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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
84
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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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