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Pathology

Jaroslava Dušková

Inst. Pathol. ,1st Med. Faculty,

Charles Univ., Prague

Bridging

Medical

BranchesJaroslava Duško

vá

General Pathology I

Introduction

– where to find information

– who is a pathologist

– what is pathology

health and disease

Activities in pathology

– autopsy

– biopsy

– cyto(patho)logyPROGNOSTICATION-PREDICTION- PREVENTION

Methods

– macroscopy

– light microscopy

– ultrastructure (electron microscopy)

– molecular pathologyProf. Jaroslava Duskova, MD, PhD, FIAC

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http://pau.lf1.cuni.cz/

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Pathologist !?!

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Pathologist ????

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Pathologist =anonymous diagnostic service

for ALL medical specialisations

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Pathologyscience on diseases

– causes (etiology)

– mechanisms of

formation (pathogenesis)

– development (prognosis)

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Disease

– health disturbance

Health (WHO) – status of full

physical and mental and social

wellfare and harmony

Disease – adaptation mechanisms overcome

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Disease - manifestation

features– symptoms

– general - local

– subjective - objective

sets of features – syndromesJaroslava Duško

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W-F syJaroslava Duško

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Diagnosis – disease identification

Based on

history

symptoms

targeted search in asymptomatic

(screening)

laboratory tests and imaging

Differencial diagnosis !!!

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Disease - description

Etiology – cause(s)

Pathogenesis – development

Complications

Healing (sequela/e)

Prognosis

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Causes of

diseases

External

– physical

– chemical

– biological

– environmental

– nutritional

Internal

– genetic

– disposition

(tendency)

– immune disorders

hypersensitivity

(alergy)

immunodeficiency

autoimmunity

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Pathology general

special– organ

– nosological(nosos= illness)

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Dissection in the University of

Bologna in the 14th century. The

body, of an executed criminal,

is being studied by a group

of students.

New anatomical theatre,

University of Rome, Italy,

1785-1805.

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Steps from the History of Pathology

(starting with the „anatomical“ era)

Andreas Vesalius (1514-1564) 1543

Jan Jesenius (1566-1621 1600

G.B.Morgagni 18th cent.

A.van Leuwenhoek

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Steps from the History

of Pathology 19th cent.

R.L.K. Virchow

I.P.Pavlov

K. Rokitansky

V.Treitz

V.D.Lambl

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German anatomist and pathologist,

• Rudolf Ludwig Karl Virchow (1821-

1902). studied medicine at Berlin

University (1840-1843)

• working as a surgeon in the Charite

Hospital in Berlin

• lectures on pathological and surgical

anatomy.

• In 1847 he established the Archives for

Pathological Anatomy, Physiology &

Clinical Medicine,

• In 1855-1856 he published his major

work 'Collected Essays for Scientific

Medicine', which was followed in 1859

by his 'Treatise on Constitutional

Syphilis'.

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Karl Freiherr von

Rokitansky (1804-1878)

Austrian pathologist,

born February 19, 1804, Königgrätz, Böhmen, Austrian Empire (now Hradec Králové, East

Bohemia, Czech Republic);

died July 23, 1878, Wien.

Handbuch der

pathologischen

Anatomie IInd Band,

Wien 1842

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The Vienna School of Pathology

(& Czech Specialists)

Karl Rokitansky, Josef Škoda-signatures from the memorial book

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1837 - first autopsy (protocol preserved in the

institute archives)

pathology -

compulsory subject

founder of the

MUSEUM

VINCENC ALEXANDER

BOCHDALEK

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1858

VÁCLAV

TREITZ 1819-1872 Hernia retroperitonealis -

Treitzi

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Herwig

Hamperl

- 1945

Chairman of the German Institute of

Pathology, Charles University, Prague

in years 1940-1945.

Werdegang und Lebensweg eines

Pathologen . Stuttgart Vrlg. 1972

A Pathologist's Life and Evolution

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Steps from the History

of Pathology 20th cent.

Jaroslav Hlava

Heřman Šikl

Antonín Fingerland

Blahoslav Bednář

Ctibor Povýšil

editors of Czech textbooks

of pathology

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Activities in Pathology

Observation subject

necropsy (autopsy)

biopsy

cytology

experiment– animals– tissue cultures

molecular techniques

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Methodology of Pathology

Observation

level

macroscopy

microscopy

ultrastructure

Special methods

histochemistry

immunohistochemistry

quantitative (computer)

image analysis

genetic methods

– FISH, PCR, CGH, …

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AutopsyAfter the 2nd world war standing decrease

abroad < 10%, Czech Rep. < 50%

Aims– clinicopathological diagnosis

– cause of death

– dg. errors

– therapy effects assessment

– data on old and new diseases

– teaching

– event. medicolegal aspects of death

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Autopsy

dissection method unchanged

since the end of 19th century

changes in taking material for

special methods & their

employment to cope with clinical

questions

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Ulcus chronicum pepticum pylori

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Helicobacter pylori (Warthin – Stary impregnation)

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Clinicopathological Diagnosis

Morbus principalis

Complicationes

Causa mortis

Inventus accesorius

Epicrisis

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Biopsy

After the 2nd world war standing increase

Aims

– nosological diagnosis

– tumour pathology

– typing, staging, grading, prediction

– evaluation of therapy efficiency

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Biopsy sample - fixed

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Basic staining

H&E

van Gieson

and elastics

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Atherosclerosis gr. II. a. coronariae cordis

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Myofibrosis ventriculi sin. cordis

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alc. blue, pH 2,5

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Carcinoma mammae lobullare invasivum alc. blue pH2,5

signet ring cells

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Fe

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Klűver- Barrera

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Immunohistochemistry

detection of an antigenic component in

the histology section

helpful in identifying cellular &

extracellular components

part of daily routine & investigation

useful but limited (like any other method)Jaroslava Duško

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Immunohistochemistry - steps

blockage of non-specific positivities- esp.

endogenous peroxidase

incubation with a commercially available

specific antibody

visualisation of the positive reactionJarosla

va Dušková

Direct immunohistochemical method

Primary antibody

Antigen

Peroxidase

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Primary antibody

Secondary antibody

Streptavidin-biotin method. Enzyme marked

avidin or avidin-biotin complex with enzyme

marked biotin reacts with biotinylated secondary

antibody.

Peroxidase

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Leiomyoma intestini crassi (MSA immunohistochemistry)

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H&E Fe

TGB

PTH

Adenoma glandulae

parathyreoideae

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Carcinoma mammae lobulare invasivum ILC

HE ER

PRalc. blue 2,5

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Carcinoma mammae ductale invasivum IDC

HE PRER

MIB1 e-cadherin c-erbB2 / Her2-neu

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„Classical“ Biopsy (formol paraffin technique)

simple may be done in two days

immuno reactions two days more

further sectioning two days more

oncol. dg. - WHO classificationJarosla

va Dušková

Peroperation Biopsy-Frozen section

reported DURING MINUTES !!!

morphological artefacts

(combination with cytology)

limited extensity of investigation

limited time

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Cytology

After the 2nd world war standing increase

Aims

– screening

– nosological diagnosis

– evaluation of therapy efficiencyJarosla

va Dušková

Diagnostic Cytopathology

Jaroslava Dušková

Inst. Pathol. ,1st Med. Faculty, Charles Univ. Prague

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Gynecological

oncologic

cytology

laboratory investigation standard

Authors: MUDr Alena Beková, MIACMUDr Pavel Tretiník, MIAC

Oponents: doc. MUDr J. Dušková, CSc,FIACMUDr Eva Svobodová

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SIL H

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invasive ca

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F

N

A

B

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respiratory

epithelia

muscle

fatty

tissue

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Morphological Diagnostic Methods

Clinical

PathologicalJarosla

va Dušková

Morphological Diagnostic Methods

Clinical:

macroscopy of lesions

visible with the naked eye

invisible with the naked eye -

IMAGING (X-ray,

sonography, scintigraphy, endoscopy,

CT,…)

magnifying glass - colposcopy

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Morphological Diagnostic Methods

Pathological

macroscopy

microscopy

ultrastructure

IMAGINGJarosla

va Dušková

Archiving- sending- wireless consultations…..

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Morphometric Investigations

Objectivisation & refinement

of diagnostic methods

staging (e.g. malignant melanoma –

thickness of the neoplasm)

grading (e.g. kidney carcinoma – size of the

nuclei)

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Carcinoma intestini crassi

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Malignant Melanoma measurement - a compulsory part of biopsy report

Breslow – max. thickness [mm]

Clark – level of skin involvement

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AgNOR Measurements

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Morphometric evaluation of

the Focus Score

in the LUCIA system

Jaroslava DuškováLadislav Korábek

Inst Pathol. and Stomatology Clinic 1.st Med. Faculty, Prague

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Focus Score

morphometric expression of intensity of

focaly accented chronic sialoadenitis

focus – agregate of 50 and more

lymphocytes(defined 1968)

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Ultra-

structural

morphometry

of internal

limiting

membrane

of retina

Dg. H35.3 Degeneration of macule

and posterior eye pole

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Epimacular

membrane of retina

Ultrathin section

5000x

Semithin section 400x

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Molecular Genetic Methods

PCR, FISH, CGH, Hybrid capture, New

Generation Sequencing…

a part of daily routine diagnostics of

neoplasms and other diseases

– prognostic, and

– predictive (therapeutic response) – EGFR,

VEGF, k- ras….

histopathological & cytopathological samples

suitable

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Invasive ductal breast cancer with signal amplification

c-erbB2 (Her2-neu)

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Hybrid capture system– DML 2000 microtitration plate– 8channel pipette– disposable pipettes– heater block– rotary shaker – luminometer– pc– sw– printer

Detection of LR & HR

HPV1. specimen denaturation

2. hybridization with HPV RNA-

probes

3. capture hybrids RNA/DNA using

monoclonal AB on microtiter plates

4. second monoAB marked with

alkaline phosphatase AP

5. AP splits chemoluminiscent

substrat

QUANTIFIABLE RESULT

detection of 5 types LR and 13 types HR HPV

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Particitation of Pathologists

in the Czech National Screening Programs:

Breast cancer: mammography – core biopsy- resecate

Colon Cancer: occult bleeding test– endoscopy – endoscopic

biopsy - resecate

Cervical cancer: Pap test – colposcopy - punch biopsy - resecate

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Cancer Immunotherapy and the Role

of Pathologist in Immuno-Oncology

Tumor antigens on the cell membrane of

cancer cells are recognized by the

immune cells.

Multiple antibody therapies are approved

to treat a wide range of cancers.

Immune checkpoints can be stimulatory or

inhibitory. Tumors can use these

checkpoints to protect themselves from

immune system attacks

85

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Testing Lung Cancer for PD-L1 (Programmed Death-1 Ligand)

The interaction of PD-L1 on the tumor

cells with PD-1 on a T-cell reduces T-cell

function signals to prevent the immune

system from attacking the tumor cells

PD-1 inhibitors (Nivolumab, Pembrolizumab)

and PD-L1 inhibitors increase the T- cell

ability to destroy cancer cells

86

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The Role of Pathologist in Immuno-oncology

For certain

types/stages

of cancer, knowing

PD-L1 expression

may help identify

patients that will

benefit most from

immune checkpoint

blockade.

88

Reasons for testing PD-L1 expression in patients

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Pathology an extremely exciting medical

specialty

helping to understand & treat the diseases

via

diagnostic service

for ALL other specialties

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