PNET: CD99+, FL-1+, WT-1+. (PNET has rosettes vs. no
rosettes in Ewing)
• Wilms’ : CD99+, FL-1(-), WT-1(-)
• Hemangiopericytoma: weak CD34+, CD99+
• Myofibroblastoma: CD34+, SMA+
• Mesenchymal chondrosarcoma: CD99+, CD34(-), focal S100+
• Small cell carcinoma lung: CD99+, Merkel tumour: CD99(-)
• Epithelioid sarcoma: CD34+
• Peripheral nerve sheath tumours: S100+, CD34+
• Perineurioma: CD34-, EMA+
• Hepatocellular carcinoma: CD34+ vs. normal liver (CD34(-)
Desmin
• Desmoid Tumour: Desmin+
• Desmoplastic small cell tumour: Desmin+
• Reactive mesothelial cells: Desmin+
Neurofilaments:
Positive in:
 Neurogenic tumours as neuroma, ganglioneuroma, neuroblastoma
 Neuroendocrine as paraganglioma, carcinoid, pheochromocytoma, carcinoid
and neuroendocrine carcinomas (small cell carcinoma and Merkel cell
tumour)
Vimentin Dilemma

All mesenchymal tissue should be Vimentin positive; however, some epithelial

tumours are Vimentin positive too.

203
 Histopathology Diagnosis

CK+ & Vimentin+ Tumours

• Adrenal carcinoma (EMA –ve)
• Renal cell carcinoma (EMA+) (except...see below)
• Thyroid tumours
• Breast carcinoma
• Ovarian epithelial tumours
• Endometrial adenocarcinoma
• Large-cell neuroendocrine tumour, lung
• Hepatocellular carcinoma (HCC)
• Mesothelioma
Note: Seminoma: Vimentin+, Keratin(-)
Vimentin negative renal tumours:
 Chromophobe RCC
 Oncocytoma
Cytokeratin Dilemma
Cytokeratin (+) mesenchymal tumours
Biphasic tumours
o Synovial sarcoma (monophasic and biphasic)
o Mesothelioma
o Malignant peripheral nerve sheath tumour (only stains the glands)
o Melanoma (dimorphic rather than biphasic)
Tumours with epithelioid variant
o Angiosarcoma
o Leiomyosarcoma
Tumours with epithelioid morphology
o Chordoma
o Epithelioid sarcoma
o Meningioma

Predictable positivity Unpredicted positivity

Carcinoma Epithelioid vascular tumours
Chordoma Ewing / PNET
DSRCT Leiomyosarcoma
Epithelioid sarcoma MPNST
Mesothelioma Pleomorphic liposarcoma
Myoepithelioma Rhabdomyosarcoma
Rhabdoid tumour
CYTOKERATINS Staining
CEA
Positive in:
 Adenocarcinoma of lung, colon, pancreas
 Medullary thyroid ca
 HCC
 Mucinous ovarian ca
Negative in:
 RCC

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 The Skilful Pathologist Series

 Prostate adenocarcinoma
 Thyroid ca (except medullary)
 Serous ovarian ca
 Endometriosis
EMA (Epithelial Membrane Antigen) is positive in:
o Adenocarcinomas
o Epithelioid sarcoma
o Meningioma
o Anaplastic large cell lymphoma
o Myeloma

EMA: non-specific and it stains epithelial and epithelioid tumours, so it stains

epithelioid sarcoma, large cell lymphoma and even myeloma

TTF1:
Positive: normal lung & thyroid tissue and their tumours
Negative: in squamous cell carcinoma lung
HMW CK (CK 5/6)
Positive: mesothelioma, squamous component of tumours
Negative: most of lung adenocarcinomas
WT-1 (nuclear), positive in:
 Wilms’ tumours & DSRT (desmoplastic round small cell tumour)
 Rhabdoid tumour
 Metanephric adenoma
 Mesothelioma (DDx; thymic tumours which are WT-1 –ve)
 AML (acute myeloid leukaemia)
 Ovarian epithelial tumours
CD30 (Ki-1) positive tumours
 Hodgkin’s
 Embryonal carcinoma, ovary
 Melanoma
 Anaplastic large cell lymphoma
CD10 (Zinc-dependent protein, CALLA)
Adrenal and neural tissue are CD10+. It is a marker of lymphoid germinal centre
Uses:
 Normal adrenal and RCC are CD10 (+), except Chromophobe RCC , CD10
(-)
 All T-cell lymphomas are CD10 (-) except angioimmunoblastic.
 Differentiates follicular hyperplasia (centre of follicle only is CD10 (+), from
follicular lymphoma [follicles and interfollicular areas are CD10 (+)].
 CD10 is (+) in Burkitt’s, lymphoma of follicle centre origin (follicular
lymphoma, diffuse large B-cell lymphoma). MALT lymphoma (-), especially
cells of follicular colonisation.
 CD10 in nodular lymphoma: CD10 negativity is diagnostic in Mantle cell
lymphoma and MALT lymphoma vs. follicular lymphoma (CD10+)

205
 Histopathology Diagnosis
 Uterine stroma is CD10+ (glands are –ve), therefore it differentiate stromal
tumours (+) from smooth muscle tumours (CD10-, h-caldesmon+) of the
uterus.
 CD10 can highlight the endometriosis (stroma, not glands) and stromal
nodule
 Mesonephric derivatives (remnants, hyperplasia and tumours “Mullerian”)
are CD10+, common in the uterus.
 All trophoblastic derivatives (nodules, moles, choriocarcinoma..etc) are
CD10+
 Ovarian tumours which are CD10+: adenocarcinoma, FATWO, granulosa ,
yolk sac, Sertoli-Leydig
 Clear cell RCC metastatic to genital tract are CD10(+) vs. primary clear cell
tumours of genital tract
 Colorectal adenocarcinoma metastatic to genital tract (+) vs. primary
adenocarcinoma of genital tract
 Hepatocellular carcinoma (CD10+, typically canalicular) vs. metastatic
carcinoma to liver
 CD10 positivity is linked with tumour progression and poor prognosis in
melanoma, breast carcinoma and malignancy in phyllode tumour
CD56 (N-CAM) is a neuronal cell adhesion molecule, positive in
 Normal nerve structures and all neuronal tumours (as well as CD57)
 Small cell carcinoma
 Natural killer cells
 PNET
 Merkel cell tumour
p63 (nuclear)
 Expressed in BCC, Sq CC& TCC, but not in adenocarcinomas
 Stains myoepithelial cells: positive in DCIS and LCIS, but negative in IDC
(infiltrating duct carcinoma)
 Stains basal cells in the prostate; differentiate adenocarcinoma
(-) from ASAP (atypical small acinar proliferation) (+)
 Differentiates myoepithelial cells (+) from myofibroblasts (-)
Calretinin (CALcium-binding protein):
 Mesothelioma (+), nuclear and cytoplasmic) vs. adenocarcinoma (-)
 Sex cord stroma tumours + (Granulosa, Thecoma, Sertoli and Leydig).
Calretinin is more sensitive but less specific than inhibin
 Cardiac myxoma (+) vs. cardiac mural thrombi (-)
 Ameloblastoma (+) vs. odontogenic tumours (-)
Inhibin
 Sex cord-stromal tumours; Granulosa and sertoli cell tumours are (+)vs.
uterine stromal tumours metastatic to ovary & endometrioid carcinoma which
are (-)
 Choriocarcinoma (+) & Syncytiotrophoblasts (+) in testicular tumours
 Peritoneal washing: differentiate metastatic sex cord-stromal tumour (+) vs.
mesothelial cells (-) [Both are (+) for calretinin]

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 The Skilful Pathologist Series

Antibodies, which succeed when others fail:

AE1/AE3: broad spectrum CK, for carcinoma micrometastasis in a lymph node
CAM 5.2: for epithelial tumours
CD79a: for B-cells + plasma cells
CA19.9= GIT carcinoma
CA125= Ovarian tumours

MOLECULAR DIAGNOSIS (MOLECULAR DIFFERENTIATION METHOD)

Molecular techniques
 Cytogenetic analysis
 Southern blot (for DNA) & Northern blot (for RNA)
 FISH and CISH (Fluorescent and chromogen in situ hybridization)
 PCR (Amplification)
 Genomic hybridization
 Sequence and fusion analysis
 RFLP (restriction fragment length pleomorphism) analysis
 LOH (Loss of Heterozygosity)
 Rearrangement studies
 DNA microarray studies

Uses:
Diagnosis:
o T cell lymphoma diagnosis
o Leukaemia subtypes
o Undifferentiated tumours
Prognosis
o Neuroblastoma (number of copies of N-myc)

Common molecular findings in tumours

 Anaplastic large cell lymphoma: t(2:5); ALK

 Burkitt’s lymphoma: t(8;14)
 Chronic myeloid leukaemia: t(9;22); Philadelphia chromosome
 Diffuse large B cell lymphoma: Bcl-6 rearrangement
 Fibrosarcoma (infantile): +8, +11, +17, +20
 Follicular lymphoma: t(14;18)
 Leiomyoma: t(12;14); del 7
 Leiomyosarcoma: del 1p
 Liposarcoma (myxoid): t(12;16)
 Liposarcoma (well-differentiated): ring chromosome 12
 Meningioma: del 22
 Mesothelioma: del of 1p, 3p
 Myxoid chondrosarcoma: t(9;22)
 Rhabdomyosarcoma (alveolar): t(2;13)
 Rhabdomyosarcoma (embryonal): +2q, +8, +20
 Synovial sarcoma: t(X; 18)

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 Histopathology Diagnosis

ELECTRON MICROSCOPE (EM) (ULTRA STRUCTURE)

3
Fixation: 2% Buffered Glutraldehyde. 1mm tissue cubes are used
EM Diagnostic Uses and structures detectable by EM
 Granules:
o Atypical granules in α-cell tumour of pancreas (glucagonoma)
o Birbeck’s granules in Langerhans’ cell histiocytosis
o dense-core granules containing crystalline material in β-cell tumour
of pancreas (insulinoma) and Pituitary
o Electron-dense variable sized (zymogen-like) granules in acinic cell
carcinoma, salivary
o Melanosomes and premelanosomes, especially in Amelanotic
melanoma
o Neurosecretory granules in neuroendocrine tumours
 Bodies:
o Asbestos bodies in asbestosis & mesothelioma
o Auer bodies in leukaemia
o Glycogen in certain tumours and glycogen storage diseases
o Myelin figures (lamellated bodies) in adenocarcinoma
o Weible Palade bodies in vascular tumours
 Filaments as evidence of differentiation in certain tumours:
o Actin filaments in smooth muscle tumours
o Tonofilaments in carcinoma (also desmosomes)
o Neurofilaments in neuroblastoma
 Basal lamina (hemi basement membrane) status in CIS. If breached indicates
an invasive component.
 Glomerular Basement Membrane (2 densa, 1 rara) thickness, immune
complex deposits, epithelial cells foot process fusion...etc in glomerulonephritis
classification
 Contraction bands in myocardial infarction
 Crystals: in alveolar rhabdomyosarcoma, β-cells of Langerhans and juxta
glomerular cells
 Short microvilli and glycocalyx in lung adenocarcinoma vs. long microvilli with
no glycocalyx in mesothelioma
 Filopodia and cytoplasmic extensions in synovial sarcoma
 Immune complex deposits in skin, blood vessels and kidney
 In cerebral infarction: detection of neuronal ischemic injury as early as 20-40
min following injury
 Intracytoplasmic lumens in adenocarcinoma, IDC and certain vascular
tumours
 Lipid vacuoles in microsteatosis
 Mitochondrial abnormalities in mitochondrial myopathies, mitochondrial
encephalomyelopathies and mitochondrial changes in lethal and non-lethal
cell/tissue injuries
 Smooth endoplasmic reticula and lysosomes in cell injury and storage
diseases & Peroxisomes in certain encephalopathies
 Viral inclusions

208
 The Skilful Pathologist Series

APPENDIX

209
SNOMED CODES M80703
Carcinoma, squamous cell
M80413
As described by Wikipedia, SNOMED Carcinoma, small cell
is a systematically organized M33400 and M3340A
computer processable collection Cyst, NOS
of medical terms providing codes F53812
used in clinical documentation and Chemotherapy effect
reporting. M90840
Dermoid cyst
M74000
Morphology code (M), Tissue
Dysplasia
(topography) code (T), E70000
disease/diagnosis code (D), Etiology Drug-induced disease
code (E) and Functional (F) codes are M54110
commonly used in pathology reports. Fat Necrosis
M49000, M78000
SNOMED codes are important for Fibrosis
cancer registry, statistics, clinical M30400
Foreign body
audits and many others. M44100
Foreign body giant cell reaction
Below are the commonly used M46300
codes Fistula
M54600
GENERAL CODES Gangrene
M45020
M75400 Granulation tissue
Aplasia M44000
M41610 Granuloma
Abscess M37000
M49400 Haemorrhage
Adhesion M75500
M81403 Hamartoma
Adenocarcinoma M31680
M81406 Hernia sac
Adenocarcinoma, metastatic M37100
M55100 Haematoma
Amyloid M26000
M81400 Heterotopic/ectopic tissue
Adenoma, NOS M72000
M58000 Hyperplasia, NOS
Atrophy M54700
M67000 Infarct
Atypia M41000
M55400 Inflammation, acute
Calciication M43000
M82401 Inflammation, chronic
Carcinoid tumour M42100
M80102 Inflammation, active chronic
Carcinoma in situ M44000
M80106 Inflammation, granulomatous
Carcinoma, metastatic, NOS F72240
M80103 Ischaemia
Carcinoma, NOS M88500
 The Skilful Pathologist Series

Lipoma SKIN
M40000
Inflammation, NOS SKIN, NON TUMOUR
M87203
Malignant melanoma M46540
M80006 Acne
Melanoma, metastatic M46620
M73000 Acne rosacea
Metaplasia, NOS M58600
M73000 Alopecia, NOS
Metaplasia, squamous M48210
M09350 Atopic dermatitis
Morphological description only M11100
M97303 Burn injury
Multiple myeloma M55500
M98003 Calcinosis cutis
Leukaemia, NOS M47600
M95903 Contact dermatitis
Lymphoma, NOS M74440
M88900 Darier's disease
Leiomyoma M48550
M88903 Drug eruption, fixed
Leiomyosarcoma M48540
M54000 Drug eruption, lichenoid
Necrosis M48000
M80000 Eczema
Neoplasm, benign M48560
M80003 Erythema multiforme
Neoplasm, malignant M45620
M80006 Erythema nodosum
Neoplasm, metastatic M47400
M09413 Folliculitis
No evidence of malignancy M54600
M00100 Gangrene
Normal tissue M48920
M39800 Granuloma annulare
Perforation/Rupture M46520
M11600 Hidradenitis suppurativa
Radiation effect M77910
M76800 Histiocytosis X
Polyp, NOS M14360
M80520 Insect bite
Papilloma, squamous cell M47250
M34160 Jessner’s lymphocytic infiltrate
Stricture M48890
M09010 Lichen plano-pilaris
Tissue insufficient / unsatisfactory M48890
material Lichen planus
M09150 M48120
Tissue lost in processing Lichen simplex chronicus
M35100 D38670
Thrombus Lupus erythematosus, NOS
M38000 D38720
Ulcer Lupus erythematosus, systemic
M44930

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 Histopathology Diagnosis
Necrobiosis lipoidica M84000
D36100 Adenoma, sweat gland
Pemphigus, NOS M91410
M46350 Angiokeratoma
Pilonidal sinus M88940
M48520 Angioleiomyoma
Pityriasis lich et var acuta (PLEVA) M88610
M48960 Angiolipoma
Pityriasis lichenoides chronica M80812
M48880 Bowen's disease
Pityriasis rosea M80102
M58550 Carcinoma in situ
Poikiloderma M80903
M11460 Carcinoma, basal cell
Polymorphous light eruption M80923
M72940 BCC, morphoea type
Porokeratosis M80943
M72090 BCC, basosquamous
Pseudoepitheliomatous hyperplasia M80433
M56890 Carcinoma, Merkel cell
Pseudoxanthoma elasticum M80703
M48840 Carcinoma, squamous cell
Psoriasis, NOS M33410
M41730 Cyst, epidermal inclusion (Sebaceous
Pyoderma gangrenosum cyst)
M44440 M33400
Pyogenic granuloma Cyst, NOS
M11620 M33430
Radiation dermatitis Cyst, pilar
M44940 M33430
Rheumatoid nodule Cyst, sebaceous
M46620 M88320
Rosacea Dermatofibroma
M49060 M88323
Scar Dermatofibrosarcoma, NOS
M46350 M76100
Sinus, pilonidal Fibromatosis, NOS
M48006 M87120
Spongiotic dermatitis Glomangioma
M48010 M87110
Stasis dermatitis Glomus tumour
M10540 M91310
Ulcer, decubitus Haemangioma, capillary
D48080 M91210
Vasculitis, leukocytoclastic Haemangioma, cavernous
M91200
SKIN TUMOURS AND PRENEOPLASTIC Haemangioma, NOS
CONDITIONS M84000
Hidradenoma
M72850 M55380
Actinic keratosis Juvenile xanthogranuloma
M75730 M49720
Adenoma sebaceum Keloid
M83900 M72860
Adenoma, skin appendage Keratoacanthoma

212
 The Skilful Pathologist Series

M87422 M76620
Lentigo maligna Verruca plana
M87423 M76630
Lentigo maligna melanoma Verruca vulgaris
M57250 M55300
Lentigo simplex Xanthoma, NOS
M57250
Lentigo, NOS GASTROINTESTINAL TRACT
M88500
Lipoma M82100
M91700 Adenoma, tubular
Lymphangioma M82630
Molluscum contagiosum Adenoma, tubulovillous
M97003 M82611
Mycosis fungoides Adenoma, villous
M88400 M82105
Myxoma, NOS Adenoma, serrated
M87800 M72440
Naevus, blue Adenomyoma of gallblader
M87600 M76810
Naevus, compound Anal tag (fibroepithelial polyp)
M87500 M74850
Naevus, intradermal Angiodysplasia
M87400 M73320
Naevus, junctional Intestinal metaplasia, Barrett's
M57250 oesophagus
Lentigo simplex M30010
M74000 Cholelithiasis
Naevus, dysplastic M54200
M87700 Colitis, ischaemic
Naevus, Spitz M40480
M95600 Colitis, pseudomembraneous
Neurilemmoma M46420
M95400 Diverticulitis
Neurofibroma M32710
M49770 Diverticulosis
Neuroma, traumatic M40010
M76130 Gastritis, atrophic
Nodular fasciitis M40011
M80520 Gastropathy, reactive
Papilloma, squamous cell M89361
M81100 GIST
Pilomatrixoma M32620
M76810 Haemorrhoids
Polyp, fibroepithelial (skin tag) M76820
M95600 Inflammatory polyp
Schwannoma M31130
M72750 Intussusception
Seborrhoeic keratosis M57740
M84070 Melanosis coli
Syringoma M40012
M81000 Oesophagitis, reflux
Trichoepithelioma M82905
M81010 Oncocytoma
Trichofolliculoma M75630

213
 Histopathology Diagnosis
Polyp, hamartomatous Carcinoma, metaplastic / carcinosarcoma
M72040 M84803
Polyp, hyperplastic Carcinoma, mucinous (colloid)
M76820 M80715
Polyp, inflammatory Carcinoma, microinvasive
M76800 M85623
Polyp, NOS Carcinoma, myoepithelial
M75630 M82403
Polyp, Peutz-Jeghers' Carcinoma, neuroendocrine
M31050 M85023
Prolapse Carcinoma, secretory
M84806 M82113
Pseudomyxoma peritonei Carcinoma, tubular
M34160 M43000
Stricture Chronic inflammation / mastitis
M34210 M50052
Torsion Collagenous sphherulosis
M32600 M49060
Varices Complex sclerosing lesion
M34220 M32100
Volvulus Duct ectasia
M90100
BREAST Fibroadenoma
M74320
M89820 Fibrocystic disease, NOS
(Adeno)myoepithelioma M76100
M74200 Fibromatosis
Adenosis M71000
M74220 Gynecomastia
Adenosis, sclerosing M72000
M91203 Hyperplasia, NOS
Angiosarcoma M72430
M73310 PASH
Apocrine metaplasia M15800
M85733 Implant
Carcinoma, apocrine M69880
M83103 Lactational change
Carcinoma, cribiform M32640
M85002 Mucocele-like lesion
Carcinoma, in situ, ductal, NOS M90101
M85032 Myofibroblastoma
Carcinoma, in situ, intraductal, papillary M85403
M85202 Paget's disease of the nipple
Carcinoma, in situ, lobular M85030
M85003 Papilloma, intraductal
Carcinoma, infiltrating ductal M85055
M85203 Papillomatosis, juvenile
Carcinoma, infiltrating lobular M85060
M85303 Papillomatosis, subareolar duct
Carcinoma, inflammatory M90201
M85033 Phyllodes tumour
Carcinoma, invasive micropapillary M49100
M85103 Radial scar
Carcinoma, medullary M22300
M89803 Supernumerary nipple

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 The Skilful Pathologist Series

Cystadenoma, NOS
FEMALE GENITAL TRACT M84410
Cystadenoma, serous
M85703 M79500
Adenoacanthoma Decidual change
M90130 M90603
Adenofibroma Dysgerminoma
M90540 M89303
Adenomatoid tumour Endometrial stromal sarcoma
M89320 M76500
Adenomyoma Endometriosis
M76510 M79370
Adenomyosis Endometrium, atrophic
M58000 M79330
Atrophy Endometrium, menstrual
M84710 M79310
Borderline tumour, mucinous Endometrium, proliferative
M84411 M79320
Borderline tumour, serous Endometrium, secretory
M90000 M88100
Brenner tumour Fibroma, NOS
M85603 M86201
Carcinoma, adenosquamous Granulosa CELL tumour
M83103 M91000
Carcinoma, clear cell Hydatidiform mole
M83803 M33300
Carcinoma, endometrioid Hydrosalpinx
M84603 M72005
Carcinoma, papillary serous Hyperplasia, atypical
M84803 M84906
Carcinoma, mucinous Kruckenberg tumour
M91003 M88900
M89803 Leiomyoma, NOS
Carcinosarcoma M88903
M74008 Leiomyosarcoma
CIN3 M58240
M74007 Lichen sclerosus et atrophicus
CIN2 M89513
M74006 Mesodermal mixed tumour
CIN1 M85423
M76720 Paget's disease, extramammary
Condyloma accuminatum M80520
M33520 Papilloma, squamous cell
Cyst, corpus luteum M33800
M33500 Polycystic change, NOS
Cyst, follicular M28000
M33540 Products of conception, NOS
Cyst, haemorrhagic M31050
M84703 Prolapse
Cystadenocarcinoma, mucinous M79590
M84413 Pseudodecidual reaction
Cystadenocarcinoma, serous M90900
M84700 Struma ovarii
Cystadenoma, mucinous M90800
M84400 Teratoma, mature

215
 Histopathology Diagnosis
M86000 M14940
Thecoma Torsion
M34210 M26200
Torsion Undescended testis

URINARY AND MALE GENITAL RENAL PATHOLOGY

M72450 M53150
Prostatic hyperplasia Acute tubular necrosis
M58240 D23810
Balanitis xerotica obliterans Diabetes mellitus
M90703 M46880
Carcinoma, embryonal Glomerulonephritis, crescentic
M81203 M53341
Carcinoma, TCC Glomerulonephritis, focal and segmental
M81303 D67300
CIS, urothelial Glomerulonephritis, IgA nephropathy
M83123 M68130
Carcinoma, renal cell Glomerulonephritis, membranous
M84460 M46840
Caruncle, uretharal Glomerulonephritis, proliferative
M91003 M46850
Choriocarcinoma Glomerulonephritis, minimal change
M76720 M46860
Condyloma accuminatum Glomerulonephritis, mesangioproliferative
M26000 M46810
Cryptorchidism Glomerulonephritis, proliferative
M73370 M47740
Cystitis cystica Light-chain disease
M73300 M97303
Glandular metaplasia Multiple myeloma
M33380 M89603
Hydrocele sac Wilms' tumour
M33300
Hydronephrosis CARDIOVASCULAR SYSTEM
M43180
Malakoplakia M32400
M82905 Aneurysm
Oncocytoma M40000
M81200 Arteritis
Papilloma, transitional cell M52100
M74000 Atheroma
HGPIN M35300
M90603 Embolus
Seminoma, Classic M37100
M90623 Haematoma
Seminoma, anaplastic M40160
M90633 Temporal arteritis
Seminoma, spermatocytic M35110
M75010 Thrombus
Spermatocele
M90801 ENDOCRINE
Teratoma
M90803 M83700
Teratoma, malignant Adenoma, adrenal cortical

216
 The Skilful Pathologist Series

M83300 M84303
Adenoma, follicular Carcinoma mucoepidermoid
M82900 M88501
Adenoma, Hurthle Acinic cell tumour
M83703 M89400
Carcinoma, adrenal cortical Adenoma, pleomorphic (benign mixed
M82803 tumour)
Carcinoma, anaplastic M43000
M83303 Chalazion
Carcinoma, follicular M72900
M82903 Cholesteatoma
Carcinoma, Hurthle cell M43750
M83453 Chondrodermatitis nodularis helicis
Carcinoma, medullary M76820
M82603 Nasal polyp
Carcinoma, papillary M30010
M86921 Sialolithiasis
Carotid body tumour D38300
M86931 Sjogren’s syndrome
Chemodectoma M85610
M26090 Warthin’s tumour
Ectopic adrenal cortex
M26100 RESPIRATORY
Ectopic thyroid tissue
M94903 M34310
Ganglioneuroblastoma Atelectasis
M94900 M32100
Ganglioneuroma Bronchiectasis
M71600 M45700
Goitre, NOS Bronchiolitis obliterans
D21930 M82401
Grave’s disease Carcinoid tumour
M45810 M82503
Hashimoto's thyroiditis Carcinoma, bronchioloalveolar
M95003 M80123
Neuroblastoma Carcinoma, large cell
M82905 M80333
Oncocytoma Carcinoma, sarcomatoid
M86801 M80413
Paraganglioma Carcinoma, small cell
M87000 M86931
Pheochromocytoma Chemodectoma
M11600 M35300
Radiation injury Embolus
M26500 M32800
Thyroglossal duct cyst Emphysema
M45000 M41400
Thyroiditis, Riedel's Empyema
M44050
Eosinophilic granuloma
HEAD AND NECK M90500
M91600 Mesothelioma, benign
Angiofibroma, juvenile M90503
M82003 Mesothelioma, malignant
Carcinoma, adenoid cystic M85801

217
 Histopathology Diagnosis
Thymoma Giant cell tumour of tendon sheath
D12010
BONE AND SOFT TISSUE Gout
M88500
M93100 Lipoma
Adamantinoma M74100
M93100 Lipomatosis
Ameloblastoma M88503
M33640 Liposarcoma
Aneurysmal bone cyst M88303
M88610 Malignant fibrous histiocytoma
Angiolipoma M88003
M88600 Malignant soft tissue tumour
Angiomyolipoma M74940
M33600 Metaphyseal fibrous defect
Baker's cyst M73410
M88000 Myositis ossificans
Benign soft tissue lesion M95600
M92300 Neurilemmoma
Chondroblastoma M95400
M92200 Neurofibroma
Chondroma, NOS M95403
M73670 Neurogenic sarcoma
Chondromatosis, synovial M49770
M92410 Neuroma, traumatic
Chondromyxoid fibroma M76130
M92203 Nodular fasciitis
Chondrosarcoma, NOS M50230
M93703 Osteoarthritis
Chordoma M92000
D80810 Osteoblastoma
Dermatomyositis M92100
M88211 Osteochondroma
FibromatosiS M91800
M76120 Osteoma
Dupuytren's contracture M91803
M92200 Osteosarcoma
Enchondroma M74970
M44050 Paget's disease of bone
Eosinophilic granuloma M47830
M92603 Pigmented villonodular synovitis (PVNS)
Ewing's sarcoma D73210
M71440 Polyarteritis nodosa
Exostosis M89003
M88100 Rhabdomyosarcoma
Fibroma, NOS D30710
M74920 Rheumatoid arthritis
Fibrous dysplasia M88003
M12000 Sarcoma, NOS
Fracture M95600
M33600 Schwannoma
Ganglion cyst
M92501
Giant cell tumour of bone
M47830

218
 The Skilful Pathologist Series

HAEMATOPATHOLOGY Lymphoma, T-cell

M97303
M72280 Multiple myeloma
Angioimmunoblastic lymphadenopathy M98620
M72220 Myelodysplastic syndrome
Dermatopathic lymphadenopathy M99601
M73500 Myeloproliferative disease, chronic
Extramedullary haematopoiesis M72200
M57510 Reactive lymphoid hyperplasia, NOS
Haemosiderosis M77810
M97513 Sinus histiocytosis
Langerhans cell histiocytosis M77940
M96533 Sinus histiocytosis with massive
Hodgkin Lymphoma, Classical lymphocyte lymphadenopathy
depleted M85800
M96513 Thymoma
Hodgkin Lymphoma, Classical lymphocyte
predominant
M96523
Hodgkin Lymphoma, Classical mixed
cellularity
M96563
Hodgkin Lymphoma, Classical nodular
sclerosis
M96503
Hodgkin Lymphoma, Classical NOS
M96593
Hodgkin Lymphoma, nodular lymphocyte
predominant
M98003
Leukaemia, chronic lymphocytic
M98613
Leukaemia, Acute myeloid
M98003
Leukaemia, NOS
M95903
Lymphoma, NOS
M95903
Lymphoma, diffuse large cell
M96903
Lymphoma, follicular
M98233
Lymphoma, small lymphocytic
M96733
Lymphoma, mantle cell
M96993
Lymphoma marginal zone, MALT
M96993
Lymphoma marginal zone, nodal
M96893
Lymphoma, marginal zone, splenic
M96223
Lymphoma, mantle cell
M95910

219
SYNDROMES
POLYPOSIS SYNDROMES:
 Gardner's: AD; polyposis + osteomas + skin cysts + soft tissue fibromatosis;
high risk of colon cancer
 Cowden's: non-Peutz-Jegher's hamartomatous polyps + facial
trichilemmomas + oral papillomas
 Cronkhite-Canada: polyposis +alopecia + hyperpigmentation + dystrophic
changes in nails
 Turcot's: AR; adenomatous polyps + glioblastoma
 Peutz-Jeghers: AD, hamartomatous polyps + pigmentation around lips,
mouth, face, genitalia, palmar surfaces of hands
ENDOCRINE SYNDROMES
 Addison's disease: 1ry chronic adrenocortical insufficiency (weakness +
fatigability + anorexia + weight loss + hypotension)
 Adrenogenital: adrenocortical hyperplasia  virilisation in women,
feminization in men or precocious puberty in children
 Carcinoid: ++ serotonin release (metastatic carcinoid to liver)  blushing +
angiomas of the skin+ (R) side valves vegetations + diarrhoea + bronchospasm
 Conn's: 1ry hyperaldosteronism due to an adrenocortical adenoma
 Cushing's: ++ secretion of cortisol caused by elevated ACTH levels; moon
facies + acne + abdominal striae + hypertension + amenorrhea + hirsutism
 Nelson's: pituitary adenoma + malignant histology, after bilateral
adrenalectomy
 Sheehan's: postpartum pituitary infarction
 Stein-Leventhal: polycystic ovaries + amenorrhea+ sterility
 Waterhouse-Friderichsen: haemorrhage + destruction of adrenals, 2ry to
toxaemia or meningitis
LIVER SYNDROMES
 Alagille: AD; jaundice due to progressive loss of bile ducts + vertebral
anomalies, +hypogonadism
 Caroli's disease: communicating cavernous biliary ectasia
 Crigler-Najiar: Jaundice, due to impaired conjugation of bilirubin by the liver
 Dubin-Johnson: AR defect in bile canalicular transport,  Black liver
 Gilbert's: Jaundice due to decreased uptake of bilirubin by the liver
 Reye's: steatosis + encephalopathy in children treated with aspirin for a viral
illness
 Vanishing bile duct: irreversible loss of bile ducts after liver transplantation
BONE/SOFT TISSUE SYNDROMES

 Albright's: polyostotic fibrous dysplasia + skin pigmentation

 Ehlers-Danlos: defect in collagen synthesis
 Gorham's disease: bone resorption and replacement by ++ vascularised
tissue
 Maffucci's : multiple haemangiomas + enchondromas
 The Skilful Pathologist Series

 Marfan's: AD defect in connective tissue

 Ollie’s disease: multiple enchondromas + ovarian sex cord-stromal tumours
 Pott's disease: TB vertebrae
CANCER PRONE-HEREDOFAMILIAL DISEASES/SYNDROMES
 Ataxia-telangiectasia: AR, cerebellar ataxia + telangiectasias
(chromosome instability) lymphoma, leukaemia, gastric carcinoma
 Beckwith-Wiedemann: macroglossia + omphalocele + hemihypertrophy+
adrenal cytomegaly + islet hyperplasia 5%, Wilms' tumour
 Bloom's: Spontaneous chromatid breakage leukaemia, GI carcinoma
 Fanconi's anaemia: AR; renal hypoplasia + absent thumbs or radii
+pigmentation of skin+ microcephalyAML, Sq.CC, HCC
 Others:
 Bruton's agammaglobulinemia
 Cockayne syndrome
 Cowden Ds
 Diaphyseal Medullary Stenosis with Mg Fibrous Histiocytoma (DMS-
MFH)
 Dyskeratosis congenita (DKC)
 Dysplastic nevus syndrome (DNS)
 Familial /sporadic gastrointestinal stromal tumours (GISTs)
 Familial adenomatous polyposis (FAP)
 Familial Chronic Lymphocytic Leukaemia
 Familial nervous system tumour syndromes
 Hereditary breast cancer
 Hereditary non polyposis colorectal carcinoma (HNPCC Syndrome)
 Hereditary Pancreatic Cancer
 Hereditary papillary renal cell carcinoma
 Li-Fraumeni Syndrome
 Multiple Endocrine Neoplasia (MEN) type 1&2
 Naevoid basal cell carcinoma syndrome (NBCS)
 Neurofibromatosis (NF) type 1 & 2
 Peutz-Jeghers syndrome
 Retinoblastoma (Rb)
 Tuberous Sclerosis (TSC)
 Von Hippel-Lindau (VHL)
 WAGR (Wilms' tumour/aniridia/genitourinary anomalies/mental
retardation syndrome)
 Werner syndrome
 Xeroderma pigmentosa
LUNG SYNDROMES
 Caplan's: pulmonary rheumatoid nodules in pneumoconiosis/fibrosis
 Kartagener's: congenital absence of cilia  dextrocardia + sinusitis +
bronchiectasis+ infertility
 Loffler's: eosinophilic pneumonia + granulomas

221
 Histopathology Diagnosis
CARDIOVASCULAR SYNDROMES
 Eisenmenger's: reversal of cardiac (L) to (R) shunts (ASD, VSD, or PDA)
into (R) to (L) due to (R) ventricular hypertrophy + pulm. hypertension
 Fallot tetralogy: VSD + overriding aorta + pulmonary stenosis + (R)
ventricular hypertrophy cyanosis
 Osler-Weber-Rendu: AD, hereditary hemorrhagic telangiectasias
INFECTION DISEASES SYNDROMES
 Fitz-Hugh-Curtis: gonorrhoeal cervicitis spread to peritoneum
perihepatitis right upper quadrant pain
 Hansen's disease: leprosy
 Ramsay Hunt: facial paralysis, due to H.zoster
 Goodpasture's: type II, anti-GBM Ab destroys glomeruli
STORAGES SYNDROMES
MUCOPOLYSACCHARIDOSIS (MPS)
 Hurler's: type I MPS
 Hunter's: type II MPS; XL
 Sanfilippo's: type Ill MPS
 Morquio's: type IV MPS
GLYCOGENOSIS
 von Gierke's: type I glycogenosis
 Pompe's: glycogenosis II, lysosomal storage disease
 McArdle's: type V glycogenosis

SPHINGOLIPIDOSIS
 Tay-Sachs: sphingolipidosis, lysosomal storage disease
 Fabry's: sphingolipidosis, XL lysosomal storage disease
 Krabbe's: sphingolipidosis, lysosomal storage disease
(= globoid cell leukodystrophy)
 Gaucher's disease: AR, lysosomal storage disease (sphingolipidosis)
OTHERS
 Niemann-Pick disease: AR, lysosomal storage disease with zebra bodies
 Menkes': XL disorder of intestinal copper absorption, needed by lysyl-oxidase,
resulting in changes in aortic collagen and elastin
 Milroy's disease: resembles lymphedema praecox but present from birth and
inherited as Mendelian trait
 Plummer-Vinson: microcytic hypochromic anaemia, atrophic glossitis,
oesophageal webs
 Reiter's: triad of conjunctivitis, urethritis, and arthritis
VASCULAR SYNDROMES
 Agammaglobulinemia of Bruton: X-linked 1ry immunodeficiency with
defective B-cell maturation and near-total absence of immunoglobulins in
serum
 Arthus reaction: localized form of type Ill (immune complex mediated)
hypersensitivity reaction
 Chediak-Higashi: several defects in leukocytes, including impaired
chemotaxis; autosomal recessive

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 Churg-Strauss: variant of polyarteritis nodosa (PAN) + bronchial asthma +

pulmonary vasculitis + granulomata
 CREST: calcinosis, Raynaud's phenomenon, oesophageal dysmotility,
sclerodactyly, telangiectasia: a limited form of scleroderma
 DiGeorge's: selective T-cell immunodeficiency resulting from failure of
development of the 3rd and 4th pharyngeal pouches (thymus, parathyroids, C
cells of thyroid)
 Horton's disease: temporal (giant cell) arteritis
 Kasabach-Merritt: thrombocytopenia complicating a giant haemangioma
 Loffler’s endocarditis: restrictive cardiomyopathy/ endocarditis
 Raynaud's disease: Raynaud's phenomenon occurring in the absence of an
anatomic lesion in the vessel walls
 Raynaud's phenomenon: pain+cold+blue skin of hand/feet in response to
cold
 Sturge-Weber: port wine stain of face in distribution of trigeminal nerve
associated +ipsilateral vascular malformations of the leptomeninges &
retina
 Trousseau's: migratory thrombophlebitis in malignancy; first described for
pancreatic carcinoma
 von Hippel-Lindau: AD, cavernous haemangioblastomas of cerebellum or +
haemangiomas +cysts of pancreas, liver, kidneys
 von Recklinghausen's disease: AD, multiple plexiform neurofibromas+ cafe'
-au-lait macules+ Lisch nodules
 Werdnig-Hoffman disease: =infantile spinal muscular atrophy: AR,
hypotonia caused by absence/loss of LMN from the anterior horns of the
spinal cord
 Zollinger-Ellison: gastric hyperplasia 2ry to a gastrin secreting tumour
IMMUNITY DISORDERS
 DiGuglielmo's: erythromyeloblastic leukaemia (M6 AML)
 HELLP: haemolysis+ elevated liver function tests + low platelets in
toxaemia of pregnancy
 Mikulicz's: = Sjogren's syndrome, autoimmune sialadenitis
 Nezelof's: absent thymus and cell mediated immunity (like DiGeorge's)
but with normal parathyroids
 Parinaud's (= oculoglandular syndrome): swelling of the eye, jaw, and high
cervical lymph nodes
 Schmidt's: type II autoimmune Addison's disease
 Stevens-Johnson: severe form of erythema multiforme with mucosal
involvement, conjunctivitis, high fever
 Wiskott-Aldrich: XL, immunodeficiency of T cells + thrombocytopenia
+eczema
BODIES

 Alder-Reilly bodies: accumulation of GAGs (glucosaminoglycans) in WBCs

in MPS (mucoploysaccharidosis). These bodies accumulate in neurones as
ZEBRA

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 Histopathology Diagnosis
 Aschoff bodies: foci of fibrinoid necrosis within the myocardium of a patient
with acute rheumatic fever
 Asteroid bodies: acidophilic, stellate inclusions in giant cells in sarcoidosis
and berylliosis
 Barr bodies: inactivated X chromosome-dark staining mass in contact with
the nuclear membrane
 Blue bodies: laminated PAS+ iron-containing bodies in alveolar macrophages
of desquamative interstitial pneumonia
 Call-Exner bodies: small gland like "follicles" filled with acidophilic material
often seen in ovarian granulosa cell tumours
 Civatte bodies: apoptotic basal epidermal cells in Lichen Planus (= colloid
bodies)
 Corpora amylacea: argyrophilic and PAS+ polyglucosan globules in terminal
processes of astrocytes
 Corpora arantii: small fibrous nodules at the centres of the semilunar valve
cusps along the lines of closure
 Councilman bodies: apoptotic, eosinophilic hepatocytes extruded into the
sinuses
 Cowdry type A inclusion: acidophilic intranuclear inclusion separated from
the nuclear membrane by an artefactual cleft-typical of herpes-infected cells
 Donovan's body: intracellular bacillus; C. donovani, seen in histiocytes in the
genital skin in granuloma inguinale
 Dutcher bodies: "intranuclear" inclusions of immunoglobulin in plasmacytoid
cells
 Dӧhle bodies: large blue, cytoplasmic inclusions in reactive neutrophils and
toxic granulations
 Gandy-Gamna bodies: calcium + hemosiderin + fibrosis in the spleen in
hemolysis or chronic congestion
 Glomus bodies: small arteriovenous anastomoses in the skin responsible for
thermoregulation. These are the origin of glomus tumour
 Guarnieri's bodies: epidermal cells + eosinophilic cytoplasmic inclusions in
smallpox
 Haematoxylin bodies: = LE bodies
 Heinz bodies: clumps of precipitated oxidized Hb in the cytoplasm of RBCs
 Hirano body: eosinophilic, football-shaped inclusion seen in neurons of the
brain; part of normal aging, but more numerous in Alzheimer's disease
 Kamino bodies: intraepidermal hyaline globules, in Spitz nevus
 LE bodies: nuclei of damaged cells with bound anti-nuclear antibodies that,
when phagocytosed, form LE cells
 Lewy bodies: round, concentrically laminated, eosinophilic cytoplasmic
inclusions in niagral neurons in Parkinson's disease
 Mallory bodies: eosinophilic intracytoplasmic inclusions in hepatocytes:
intermediate filaments, predominantly prekeratin. Seen in alcoholic hepatitis and
other lesions
 Michaelis-Gutmann bodies: partially digested bacteria (calcified) in stroma
and in cells; seen in malakoplakia
 Negri bodies: bullet-shaped cytoplasmic inclusions in neurons (esp. Purkinje
cells); pathognomonic for rabies infection

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 The Skilful Pathologist Series

 Nemaline bodies: Z-bands seen by electron microscopy in degenerative

skeletal muscle diseases
 Oval fat bodies: renal tubular epithelial cells full of fat in nephrotic syndrome,
associated with fatty casts. Maltsese crosses
 Pick bodies: oval, filamentous inclusion, stains with silver in Pick’s disease
 Russell bodies: cytoplasmic immunoglobulin inclusions in plasma/
plasmacytoid cells
 Schaumann bodies: concentrically laminated inclusions in giant cells in
sarcoidosis and berylliosis
 Schiller-Duval bodies: endodermal sinuses: glomeruloid structures seen in
yolk sac tumours
 Verocay bodies: palisades of nuclei at the end of a fibrillar bundle in a
schwannoma (neurilemmoma)
 Weibel-Palade bodies: rod-shaped cytoplasmic organelles in endothelial cells
containing von Willebrand factor
 Zebra bodies: palisaded lamellated membranous cytoplasmic bodies seen by
EM in macrophages in mucopolysaccharidosis, e.g., Niemann-Pick disease,
CELLS

 Adria cell: cardiac myocyte that has lost its cross-striations and myofilaments
2ry to Adriamycin (doxorubicin) toxicity
 Caterpillar cells: large multinucleated giant cells with lengthwise chromatin
clumping in nucleus; seen in heart in acute rheumatic fever
 Faggot cells: malignant promyelocytes of M3 AML containing Auer rods, like
"sticks in a fireplace"
 Physaliferous cells: huge tumour cells have bubbly vacuolated cytoplasm
(glycogen) + vesicular nuclei (diagnostic for chordoma)
 Smudge cell: cell with a large, ovoid nucleus filled with a granular
amphophilic mass + indistinct nuclear membrane; seen in adenovirus-
infected cells
 Warthin-Finkeldey cells: multinucleated giant cells + eosinophilic nuclear
and cytoplasmic inclusions in measles
RODS
 Auer rods: red rod-shaped lysosomes (abnormal) seen in malignant cells of
predominantly M3 acute myeloid leukaemia
GRANULES
 Birbeck granules: "tennis racket"-shaped granules in cytoplasm of
Langerhans' cells (histiocytosis X) with trilaminar handle"
 Lipofuscin granules: polymers of lipid complexed with proteins; responsible
for brown atrophy
 Sulphur granules: yellow foci of Actinomyces
BLOBS
 Blue-blobs: atrophy in Pap smears
CRYSTALS
 Charcot-Leyden crystals: crystals shaped like double pyramids; found in
sputum of asthma patients; made by eosinophils

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 Histopathology Diagnosis
 Reinke's crystalloids: crystals found in Leydig cells of testes: hexagonal
prisms, tapered ends, moderately electron dense
CORPUSCLES
 Hassall's corpuscles: concentric aggregates of keratinized epithelial cells
and keratin in the medulla of the thymus

TEETH

 Hutchinson's teeth: inflammatory destruction of the teeth seen in tertiary

syphilis
RINGS
 Kayser-Fleischer rings: rings of discoloration on cornea of patients with
Wilson's disease
SPOTS
 Koplik's spots: spotty lesions that blister and ulcerate deep in the cheek
mucosa; diagnostic for measles
PATCHES
 Cafe au lait patches, seen in neurofibromatosis
SPIRALS

 Curschmann's spirals: twisted mass of mucus seen in sputum of patients

with asthma
EXCRESCENCES
 Lambl's excrescences: small fibrin vegetations overlying sites of
endothelial damage on flow side of cardiac valves
NODULES
 LibmanSacks nodules: non-bacterial verrucous cardiac valve leaflet
vegetations seen in SLE
 Lisch nodules: pigmented iris hamartomas seen in patients with type I
neurofibromatosis

PLAQUES

 MacCallum's plaques: map like thickening of the endocardium over

myocardial lesions in acute rheumatic fever
 Soldier's plaque: white thickening of the pericardium from a healed
pericarditis
TANGLES
 Neurofibrillary tangles: microtubule-associated proteins and
neurofilaments, seen in Alzheimer's disease

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 The Skilful Pathologist Series

PROTUBERANCE
 Rokitansky's protuberance: central area of an ovarian mature cystic
teratoma containing bone and well-formed teeth
FIBRES
 Rosenthal fibres: intracytoplasmic hyaline structure, sometimes corkscrew
shaped, found in pilocytic astrocytes
CANALS
 Sucquet-Hoyer canals: shunts of glomus bodies, involved in thermal
regulation
OTHERS

 Zellballen: clusters of tumour cells surrounded by a thin fibro-vascular

stroma, seen in pheochromocytoma and extra-adrenal paragangliomas
 Rare Thyroid tumours:
 SETTLE (spindle epithelial tumour with thymus like element): spindle
cells + mucinous cyst or tubules
 CASTLE (carcinoma showing thymus-like element):epithelial lobules
separated by lymphocytes
 Collision tumour: follicular/papillary + medullary

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 Histopathology Diagnosis

REFERENCES
BOOKS
 Atlas of Tumour Pathology (AFIP) Series
 Current Diagnostic Pathology
 Diagnostic antibodies for immunohistochemistry
 Diagnostic Cytopathology
 Diagnostic Histopathology of Tumours
 Diagnostic immunohistochemistry
 Functional Histology: A text and colour atlas
 Histology for Pathologists
 Intraoperative Pathologic Diagnosis. Frozen section and other
techniques
 Introduction to Immunocytochemistry
 Modern Surgical Pathology
 Manual of surgical pathology
 Progress in Pathology
 Recent Advances in Histopathology Series
 Robbin’s Pathologic Basis of Disease
 Rosai and Ackerman’s Surgical Pathology
 Sternberg’s Diagnostic Surgical Pathology
 TNM Classification of Malignant Tumours”, Wiley-Blackwell; 7th edition
(27 Nov 2009), ISBN-10: 1444332414The
 Hospital Autopsy Theory and Practice of Histological Techniques

JOURNALS
 American Journal of Clinical Pathology
 American Journal of Surgical Pathology
 Histopathology Journal
 Journal of Clinical Pathology
 Journal of Pathology
 Modern Pathology

WEBSITES
 College of American Pathologists: www.cap.org/apps/cap.portal
 Department of Health: www.dh.gov.uk
 IHC: www.immunoquery.com
 Modernising Medical Career: www.mmc.nhs.uk
 NHS publications at NHS website: www.nhs.uk
 Pathmax website: www.pathmax.com
 Pathology Outlines website: www.pathologyoutlines.com
 Royal College of Pathologists Publications at: www.rcpath.org
 Research Articles: www.sciencedirect.com

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Index
CUT SECTION, 13

A
D
Acinic cell carcinoma, 52, 93, 159,
189, 197, 206 DCIS, 5, 42, 45, 51, 59, 119, 134, 138,
Adamantinoma, 12, 15, 62, 171, 186, 139, 148, 185, 186, 187, 203, 214
188, 226 Dermoid, 12, 181, 182, 218
Adenoacanthoma, 47, 223 Diffuse pattern, 60, 84
Adenoid cystic pattern, 54
Adenoma, 43, 46, 81, 206, 218, 220,
221, 225 E
Adenomatoid pattern, 54
Adenosquamous, 47, 48 Embryonal tumours, 47, 88
Alveolar pattern, 64 Endometrial carcinoma, 52, 54, 57,
Alveolar soft part sarcoma, 65, 171 59
Amyloidosis, 41 Endometrioid carcinoma, 54, 209
angiomyxoma, 70, 71, 73, 154, 160, Epithelial tumour, 34, 35
205 Epithelioid granuloma, 30
Angiomyxoma, 47, 73 Ewing’s sarcoma, 92, 93, 197
Angiosarcoma, 51, 58, 77, 203, 204,
212, 222 F
Apoptosis, 41, 80
fibrinoid necrosis, 38, 233
Fibromyxoid sarcoma, 69
B
Fibrosarcoma, 66, 215
Basal cell carcinoma, 51, 62, 171 Follicular pattern, 26, 53, 85
Benign bizarre tumours, 45
Bilharziasis, 20, 38, 178 G
breast carcinoma, 11, 28, 69, 174,
202, 214 gangrene, 12, 41, 42
Bronchogenic carcinoma, 47 Giant cell tumour, 29, 68, 171, 226
Giant cells, 29, 96
granulation tissue, 29, 30
C
Carcinosarcoma, 47, 48, 73, 75, 223 H
CELL INJURY, 40
Circumferential margin, 9 haemangioma, 34, 45, 68, 76, 179,
Clear cell carcinoma, 4, 58, 59, 93, 183, 184, 205, 232
209 Hemangiopericytoma, 53, 76, 152,
Clear cells, 59, 90, 92, 206 160, 161, 211
Clinical Pathology, 237 Hepatoblastoma, 48, 190
Cribriform, 54, 55, 135 Hobnail pattern, 58

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 Histopathology Diagnosis
Hodgkin’s, 6, 24, 26, 27, 30, 38, 47,
82, 85, 86, 87, 97, 163, 173, 184, N
186, 201, 213
Necrosis, 7, 12, 14, 41, 42, 51, 80,
Human Papilloma Virus, 5
137, 148, 162, 170, 186, 218, 219
Necrotizing granuloma, 39
I Nephroblastoma, 35, 48, 188, 190
Neuroendocrine, 26, 87, 90, 95, 117,
IDC, 5, 51, 161, 185, 202, 214, 216 135, 190, 211
Immunocytochemistry, 237 Non-caseating granuloma, 39
Inclusions, 41 Non-infective granuloma, 39
Indian-file pattern, 63 Non-malignant invasion, 45
Infiltrating Duct Carcinoma, 5
inflammatory atypia, 29, 170, 174
INFLAMMATORY PATTERN, 36 O
intracellular mucin, 57
osteoid, 34, 65, 67, 73, 74, 161, 181
Osteosarcoma, 34, 73, 74, 75, 227
L
Leiomyosarcoma, 66, 67, 96, 122, P
203, 209, 212, 215, 219, 223
Palisaded granuloma, 39
Lethal injury, 41, 80
papilloma, 20, 43, 44, 59, 60, 177, 179
Leukaemia, 5, 46, 60, 215, 219, 227,
Pathologic calcification, 28
230
Pattern recognition, 35, 152
Lipid vacuoles, 216
Pigmentation, 41
Lipoid granuloma, 38
PLAP, 208
Lung abscess, 17
Pleomorphic sarcomas, 68, 89, 90
Pleomorphic spindle, 67
M PROFORMA, 10
prostate, 208
Marjoline ulcer, 180 Pseudosarcomas, 68
Mesenchymoma, 48
mesothelioma, 49, 59, 60, 64, 69, 88,
119, 160, 161, 179, 183, 197, 213, R
216
Retiform pattern, 54
MIXED GLANDULAR PATTERN,
rhabdomyosarcoma, 47, 48, 65, 66,
56
67, 70, 71, 73, 88, 89, 90, 96, 172,
MPNST, 35, 66, 67, 73, 74, 89, 190,
204, 205, 216
203, 212
Ring-shape (doughnut) granuloma,
MULTIPLE LESIONS, 18
39
Myoepithelioma, 48, 93, 95, 212
Rosettes, 61
Myxoid liposarcoma, 48, 72, 73
Round cells, 89
Myxoid matrix, 70

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Synovial sarcoma, 34, 48, 54, 89, 94,

S 152, 171, 173, 189, 190, 204, 212,
215
Sarcoma, 14, 34, 46, 47, 159, 183,
210, 227
Sarcomas, 14, 34, 45, 74, 87 T
Sarcomatoid, 34, 68, 90, 125, 209
schwannoma, 68, 73, 74, 89, 150, Teratoma, 34, 47, 48, 224
185, 189, 196, 234 TNM, 2, 7, 10, 109, 111, 112, 117, 121,
Signet-ring, 90, 96, 185 126, 131, 237
Small round cell tumour, 184 TUMOUR CLASSIFICATION, 46
Spindle cell, 66, 184, 185, 203
Spindle cells, 69, 89
Squamoid, 64, 90, 154 V
Villous adenoma, 59

231