Acute appendicitis
Sections of the appendix show luminal purulent exudate colonized with enteric bacteria. There is mucosal and focal transmural hemorrhagic necrosis and transmural neutrophilic infiltrate. The serosa and the periappendiceal soft tissues are coated with acute fibrinopurulent exudate.
APPENDIX, APPENDECTOMY:
ACUTE APPENDICITIS WITH PERIAPPENDICITIS.
PERFORATION (if present).
FECALITH (if present).
Allergic Esophagitis
The histologic features in this specimen are consistent with allergic esophagitis (see Walsh SV, Antonioli DA, Goldman H, Fox VL, Bosvaros A, Leichtner AM, Furuta GT. Allergic esophagitis in children: a clinicopathological entity. Am J Surg Pathol 23:390-396, 1999.).
Analyte Specific Reagents
*The test for _________ was developed and its performance characteristics determined by --------. It has not been cleared or approved by the U.S. Food and Drug Administration. The FDA has determined that such clearance or approval is not necessary. This test is used for clinical purposes. It should not be regarded as investigational or for research. This laboratory is certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA) as qualified to perform high-complexity testing. Pursuant to the requirements of CLIA, this laboratory has established and verified the test’s accuracy and precision. Additional information about this type of test is available upon request.
Appendiceal Neuroma (fibrous obliteration of the lumen)
There is obliteration of the distal appendiceal lumen. The lumen has been filled in by loose fibrovascular connective tissue that contains a small amount of lobular fatty tissue and a proliferation of fine nerve trunks, typical of appendiceal neuroma (neurogenous hyperplasia, also known as fibrous obliteration of the appendiceal lumen). There is no significant inflammation in the distal appendix.
Dx
APPENDIX, APPENDECTOMY:
NEUROMA (NEUROGENOUS HYPERPLASIA / FIBROUS OBLITERATION OF THE
APPENDICEAL LUMEN).
Bronchial Alveolar Lavage
Examination of Wright's-stained and hematoxylin and eosin-stained cytospin preparations of lavage fluid reveals numerous alveolar macrophages, many of which are vacuolated, and a few of which are multinucleated. The specimen also contains scattered ciliated tracheobronchial epithelial cells and is contaminated with a rare squame from the oropharyngeal cavity. These cells are coated on their surface by large numbers of cocci. Small mature lymphocytes and occasional neutrophils are noted in the background. Scattered lipid-laden macrophages are also noted. They are relatively uncommon but contain abundant amounts of lipid material. Lipid-laden macrophages are a non-specific marker for parenchymal disease and may be present due to endogenous or exogenous lipid pneumonia, interstitial lung disease, sickle cell crisis, pulmonary hemorrhage, or other disorders. Special stains for fungi, Pneumocystis, and mycobacteria are negative. Control slides for the special stains react appropriately.
Dx
LUNG, _____ _____ LOBE, BRONCHOALVEOLAR LAVAGE, CYTOLOGIC MATERIAL:
BRONCHUS ASPIRATION, CYTOLOGIC MATERIAL:
RARE LIPID LADEN MACROPHAGES PRESENT
Comment for lipid laden macrophages indexThe lipid-laden macrophage index lacks the specificity necessary to detect reflux-related respiratory disease (see Rosen R, Fritz J, Nuroka A, Simon D, Nurko S. Lipid-laden macrophage index is not an indicator of gastroesophageal reflux-related respiratory disease in children. Pediatrics 121:e879-884, 2008.).
Bone Marrow Bx
The peripheral smear shows normochromic red cells with no significant anisocytosis or poikilocytosis. There are no red cell inclusions. The white blood cells are normal in number and morphology. There are no white cell inclusions. Circulating blasts are not seen. Platelets are normal in number and have normal morphology. The marrow aspirate has good cellularity. There is a moderate number of modestly cellular spicules. The marrow is trilineage. Orderly maturation is seen in the erythroid and myeloid cell lines. The M:E ratio is -------. Scattered hemosiderin-laden macrophages are seen. An excessive number of blasts is not recognized. There is no abnormal increase in lymphocytes. The bone marrow biopsy is adequate. The cellularity is normal (----%). All three hematopoietic cell lines are represented. Scattered hemosiderin-laden macrophages are seen. No atypical cells or blasts are seen. The PASH stain marks the myeloid cells and the megakaryocytes. There is no reticulin or collagen fibrosis. The bony trabeculae are unremarkable. Control slides for the special stains react appropriately.
Dx
BONE MARROW, RIGHT POSTERIOR ILIAC CREST, BIOPSY:
NORMAL (HYPOCELLULAR/HYPERCELLULAR) HEMATOPOIETIC MARROW.
NEGATIVE FOR MALIGNANCY.
BONE MARROW, LEFT POSTERIOR ILIAC CREST, BIOPSY:
NORMAL HEMATOPOIETIC MARROW.
NEGATIVE FOR MALIGNANCY.
Capillary Hemangioma
The sections show a benign capillary hemangioma. The lesion is pedunculated, with a typical lobular architecture, and is circumscribed but not encapsulated. The lobules are composed of numerous thin-walled blood vessels, which are lined by a single layer of endothelium. Many of the vascular channels are filled with red blood cells. The central and deep aspects of the lesion contain larger "feeder" vessels.
Dx
SKIN, _____, EXCISIONAL BIOPSY:
CAPILLARY HEMANGIOMA.
Celiac Disease (Comment)
The immunohistochemical features of gluten-sensitive enteropathy (celiac disease) are described in: Settakorn J, Leong AS-Y. Immunohistologic parameters in minimal morphologic change duodenal biopsies from patients with clinically suspected gluten-sensitive enteropathy. Appl Immunohistochem Mol Morphol 12:198-204, 2004.
*The test for MIB-1 (Ki-67) was developed and its performance characteristics determined by ------. It has not been cleared or approved by the U.S. Food and Drug Administration. The FDA has determined that such clearance or approval is not necessary. This test is used for clinical purposes. It should not be regarded as investigational or for research. This laboratory is certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA) as qualified to perform high-complexity testing. Pursuant to the requirements of CLIA, this laboratory has established and verified the test’s accuracy and precision. Additional information about this type of test is available upon request.
Micro for Immuno
Immunoperoxidase stains show crypt hyperplasia, characterized by a high Ki-67 (MIB-1*) index (>66). There is an even distribution pattern of intraepithelial T lymphocytes (IETL) along the sides and tips of the villi, with increased numbers of CD3+ IETL (>30/100 enterocytes), and increased numbers of CD8+ IETL (>30/100 enterocytes). Control slides for the special stains react appropriately.
Dx
ESOPHAGUS, BIOPSY:
NO PATHOLOGIC CHANGE.
STOMACH, ANTRUM, BIOPSY:
NO PATHOLOGIC CHANGE.
INTESTINE, SMALL, DUODENUM, BIOPSY:
MUCOSAL LYMPHOCYTOSIS WITH VARIABLE VILLOUS ABNORMALITY AND CRYPT
HYPERPLASIA, CONSISTENT WITH GLUTEN SENSITIVE ENTEROPATHY (CELIAC
DISEASE).
Cilia Dynein arms:
A mean dynein arm count (inner, outer or both) of less than two per ciliary cross-section is diagnostic of a congenital ciliary dynein arm defect and consistent with immotile cilia syndrome (see Teknos TN, Metson R, Chasse T, Balerica G, Dickersin GR. New developments in the diagnosis of Kartagener' s syndrome. Otolaryngol Head Neck Surg 116:68-74, 1997.).
Dx
NOSE, INFERIOR NASAL TURBINATES, NASAL BRUSHING:
NO PATHOLOGIC CHANGE.
Cholesteatoma
Sections of the left middle ear specimen show portions of inflamed fibrous connective tissue with partial squamous and stratified cuboidal linings and abundant keratinous debris consistent with cholesteatoma. Embedded in a connective tissue are small portions of necrotic bone.
Dx
EAR, ____ MIDDLE, EXCISION:
CHOLESTEATOMA.
Congenital Nevus
Sections of the _________ lesion show a slightly dome-shaped compound melanocytic nevus. The junctional nevus cell nests are lightly pigmented with melanin. The dermal nevus cells form a dense, symmetrical band in the superficial dermis and extend downward into the dermis around hair follicles and along tissue planes in a congenital growth pattern. The nevus cells mature as they descend into the dermis. There is no significant cytologic atypia. No architectural disorder is identified in this specimen. The lesion does not extend to any margin.
Dx
SKIN, _______, EXCISIONAL BIOPSY:
CONGENITAL PATTERN MELANOCYTIC NEVUS, COMPOUND TYPE.
Control slides
Control slides for the special stains react appropriately.
Cortical dysplasia
This case has been seen in consultation with Dr. ------- (---Neuropathology), who concurs with the diagnosis. The terminology used in classifying these lesions is from: Palmini A, Najm I, Avanzini G, Babb T, Guerrini R, Foldvary-Schaefer N, Jackson G, Lüders HO, Prayson R, Spreafico R, Vinters HV. Terminology and classification of the cortical dysplasias. Neurology 62(Suppl 3):S2-S8, 2004.
Cystic Adenomatoi Malformation, Large Cyst Type I
Sections of the bronchial and vascular margins show no pathologic abnormalities. The peribronchial lymph nodes show reactive hyperplasia. Sections of the lung show multiple large dilated cystic spaces lined by respiratory epithelium overlying fibrous connective tissue and small amount of smooth muscle. Within the cystic space there is abundant cellular debris and mucous with focal occasional rounded birefringent profiles and small collections of calcium. The adjacent pulmonary parenchyma shows fibrosis, remodeled vascular channels, lymphoid aggregates, alveoli with remodeled appearance, and abundant foamy and pigmented macrophages. Areas of atelectasis are also present.
Dx
LUNG, ____ _____ LOBE, LOBECTOMY:
CYSTIC ADENOMATOID MALFORMATION, LARGE CYST TYPE (STOCKER TYPE I)
WITH SECONDARY INFLAMMATORY CHANGES.
HILAR LYMPH NODES WITH REACTIVE HYPERPLASIA.
Deep Granuloma Annulare (pseudorheumatoid nodule)
Sections show several areas of fibrinoid degeneration of collagen and prominent mucin with a pale appearance surrounded by proliferating blood vessels with a perivascular lymphohistiocytic infiltrate consistent with deep granuloma annulare (pseudorheumatoid nodule).
Dx
SOFT TISSUES, _____, EXCISION:
DEEP GRANULOMA ANNULARE (PSEUDORHEUMATOID NODULE).
Dermatopathic lymphadenopathy
Sections of right and left posterior auricular lymph nodes show nodular expansion of the cortex and scattered light-brown pigment containing histiocytes. There is accompanied focal follicular hyperplasia and sinus histiocytosis. The center of the right postauricular lymph node shows dense fibrosis.
Dx
LYMPH NODE, POSTERIOR AURICULAR, ______, EXCISION:
DERMATOPATHIC LYMPHADENOPATHY.
Dermoid cyst
The sections show a dermoid cyst. The lesion is characterized by a thin lining of keratinizing stratified squamous epithelium with pilosebaceous glands. The cyst is filled with lamellar keratinous debris and hair fragments.
Dx
SOFT TISSUES, ___________, EXCISIONAL BIOPSY:
DERMOID CYST.
Diffuse Active Colitis
The diffuse active colitis pattern of injury can be seen in ulcerative colitis in an active phase. It may also be encountered in some examples of Crohn colitis and in some cases of documented infectious colitis. It has also been noted in a form of colitis associated with diverticular disease.
Upper GI
The fragments of esophageal mucosa are randomly oriented and tangentially sectioned. The basal cell thickness and height of the vascular papillae do not appear to be increased. There is minimal congestion in some of the vascular papillae but no significant hemorrhage. Rare intraepithelial lymphocytes are present, but no intraepithelial eosinophils are recognized. Sections from the gastric antrum show no ulceration or erosion. The cellularity of the lamina propria does not appear to be increased. No bacteria are recognized along the mucosal surface. Sections of the duodenum show intact surface epithelium with no ulceration or erosion. The villous architecture, with long finger-like villi, is maintained. The crypt-to-villous ratio appears normal. The cellularity of the lamina propria is within normal limits. There is no significant lymphocytosis of the villous epithelium. No bacteria or parasites are recognized along the mucosal surface. There are no cells with viral inclusions.
Dx
ESOPHAGUS, BIOPSY:
NO PATHOLOGIC CHANGE.
STOMACH, ANTRUM, BIOPSY:
NO PATHOLOGIC CHANGE.
INTESTINE, SMALL, DUODENUM, BIOPSY:
NO PATHOLOGIC CHANGE.
Lower GI
The terminal ileal specimen consists of fragments of small intestinal mucosa with finger-like villi with a normal crypt:villous ratio and the usual numbers of inflammatory cells within the lamina propria. No parasites are observed in the superficial mucous layer. There are occasional prominent lymphoid aggregates in the lamina propria and submucosa. The cecal and ascending colon specimens show colonic mucosa with a regular luminal surface and normal tubular glands. The lamina propria contains the usual numbers of inflammatory cells. Occasional lymphoid aggregates and Paneth cells are present. The specimens from the colon at the hepatic flexure, transverse colon, colon at the splenic flexure, descending colon, sigmoid colon, rectosigmoid colon, and rectum show colonic mucosa with a regular luminal surface and normal tubular glands. The lamina propria contains the usual numbers of inflammatory cells and occasional lymphoid aggregates. The usual number of muciphages is seen in the rectum. No active inflammation, granulomas, or glandular distortions are seen at any site.
Dx
INTESTINE, SMALL, TERMINAL ILEUM, BIOPSY:
NO PATHOLOGIC CHANGE.
INTESTINE, LARGE, CECUM, BIOPSY:
NO PATHOLOGIC CHANGE.
INTESTINE, LARGE, ASCENDING COLON, BIOPSY:
NO PATHOLOGIC CHANGE.
INTESTINE, LARGE, COLON AT HEPATIC FLEXURE, BIOPSY:
NO PATHOLOGIC CHANGE.
INTESTINE, LARGE, TRANSVERSE COLON, BIOPSY:
NO PATHOLOGIC CHANGE.
INTESTINE, LARGE, COLON AT SPLENIC FLEXURE, BIOPSY:
NO PATHOLOGIC CHANGE.
INTESTINE, LARGE, DESCENDING COLON, BIOPSY:
NO PATHOLOGIC CHANGE.
INTESTINE, LARGE, SIGMOID COLON, BIOPSY:
NO PATHOLOGIC CHANGE.
INTESTINE, LARGE, RECTOSIGMOID COLON, BIOPSY:
NO PATHOLOGIC CHANGE.
INTESTINE, LARGE, RECTUM, BIOPSY:
NO PATHOLOGIC CHANGE.
EBER comment
*The performance characteristics of this test, Epstein-Barr encoded RNAs (EBER), was developed, evaluated, and validated by the --------. This test has not been cleared or approved by the U.S. Food and Drug Administration (FDA). Analyte Specific Reagent (ASR) use does not require FDA approval.
Bronchial esophageal lavage and esophageal Bx
Examination of Wright' s-stained and hematoxylin and eosin-stained cytospin preparations of aspirate fluid reveals a suboptimal specimen. There are more ciliated tracheobronchial epithelial cells in the specimen than there are alveolar macrophages. Small mature lymphocytes and occasional neutrophils are noted in the background. The specimen is contaminated with a rare squame from the oropharyngeal cavity. These cells are coated on their surface by large numbers of bacteria. Rare lipid-laden macrophages are also present. Some of these macrophages contain abundant lipid material. Lipid-laden macrophages are a non-specific marker for parenchymal disease and may be present due to endogenous or exogenous lipid pneumonia, interstitial lung disease, sickle cell crisis, pulmonary hemorrhage, or other disorders. The control slide for the special stain reacts appropriately. The fragments of esophageal mucosa are relatively well oriented. There is no basilar cell hyperplasia or proliferation of the vascular papillae. Mild congestion is seen in some of the vascular papillae, but no significant hemorrhage is present. A few intraepithelial lymphocytes are noted, but no intraepithelial eosinophils are seen.
Dx
BRONCHUS, ASPIRATION, CYTOLOGIC MATERIAL:
RARE LIPID-LADEN MACROPHAGES PRESENT.
ESOPHAGUS, MID, BIOPSY:
NO PATHOLOGIC CHANGE.
Eosinophils for colon
Multiple sections from all the colon biopsy sites (except rectum) reveal mild to moderate increases in cellularity resulting from eosinophilic infiltration. The eosinophils cluster within the lamina propria and infiltrate the glands and surface mucosa. A conspicuous number of eosinophil granules is present in the lamina propria of the cecum, ascending colon, transverse colon and descending colon. The absolute number of eosinophils appears to decrease as one moves from proximal to distal sites within the colon. No ulcers or granulomas are recognized at any site. Parasites are not seen.
Normal values of eosinophils for GI
(For normal eosinophil counts at various sites within the gastrointestinal tract, see Lowichik A, Weinberg AG. A quantitative evaluation of mucosal eosinophils in the pediatric gastrointestinal tract. Mod Pathol 9:110-114, 1996.).
NASH scoring system for fatty liver disease
According to the NASH CRN scoring system, the score for this liver biopsy is @@. The NAFLD activity score is ---. The fibrosis score is ---. (For more information on this scoring system, see Kleiner DE, Brunt EM, Van Natta M, et al. Nonalcoholic Steatohepatitis Clinical Research Network. Design and validation of a historical scoring system for nonalcoholic fatty liver disease. Hepatology. 41:1313-1321, 2005.).
Comment for focal active colitis
The focal active colitis pattern of injury suggests Crohn colitis or infectious colitis and/or acute self-limited colitis. The pattern may also be seen in resolving ulcerative colitis under medical management and has been described in some patients with ischemia. It has been linked to the use of nonsteroidal anti-inflammatory drugs and to bowel preparation itself.
Reference for focal segmental glomeruloesclerosis
McAdams AJ, Valentini RP, Welch TR. The nonspecificity of focal segmental glomerulosclerosis. The defining characteristics of primary focal segmental glomerulosclerosis, mesangial proliferation, and minimal change. Medicine (Baltimore) 76:42-52, 1997.
The renal biopsy shows light microscopic and ultrastructural features of focal and segmental glomerulosclerosis, not otherwise specified, according to the proposed working classification (see D'Agati VD, Fogo AB, Bruijn JA, Jennette JC. Pathologic classification of focal segmental glomerulosclerosis: a working proposal. Am J Kidney Dis 43:368-382, 2004.).
Fungi comment
Morphologically, the fungi have the appearance of aspergillus. Other pathogenic fungi that form branched, septate hyphae that can be mistaken for aspergillus include Pseudallescheria boydii, the Fusarium spp. and other opportunistic hyalohyphomycetes, and, on occasion, the Candida spp. Unless typical conidial heads are observed, the histopathologic diagnosis of aspergillosis is considered presumptive, and confirmation by immunohistochemical methods or microbiological isolation is required.
Gallbladder
The sections show congestion of the serosal blood vessels. There is a very mild chronic inflammatory cell infiltrate in the lamina propria accompanied by occasional Rokitansky-Aschoff sinuses in the wall. The cystic duct lymph node shows mild congestion with sinus histocytosis.
Dx
GALLBLADDER, CHOLECYSTECTOMY:
MILD CHRONIC CHOLECYSTITIS WITH CHOLELITHIASIS.
Comment for gastric lymphoid aggregate
Lymphoid follicles can rarely be present in an otherwise normal gastric mucosa; however, they are more frequently found in cases of gastritis and are strongly associated with H. pylori infection. Lymphoid aggregates are not significantly associated with H. pylori infection and may be a component of the normal gastric lymphoid tissue (see Carpentieri DF, Wenner W, Liquornik K, Ruchelli E. Significance of lymphoid follicles and aggregates in gastric mucosa of children. Pediatr Dev Pathol 3:177-179, 2000.).
GI eosinophils comment
Eosinophilic infiltration in the gastrointestinal tract may occur in a variety of disorders, including parasitic infestations, Crohn disease, early C. difficile infection, resolving viral infection, intestinal obstruction and allergic/hypersensitivity reactions.
Micro
Multiple sections from all the colon biopsy sites (except rectum) reveal mild to moderate increases in cellularity resulting from eosinophilic infiltration. The eosinophils cluster within the lamina propria and infiltrate the glands and surface mucosa. A conspicuous number of eosinophil granules is present in the lamina propria of the cecum, ascending colon, transverse colon and descending colon. The absolute number of eosinophils appears to decrease as one moves from proximal to distal sites within the colon. No ulcers or granulomas are recognized at any site. Parasites are not seen.
Comment for GI lymphocytosis
Colonic intraepithelial lymphocytosis is defined as 20 or more intraepithelial lymphocytes per 100 colonocytes present in at least one colonic mucosal biopsy. Pediatric colonic intraepithelial lymphocytosis, in the absence of other histologic findings, is associated with various diseases, including celiac disease, lymphocytic colitis, and autoimmune enteropathy. Colonic intraepithelial lymphocytosis in the presence of other inflammatory changes indicates the possibility of idiopathic inflammatory bowel disease (see Najarian RM, Hait EJ, Leichtner AM, Glickman JN, Antonioli DA, Goldsmith JD. Clinical significance of colonic intraepithelial lymphocytosis in a pediatric population. Mod Pathol 22:13-20, 2009.).
Reference for grading ovarian teratoma
This tumor is considered a grade ___ immature (malignant) teratoma based on the grading scheme of Norris et al (Norris HJ, Zirkin HJ, Benson WL. Immature (malignant) teratoma of the ovary. A clinical and pathologic study of 58 cases. Cancer 37:2359-2372, 1976.). These authors have shown that size and stage of teratomas is related to survival, but that it is the microscopic grade of the tumor that best determines the likelihood of extraovarian spread.
Grading reference for Graft vs Host Disease
The graft-versus-host grading scheme is from Abramowsky CR, Coccia PF. Bone marrow transplantation in pediatrics. In, Abramowsky CR, Colvin RB (eds). Organ Transplantation in Children. Perspect Pediatr Pathol. Basel, Karger, 1989, vol 13, pp 6-43.
(see Snover DC. Biopsy interpretation in bone marrow transplantation. Pathol Annu 24 (part 2): 63-101, 1989.).
Gynecomastia
Sections of right and left breast tissue show scattered lactiferous ducts with focal ductal hyperplasia, set within a paucicellular compact fibrous stroma. There is minimal periductal inflammation and no significant edema. Mature lobular adipose tissue separated by thin fibrous septa. The features in each specimen are consistent with gynecomastia.
Dx
BREAST, RIGHT, SIMPLE MASTECTOMY:
CONSISTENT WITH GYNECOMASTIA.
BREAST, LEFT, SIMPLE MASTECTOMY:
CONSISTENT WITH GYNECOMASTIA.
Hernia sacs
Sections of right and left inguinal soft tissues reveal fibrovascular connective tissue lined by mesothelium and consistent with hernia sacs.
Dx
SOFT TISSUES, INGUINAL REGIONS, RIGHT AND LEFT, HERNIORRHAPHIES:
HERNIA SACS.
SOFT TISSUES, INGUINAL REGIONS, RIGHT AND LEFT, HYDROCELECTOMIES:
HYDROCELE SACS.
+ hydrocele
Sections of right and left inguinal soft tissues reveal fibrovascular connective tissue lined by mesothelium and consistent with hernia sacs. Sections of right and left inguinal soft tissues reveal fibrovascular connective tissue lined by mesothelium and consistent with hydrocele sacs.
Dx
SOFT TISSUES, INGUINAL REGIONS, RIGHT AND LEFT, HERNIORRHAPHIES:
HERNIA SACS.
SOFT TISSUES, INGUINAL REGION, RIGHT AND LEFT, HYDROCELECTOMIES:
HYDROCELE SACS.
Comment for IgA deposition in Renal transplant
Glomerular IgA deposition is present in approximately 5.4% of cadaveric donors. Donor kidneys with IgA deposits function normally, and the IgA typically disappears on follow-up biopsy.
IgA Reference
The biopsy specimen shows light microscopic, immunofluorescence, and ultrastructural features of IgA nephropathy (WHO class __). The specimen is scored for activity and chronicity. The activity index is __, and the chronicity index is __ (as modified from Andreoli SP, Bergstein JM. Treatment of severe IgA nephropathy in children. Pediatr Nephrol 3:248-253, 1989.).
Infantile Hemangioma
The sections show a benign infantile (cellular) hemangioma. The lesion has the typical lobular architecture and is circumscribed but not encapsulated. The lobules are composed of numerous vascular channels, many of which are lined by a single layer of still swollen endothelial cells, characteristic of the proliferative phase. A few of the vessels are starting to show more luminal area and an anastomosing course. Some of the vascular channels are filled with red blood cells.
Dx
SOFT TISSUES, _________, EXCISIONAL BIOPSY:
INFANTILE HEMANGIOMA.
Intraepithelial lymphocytes (comment)
Increased intraepithelial lymphocyte density in an architecturally normal proximal small intestinal mucosal biopsy may be seen in 1% to 2% of specimens. Minimal change gluten-sensitive enteropathy (celiac disease) is one cause. Other common associations include non-gluten food hypersensitivity (cereals, cow' s milk, soy products, fish, rice, and chicken), infections (viral enteritis, Giardia, Cryptosporidia, and gastric Helicobacter), bacterial overgrowth, drugs (nonsteroidal anti-inflammatory drugs and possibly proton pump inhibitors), immune dysregulation disorders (Hashimoto thyroiditis, rheumatoid arthritis, systemic lupus erythematosus, and autoimmune enteropathy), immune deficiency (IgA deficiency and common variable immunodeficiency), and inflammatory bowel disease. For other less common associations, see Brown I, Mino-Kenudson M, Deshpande V, Lauwers GY. Intraepithelial lymphocytosis in architecturally preserved proximal small intestinal mucosa. An increasing diagnostic problem with a wide differential diagnosis. Arch Pathol Lab Med 130:1020-1025, 2006.
Reference for iron storage
The liver biopsy shows grade ___+ iron deposition in Kupffer cells and hepatocytes in a predominantly periportal pattern with extension into the lobules (zones 1 and 2). No iron deposition is seen within bile duct epithelium. In hereditary hemochromatosis, iron deposition is characteristically seen within hepatocytes and bile duct epithelium with extension to the centrilobular region (central vein area, zone 3) with progression of the disease. The pattern of iron deposition in this case is more characteristic of transfusion-associated iron overload (see Batts KP. Iron overload syndromes. United States and Canadian Academy of Pathology Annual Meeting, Atlanta, GA, February, 2006). For grading of iron storage, see Histological grading of iron storage, according to Searle J, et al. Iron storage diseases. In: Pathology of the Liver. Fourth Ed. McSween RNM, Burt AD, Portmann BC, Ishak KG, Scheurer PJ, Anthony PP, eds. Edinburgh: Churchill Livingstone, 2002, p 260.
Micro
The biopsy is adequate, with ____ portal tracts present in multiple sections. The sections show preserved/altered acinar (lobular) architecture. The portal tracts are not/minimally/mildly/other expanded by chronic inflammation and fibrosis. No bile duct injury, proliferation, or pigment deposition is recognized. No significant interface activity is seen. No significant lobular activity is recognized. No steatosis, cell swelling, individual cell necrosis (apoptosis), or cholestasis is present. Golden yellow hemosiderin pigment deposition (grade__+ of 4+) is seen within Kupffer cells and hepatocytes in a predominantly periportal (zone 1) pattern, although pigment deposition is also seen within hepatocyte cytoplasm within the lobules (zone 2). PASH staining shows normal abundant glycogen within hepatocytes. PASH staining after diastase treatment highlights scattered Kupffer cells containing lipofuscin-like pigment and shows no abnormal PAS-positive deposits. A trichrome stain for collagen shows no/increased portal/fibrous septa extending from portal tracts/ perivenular/with incomplete/complete bridging fibrosis. A reticulin stain confirms normal acinar (lobular) architecture or shows condensation of fibers in a portal pattern with extension to adjacent portal areas or perivenular areas. A special stain for iron confirms the presence of iron granules within Kupffer cells and hepatocytes. Control slides for the special stains react appropriately.
Dx
LIVER, BIOPSY:
NO, MILDLY, MODERATELY, MARKEDLY INCREASED STAINABLE IRON (GRADE +
OF +), CONSISTENT WITH TRANSFUSION-ASSOCIATED IRON OVERLOAD
SYNDROME (CLINICAL: SICKLE CELL DISEASE).
#2
The biopsy is adequate, with 13 portal tracts present. The sections show preserved lobular architecture. The portal tracts are mildly expanded by fibrosis and occasionally contain small collections of lymphoid cells. No interface activity is seen. No bile duct injury, proliferation, or pigment deposition is recognized. There is focal mild periportal fibrosis highlighted with trichrome stain. No significant lobular activity is recognized. No steatosis, apoptosis, or cholestasis is recognized. There is mild congestion of the sinusoids. Golden yellow hemosiderin pigment deposition (grade 3+ of 4+) is seen within Kupffer cells and hepatocytes. PASH staining shows normal abundant glycogen within hepatocytes. PASH staining after diastase treatment highlights scattered Kupffer cells containing lipofuscin-like pigment and shows no abnormal PAS-positive deposits. A reticulin stain confirms normal lobular architecture. A special stain for iron confirms the presence of iron granules within Kupffer cells and hepatocytes. Control slides for the special stains react appropriately.
Dx
LIVER, BIOPSY:
MODERATELY INCREASED STAINABLE IRON (GRADE 3+ OF 4+), CONSISTENT WITH
TRANSFUSION-ASSOCIATED IRON OVERLOAD SYNDROME (CLINICAL: SICKLE
CELL DISEASE).
FOCAL PORTAL INFLAMMATION.
Liver sinus dilatation
Sinusoidal dilatation and congestion in a liver biopsy is associated with venous outflow impairment in two thirds of the cases. In the absence of clinical and / or radiological evidence of venous outflow, diagnostic considerations include other vascular conditions, such as portal vein insufficiency and nodular regenerative hyperplasia. Sinusoidal dilatation and congestion can also occur in the setting of systemic inflammatory diseases, granulomatous disorders, and neoplasms, as well as in wedge biopsies obtained during abdominal surgery.
Reference for preceding IgA
(see Julian BA, Cannon VR, Waldo FB, Egido J. Macroscopic hematuria and proteinuria preceding renal IgA deposition in patients with IgA nephropathy. Am J Kid Dis 27:472-479, 1991.).
Liver TPN disease (total parenteral nutrition)
The biopsy is adequate, with up to ___ portal tracts present in multiple sections. The sections show markedly altered acinar (lobular) architecture. The portal tracts are mildly expanded by chronic inflammation and fibrosis. There are fibrous septa extending from portal tracts with complete bridging fibrosis to adjacent portal tracts, resulting in nodule formation. Central veins are preserved within the remodeled lobules. The mild chronic inflammatory cell infiltrate (lymphocytes) extends along the fibrous septa as well. The altered architecture is confirmed with the trichrome stain and the reticulin stain. The reticulin stain shows condensation of fibers in a portal pattern with extension to adjacent portal areas. No significant interface activity or lobular activity is recognized. Rare multinucleated hepatocytes are noted. There is canalicular cholestasis but no significant steatosis, cell swelling, or individual cell necrosis (apoptosis). PASH staining shows normal abundant glycogen within hepatocytes. PASH staining after diastase treatment highlights the liver cell dropout associated with the bridging fibrosis. Scattered clusters of Kupffer cells contain lipofuscin-like pigment. There are no abnormal PAS-positive deposits within liver cells. Control slides for the special stains react appropriately.
Dx
LIVER, BIOPSY:
CHOLESTASIS AND PORTAL FIBROSIS WITH COMPLETE BRIDGING FIBROSIS AND
CHRONIC INFLAMMATION (ASSOCIATED WITH LONG-STANDING TREATMENT
WITH TOTAL PARENTERAL NUTRITION).
Reference for Lupus chronicity/activity
The biopsy is scored for activity (0-24) and chronicity (0-12) (see Austin HA, Muenz LR, Joyce KM, Antonovych TT, Balow JE. Diffuse proliferative lupus nephritis: identification of specific pathologic features affecting renal outcome. Kidney Int 1984;25:689-695.). The activity index is ----, and the chronicity index is----
Lupus classification
The biopsy shows ......................, consistent with ........... lupus nephritis (ISN/RPS Classification of Lupus Nephritis (2004)).
Lymphocytic gastristis
Lymphocytic gastritis is characterized by a dense lymphocytic infiltration (≥25 lymphocytes/100 epithelial cells) of the gastric foveolar and pit epithelium, together with a variable increase in chronic inflammatory cells in the lamina propria of the gastric mucosa, and is seen in 42% of patients associated with celiac disease (see Prasad KK, Thapa BR, Lal S, Sharma AK, Nain CK, Singh K. Lymphocytic gastritis and celiac disease in Indian children: evidence of a positive relation. J Pediatr Gastroenterol Nutr 47:568-572, 2008.).
Malignant Mixed Germ Cell Tumor with Yolk Sac and Mature Teratoma Components
The ---- ovary shows a mixed malignant germ cell tumor. The tumor has two components. The first component consists of yolk sac tumor composed of cells with large vesicular nuclei and prominent nucleoli with a reticular arrangement of cells forming small cysts. Eosinophilic, hyaline intracytoplasmic and extracytoplasmic globules and strands are prominent. There are scattered mitoses. The tumor is positive with immunohistochemical stains for cytokeratin and shows focal granular positivity for alpha-fetoprotein. The hyaline globules are labeled with immunohistochemical stains for alpha-1-antitrypsin/chymotrypsin. The immunohistochemistry for â-hCG is negative. The special stains have appropriately reactive controls. The second component is a mature teratoma composed of skin with adnexal structures, small amount of neuroglial tissue and a portion of necrotic cartilage. There is extensive coagulative necrosis of the tumor involving predominantly yolk sac component.
OVARY, RIGHT/LEFT OOPHORECTOMY:
MALIGNANT MIXED GERM CELL TUMOR WITH YOLK SAC AND MATURE TERATOMA
COMPONENTS.
Mature Teratoma
The ___ ovarian mass is a mature teratoma composed of tissues derived from the three germ layers. Mature glial tissue and choroid plexus are present along with retinal epithelium. There are cysts lined by skin with its appendages as well as cysts lined by ciliated epithelium with goblet cells. Occasional cysts are lined by multinucleated foreign body giant cells and foam cells. Both ovaries show remnants of ovarian stroma with primordial follicles and scattered cystic follicles.
Dx
OVARY, LEFT/RIGHT, OOPHORECTOMY:
MATURE TERATOMA.
Minimal Celiac Disease (comment)
Some patients with clinically suspected celiac disease and serologic positivity for antigliadin, antiendomysium, and/or antitissue transglutaminase antibodies may have architecturally normal villi in a small bowel biopsy specimen, irrespective of the orientation of the villi. The diagnosis of minimal change gluten-sensitive enteropathy may be aided by the following immunohistologic parameters: crypt hyperplasia detected by high Ki-67 (MIB-1*) index (>66); an even distribution pattern of intraepithelial T lymphocytes (IETL) along the sides and tip of the villi; increased numbers of CD3+ IETL (>30/100 enterocytes); and increased numbers of CD8+ IETL (>30/100 enterocytes).
Molluscum contagiosum
The sections show several small rounded nodules composed of epidermal cells that contain large intracytoplasmic inclusion bodiesso-called molluscum bodies. The bodies have a glassy eosinophilic appearance and displace the nuclei to one side of the cell. The nodules of molluscum bodies sit within one or more craters within the epidermis. The adjacent epidermis is acanthotic. There is no significant inflammation. Clusters of viral particles (from the poxvirus group) comprise the inclusions. Over time, the lesion(s) will involute spontaneously.
Nash Fatty Liver score
According to the NASH CRN scoring system, the steatosis grade is 0, the NAFLD activity score is 0, and the fibrosis score is 0 (see Kleiner DE, Brunt EM, Van Natta M, et al. Nonalcoholic steatohepatitis Clinical Research Network: Design and validation of a histological scoring system for nonalcoholic fatty liver disease. Histopathology 41:1313-1321, 2005.).
Obesity Liver
The liver parenchyma shows preserved acinar architecture. There is relatively mild steatosis with large and small fat droplets in the hepatocytes. The fat is predominantly macrovesicular. No significant cell swelling or Mallory hyaline is identified. There are scattered hepatocytes with glycogenated nuclei in the periportal areas. No necrosis, cholestasis, granulomatous inflammation, or acidophil bodies are seen. The portal areas appear normal with no significant increase in cellularity. The central veins are histologically unremarkable. Minimal incomplete bridging fibrosis is present with septate fibrosis extending from some portal tracts. No centrilobular fibrosis is seen. There is no significant reticulin collapse. PASH stains with and without diastase show lipofuscin-like material in some of the hepatocytes. Control slides for the special stains react appropriately.
Dx
LIVER, NEEDLE BIOPSY:
MILD STEATOSIS WITH MINIMAL INCOMPLETE BRIDGING FIBROSIS.
NO EVIDENCE OF STEATOHEPATITIS.
Osteochondroma
Multiple sections of bone and cartilage fragments reveal a benign osteochondroma. The periosteum along the cortical bone is reactive. A mildly nodular cartilage cap is relatively thin. The columns of chondrocytes are fairly well organized in most areas. There is no evidence of atypical changes in the chondrocytes. The mineralized trabecular bone has a normal appearance. The marrow space is filled with fat and scattered small clusters of hematopoietic marrow.
Pectus carinatum
Dx
BONE AND CARTILAGE, RIBS, PECTUS CARINATUM REPAIR:
NO PATHOLOGIC CHANGE (GROSS ONLY).
Pectus excavatum
Dx
BONE AND CARTILAGE, RIBS, PECTUS EXCAVATUM REPAIR:
NO PATHOLOGIC CHANGE (GROSS ONLY).
Pericardial CystSections show fibrous connective tissue wall with mesothelial lining and scattered small lymphoid aggregates.
Dx
SOFT TISSUES, PERICARDIUM, _____, RESECTION:
BENIGN MESOTHELIAL LINED CYST CONSISTENT WITH PERICARDIAL CYST.
Pilomatrixoma
The sections reveal a pilomatrixoma, a benign skin appendage tumor with differentiation toward hair cells, particularly hair cortex cells. The tumor is sharply demarcated from the surrounding soft tissues of the dermis and is partially encapsulated by a pseudocapsule of compressed connective tissue. It is composed of irregularly shaped islands of epithelial cells that display two basic forms, basophilic cells and "shadow" cells. The basophilic cells possess elongated deeply basophilic nuclei and scanty cytoplasm and are arranged along the periphery of the tumor islands. In some areas there is a transition of basophilic cells into (necrotic) "shadow" cells. Numerous multinucleated foreign body giant cells surround many of the clumps of "shadow" cells. Centers of keratinization and foci of calcification are present. Pilomatrixoma is the most common skin appendage tumor in children younger than 10 years. This benign tumor is usually solitary and arises in the face and upper extremities.
Dx
SOFT TISSUES (SKIN), ______________, EXCISIONAL BIOPSY:
PILOMATRIXOMA.
Pyogenic granuloma
The sections show a pedunculated granulation tissue-type hemangioma (pyogenic granuloma). The lesion is characterized by lobular proliferation of small capillaries set in a fibromyxoid matrix. A very mild sprinkling of mononuclear cells is present within the stroma. Some of the lobules are associated with a larger central blood vessel. The skin surface is not ulcerated.
Dx
SKIN, __________, EXCISIONAL BIOPSY:
PYOGENIC GRANULOMA.
Rapid viral rejected EM stool
The specimen is received in a container labeled with the patient' s name. It consists of approximately 5 mL of dark green formed stool. The specimen is rejected as an inappropriate sample, since it is not a diarrhea (liquid, watery) stool. Nursing Service on ------ was notified.
Dx
FECES:
SPECIMEN REJECTED FOR EXAMINATION; INAPPROPRIATE SPECIMEN
SUBMITTED FOR EVALUATION (SEE DESCRIPTION).
FECES:
CORONAVIRUS-LIKE PARTICLES PRESENT (SEE COMMENT).
FECES:
NO VIRUSES IDENTIFIED.
Rare eosinophils in esophagus
The presence of intraepithelial eosinophils in this case may or may not represent reflux esophagitis. There are few other features of reflux esophagitis in this specimen.
Rectal Biopsy
Sections of rectal mucosa obtained by suction biopsy show an adequate and well-oriented portion of tissue. The mucosal surface shows no evidence of erosion or ulceration. There is no significant inflammatory infiltrate. The submucosa contains scattered clusters of ganglion cells. There are no hypertrophied nerve trunks. The acetylcholinesterase stain shows a normal pattern in the muscularis mucosae and in the submucosal nerve trunks. The control slide for the special stain reacts appropriately.
Dx
INTESTINE, LARGE, RECTUM, BIOPSY:
GANGLION CELLS PRESENT.
Small Bowel Allograft Rejection Reference
This biopsy specimen was evaluated for acute rejection using the criteria established by the pathology workshop on small bowel transplants (see Ruiz R, Bagni A, Brown R, Cortina G, Harpaz N, Magid MS, Reyes J. Histological criteria for the identification of acute cellular rejection in human small bowel allografts: results of the pathology workshop at the VIII International Small Bowel Transplant Symposium. Transplant Proc 36:335-337, 2004.).
Renal allograft
The specimen is adequate. It consists of _____ cores of renal cortex with medulla and contains up to ____ glomeruli and ____ small and large arteries in various sections. There are no segmentally or globally sclerosed glomeruli. The glomeruli are normal in size and are normocellular. No glomeruli show ischemic changes. The peripheral capillary loops have a thin and delicate appearance with no double contours, areas of collapse or capsular adhesions. There is no glomerulitis. The tubules and interstitium are not altered. There is no interstitial inflammatory cell infiltrate, edema, hemorrhage, or fibrosis. The peritubular capillaries are not dilated and do not contain inflammatory cell infiltrates. There is no tubulitis, tubular cell injury, or tubular atrophy. No intranuclear viral inclusions are identified in tubular epithelium, and the immunoperoxidase stain for BK virus is negative. The arteries do not show intimal or transmural arteritis, fibrinoid necrosis or intimal fibrosis. Similarly, the arterioles do not show transmural inflammation, and there is no nodular medial hyaline arteriolar change. Control slides for all the special stains react appropriately.
Rocky Mountain Spotted Fever comment
Control slides for this special stain react appropriately. This test was developed and its performance characteristics determined by the ----- Hospital Histology Laboratory and the Immunohistochemistry Laboratory at -------. It has not been cleared or approved by the U.S. Food and Drug Administration (FDA). The FDA has determined that such clearance or approval is not necessary. This test is used for clinical purposes and should not be regarded as investigational or for research.
RUO Antibodies comment
(The manufacturer of this antibody (-------) has designated this antibody as an "RUO" (Research Use Only) antibody.)
Spermatic cord (Remnant testicle)
Sections of the _____ spermatic cord show a blind-ending vas deferens (present only in the proximal portion of the cord). The rest of the spermatic cord consists of the loose fibrovascular connective tissue, the congested pampiniform vascular plexus and slender bundles of skeletal muscle. There is some central scarring and more extensive scarring at the bulbous distal portion of the cord. Hemosiderin deposits and hemosiderin-laden macrophages and dystrophic calcification are seen in the areas of scarring at the bulbous end. Foreign body giant cells surround some of the calcifications. No testicular or epididymal remnants are identified.
Dx
SPERMATIC CORD, _____, RESECTION:
BLIND-ENDING VAS DEFERENS WITH SCARRING, DYSTROPHIC CALCIFICATION,
AND HEMOSIDERIN DEPOSITION.
ABSENCE OF TESTIS (TESTICULAR REGRESSION SYNDROME).
Spermatocele
Multiple sections show cystic spaces lined by ciliated tall columnar epithelium with lumina filled with sperm. The wall is composed of connective tissue.
Dx
EPIDIDYMIS, RIGHT/LEFT, RESECTION:
SPERMATOCELE.
Squamous Papilloma
The sections show fragments of a laryngeal squamous papilloma. Short papillary fronds are covered by nonkeratinizing squamous epithelium that shows mild basilar hyperplasia. Scattered koilocytes are present.
Dx
LARYNX, EXCISIONAL BIOPSY:
SQUAMOUS PAPILLOMA.
Tonsils and Adenoids
Sections of right and left tonsils show follicular hyperplasia. The lymphoid follicles have active germinal centers that contain numerous tingible-body macrophages. The adenoids also show follicular hyperplasia.
Dx
TONSIL, RIGHT, TONSILLECTOMY:
FOLLICULAR HYPERPLASIA.
TONSIL, LEFT, TONSILLECTOMY:
FOLLICULAR HYPERPLASIA.
ADENOIDS, ADENOIDECTOMY:
FOLLICULAR HYPERPLASIA.
Umbilical Hernia
Sections of soft tissues from the umbilical region show dense fibrous connective tissue without a mesothelial lining. The lesion is consistent with a hernia sac.
Dx
SOFT TISSUES, UMBILICAL REGION, HERNIORRHAPHY:
HERNIA SAC.
Upper proximal ureter junction obstruction
Sections of the proximal ureter show a very narrow, stenotic lumen that is lined with redundant mucosa. The wall of the pelvis is thickened, and there is some degree of smooth muscle hypertrophy. The overlying transitional mucosa is somewhat thin. The histologic features are consistent with ureteropelvic junction obstruction.
Dx
URETER AND URETEROPELVIC JUNCTION, ______, PYELOPLASTY:
URETERAL STENOSIS, CONSISTENT WITH URETEROPELVIC JUNCTION
OBSTRUCTION.
Vp shunt catheter
Dx
BRAIN, LATERAL VENTRICLE, CATHETER REMOVAL:
PORTION OF VENTRICULAR CATHETER WITH INTRALUMINAL DEBRIS COMPOSED
OF GLIOTIC NEUROPIL WITH SCAR TISSUE, MILD CHRONIC INFLAMMATION,
HEMOSIDERIN DEPOSITION, DYSTROPHIC CALCIFICATION, AND FRAGMENTS
OF CHOROID PLEXUS.
Referencias
Experiencia por la rotación de patología pediátrica en EEUU
Espero que les sea útil!
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