systemic_path_slides_final-by_a_student.pdf

8/10/2019 Systemic_path_slides_Final-by_a_student.pdf

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Case # 1, Alcoholic liver cirrhosis


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1. Alcoholic Micronodular cirrhosis of the liver:

This is a liver specimen with an irregular scarred capsular surface and

shows fine, diffuse, nodularity, the nodules varying from 1-3 mm in

diameter. Note also the yellowish-brown discoloration * Hepatic cirrhosis is defined as a diffuse fibrosis, irreversible condition

characterized by hepatocellular injury leads to compensatory

hyperplasia (regenerative nodules) with disruption of the normal

architecture. Subclassified into 2 types on the basis of the size of

nodules; Micro-nodular is less than 3 mm. and Macro-nodular islarger than 3 mm. up to 5 cm.(is not value)

The most important classification of the cirrhosis is according to the

cause; 65% of the cases are due to alcoholic liver disease. The second

cause of the cirrhosis is chronic hepatitis B and C viruses.

* Complications: hepatic failure which leads to hepatic encephalopathy,portal hypertension (with associated splenomegaly, ascites and

esophageal varices) and renal failure.


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Case # 2, Budd-Chairi syndrome of the liver


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2. Budd-Chairi syndrome of the liver: This is a post-mortem liver specimen, at autopsy there were extensive

thrombosis within the efferent hepatic veins. The cut surface of theliver shows irregular areas of intense congestion and mottling,

separated by rather pale, yellowish-brown parenchyma. Many of the

veins are visibly occluded by thrombus.

* Budd-Chairi syndrome results from occlusion of the major hepatic

veins, most often by thrombus, while many cases remain idiopathic,recognized causes include any coagulopathy (particularly

polycythemia rubra vera), occlusion of major hepatic veins or inferior

vena cava by tumor, thrombophlebitis of the hepatic veins and various

drugs (e.g. birth control bills) or chemical toxins


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Case # 3, Chronic active hepatitis & cirrhosis


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3. Chronic Active Hepatitis and Cirrhosis of the Liver:

This is a post-mortem liver specimen, with the cut surface of the liver

shows an obvious irregular macronodular cirrhosis with evidence of

active hepatitis histologically by presence of piecemeal necrosis. *

Chronic hepatitis, which most often complicates hepatitis B or

hepatitis C

infection. Rare causes by drugs (such as methyl dopa) or autoimmune

hepatitis. *Chronic active hepatitis usually represents a particularly

aggressive host response to type B or C infection. Its significance lies

in the fact that changes in the lobular liver architecture leads to

cirrhosis in 50 % or more of patients.


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Case # 4, acute fulminant viral hepatitis


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4. Acute Fulminant Viral Hepatitis of the Liver with massive

necrosis:

This is a post-mortem liver specimen of elderly man died from hepaticfailure after infection by acute viral hepatitis.

The cut surface of the liver is notably pale, enlarged in size (normally,

the liver in fresh state weighing only 670 gram = approximately 11/2

pound) and representing almost total necrosis with a few islands of

viable hepatic parenchyma remaining as brownish foci on the left.

*Microscopic finding : Multifocal areas of necrosis with lymphocytic

infiltrate, degeneration of hepatocyte cells, hyperplasia of Kupffer cells

and councilman bodies (fragmented, eosinophilic staining and

shrunken cells).

*Causes of the acute viral hepatitis include 5 types (please see the tablein page 101 of A Lecture Guide of Pathology II).

*Complications: Patients become carriers of infection or may develop

chronic hepatitis, cirrhosis or hepatocellular carcinoma


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Case # 5 Hepatocellular carcinoma with cirrhosis


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5. Hepatocellular Carcinoma with Micronodular Cirrhosis of the

Liver:

This is a post-mortem liver specimen. The cut surface of this liver shows a fine, uniform, micronodular

cirrhosis. A rounded, partly bile-stained tumor, measuring 6.5 cm in

diameter, arises near the diaphragmatic surface and appears well-

circumscribed. A similar tumor is apparent at the bottom right.

*Hepatocellular carcinoma is relatively uncommon in Caucasians butappears increasing incidence in Asia and Africa. This tumor most

often affects adults between the ages of 40 and 60 with pre-existing

cirrhosis (This is the most common cause), also cirrhosis of chronic

active hepatitis B&C. A well-recognized environmental carcinogen, is

aflatoxin derived from a fungus (such as aspergillus flavus) in food.

* Prognosis is very poor with few patients surviving more than one

year.


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Case # 6, Cholelithiasis of the gall bladder


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6. Cholelithiasis of the Gall Bladder:

These calculi were removed from a woman who had undergone

cholecystectomy. The specimen consists of a very large number of yellowish-brown

calculi, ranging in diameter from 0.2 -2 cm. Many of the stones have

facetted surfaces, a result of their rubbing against one another in the

gall bladder.

Cholelithiasis is an extremely common condition, particularly withadvancing age, but is often asymptomatic. Females are affected twice

as often as males and recognized predisposing factors include obesity,

multiparity, diabetes mellitus, chronic hemolytic anemia, there is also

an increased familial incidence. * Types: cholesterol, bile pigment or

mixed type (the mixed type is the most common type).


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Case # 7, Acute cholecystitis of the gall bladder


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7. Acute Cholecystitis of the Gall Bladder:

This specimen was excised from a woman, following a long history of

non-specific dyspepsia. No gall stones were found.

The gall bladder has been opened to show marked mucosal and

transmural congestion and edema, associated with a multifocal

fibrinopurulent exudate. Acute cholecystitis in the absence of

cholelithiasis is uncommon, but may be idiopathic or bacterial

infection


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Case # 8, Acute hemorrhagic pancreatitis


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8. Acute Hemorrhagic Pancreatitis of the Pancreas: The pancreas is markedly swollen and extensive hemorrhagic necrosis,

particularly in the body. A small fragment of adjacent adipose tissue(portion of the greater omentum) shows multiple foci of bright yellow

necrosis.

*Acute pancreatitis is very common, accounting for approximately 1 in

500 hospital admissions in the western world. 70% of the cases

associated with alcoholism and gall stone diseases. *It results from the sudden onset of enzymatic autodigestion of the

pancreatic parenchyma and adjacent tissues. Activation of protease and

lipase leads to the destruction of the pancreatic tissue, blood vessel wall

(hence the hemorrhage) and adjacent adipose tissue.

*This extensive tissue damage, associated with loss of blood and bodyfluids, may lead to the development of shock and renal failure.

*Prognosis : death in up to 10% 0f the cases.


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Peritonitis due to acute pancreatitis


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Case # 1, Horseshoe Kidney


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1. Horseshoe kidney:

Both kidneys with the aorta, renal arteries and ureters are shown. The

kidneys are enlarged and united at their lower poles by an isthmus of

renal tissue which leis over the aortic bifurcation.

*Renal fusion is not rare abnormality, being found in about 1 in 250

autopsies results from an embryological failure of ascent of

nephrogenic tissue. Associated abnormalities of the vascular supply

and ureters are common. This deformity is more common in males

than females


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2. Adult Polycystic disease with renal transplant:

These are post-mortem specimens from adult male who was found to

have polycystic disease 6 years before his death. Later he underwent

renal transplantation. * The two diseased kidneys are grossly enlarged and the parenchyma is

replaced bilaterally by numerous cysts of varying size. The cysts are

smooth-walled and some contain gelatinous material. Hemorrhage is

apparent within a few of the cysts. The renal hemograft (center) is

normal in appearance and serves to demonstrate the size of the patient'sown kidneys.

* Adult polycystic disease is a common condition which has an

autosomal dominant inheritance.

Patients most often present in middle age, either hematuria,

hypertension or pyelonephritis. * Associated with other anomalies suchas liver cysts and Berry aneurysms in the circle of wills.

* Complications of hypertension (as MI), and chronic renal failure


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Case # 3, Acute tubular necrosis


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3. Acute Tubular Necrosis:

This is a post-mortem specimen from a person who committed suicide

by taking drug (paracetamol). * The kidney shows pallor and swelling

of the cortex and intense congestion of the medulla. * Acute tubular necrosis is an important cause of acute renal failure. *

It most often results from sever renal ischemia as seen in hypotensive or

hypovolemic shock , it may be nephrotoxic in origin, for example after

ingestion of heavy metals, antibiotic (aminoglycosides) and anesthetic.

* Prognosis: better prognosis with nephrotoxic than ischemic type.


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Case # 4, Acute suppurative pyelonephritis


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4. Acute Suppurative Pyelonephritis:

This specimen was excised from a young woman who was acutely ill

with Escherichia Coli septicemia. Because of severe pain in the left

flank, ureteric catheter specimens of urine were examined and only that

on the left was infected. Nephrectomy was performed and the patient

mad a rapid recovery.

* The kidney has been sectioned to show numerous abscess, mainly in

the cortex, surrounded by zone of hyperemia, with thickened,

edematous renal pelvis

* Acute pyelonephritis is due to gram negative bacilli (E.coli or

Proteus) in the majority of the cases. Infection is most commonly

ascending in origin. In young adult females are most often affected,

while in older adults males predominate.

Common predisposing causes include urinary obstruction,

instrumentation of the urinary tract, pregnancy, vesicouretric reflux and

diabetes mellitus.

* Modern antibiotic therapy had led to greatly improved treatment of

these cases, nephrectomy is very rarely necessary.


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Case # 5, Oxalate stones (nephrolithiasis)


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C # 6 R l ll i f h kid


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Case # 6, Renal cell carcinma of the kidney

(Adenocarcinoma)


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6. Renal Cell Carcinoma of the Kidney (Adenocarcinoma,

previously known as Hypernephroma):

This is a nephrectomy specimen from old person who had suffered

intermittent hematuria for 7 years.

A section through the kidney shows virtual replacement of the

parenchyma by a tumor mass measuring 13 X 10 cm. It has the

characteristic appearance of a renal carcinoma, being predominantly

golden-yellow in color with area oh hemorrhage, fibrosis, necrosis and

cyst formation. The adjacent renal pelvis is compressed.

* Adenocarcinoma of the kidney is the most common primary renal

malignant tumor and predominantly occurs in older adults, affecting

males more than females.

*These tumors are derived from renal tubular epithelium and usually

arise in the cortex. Associated systemic manifestations are common

and include fever, hypercalcemia (due to parathormone), polycythemia

(due to erythropoietin) and hypertension (due to renin).

* Spread : local invasion, grow along renal vein (blood metastasis) to

the lungs and lymphatic to the periaortic lymph nodes.

* Treatment : surgery and radiotherapy


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Case # 7, Cystitis of the urinary bladder


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7. Cystitis of the Urinary Bladder:

This is a post-mortem specimen from a person who suffered from

severe urine infection with foul-smelling of the urine.

The bladder has been opened to show intense congestion of theposterior wall. On the left, the ostium of a small diverticulum is visible

just above the ureteric orifice and on the right, there are small flecks of

calcific material adherent to the urothelium.

* Acute infection of the urinary tract is most often due toE. Coli and

Proteus group. * Predisposing factors include diabetes mellitus, radiation therapy,

instrumentation (catheter), neurogenic bladder and chemotherapy.

C # 8 P ill t iti l ll i


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Case # 8, Papillary transitional cell carcinoma

of the urinary bladder


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8. Papillary Transitional Cell Carcinoma of the Urinary Bladder:

This papillary tumor, measuring 2 cm. in diameter, has been excised

from the bladder. It has been bisected to show the typical long,

branching villous processes. At the core is a small fragment of musclefrom the bladder wall which shows superficial invasion by tumor.

Unknown cause but carcinogenic chemicals (aniline dye) are high risk

to develop cancer.

* Transitional cell carcinoma is the most common primary malignant

tumor of the bladder, predominantly in males over the age of 50's.While these tumors tend to be multiple, the trigone is the single

common site. Most of the patients present by painless hematuria.

* Metastasis by either local invasion or lymphatic spread.

* Prognosis: high incidence of recurrence and overall, 5 year survival

rate is 30%.


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Case # 1, Maldescent of testis (cryptorchidism)


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1. Maldescent of Testis:

The left side of the scrotum was noted to be empty and the

corresponding testis was found in the left inguinal canal, at the head of

a hernial sac.

* Both testes have been sectioned to contrast the normal right testis

with the imperfectly descended left one, which is markedly atrophic

and appears fibrotic.

Incidence : is about 4 % in male neonates and about 1 % in all males

over the age of 1. The most common sites of arrest in the normal path

are high in the scrotum, the superficial inguinal pouch, the inguinal

canal or within the abdomen. If brought down into the scrotum by the

age of 4-6 years, such testes can retain normal function. If left, the

affected testis will fail to show spermatogenesis and there is an

increased risk of developing a testicular neoplasm, most commonly aseminoma.


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Case # 2, Seminoma of

the testis


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2. Seminoma of the Testis:

This specimen was excised from a man who had noticed gradual

enlargement of the testicle for 6 months.

The testicle has been sectioned to show a pale solid ovoid tumor, whichhas replaced the entire body of the testis with nodularity than is usual.

The tunica vaginalis is closely adherent over most of the testis, the

remaining space containing some recent blood clot. Notice that the

tumor has invaded the epididymis. * Seminoma is the most common

primary malignant tumor of the testis and arises most often in patients30-40 years of age. It is classically a well-circumscribed tumor of

uniform grayish-pink color, which occasionally shows foci of necrosis

but is rarely hemorrhagic.

It spreads largely by lymphatic. These tumors are very radiosensitive

such that 5-year survival is now at least 95 %.


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Case # 3 malignant teratoma of the testis


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3. Malignant Teratoma of the Testis:

The specimen was excised from a young man who presented by a one

month history of a painless swollen testis. The testis is enlarged and

contains a well-defined tumor, composed largely of solid pale tissuewith cystic foci. There is a rim of residual normal testis at the upper

pole and the cord shows no evidence of invasion.

* Teratomas account for 30 % of primary testicular tumors and are

most common in the third decade. A very small proportion arise in

undescended testes. * Spread is both lymphatic and hematogenous.Five-year survival has improved dramatically in recent years with the

addition of sophisticated chemotherapy to radiotherapy


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Case # 4 Benign

Prostatic Hyperplasia

(hypertrophy)


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4. Benign Hypertrophy of the Prostate:

The bladder has been opened to show a symmetrically enlarged

prostate gland at its base, with a prominent 'middle lobe' which

projects into the trigone and obstructs the bladder neck. The prostate

shows marked nodularity and the bladder is trabeculated.

This is the typical appearance of benign, prostatic, nodular hyperplasia

which is increasingly with the age and is almost universal in men in the

8th and 9th decades. It results from proliferation of both the

connective tissue and glandular components, usually of the inner group

of glands in the middle and lateral lobes. It is thought to be due to an

imbalance in the androgen / estrogen ratio. The main complications

are those of urinary obstruction.

This condition does not predispose to carcinoma of the prostate.


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Case # 5 Adenocarcinoma of the prostate


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Case # 1, Endometriosis at the umbilicus


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1. Endometriosis at the umbilicus:

This specimen was excised from a woman who noticed a pigmented

nodule at the umbilicus for 3 years. The nodule steadily increased in

size and bled at the menstrual periods.

The umbilicus has been sectioned to show a smooth, rounded, fibrous

nodule projecting from the surface. Numerous tiny cysts and foci of

brown discoloration are barely visible within the lesion.

Endometriosis is abnormal location of the endometrial tissue outside the

uterus and usually causes symptoms during the reproductive years dueto the normal cyclical changes that the ectopic tissue undergoes. Some

patients with endometriosis present with infertility but others are often

cured by undergoing a normal pregnancy. Very occasionally

endometriotic foci may develop hyperplasia or even carcinoma.


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Case # 2, Endometrial

carcinoma of the uterus


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2. Endometrial Adenocarcinoma of the Uterus:

This specimen was excised from a nulliparous old woman in whom the

menopause had occurred 9 years previously and who presented withpostmenopausal bleeding.

The uterus has been sectioned in the sagittal plane to show a pale

neoplasm arising in the fundus and projecting into the uterine cavity

and widely infiltrating the muscle coat.

Endometrial carcinoma accounts for about 10 % of female malignantdisease. The majority of cases arise postmenopausal and known

associations include infertility, nulliparity, obesity and possibly

hypertension and diabetes mellitus.

Clinical manifestations: patient presents with vaginal bleeding in

postmenopausal women. Prognosis: it is dependent upon tumor grade, depth of myometrial

invasion and clinical stage, but overall 5-year survival rate is of the

order of 85 %.


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Case # 3, Leimyoma of

the myometrium

(Fibroid)


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3. Leiomyoma of the Myometrium ( Fibroid of the Uterus) :

This specimen was excised from a woman who presented with a 3 year

history of dysmenorrhea and metrorrhagia. Most recently she hadnoticed an abdominal mass and she developed intermittent constipation

and urinary frequency.

This grossly enlarged and distorted uterus has been sectioned to show

multiple, well-circumscribed intramural and submucosal tumors which

have displaced and compressed the uterine cavity. The all lesions have

a typical whorled appearance except one on the left which has

undergone degeneration and dystrophic calcification.

*Leiomyomas, known as 'fibroid', are most common benign tumor of

uterine smooth muscle which arise only during the reproductive years.

They are often multiple and are thought to result from estrogenic

stimulation (enlargement is common during pregnancy or with the use

of oral contraceptive). Malignant changes are very rare.


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Case # 4, Pyosalpinx of

the fallopian tube

4 Pyosalpinx of the Fallopian Tube:


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4. Pyosalpinx of the Fallopian Tube:

This specimen was excised from a middle age woman who presented

with infertility and dysmenorrhea. A bilateral salpingo-oophorectomy

and hysterectomy were done.

The fallopian tubes attached to the uterus and ovary are shown. Thereare dense adhesions, the wall of the fallopian tube is thickened and

fibrotic and there are a series of abscesses within the tube.

Pyosalpinx is usually bilateral and represents the result of prolonged or

particularly severe bacterial salpingitis. The most common organisms

which responsible for this disease are chlamydia , gonococcus,mycoplasma, ....etc. The predisposing factors include intrauterine

devices (IUDs), surgical instrumentation and abortion, but most cases

are sexually transmitted.

C # 5 S ll i f h i i


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Case # 5, Squamous cell carcinoma of the uterine cervix


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5. Squamous Cell Carcinoma of the Uterine Cervix:

This specimen was excised from a 49-year old multiparous woman who

had noticed irregular bleeding for the last 3 months.

A sagittal section through the uterus and upper vagina shows a bulky,polypoid tumor arising from the external cervical os and extending into the

vaginal vault. The surface of the tumor is extensively ulcerated.

Carcinoma of the cervix is common but has declined due to screening with

yearly pap smears.

It increased, particularly in younger women and most often in the 4th and

5th decades.

The most important risk factor is early age at first coitus, of which

promiscuity, early marriage or pregnancy, multiparity and lower social

class are co-variable.

Spread: Local spread causing ureteral obstruction and renal failure (which

is the most common cause of death in case of carcinoma of cervix ),

lymphatic and may be hematogenous spread to the lung and liver.

Prognosis: overall, 5-year survival chance is 60 %.


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Case # 6, Fibrocystic disease of the breast


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C # 7 Fib d f h b


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Case # 7, Fibroadenoma of the breast


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7. Fibroadenoma of the Breast:

This specimen was excised from a young woman who had noticed a

slowly growing lump in the right breast for 3 years. The mass was

tender during menstruation. Examination revealed a smooth, discrete

mass, which at operation was easily separated from the adjacent

compressed breast tissue. * A rounded, coarsely lobulated benign

tumor, measuring 8 cm in diameter, is surrounded by a smooth fibrous

tissue.

C # 8 Ad i f h b


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Case # 8, Adenocarcinoma of the breast

8. Adenocarcinoma of the Breast:

Thi i f 55 ld i h 3 h hi f fi


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This specimen was from a 55-year old woman with a 3-month history of a firm

painless enlarging lump in the right breast. At presentation, firm axillary lymph

nodes were palpable.

A section through the breast shows an irregular, rounded tumor, measuring 4 cm in

diameter. The tumor is adherent to both the skin and pectoral fascia. At the top left

of the picture an enlarged lymph node replaced by metastatic tumor is seen.

* Carcinoma of the breast occurs in 1 out of every 10 woman in the United States,

the most common cancer in females and the second most common cause of death

due to cancer (lung is the first cause).

* The etiology remains uncertain but the following factors have been noted:

Family history, increasing age (uncommon before age 25), geographic influences

(more in United States), previous history of contralateral breast cancer, early

menarche, nulliparity, late menopause, obesity, low fiber and high fat diet,

endometrial cancer or history of irradiation therapy.

* Adenocarcinoma of the breast may be of lobular or ductal origin, the latter group

constituting at least 90 %. Up to 50 % of carcinoma develops in the upper, outer

quadrant of the breast, which therefore spread to axillary lymph nodes,

approximately 50 % of all cases show metastatic involvement of lymph nodes at

presentation Spread by blood in late stage to the lungs liver bone and adrenal

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