CPCils With Answers

Chapter 1 : Cell Injury

YEAU MING SONG
MBBS 2008/2013

Slide 27D Liver - Fatty change (H&E x 10)
This slide of liver shows extensive areas of fatty change in which you can see
macrovesicular cytoplasmic vacuoles which are large and clear owing to
accumulation of lipids and this is compressing and displacing the nucleus of the
hepatocytes to the periphery of the cell. There is therefore a striking resemblance to
adipose tissue cells. Areas of congestion are also seen with pigment in the sinusoids.
The portal tracts show sparse inflammatory infiltrates.

Case 1: This is a section of liver of a 25 year old Chinese male engineer who had 6
beers at a bar. Despite being drunk, he ignored his friends advice to take a
taxi home, and sped off on his Harley Davidson bike. He crashed into a
lamp post and at the A&E unit he was found to be dead on arrival.

Q1: What do you expect the liver to look like grossly?
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Q2: What do you seen in section of his liver?
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Q3: How would you classify this liver injury? Is it reversible or irreversible?
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Intracellular accumulations of a variety of materials can occur in response to cellular
injury. Here is fatty metamorphosis (fatty change) of the liver in which deranged
lipoprotein transport frominjury (most often alcoholism) leads to accumulation of
lipid in the cytoplasmof hepatocytes.


Liver Necrosis in amoebic abscess
Large are of necrosis in liver parenchyma
Necrotic tissue is pale in colour, structureless & friable loss of normal
architecture
Irreversible change
YEAU MING SONG
MBBS 2008/2013

Slide 7C - Lymph node Coagulative necrosis (H&E x 20)

Case 2: This section shows a large area of coagulative necrosis. This type
of necrosis is seen in tuberculosis where it is also know as
caseation necrosis.

Q1: What are the morphological characteristics of necrotic tissue?
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Q2: How would you classify this type of injury? Is it reversible or
irreversible?
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Q3: Name other types of necrosis.
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Microscopic, caseous necrosis is characterized by acellular pink areas of necrosis, as
seen here at the upper right, surrounded by a granulomatous inflammatory process.


Lung Caseation necrosis in tuberculosis
Apex of lung, an area of necrosis & a cavity seen
Necrotic tissue is creamin colour, structureless, cheesy & crumbles easily
Caseation necrosis is a formof coagulative necrosis found in tuberculosis
Irreversible change
YEAU MING SONG
MBBS 2008/2013

Slide 11Q Kidney Amyloidosis (H&E x 10)
This slide of kidney shows amyloid deposits in a glomeruli, around the tubules,
around the blood vessel and in the interstitium. The glomerular (amyloid) deposits
are mainly in the mesangiumand around the capillary basement membrane where
they appear as pink acellular material. The extent of involvement of glomeruli is
variable with some showing only mild or segmental involvement while others show
almost complete obliteration of the glomerular tuft by confluent masses of
interlacing mesangial amyloid deposits. Around the blood vessels, the amyloid
deposits appear as broad pink bands of acellular material.

Case 3: This is a section of a kidney froma patient who suffered fromleprosy for
20 years and finally died frommulti-organ failure

Q1: What is this hyaline material seen in the kidney?
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Q2: Where is this hyaline material located?
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Q3: What would you see if you polarized the section stained with Congo
Red?
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This Congo Red stain reveals orange-red deposits of amyloid, which is an abnormal
accumulation of breakdown products of proteinaceous material that can collect
within cells & tissues


Kidney - Infarct
Wedged-shaped areas of infarction are present
These areas of necrosis are pale, lack form& are sharply demarcated fromthe
adjacent viable tissue.
Irreversible change
Chapter 2 : Inflammations
YEAU MING SONG
MBBS 2008/2013

Slide 24A Appendix Acute appendicitis (H&E x 10)
This slide shows complete destruction of the appendiceal mucosa and glands and
infiltration of the entire wall of the appendix by polymorphs. The mucosa is
completely necrotic and inflammation extends into the periappendicial fatty tissue
(periappendicitis).

Case 1: This is a section of the appendix of a second year medical student who
presented with right iliac fossa pain, fever & nausea.

Q1: Identify & name the inflammatory cells seen in the section
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Q2: What type of inflammation is this?
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Q3: Explain the pathogenesis of this type of inflammation
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Microscopically, acute appendicitis is marked by mucosal inflammation and
necrosis. Here, the mucosa shows ulceration and undermining by an extensive
neutrophilic exudate.


Appendix Acute appendicitis
Appendix is swollen (cellular & fluid exudates) & reddish ( vascularity)
Acuteinflammatory
cellular exudates
YEAU MING SONG
MBBS 2008/2013
Compare this with normal appendix

Slide 10B - Skeletal muscle Abscess (H&E x 10)
This slide shows skeletal muscle bundles on one side and fibrous tissue on the other.
In between these 2 there is a large area occupied by numerous polymorphs. Some of
the polymorphs are necrotic and in between the polymorphs, capillaries can be seen.
These polymorphs are also separating the collagen bundles and infiltrating between
them. At one focus the polymorphs are going in between the skeletal muscle fibres.

Case 2: A 50 year old man who is known diabetic, complained of pain & swelling
in left leg. On examination the swelling was red. Warm& tender. This is a
section through the swelling

Q1: Explain the pathogenesis of this lesion?
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Q2: What is the main inflammation cell seen here?
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Q3: List the cardinal feature of inflammation & correlate them with the
pathological changes
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Liver Fatty change
Liver is diffusely enlarge, yellowish & feels greasy
YEAU MING SONG
MBBS 2008/2013
Reversible change

Slide 11E Kidney - Chronic pyelonephritis (H&E x 10)
This slide of kidney shows renal capsule at one end and one of the calyces at the
other end of the section. The calyceal epitheliumis partly ulcerated with underlying
infiltrates of plasma cells, lymphocytes and eosnophils. A few foamy histiocytes are
also seen(lipid laden histiocytes). As you proceed towards the capsular end of the
section you will see that the interstitiumis heavily inflamed and is mainly infiltrated
by lymphocytes. Lymphoid follicles are also seen. Focal tubular atrophy is seen in
which pink casts are present in the tubules giving a resemblance to thyroid tissue
(thyroidization). Some of the tubules contain polymorphs in their lumen. The
inflamed and scarred areas of renal parenchyma also show glomerular changes such
as partial or complete hyalinization and periglomerular fibrosis. A few of the vessels
show hyaline arteriolosclerosis.

Case 3: This is a section of kidney froma patient who suffered fromchronic urinary
obstruction for 10 years

Q1: Identify & name the inflammatory cells seen
Plasma cells, lymphocytes, histiocytes, monocytes

Q2: What type of inflammation is this?
Chronic inflammation

Q3: Describe the gross / macroscopic features of kidney in this condition
Shrunken in size, uneven surface,


The large collection of chronic inflammatory cells here is in a patient with a history
of multiple recurrent urinary tract infections. This is chronic pyelonephritis. Both
lymphocytes and plasma cells are seen in this case of chronic pyelonephritis. It is not
uncommon to see lymphocytes accompany just about any chronic renal disease:
glomerulonephritis, nephrosclerosis, and pyelonephritis. However, the plasma cells
are most characteristic for chronic pyelonephritis.

Kidney Chronic inflammation
Kidney is shrunken in size.
Surface is uneven & scarring due to long standing inflammation


YEAU MING SONG
MBBS 2008/2013



Slide 7C - Lymph node Tuberculosis (H&E x 10 & x 20)
This slide shows a lymph node with its nodal architecture preserved over only part of
cortex where lymphoid follicles are visible. The rest of node shows loss of
architecture due to large areas of cheesy (caseation) necrosis. Around these areas of
caseation necrosis epithelioid cell granulomas are seen, some of which show
Langhans giant cells while others show central necrosis in the centre of the node
also show a lot of nuclear debris which appears as purple staining dots of variable
sizes. The capsule is thickened over part of node and near this area the capsule is
infiltrated by lymphocytes, plasma cell, eosinophilis and polymorphs and some
caseating granulomas (periadenitis).

Case 4: A 29 year old Bangladeshi waiter presented with cough, night sweats and a
swelling at the right neck region of 2 months duration. Chest X-ray showed
apical cavitation & the Mantoux skin test was positive. A biopsy of right
cervical lymph node was done

Q1: Identify & name the characteristic pathological lesion seen in this
section
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Q2: Draw a schematic diagram of this lesion & label its components

YEAU MING SONG
MBBS 2008/2013


The focal nature of granulomatous inflammation is demonstrated in this microscopic
section of lung in which there are scattered granulomas in the parenchyma. This is
why the chest radiograph with tuberculosis or other granulomatous diseases is often
described as "reticulonodular". A biopsy could miss such lesions fromsampling error,
too. Giant cells are a "committee" of epithelioid macrophages. Seen here are
two Langhans type giant cells in which the nuclei are lined up around the periphery
of the cell. Additional pink epithelioid macrophages compose most of the rest of the
granuloma.
Chapter 3 : Repair
YEAU MING SONG
MBBS 2008/2013

Slide 9E skin - Granulating wound (H&E x 4)
The slide shows skin with an area of ulceration in the centre. On both ends of the
ulcer the epidermal lining can be seen. The ulcer shows a superficial zone of fibrin
and inflammatory exudates and under this is a zone of granulation tissue which
consists of capillaries of varying sizes. Polymorphs, plasma cells, lymphocytes and
deeper down, fibroblasts are also seen. The area of granulation tissue also shows a
lot of pink fluid like material (possibly plasma) that has probably oozed out of the
leaky vessels of granulation tissue. The dermis underneath the intact skin on both
sides of the ulcer is also inflamed with many plasma cells and proliferating vessels.
Some underlying adipose tissue (subcutaneous tissue) also seen.

Case 1: Imagine that a section through a surgical wound is taken. This is the tissue
you would see within the first week of the healing process.

Q1: Identify and name the tissue seen in the section
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Q2: Name the components of this tissue
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Q3: List the stages of healing
1
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Healing of inflammation often involves ingrowths of capillaries and fibroblasts. This
forms granulation tissue. Here, an acute myocardial infarction is seen healing. There
are numerous capillaries, and collagen is being laid down to forma scar. Non-
infarcted myocardiumis present at the far left.
At high magnification, granulation tissue has capillaries, fibroblasts, and a variable
amount of inflammatory cells (mostly mononuclear, but with the possibility of some
PMN's still being present).












YEAU MING SONG
MBBS 2008/2013


Slide 1D Heart - Organizing Thrombus in Auricle (H&E x 4 & x 10)
The slide shows cardiac muscle around a central irregular heamorrhagic space. This
space is partly lined by endotheliumand around the areas of hemorrhage , thin wall
capillaries of varying sizes (some uncanalized) are proliferating along with
inflammatory cells (constituting granulation tissue). The cardiac muscle adjacent to
the endotheliumshows mild hydropic changes. One or two more hemorrhage-filled
luminal spaces surrounded by cardiac muscle are also seen which, in some slides ,
show organizing thrombi as described above.

Case 2: This is an example of thrombosis in the auricle of the heart. The formation
of a fibrin clot gradually leads to blockage of the heart chamber.

Q1: Explain how the process of repair can improve this condition
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Q2: Identify the granulation tissue. Name its components
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Q3: Name another site where a similar situation may arise
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A coronary thrombosis is seen microscopically occluding the remaining small
lumen of this coronary artery. Such an acute coronary thrombosis is often the
antecedent to acute myocardial infarction.
Chapter 4 : Thrombosis & Other Circulatory Disorder
YEAU MING SONG
MBBS 2008/2013

Slide 6S Lung - Pulmonary oedema (H&E x 10)
This slide shows many of the alveolar spaces filled with pink fluid-like material. The
alveolar septae are congested. Some bronchioles are visible and the medium-sized
and large blood vessels are also congested.

Case 2: This is a section of lung of a patient who died of acute left ventricular
failure

Q1: Examine this slide
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Q2: Explain the mechanism involved in the formation of pulmonary
oedema
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Q3: List the main symptoms seen in this patient before death
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Heart is opened showing a mural thrombus on the wall of the left ventricle


A thrombus emerging fromwithin the Superior Vena Cava (SVC) as it
enters the right atrium
Chapter 5 : Neoplasm
YEAU MING SONG
MBBS 2008/2013

Slide 9J skin - Squamous cell carcinoma (H&E x 4)
This slide shows skin. In the dermis, dermal appendages such as sweat glands and
sebaceous gland are seen. Also seen is a tumour arising form the lower part of
epidermis and going down and filtrating the dermis in the form of sheet and
interconnecting trabeculae. The individual tumours cells show abundant pink
cytoplasm(evidence of keratinization) and large vesicular nuclei and macronucleoli.
Mitotic figures are numerous and nuclear pleomorphismis prominent. Occasional
multinucleated tumour cell are seen. A few keratin pearls are seen.

Case 1: J anaki, a 60 year old Indian woman presented with an ulcer on the inner
cheek. She gave a history of chewing sireh for many years. This is a
section through the ulcer

Q1: Identify the normal tissue
Keratinized stratified squamous spindle shaped

Q2: Identify and describe the microscopic features of the neoplastic changes
seen
Pleomorphism, hyperchromatic of nuclei,
nuclear:cytoplasmic ratio, loss of polarity, mitotic activity

Q3: Name some of the aetiological factors of this type of neoplasm. Explain
what is meant by sireh
Chemical carcinogen
a) Polycyclic aromatic hydrocarbon (soot, coal tar,
cigarette smoke)
b) Aromatic amines (alpha & beta-napthylamine,
benzidine, aniline dye & rubber industry)
c) Azo-compounds (dye in food)
d) Aflatoxin (toxic product of Aspergillus flavus)
Physical agents
a) Ionizing radiation (x rays)
b) Ultraviolet light
Hereditary, Chronic diseases, Infections, Hormones

Sireh means betel.


This is the microscopic appearance of neoplasia, or uncontrolled new growth. Here,
the neoplasmis infiltrating into the underlying cervical stroma. Of course, there can
be carcinoma in situ in which a full-fledged neoplasmis present, but has not yet
invaded. Over time, neoplasms may acquire characteristics that make themable to
invade tissues, and this distinguishes themas malignant. This is a squamous cell
carcinoma. Note the disorderly growth of the squamous epithelial cells in these large
nests with pink keratin in the centers. Neoplasms may retain characteristics of their
YEAU MING SONG
MBBS 2008/2013
cell of origin. Benign neoplasms mimic the cell of origin very well, but malignant
neoplasms less so.


Slide 26B Colon Adenocarcinoma (H&E x 4)
This slide shows large intestine with an abrupt transitional zone fromnomal to
malignant mucosa. The malignant mucosa consists of back papilloglandular
structures that are lined by tall columnar pleomorphic cells with frecuent mitosis and
focal stratification. These malignant glands also infiltrate the submucosa and part of
the muscle and extend into the serosa.

Case 2: A 66 year old Malay man complained of passing fresh blood with stools for
several weeks. A section through the resected bowel is shown

Q1: Identify the normal tissue
ciliated columnar epithelium with goblet cells lining the crypts

Q2: Identify and describe the microscopic features of the neoplastic changes
seen
Same with previous

Q3: What type of epithelium does this neoplasm arise from?
Ciliated columnar to columnar


The infiltrating glands of this colonic adenocarcinoma demonstrate less
differentiation than the adenomatous polyp, although they still resemble glands. In
general, less differentiation of a neoplasmmeans a greater likelihood of malignant
behavior. This is the basis for grading. The higher the grade, the more aggressive the
malignant neoplasm. Benign neoplasms are not graded.



YEAU MING SONG
MBBS 2008/2013


Slide 7D - Lymph node - Squamous cell carcinoma
This slide shows a lymph node in which only few cortical lymphoid follicles are seen.
The rest of the node is replaced by malignant tumour which consists of
interconnecting sheets and island of large cells with abundant pink cytoplasmand
oval vesicular nuclei with one or more nucleoli. There is abundant keratin pearl
formation within these islands (indicating that this is a well differentiated squamous
cell carcinoma). In fact, in some areas there are mainly keratin pearls seen with very
few tumour cells. Some areas of tumour show spindle cells.

Case 3: Six months after major oral surgery, J anaki presented to follow-up clinic
with enlarged cervical lymph nodes. This a section through an excised
lymph node

Q1: Identify the normal lymphoid tissue
Primary & secondary follicles

Q2: Identify and describe the neoplastic tissue
Same with previous + well differentiated (keratin pearl &
intercellular bridge)

Q3: Explain the pathogenesis of Janakis illness
Sireh genetic / DNA changes activation of proto-
oncogenes excessive expression of cellular oncogenes
excessive clonal proliferation abnormal growth neoplasia
blood vessels / lymphatics spread metastasis


Microscopically, metastatic adenocarcinoma is seen in a lymph node here. It is
common for carcinomas to metastasize to lymph nodes. The first nodes involved are
those receiving lymphatic drainage fromthe site of the primary neoplasm.














Squamous cell
carcinoma
infiltrating the
lymph node
YEAU MING SONG
MBBS 2008/2013




Slide 2D Uterus Leiomyoma (H&E x 4)

Case 4: This is a section taken fromone of the nodules present in the uterus of Mrs
Wong

Q1: Identify and describe the microscopic features of the neoplasm seen in
this section
Myometrium cells do not vary greatly in size and shape and
closely resemble normal smooth muscle cells.

Q2: What is the tissue of origin of the neoplasm?
Smooth muscle

Q3: Describe the macroscopic (gross) appearance of this neoplasm
Nodules are benign & well-circumscribed firm white masses



Mrs Wong, a 49 year old teacher, presented with menorrahgia for two months.
She was married for many years but did not have any children
This is the hysterectomy specimen showing multiple leiomyomas in the
uterus

Ovary Benign Cystic Teratoma
J enny, a 20 year old clerk, presented with acute & severe left-sided abdominal
pain. A laparotomy was performed.
Chapter 6 : Cardiovascular System
YEAU MING SONG
MBBS 2008/2013

Slide 2A Heart - Acute pericarditis, organizing (H&E x 4)
The slide shows cardiac muscle with pericardiumon one side. The pericardial region
is infiltrated by neutrophils, lymphocytes, eosinophils and plasma cells. External to
this is a zone of granulation tissue consisting of capillaries of varying sizes,
fibroblast laying down collagen and a sprinkling of inflammatory cells.

Case 1: A 28 year old woman complained of severe central chest pain following a
bout if viral upper respiratory tract infection. On auscultation she was found
to have a pericardial rub. If the pericardiumwere sampled, this is the tissue
you would see

Q1: Name the components of this tissue
Infiltration of neutrophils, lymphocytes, eosinophils
and plasma cells
Granulation tissues with varying sizes of capillaries,
fibroblast

Q2: Name the pathological process seen and the cells involved
Organization & remodeling
Neutrophils, lymphocytes, eosinophils, plasma cells, fibroblasts


A 55 year old woman collapsed & died at home. She had a known history of
chronic rheumatic heart disease
An autopsy was done. Examination of the heart revealed fibrosis of the mitral
valve, & fusion of mitral valve, & fusion of chordae tendineae. Multiple,
friable vegetations are present on the deformed valve

YEAU MING SONG
MBBS 2008/2013

Slide 2C - Heart Recent infarct (H&E x 10)

Slide 2B - Heart Healed myocardial infarct (H&E x 10)
This slide shows mainly myocardial tissue with many areas of fibrosis. In some foci
small groups of necrotic muscle bundles are seen in which nuclei are absent. Some of
the viable cardiac muscle fibres show varying degrees of nuclear enlargement.
Case 2: Mr Balan, a 70 year old shopkeeper was brought in dead to A&E after
experiencing severe chest pain. Autopsy was done & examination of the
heart revealed thrombosis of the left descending coronary artery. Sections
through the left ventricle are shown here

Q1: Explain the pathogenesis of this condition
Atherosclerosis turbulent flow thrombosis ischemia
infarction

Q2: Identify the pathological changes seen in slides 2C & 2B & correlate
them with clinical events
































YEAU MING SONG
MBBS 2008/2013

Aorta Atherosclerosis
Examination of aorta revealed extensive atherosclerotic changes which include
calcification & ulceration of atherosclerotic plaques in the case of Mr
Balan


A section through the left ventricle shows a recent infarct in the anterior
wall of the left ventricle. The colour of recently infarcted area is dark due to
haemorrhage. This infarct caused the death of the patient
In another area of the anterior wall of the left ventricle is a whitish are of
fibrosis . This corresponds to an area of previous infarction which has
healed


Chapter 7 : Respiratory System
YEAU MING SONG
MBBS 2008/2013

Slide 6A Lung Bronchopneumonia (H&E x 10)
The slide shows lung tissue. The alveolar septae are all congested and patchy areas
of consolidation are seen around some of the bronchi. The lumina of these bronchi
are filled with inflammatory cells and the walls of the bronchi are inflamed. The
alveoli around these inflamed bronchi show filling up of their air spaces with
inflammatory cells (mainly polymorphs). Erythrocytes are also seen within the
alveolar spaces. In between these patchy areas of concolidation, normal alveoli are
seen. (Compare this slide with slide 6C-lobar pneumonia where you will see that all
the alveoli are filled with inflammatory exudates.)

Case 1: A 28 year old man, who was a known drug abuser with HIV was found
dead in an alley. Post mortemwas done. The lungs were congested &
heavier than normal. The cut surface showed whitish areas of consolidation
around bronchioles with collections of pus.

Q1: Identify the structure if lung i.e. bronchioles (respiratory epithelium,
muscular walls/cartilage), alveolar spaces, alveolar walls etc.

Q2: Identify the pathological process seen & the cells involved.
Pathological process:
Bronchopneumonia implies a patchy distribution of
inflammation that generally involved > 1 lobe
This pattern result from initial inflammation of bronchi &
bronchiole into adjacent alveoli (mainly neutrophils)
Well developed lesions are slightly elevated & grey-yellow
colour
Confluence if the foci of inflammatory consolidation may
occur appearance of lobar consolidation
Cells involved:
Acute inflammatory cells



The cut surface of this lung
demonstrates the typical appearance
of a bronchopneumonia with areas of
tan-yellow consolidation. Remaining
lung is dark red because of marked
pulmonary congestion.
Bronchopneumonia (lobular
pneumonia) is characterized by
patchy areas of pulmonary
consolidation. These areas become
almost confluent in the left lower
lobe on the bottom left of the
photograph. The areas of
consolidation are firmer than the
surrounding lung.
This radiograph demonstrates patchy
infiltrates consistent with a
bronchopneumonia from a bacterial
infection. Typical organisms include
Streptococcus pneumoniae, Staphylococcus
aureus, Pseudomonas aeruginosa,
Hemophilus influenzae, Klebsiella
pneumoniae, among others.
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YEAU MING SONG
MBBS 2008/2013


Here is another example of a
bronchopneumonia. The lighter areas
that appear to be raised on cut surface
from the surrounding lung are the
areas of consolidation of the lung.
At higher magnification, the pattern of
patchy distribution of a bronchopneumonia
is seen. The consolidated areas here very
closely match the pattern of lung lobules
(hence the term "lobular" pneumonia).A
bronchopneumonia is classically a "hospital
acquired" pneumonia seen in persons
already ill from another disease process.
Typical bacterial organisms include:
Staphylococcus aureus, Klebsiella, E. coli,
Pseudomonas.


This is a lobar pneumonia in which
consolidation of the entire left upper
lobe has occurred. This pattern is
much less common than the
bronchopneumonia pattern. In part,
this is due to the fact that most lobar
pneumonias are due to Streptococcus
pneumoniae (pneumococcus) and for
decades, these have responded well
to penicillin therapy so that
advanced, severe cases are not seen
as frequently. However,
pneumoccoci, like most other
bacteria, are developing more
resistance to antibiotics. Severe
pneumococcal pneumonia still
occurs, even in young to middle aged
persons (not just the very young and
the very old) and has a mortality rate
of 20%!
A closer view of the lobar pneumonia
demonstrates the distinct difference between
the upper lobe and the consolidated lower
lobe. Radiographically, areas of
consolidation appear as infiltrates.

YEAU MING SONG
MBBS 2008/2013

At higher magnification can be seen a patchy area of alveoli that are filled with
inflammatory cells. The alveolar structure is still maintained, which is why a
pneumonia often resolves with minimal residual destruction or damage to the lung.

At high magnification, the alveolar exudate of mainly neutrophils is seen. The
surrounding alveolar walls have capillaries that are dilated and filled with RBC's.
Such an exudative process is typical for bacterial infection. This exudate gives rise to
the productive cough of purulent yellow sputumseen with bacterial pneumonias.



Lung Bronchiectasis
Cut surface of lung shows fibrosis & bronchial dilation in the lower lobe
Bronchial dilation may be cylindrical or saccular





YEAU MING SONG
MBBS 2008/2013

Slide 6N - Lung Squamous cell carcinoma (H&E x 10)
This slide shows lung tissue which is congested. One large bronchiole is filled with
necrotic material and exudates. Adjacent to this bronchiole is a focus of malignancy
consisting of sheets and islands of tumour cells that show abundant pink cytoplasm,
pleomorphism, vesicular nuclei and prominent mitotic activity. Some of the cells
show excessively pink cytoplasm (evidence of individual cell keratinization).
However, no keratin pearls are seen indicating that is not well differentiated
squamous cell carcinoma. Some of u may have slides which u can also see foci of
tumor necrosis.

Case 2: En Ahmad, a 75 year old retired army personnel was admitted for chronic
cough & more recently coughing out blood. He gives a history of heavy
smoking for past 50 years. Chest X-ray showed a large mass in the right
hilar region. Tumour debulking surgery was performed followed by
radiation therapy. This is a section fromthe tumour.

Q1: Identify the tumour tissue & described the histology
Sheets of squamous cell-like pleomorphic nuclei, eosinophilic
cytoplasm, loss of nuclei polarity, nuclear hyperchromatic,
mitotic activity

Q2: Explain the pathogenesis of malignancy in this patient
Chronic smoking damage of respiratory epithelium
(columnar) atypical metaplasia (goblet cells hyperplasia
basal cell hyperplasia) squamous dysplasia carcinoma in
situ invasive squamous cell carcinoma (hilar, cervical
lymph node)


One month later, the patient succumbed to his illness. At post mortem, a large, solid,
pale tumour was present in the hilar region of right lung. The tumour was seen to
arise from the branch of the right main bronchus & infiltrate into the
surrounding lung parenchyma.

P
PPs
ss e
eeu
uud
ddo
ooc
cca
aap
pps
ss u
uul
ll e
ee
c
cco
oom
mmp
ppr
rr e
ees
ss s
sse
eed
dd a
aal
ll o
oon
nng
gg
p
ppa
aar
rre
een
nnc
cch
hhy
yym
mma
aa
YEAU MING SONG
MBBS 2008/2013

This is the microscopic appearance of squamous cell carcinoma with nests of
polygonal cells with pink cytoplasm and distinct cell borders. The nuclei are
hyperchromatic and angular.

The pink cytoplasmwith distinct cell borders and intercellular bridges characteristic
for a squamous cell carcinoma are seen here at high magnification. Such features are
seen in well-differentiated tumors (those that more closely mimic the cell of origin).

In this squamous cell carcinoma at the upper left is a squamous eddy with a keratin
pearl. At the right, the tumor is less differentiated and several dark mitotic figures are
seen.

This chest radiograph demonstrates a
large squamous cell carcinoma of the
right upper lobe.
This chest radiograph demonstrates a
large 5 cm diameter squamous cell
carcinoma of the right lower lobe. The
1.5 cmbright opacity in the middle of
the mass is a calcified granuloma that
was seen on lateral view to be behind the
neoplasm. Additional calcified
granulomatous areas are medial to the
mass. The sternal wire loops are froma
previous coronary artery bypass
procedure.
YEAU MING SONG
MBBS 2008/2013

Slide 6Q Lung Adenocarcinoma (H&E x 10)
This slide shows lung tissue with a fairly well-circumscribed tumour nodule in the
centre. This tumour consists of well formed papillo-glandular structures arranged
back to back. These glands are lined by tall columnar cells with basal, vesicular oval
nuclei that show mild pleomorphismand overlapping.

Case 3: Mr Chan, a 50 year old retired teacher, was found to have multiple opacities
in the lung on chest X-ray at his follow-up visit. He died soon after this.
Eight months ago he was diagnosed with carcinoma of the caecum &
ascending colon with involvement of the mesenteric lymph nodes. This is a
section of the lung at post mortem.

Q1: Described the morphology of the tumour
Papillary structure, center fibrovascular look, surrounded
by cells (tall columnar stratified cells with basal nuclei),
glands x uniform (varying size & shape), pleomorphic nuclei,
high nuclear:cytoplasmic ratio, closely packed, basement
membrane is intact, well circumscribed

Q2: Explain the events that have taken place in the natural history of the
disease
1 cancer in mucosa membrane if caecum submucosa
serosa lymph node portal circulation liver emboli
of tumour cell in vein metastases to lung


This is the cut-surface of the right lung at post mortem. Multiple pale, nodular areas
of tumour are scattered throughout the lung parenchyma . Histopathological
examination of the nodules showed adenocarcinoma.

YEAU MING SONG
MBBS 2008/2013

A nest of metastatic infiltrating ductal carcinoma frombreast is seen in a dilated
lymphatic channel in the lung. Carcinomas often metastasize via lymphatics.
Prostatic adenocarcinoma is famous for metastasizing to the lungs in a
"lymphangitic" pattern in which streaks of tumor appear between lung lobules and
beneath the pleura in lymphatic spaces.

A focus of metastatic carcinoma frombreast is seen on the pleural surface of the lung.
Such pleural metastases may lead to pleural effusions, including hemorrhagic
effusions, and pleural fluid cytology can often reveal the malignant cells.

This chest radiograph demonstrates a nodular pattern resulting from multiple
metastases to the lung froma colonic adenocarcinoma. This is the same patient as the
previous radiograph, but at a later point in the course. (The plate and screws in the
cervical spine repaired a pathologic fracture frommetastasis).
Chapter 8 : Gastrointestinal & Hepatobiliary System
YEAU MING SONG
MBBS 2008/2013

Slide 23B Stomach - Adenocarcinoma (Intestinal variety) (H&E x 5)
This slide shows stomach in which a tumour is seen arising fromthe mucosa. This
tumour consists of well differentiated glands of varying sizes arranged back to back
with a tubulo-papillary architecture. The glands are lined by tall columnar cells that
show foci of stratification, pleomorphic vesicular nuclei and increased mitosis. The
transition form normal to normal mucosa is very abrupt and dramatic and the
uniformly pale staining normal mucosa contrasts very sharply with the deep staining
abnormal malignant mucosa. The malignant glands are also infiltrating the
submucosa and muscle coat and occasional lymphatics show tumour emboli. This
tumour is an example of the intestinal variety of gastric carcinoma which presumably
arises fromareas of intestinal metaplasia that has occurred in the stomach.

Case 1: Encik Badri, a 52 year old businessman, complained of vague abdominal
discomfort & noticed recent weight loss. Gastroscopic examination revealed
an ulcerative lesion in the antral region. Gastrectomy was performed.

Q1: Identify the various areas as labeled above in the histological section
provided.

Q2: Name other possible modes of presentation of this condition
A
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Q3: List the possible complication that may arise in this case
i
ii .
.. M
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nno
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:: l
ll i
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&& l
ll u
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i
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.. L
LLo
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tt s
ss:
:: L
LLo
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cca
aal
ll i
ii n
nnv
vva
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ssi
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oon
nn
p
ppa
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ccr
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aas
ss o
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bbs
sst
tt r
rru
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tt i
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oon
nn &
&& h
hha
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mmo
oor
rrr
rrh
hha
aag
gge
ee

Fungating
Early satiety
X much discomfort
Mass in stomach
Ulcerative
Pain
Weight loss
Peritonitis
Diffused infiltrative

Continue Stomach Adenocarcinoma

The gastrectomy specimen shows a large ulcerative growth in the greater curvature
measuring 6.5cmx 4cm. the floor of the ulcer is irregular. The edges are raised &
everted

G
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2
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nne
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N
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n
nnu
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ccy
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tto
oop
ppl
ll a
aas
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tti
ii o
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YEAU MING SONG
MBBS 2008/2013
Colon Adenocarcinoma

A 66 year old man complained of passing fresh blood with stools for several weeks.
Colonoscopy showed a fungating tumour obstructing the sigmoid colon.

The resected colon shows a large fungating mass measuring 4cmin diameter. The
tumour extends circumferentially & almost completely obstructs the lumen

























































YEAU MING SONG
MBBS 2008/2013

Slide 27F Liver - Hepatocellular carcinoma & cirrhosis (H&E x 5)
This slide shows normal liver tissue on one side and a tumour at the other end. The
tumour is partly separated fromthe normal tissue by a cleft like space (possibly an
artifact). The tumour cells show a marked resemblance to hepatocytes in that they
are also polygonal with abundant cytoplasmand vesicular nuclei and attempt to form
trabeculae. In many areas however the trabeculae formation is poor with no
interconnection between the trabeculae. Part of the tumour shows solid sheet like
arrangement. Tumour cells also show macronucleoli and there are frequent
multinucleated tumor cells. Many of the tumour cells show pink cytoplasmic
globules (which could be alpha-feto protein). Also seen in some of the cells are some
amorphous eosinophilic materials (Mallory hyaline). Mitotic activity is very
prominent.

Case 2: Colonel (retired) Wong, 62 years of age, presented with ascites. CT scan of
the liver showed a large solid tumour present in the right lobe. Soon after
admission the patient died & postmortemwas performed.

Q1: What relevant past history would be important in this case?
H
HHe
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tt i
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&& C
CC i
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cci
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c
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,,
W
WWi
ii l
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sso
oon
nn
s
ss d
ddi
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sse
eea
aas
sse
ee

Q2: Identify the various pathological changes seen in the section of liver
provided using the above diagram as a guide
P
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wwh
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a
aal
ll p
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oo p
ppr
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oot
tt e
eei
ii n
nn)
)).
.. A
AAl
ll s
sso
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sse
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nn i
ii n
nn s
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oom
mme
ee o
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tt h
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ss (
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MMa
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hhy
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ppr
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mmi
ii n
nne
een
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tt .
..

Q3: Explain the pathogenesis of the disease in this patient
a
aa)
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CCi
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s
ssi
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ss

b
bb)
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ppa
aat
tt i
ii t
tt i
ii s
ss B
BB &
&& C
CC
V
VVi
ii r
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ll D
DDN
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AA i
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tt e
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&&
t
tt r
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dd H
HHC
CCC
CC

C
CCh
hhr
rro
oon
nni
ii c
cc a
aac
cct
tt i
ii v
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hhe
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tt i
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Ischemic injury prominent fibrosis around central vein bridging necrosis
Toxic injury fibrosis around portal tract
Normally, fibrous tissues formseptaof hepatocytes hexagon
Cirrhosis, thicken fibrous tissues, portal tract extended, varying shape, like a nodule, shrunken
progressively








L
LLi
ii v
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rr c
cce
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ll l
ll i
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jj u
uur
rry
yy

P
PPr
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C
CCh
hhr
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nni
ii c
cc L
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tt o
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h
hhu
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mma
aan
nn D
DDN
NNA
AA

M
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tt a
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tt i
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oon
nn

P
PPr
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oon
nne
ee t
tt o
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mma
aal
ll i
ii g
ggn
nna
aan
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I
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nnf
ff l
ll a
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mmm
mma
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nn
S
SSi
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ss o
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ppe
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--
t
tt y
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ppe
ee (
(( n
nno
oor
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mma
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))
*
** 1
11 c
cce
eel
ll l
ll t
tt h
hhi
ii c
cck
kk o
oon
nnl
ll y
yy
S
SSo
ool
ll i
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ssh
hhe
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tt
=
== H
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CCC
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3
33-
-- 4
44 c
cce
eel
ll l
ll s
ss
t
tt h
hhi
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kk
YEAU MING SONG
MBBS 2008/2013
Liver cirrhosis

Mr. X, a 62 year old retired naval officer, died as a result of massive haematemesis
due to ruptured esophageal varices. Postmortemrevealed a cirrhotic liver.

Q1: Describe the morphological changes seen in the liver
Q2: List the aetiological factors that contribute to cirrhosis

Liver Metastatic carcinoma

Postmortemof a patient who died as a result of terminal illness associated with
carcinoma of the breast showed these findings in the liver

Note the multiple pale tumour deposits in the subcapsular region of the liver


Colon Familial polyposis coli

This is part of the colectomy specimen of a patient diagnosed with familial polyposis
coli. Note multiple adenomatous polyps arising on the entire mucosal surface.

Q1: What is the basis for this condition?
Q2: What is the risk of carcinoma in this condition?













YEAU MING SONG
MBBS 2008/2013
Stomach Chronic Peptic Ulcer

The gastrectomy specimen shows a solitary punched-out ulcer measuring 1cmx
1cmin the antral region.

The ulcer has perforated through the wall of the stomach. The edges of the ulcer are
flat & flush with the mucosal surface. Note the gastric folds that radiate fromthe
ulcer


Chapter 9 : Lymphoreticular system
YEAU MING SONG
MBBS 2008/2013

Slide 7A - Lymph node - Reactive lymphoid hyperplasia (H&E x 5)
This slide shows a lymph node with intact nodal architecture. The follicles are very
prominent and enlarge with large germinal centers. The medullary sinuses are filled
with many histiocytes.

Case 1: A 61 year old schoolgirl noticed a swelling in the right side of her neck. She
had poor oral hygiene & chronic eczema of the skin. There was no history
of fever or loss of weight. A lymph node biopsy was done.

Q1: Name the carious components of this tissue

Q2: Where are B cells predominantly found?
F
FFo
ool
ll l
ll i
ii c
ccl
ll e
ee (
((c
cco
oor
rrt
tt e
eex
xx)
))

Q3: Where are T cells predominantly found?
I
II n
nnt
tt e
eer
rrf
ff o
ool
ll l
ll i
ii c
ccu
uul
ll a
aar
rr (
((p
ppa
aar
rra
aac
cco
oor
rrt
tt e
eex
xx)
))

Q4: List the possible causes of non-neoplastic lymph node
N
NNo
oon
nn-
-- s
ssp
ppe
eec
cci
ii f
ff i
ii c
cc
1
11.
.. L
LLo
ooc
cca
aal
ll i
ii z
zze
eed
dd r
rre
ees
ssp
ppo
oon
nns
sse
ee t
tt o
oo a
aan
nnt
tt i
ii g
gge
een
nn

B
BBa
aac
cct
tt e
eer
rri
ii a
a
al
ll (
((S
SSt
tt r
rre
eep
pp,
,, S
SSy
yyp
pph
hhi
ii l
ll i
ii s
ss)
))

V
VVi
ii r
rra
aal
ll (
((p
ppo
oos
sst
tt v
vva
aac
ccc
cci
ii n
nna
aat
tt i
ii o
oon
nn)
))
2
22.
.. G
GGe
een
nne
eer
rra
aal
ll
i
ii z
zze
eed
dd

V
VVi
ii r
rre
eem
mmi
ii a
aa (
((R
RRu
uub
bbe
eel
ll l
ll a
aa,
,, C
CCM
MMV
VV)
))

D
DDr
rru
uug
gg h
hhy
yyp
ppe
eer
rrs
sse
een
nns
ssi
ii t
tt i
ii v
vvi
ii t
tt y
yy
S
SSp
ppe
eec
c
ci
ii f
ff i
ii c
cc
1
11.
.. I
II n
nnf
ff e
eec
cct
tt i
ii o
oou
uus
ss

P
PPy
yyo
oog
gge
een
nni
ii c
cc l
ll y
yym
mmp
pph
hha
aad
dde
een
nni
ii t
tt i
ii s
ss

I
II n
nnf
ff e
eec
cct
tt i
ii o
oou
uus
ss m
mmo
oon
nno
oon
nnu
uuc
ccl
ll e
eeo
oos
ssi
ii s
ss (
((E
EEB
BBV
VV)
))

T
TTo
oox
xxo
oop
ppl
ll a
aas
ssm
mmo
oos
ssi
ii s
ss

G
GGr
rra
aan
nnu
uul
ll o
oom
mma
aat
tt o
oou
uus
ss (
((T
TTB
BB,
,, h
h
hi
ii s
sst
tt o
oop
ppl
ll a
aas
ssm
mmo
oos
ssi
ii s
ss)
))

G
GGr
rra
aan
nnu
uul
ll o
oom
mma
aat
tt o
oou
uus
ss &
&& s
ssu
uup
ppp
ppu
uur
rra
aat
tt i
ii v
vve
ee (
((c
cca
aat
tt s
ssc
ccr
rra
aat
tt c
cch
hh
)
))

P
PPe
eer
rrs
ssi
ii s
sst
tt e
een
nnt
tt g
gge
een
nne
eer
rra
aal
ll i
ii z
zze
eed
dd (
((H
HHI
II V
VV)
))
2
22.
.. N
NNo
oon
nn-
-- i
ii n
nnf
ff e
eec
cct
tt i
ii o
oou
uus
ss
3
33.
.. U
UUn
nnc
cce
e
er
rrt
tt a
aai
ii n
nn c
cca
aau
uus
ssa
aat
tt i
ii o
oon
nn

S
SSa
aar
rrc
cco
ooi
ii d
ddo
oos
ssi
ii s
ss,
,, g
ggi
ii a
aan
nnt
tt l
ll n
nn,
,, h
hhy
yyp
ppe
eer
rrs
sse
een
nns
ssi
ii t
tt i
ii v
vvi
ii t
tt y
yy
,
,, a
aau
uut
tt o
ooi
ii m
mmm
mmu
uun
nne
ee


Slide 7E - Lymph node - Hodgkins lymphoma (H&E x 5)
YEAU MING SONG
MBBS 2008/2013

Slide 7E - Lymph node - Hodgkins lymphoma (H&E x 40)
This slide shows a lymph node in which the nodal architecture is mostly lost with
only occasional lymphoid follicles seen in cortex. The rest of the node is replaced by
a mixed population of cells consisting of lymphocytes eosinophils, plasma cells and
Reed-Sternberg cells which shows 2 or more nuclei. The nuclei are vesicular and
pale staining with prominent nucleoli and a perinucleolar halo. In the well stained
sections the nucleoli appear eosinophilic (pink staining). Note that the Reed-
Sternberg giant cells are smaller than Langhans giant cells. Also seen are
mononuclear variants of Reed-Sternberg cells which show similar nuclear features.

Case 2: Damien, a 22 year old engineering graduate was found to have several
nodular swellings on both sides of his neck during a pre-employment
medical examination. On further questioning, he gave a history of feeling
unwell & experiencing a loss of appetite for the past month

Examination revealed several firm, rubbery enlarged lymph nodes in the
right & left cervical region. The nodes were discrete not matted together.
There were no discharging sinuses seen. He was febrile, 38.5 C

Damien was admitted to hospital where several investigations including a
lymph node biopsy was done

Q1: What are the possible causes of lymph node enlargement in a young
adult like Damien?
R
RRe
eea
aac
cct
tt i
ii v
vve
ee h
hhy
yyp
ppe
eer
rrp
ppl
ll a
aas
ssi
ii a
aa,
,, n
nne
eeo
oop
ppl
ll a
aas
sst
tt i
ii c
cc

Q2: Correlate & explain the symptoms & signs seen in Damien
F
FFe
eev
vve
eer
rr
c
ccy
yyt
tt o
ook
kki
ii n
nne
ee e
eef
ff f
ff e
eec
cct
tt o
oof
ff t
tt u
uum
mmo
oou
uur
rr
E
EEn
nnl
ll a
aar
rrg
gge
eed
dd L
LLN
NN
H
HHo
ood
ddg
ggk
kki
ii n
nn
s
ss l
ll y
yym
mmp
pph
hho
oom
mma
aa (
((n
nno
ood
ddu
uul
ll a
aar
rr s
ssc
ccl
ll e
eer
rro
oos
ssi
ii n
nng
gg)
))

Q3: List the investigations that you think would be useful in Damiens case?
H
HHi
ii s
sst
tt o
ool
ll o
oog
ggi
ii c
cca
aal
ll e
eex
xxa
aam
mmi
ii n
nna
aat
tt i
ii o
oon
nn o
oof
ff l
ll y
yym
mmp
pph
hh n
n
no
ood
dde
ee b
bbi
ii o
oop
pps
ssy
yy
-
-- l
ll o
ooc
cca
aat
tt e
ee c
ccl
ll a
aas
sss
ssi
ii c
cc R
RRe
eee
eed
dd-
-- S
SSt
tt e
eer
rrn
nnb
bbe
eer
rrg
gg c
cce
eel
ll l
ll
P
PPh
hhe
een
nno
oot
tt y
yy
p
ppi
ii c
cc m
mma
aar
rrk
kke
eer
rrs
ss
-
-- E
EES
SSR
RR,
,, p
ppe
eer
rri
ii p
pph
hhe
eer
rra
aal
ll b
bbl
ll o
ooo
ood
dd c
cco
oou
uun
nnt
tt
-
-- S
SSt
tt a
aag
ggi
ii n
nng
gg
N
NNo
o
od
ddu
uul
ll a
aar
rr s
ssc
ccl
ll e
eer
rro
oos
ssi
ii n
nng
gg H
HHo
ood
ddg
ggk
kki
ii n
nn
s
ss l
ll y
yym
mmp
pph
hho
oom
mma
aa i
iin
nnv
vvo
ool
ll v
vve
ee m
mme
eed
ddi
ii a
aas
sst
tt i
ii n
nnu
uum
mm

c
cch
hhe
ees
sst
tt x
xx-
-- r
rra
aay
yy

Q4: In the low power sections of 7A & 7E, compare & contrast the
architectural morphology of the lymph nodes
N
NNo
ood
ddu
uul
ll a
aar
rr s
ssc
ccl
ll e
eer
rro
oos
ssi
ii s
ss H
HHo
ood
ddg
ggk
kki
ii n
nn
s
ss l
ll y
yym
mmp
pph
hho
oom
mma
aa i
ii s
ss c
cch
hh
a
aar
rra
aac
cct
tt e
eer
rri
ii z
zze
eed
dd b
bby
yy b
bbr
rro
ooa
aad
dd b
bba
aan
nnd
dds
ss o
oof
ff
c
cco
ool
ll l
ll a
aag
gge
een
nn c
cci
ii r
rrc
ccu
uum
mms
ssc
ccr
rri
ii b
bbi
ii n
nng
gg n
nno
ood
ddu
u
ul
ll e
ees
ss f
ff i
ii b
bbr
rro
oos
ssi
ii s
ss m
mma
aay
yyb
bbe
ee s
ssc
cca
aan
nnt
tt o
oor
rr a
aab
bbu
uun
nnd
dda
aan
nnt
tt .
.. T
TTh
hhe
ee
c
cce
eel
ll l
ll u
uul
ll a
aar
rr i
ii n
nnf
ff i
ii l
ll t
tt
r
rra
aat
tt e
ee m
mma
aay
yy s
ssh
hho
oow
ww v
vva
aar
rry
yyi
ii n
nng
gg p
ppr
rro
oop
ppo
oor
rrt
tt i
ii o
oon
nns
ss o
oof
ff l
ll y
yym
mmp
pph
hho
ooc
ccy
yyt
tt e
ees
ss,
,,
e
eeo
oos
ssi
ii n
nno
oop
pph
h
hi
ii l
ll s
ss,
,, h
hhi
ii s
sst
tt i
ii o
ooc
ccy
yyt
tt e
ees
ss,
,, l
ll a
aac
ccu
uun
nna
aar
rr c
cce
eel
ll l
ll s
ss.
.. C
CCl
ll a
aas
sss
ssi
ii c
cc R
RRe
eee
eed
dd-
-- S
SSt
tt e
eer
rrn
nnb
bbe
eer
rrg
gg c
cc
e
eel
ll l
ll i
ii s
ss
i
ii n
nnf
ff r
rre
eeq
qqu
uue
een
nnt
tt

Q5: Identify the cellular changes seen in this condition
T
TTh
hhe
eer
rre
ee i
ii s
ss a
aa v
vva
aar
rri
ii a
aan
nnt
tt o
oof
ff R
RRS
SS c
cce
eel
ll l
ll ,
,, t
tt h
hhe
ee l
ll a
aac
cc
u
uun
nna
aar
rr c
cce
eel
ll l
ll ,
,, w
wwh
hhi
ii c
cch
hh i
ii s
ss l
ll a
aar
rrg
gge
ee,
,, h
hha
aas
ss a
aa s
ssi
ii n
nng
ggl
ll e
ee
h
hhy
yyp
ppe
eer
rrl
ll o
oob
bba
aat
tt e
eed
dd n
nnu
uuc
ccl
ll e
e
eu
uus
ss w
wwi
ii t
tt h
hh m
mmu
uul
ll t
tt i
ii p
ppl
ll e
ee s
ssm
mma
aal
ll l
ll n
nnu
uuc
ccl
ll e
eeo
ool
ll i
ii &
&& a
aan
nn a
aab
bbu
uun
nnd
dda
aan
nnt
tt p
ppa
aal
ll e
ee-
--
s
sst
tt a
aai
ii n
nni
ii
n
nng
gg c
ccy
yyt
tt o
oop
ppl
ll a
aas
ssm
mm
Chapter 10 : Haemopoietic System
YEAU MING SONG
MBBS 2008/2013

3 Peripheral Blood Film Iron deficiency anemia (MGG x 400)

Case 1: A forty-five year multiparous woman was seen at the antenatal clinic.
Routine full blood count showed the following results:

Haemoglobin 52g/L
(
((1
110
005
55-
-- 1
113
335
55)
))
Red cell count 2.6 x 10
12
/L
(
((3
33.
.. 7
77-
-- 5
55.
.. 3
33)
))
MCV 64 fL
(
((7
770
00-
-- 8
886
66)
))
MCH 20 pg
(
((2
223
33-
-- 3
331
11)
))
MCHC 312 g/L
(
((3
330
000
00-
-- 3
336
660
00)
))

Q1: Comment on the full blood count
B
BBe
eel
ll o
oow
ww t
tt h
hha
aan
nn n
nno
oor
rrm
mma
aal
ll

Q2: Describe the peripheral blood findings
A
AAn
nni
ii s
sso
oop
ppo
ooi
ii k
kki
ii l
ll o
ooc
ccy
yyt
tt o
oos
ssi
ii s
ss (
((v
vva
aar
rry
yyi
ii n
nng
gg
s
ssi
ii z
zze
ee &
&& s
ssh
hha
aap
ppe
ee)
)),
,, h
hhy
yyp
ppo
ooc
cch
hhr
rro
oom
mmi
ii c
cc R
RRB
BBC
CC,
,, m
mmi
ii c
ccr
rro
ooc
ccy
yyt
tt i
ii c
cc,
,,
p
ppa
aal
ll e
ee

Q3: What are the differential diagnosis based on the full blood count &
peripheral blood film?
D
DDe
eec
ccr
rre
eea
a
as
sse
eed
dd s
sse
eer
rru
uum
mm f
ff e
eer
rrr
rri
ii t
tt i
ii n
nn l
ll e
eev
vve
eel
ll
I
II n
nnc
ccr
rre
eea
aas
sse
eed
dd i
ii n
nn p
ppl
ll a
aas
ssm
mma
aa t
tt r
rra
aan
nns
ssf
ff e
eer
rrr
rri
ii n
nn
l
ll e
eev
vve
eel
ll (
((T
TTI
II B
BBC
CC)
))

Q4: Discuss the pathophysiology underlying this condition
H
HHe
eem
mme
ee f
ff o
oor
rrm
mma
aat
tt i
ii o
oon
nn a
aaf
ff f
ff e
eec
cct
tt e
eed
dd,
,, b
bbl
ll o
ooo
ood
dd l
ll o
oos
sss
ss d
ddu
uur
rri
ii n
nng
g
g d
dde
eel
ll i
ii v
vve
eer
rry
yy,
,, i
ii n
nnc
ccr
rre
eea
aas
sse
ee d
dde
eem
mma
aan
nnd
dd,
,,
p
ppo
ooo
oor
rr d
ddi
ii e
eet
tt ,
,, c
cch
hhr
rro
oon
nni
ii c
cc i
ii n
nnf
ff e
eec
cct
tt i
ii o
oon
nn


8-2 Peripheral Blood Film Beta thalassaemia major (MGG x 400)

Case 2: Seven month old infant with distended abdomen & pallor was seen at the
outpatient clinic in Banting. A full blood count showed the following:

Haemoglobin 52g/L

Red cell count 3.1 x 10
12
/L

MCV 48 fL

MCH 17 pg

MCHC 354 g/L


Q1: Describe the major abnormalities seen on the full blood count &
peripheral blood film
A
AAl
ll l
ll v
vva
aal
ll u
uue
ees
ss b
bbe
eel
ll o
oow
ww t
tt h
hha
aan
nn n
nno
oor
rrm
mma
aal
ll e
eex
xxc
cce
eep
ppt
tt M
MM
C
CCH
HHC
CC
N
NNo
oor
rrm
mmo
oob
bbl
ll a
aas
sst
tt ,
,, b
bba
aas
sso
oop
pph
hhi
ii l
ll i
ii c
cc s
sst
tt i
ii p
ppp
ppl
ll i
ii n
nng
gg,
,, h
hhy
yyp
ppo
ooc
cch
hhr
rro
oom
mmi
ii c
cc,
,, m
mmi
ii c
ccr
rro
ooc
c
cy
yyt
tt i
ii c
cc,
,, a
aan
nni
ii s
sso
ooc
ccy
yyt
tt o
oos
ssi
ii s
ss,
,,
n
nnu
uum
mme
eer
rro
oou
uus
ss t
tt a
aar
rrg
gge
eet
tt c
cce
eel
ll l
ll s
ss,
,, p
ppo
ooi
ii k
kki
ii l
ll o
ooc
ccy
yyt
tt o
oos
ssi
ii s
ss


Q2: Discuss the genetic basis & the pathophysiology underlying the
thalassaemia syndromes
L
LLa
aac
cck
kk o
oof
ff
-
-- c
cch
hha
aai
ii n
nn s
ssy
yyn
nnt
tt h
hhe
ees
ssi
ii s
ss d
ddu
uue
ee t
tt o
oo s
ssi
ii n
nng
ggl
ll e
ee p
ppo
ooi
ii n
nnt
tt m
mmu
uut
tta
aat
tt i
ii o
oon
nn i
ii n
nn
-
-- g
ggl
ll o
oob
bbi
ii n
nn g
gge
een
nne
ee o
oon
nn
c
cch
hhr
rro
oom
mmo
oos
sso
oom
mme
ee 1
11b
bb
L
LLo
oow
ww H
HHb
bbA
AA,
,, e
eex
xxc
cce
ees
sss
ss f
ff r
rre
eee
ee

-
-- c
cch
hha
aai
ii n
nn a
aag
ggg
ggr
rre
eeg
gga
aat
tt e
ees
ss,
,, i
ii n
nne
eef
ff f
ff e
eec
cct
tt i
ii v
vve
ee e
eer
rry
yyt
tt h
hhr
rro
oop
ppo
ooi
ii e
ees
ssi
ii s
ss
YEAU MING SONG
MBBS 2008/2013

Q3: What complications may arise from this condition?
P
PPo
oos
ssi
ii t
tt i
ii v
vve
ee i
ii r
rro
oon
nn b
bba
aal
ll a
aan
nnc
cce
ee -
--
i
ii r
rro
oon
nn a
aab
bbs
sso
oor
rrp
ppt
tt i
ii o
oon
nn i
ii n
nn G
GGU
UUT
TT
-
-- b
bbl
ll o
ooo
o
od
dd t
tt r
rra
aan
nns
ssf
ff u
uus
ssi
ii o
oon
nn
H
HHa
aai
ii r
rr-
-- o
oon
nn-
-- e
een
nnd
dd a
aap
ppp
ppe
eea
aar
rra
aan
nnc
cce
ee d
ddu
uue
ee t
tto
oo e
eex
xxt
tt r
rra
aam
mme
eed
ddu
uul
ll l
ll a
aar
rr
y
yy e
eer
rry
yyt
tt h
hhr
rro
oop
ppo
ooi
ii e
ees
ssi
ii s
ss
-
-- f
ff a
aac
cci
ii a
aal
ll /
// s
ssk
kke
eel
ll e
eet
tt a
aal
ll d
dde
eef
ff o
oor
rrm
mmi
ii t
tt i
ii e
ees
ss b
bbe
eec
cca
aau
uus
sse
ee o
oof
ff b
bbo
oon
nne
ee m
mma
aar
rrr
rro
oow
ww e
eex
xxp
ppa
aan
nns
ssi
ii o
oon
nn
S
SSe
eev
vve
eer
rre
ee a
aan
nne
eem
mmi
ii a
aa,
,, h
hhe
eem
mmo
ool
ll y
yyt
tt i
ii c
cc j
jj a
aau
uun
nnd
ddi
ii c
cc
e
ee,
,, s
ssp
ppl
ll e
een
nno
oom
mme
eeg
gga
aal
ll y
yy,
,, g
ggr
rro
oow
wwt
tt h
hh r
rre
eet
tt a
aar
rrd
dda
aat
tt i
ii o
oon
nn,
,,
H
HHe
eep
ppa
aat
tt o
oom
mme
eeg
gga
aal
ll y
yy (
((e
eex
xxt
tt r
rra
aam
mme
e
ed
ddu
uul
ll l
ll a
aar
rry
yy h
hhe
eem
mmo
oop
ppo
ooi
ii e
ees
ssi
ii s
ss)
))
S
SSe
eec
cco
oon
nnd
dda
aar
rry
yy h
hha
aae
eem
mmo
ooc
cch
hhr
rro
oom
mma
aat
tt o
oos
ssi
ii s
ss
l
ll i
ii v
vve
eer
rr,
,, h
hhe
eea
aar
rrt
tt ,
,, p
ppa
aan
nnc
ccr
rre
eea
aas
ss (
((f
ff i
ii b
bbr
rro
oos
ssi
ii s
ss
x
xx i
ii n
nns
ssu
uul
ll i
ii n
nn
D
DDM
MM)
))


9 Peripheral Blood Film Acute myeloid leukemia (MGG x 400)

Case 3: Thirty year old presented with low grade fever of 2 weeks duration.
Physical examination showed Hepatosplenomegaly and pallor

Haemoglobin 95g/L

WBC 23.4 x 10
9
/L
(
((4
44-
-- 1
111
11 x
xx 1
110
00
9
99
)
))
Platelets 48 x 10
9
/L
(
((1
115
550
00-
-- 4
440
000
00 x
xx 1
110
00
9
99
)
))

Q1: Describe the major abnormalities seen on the peripheral blood film
M
MMy
yye
eel
ll o
oob
bbl
ll a
aas
sst
tt w
wwi
ii t
tt h
hh p
ppr
rro
oom
mmi
ii n
nne
een
nnt
tt n
nnu
uuc
ccl
ll e
eeo
ool
ll i
ii ,
,, f
ff i
ii n
nne
ee a
aaz
zzu
uur
rro
oop
pph
hhi
ii l
ll i
ii c
cc g
ggr
rra
aan
nnu
uul
lle
ees
ss i
ii n
nn c
ccy
yyt
tt o
oop
pp
l
ll a
aas
ssm
mm,
,,
d
ddi
ii s
sst
tt i
ii n
nnc
cct
tt i
ii v
vve
ee r
rre
eed
dd-
-- s
sst
tt a
aai
ii n
nne
eed
dd r
rro
ood
dd-
-- l
ll i
ii k
kke
ee p
ppr
rre
ees
sse
een
nnt
tt (
((A
AAu
uue
eer
rr r
rro
ood
dds
ss)
)
)

Q2: How do myeloblasts differ from lymphoblasts?
1
11.
.. L
LLy
yym
mmp
pph
hho
oob
bbl
ll a
aas
sst
tt h
hha
aas
ss n
nno
oo p
ppr
rro
oom
mmi
ii n
nne
een
nnt
tt n
nnu
uuc
ccl
ll e
eeo
ool
ll i
ii
2
22.
.. M
MMy
yye
eel
ll o
oob
bbl
ll a
aas
sst
tt c
cco
oon
nnt
tt a
aai
ii n
nns
ss A
AAu
uue
eer
rr r
rro
ood
dd
3
33.
.. S
SSo
oom
mme
ee m
mma
aat
tt u
uur
rre
ee i
ii n
nnt
tt o
oo p
ppr
rro
oom
mmy
yye
eel
ll o
ooc
ccy
yyt
tt e
ees
ss (
((h
hha
aas
ss c
cco
ooa
aar
rrs
sse
ee g
ggr
rra
aan
nnu
uul
ll e
ees
ss)
))

Q3: What complications may arise from this condition?
B
BBo
oon
nne
ee m
mma
aar
rrr
rro
oow
ww f
ff a
aai
ii l
ll u
uur
rre
ee
A
AAn
nne
eem
mmi
ii a
aa
f
ff a
aat
tt i
ii g
ggu
uue
ee,
,, m
mma
aal
ll a
aai
ii s
sse
ee,
,, p
ppa
aal
ll l
ll o
oor
rr
T
TTh
hhr
rro
oom
mmb
bbo
ooc
ccy
yyt
tt o
oop
ppe
een
nni
ii a
aa
a
aab
bbn
nno
oor
rrm
mma
aal
ll b
bbl
ll e
eee
eed
ddi
ii n
nng
gg
N
NNe
eeu
uut
tt r
rro
oop
ppe
een
nni
ii a
aa
i
ii n
nnf
ff e
eec
cct
tt i
ii o
oon
nn

YEAU MING SONG
MBBS 2008/2013

8-2 Peripheral Blood Film Chronic myeloid leukemia (MGG x 400)

Case 4: Forty year old was seen at the outpatient clinic with complaints of
abdominal fullness and lethargy

Haemoglobin 122 g/L

WBC 67.9 x 10
9
/L

Platelets 257 x 10
9
/L


Q1: What are the characteristic features seen on the peripheral blood film
M
MMa
aan
nny
yy n
nne
eeu
uut
tt r
rro
oop
pph
hhi
ii l
ll s
ss,
,, M
MMy
yye
eel
ll o
ooc
ccy
yyt
tt e
ees
ss,
,, M
MMe
eet
tt a
aam
mmy
yye
eel
ll o
ooc
ccy
yyt
tt
e
ees
ss,
,, b
bba
aas
sso
oop
pph
hhi
ii l
ll s
ss,
,, s
sso
oom
mme
eet
tt i
ii m
mme
ee
e
eeo
oos
ssi
ii n
nno
oop
pph
hhi
ii l
ll s
ss

Q2: What is the molecular basis for the development of this disease?
P
PPh
hhi
ii l
ll a
aad
dde
eel
ll p
pph
hhi
ii a
aa c
cch
hhr
rro
oom
mmo
oos
s
so
oom
mme
ee t
tt (
((9
99,
,, 2
222
22)
))
-
-- R
RRe
eec
cci
ii p
ppr
rro
ooc
cca
aal
ll t
tt r
rra
aan
nns
ssl
ll o
ooc
cca
aat
tt i
ii o
oon
nn b
bbe
eet
ttw
wwe
eee
een
nn c
cch
hhr
rro
oom
mmo
oos
ss
o
oom
mme
ee 9
99 &
&& 2
222
22

Q3: What are the clinical features of the disease?
S
SSl
ll o
oow
ww d
dde
eev
vve
eel
ll o
oop
ppi
iin
nng
gg a
aan
nne
eem
mmi
ii a
aa,
,, e
een
nnl
ll a
aar
rrg
gge
eem
mme
een
nnt
tt o
oof
ff o
oor
rrg
gga
aan
nn i
ii n
nnf
ff i
ii l
llt
tt r
rra
aat
tt e
eed
dd,
,, e
eex
xxt
tt r
rre
eem
mme
ee
s
ssp
ppl
ll e
een
nno
oom
mme
eeg
gga
aal
ll y
yy,
,, t
tt h
hhr
rro
oom
mmb
bbo
ooc
ccy
yyt
tt o
oos
ssi
ii s
ss,
,, h
hhy
yyp
ppe
eer
rrc
cce
e
el
ll l
ll u
uul
ll a
aar
rr b
bbo
oon
nne
ee m
mma
aar
rrr
rro
oow
ww,
,, s
ssp
ppl
ll e
een
nni
ii c
cc
i
ii n
nnf
ff a
aar
rrc
cct
tt i
ii o
oon
nn,
,, g
ggo
oou
uut
tt

Q4: What is the natural course of this disease?
C
CCM
MML
LL
a
aac
ccc
cce
eel
ll e
eer
rra
aat
tt e
eed
dd p
pph
hha
aas
sse
ee
a
aac
ccu
uut
tt e
ee l
ll e
eeu
uuk
kke
eem
mmi
ii a
aa


Myelocytes
Myelocyte
Promyeloblast
Basophile
Basophiles (coarse
granules covering cells)
Metamyelocytes
Chapter 11 : Renal System
YEAU MING SONG
MBBS 2008/2013

Slide 11E Renal (H&E x 10)

Case 2: Mr. KHH, a 50-year old man, was a pedestrian who was brought in dead
after being involved in a hit & run accident. At autopsy, he was found to
have multiple injuries including lacerated heart, liver, spleen & intracranial
haemorrhage. His right kidney was also found to be shrunken & scarred.
His relatives gave a history that Mr. KHH had several episodes of fever
with right loin pain in the past. However, they were unsure about he sought
any treatment for this.

Q1: Describe the histological features of the kidney.
1
11.
.. I
II n
nnt
tt e
ees
sst
tt i
ii n
nna
aal
ll f
ff i
ii b
bbr
rro
oos
ssi
ii s
ss
2
22.
.. I
II n
nnf
ff i
ii l
ll t
tt r
rra
aat
tt i
ii o
oon
nn o
oof
ff i
ii n
nnf
ff l
ll a
aam
mmm
mma
aat
tt o
o
or
rry
yy c
cce
eel
ll l
ll s
ss (
((l
ll y
yym
mmp
pph
hho
ooc
ccy
yyt
tt e
ees
ss &
&& p
ppl
ll a
aas
ssm
mma
aa c
cce
eel
ll l
ll s
ss)
))
3
33.
.. T
TTh
hhy
yyr
rro
ooi
ii d
ddi
ii z
zza
aat
tt i
ii o
oon
nn c
cc
o
ool
ll l
ll o
ooi
ii d
dd c
cca
aas
sst
tt

Q2: What is the diagnosis?
C
CCh
hhr
rro
oon
nni
ii c
cc p
ppy
yye
eel
ll o
oon
nne
eep
pph
hhr
rri
ii t
tt i
ii s
ss

Q3: Postulate a few possible underlying causes that could have resulted in
this
1
11.
.. O
OOb
bbs
sst
tt r
rru
uuc
cct
tt i
ii o
oon
nn (
((m
mma
aal
ll
i
ii g
ggn
nna
aan
nnc
ccy
yy,
,, s
sst
tt o
oon
nne
ees
ss)
)) o
oof
ff u
uur
rri
ii n
nna
aar
rry
yy t
tt r
rra
aac
cct
tt
s
sst
tt a
aas
ssi
ii s
ss o
oof
ff u
uur
rri
ii n
nne
ee

b
bba
aac
cct
tt e
eer
rri
ii a
aa m
mmu
uul
ll t
tt i
ii p
ppl
ll i
ii c
cca
aat
tt i
ii o
oon
nn
2
22.
.. V
VVe
ees
ssi
ii c
cco
oo-
-- u
uur
rre
eet
tt e
eer
rri
ii c
cc r
rre
eef
ff l
ll u
uux
xx
3
33.
.. X
XXa
aan
nnt
tt h
hho
oog
ggr
rr
a
aan
nnu
uul
ll o
oom
mma
aat
tto
oou
uus
ss C
CCh
hhr
rro
oon
nni
iic
cc P
PPy
yye
eel
ll o
oon
nne
eep
pph
hhr
rri
ii t
tt i
ii s
ss

M
MMi
ii m
mmi
ii c
cc r
rre
een
nna
aal
ll c
cce
eel
ll l
ll c
cca
aar
rrc
c
ci
ii n
nno
oom
mma
aa (
((R
RRC
CCC
CC)
)) c
ccl
ll i
ii n
nni
ii c
cca
aal
ll l
ll y
yy &
&&
h
hhi
ii s
sst
tt o
ool
ll o
oog
ggi
ii c
cca
aal
ll l
ll y
yy

G
GGr
rro
oos
sss
ss
y
yye
eel
ll l
ll o
oow
ww n
nno
ood
ddu
uul
ll e
ee
M
MMi
ii c
ccr
rro
oos
ssc
cco
oop
ppi
ii c
cc
f
ff o
ooa
aam
mm c
cce
eel
ll l
ll s
ss b
bby
yy m
mma
aac
ccr
rro
oop
pph
hha
aag
gge
ees
ss


Slide 11N Kidney (H&E x 5)

Case 1: Encik Ali complained of vague right loin pain for the past 6 months.
Recently he noticed that he has some blood in his urine. He was noted to be
polycythaemic. A right renal mass was found which was excised.

Q1: Describe the microscopic features of this excised mass
C
CCe
eel
ll l
ll s
ss a
aap
ppp
ppe
eea
aar
rr a
aal
ll m
mmo
oos
sst
tt v
vva
aac
ccu
uuo
ool
ll a
aat
tt e
eed
dd o
oor
rr s
sso
ool
ll i
ii d
dd.
.. T
TTh
hhe
ee v
vva
aac
ccu
uuo
ool
lla
aat
tt
e
eed
dd (
((l
ll i
ii p
ppi
ii d
dd l
ll a
aad
dde
een
nn)
)) o
oor
rr
c
ccl
ll e
eea
aar
rr c
cce
eel
ll l
ll s
ss d
dde
eem
mma
aar
rrc
cca
aat
tt e
eed
dd o
oon
nnl
ll y
yy b
bby
yy t
tt h
hhe
eei
ii r
rr m
m
me
eem
mmb
bbr
rra
aan
nne
ee.
.. N
NNu
uuc
ccl
ll e
eei
ii i
ii s
ss s
ssm
mma
aal
ll l
ll &
&& r
rro
oou
uun
nnd
dd

Q2: What is the diagnosis?
R
RRe
een
nna
aal
ll c
cce
eel
ll l
ll C
CCA
AA (
((c
ccl
ll e
eea
aar
rr c
cc
e
eel
ll l
ll C
CCA
AA)
)) *
**c
cco
oom
mmm
mmo
oon
nne
ees
sst
tt C
CCA
AA i
ii n
nn a
aad
ddu
uul
ll t
tt s
ss

Q3: Why was Encik Ali polycythaemic despite having haematuria?

P
PPa
aar
rra
aan
nne
eeo
oop
ppl
ll a
aas
sst
tt i
ii c
cc s
ssy
yyn
nnd
ddr
rro
oom
mm
e
ee e
eex
xxh
hhi
iib
bbi
ii t
tt e
eed
dd b
bby
yy t
tt h
hhi
ii s
ss C
CCA
AA.
..
YEAU MING SONG
MBBS 2008/2013

P
PPo
ool
ll y
yyc
ccy
yyt
tt h
hha
aae
eem
mmi
ii a
aa d
ddu
uue
ee t
tt o
oo e
eel
ll a
aab
bbo
oor
rra
aat
tt i
ii o
oon
nn o
oof
ff e
eer
rry
yyt
tt h
hhr
rro
oop
ppo
ooi
ii e
eet
tt i
ii n
nn b
bby
yy r
r
re
een
nna
aal
ll
t
tt u
uum
mmo
oou
uur
rr.
..


Chapter 12 : Endocrine System
YEAU MING SONG
MBBS 2008/2013

Slide 29E Thyroid - Non-toxic nodular goiter (H&E x 10)
The slide shows thyroid tissue composed of follicles of varying sizes lined by
flattened to cuboidal cells. Most of the follicles contain colloid. Many of the follicles
are cystically dilated and some of themshow recent haemorrhage within the lumina.
Features of fibrosis and old haemorrhage such as haemosiderin pigment and
cholesterol clefts are not seen in this section.

Case 1: Mrs. Wong, a 45 year old teacher, presented with a large swelling in the
front of the neck which had grown slowly over the past 10 years. The
swelling moved with swallowing. The patient was euthyroid.
Thyroidectomy was performed. This is the histological section.

Q1: Identify the cellular changes in the section
-
-- F
FFo
ool
ll l
ll i
ii c
ccl
ll e
ees
ss o
oof
ff v
vva
aar
rry
yyi
ii n
nng
gg s
ssi
ii z
zze
ees
ss l
ll i
ii n
nne
eed
dd b
bby
yy f
ff l
ll a
aat
tt t
tt e
een
nne
eed
dd t
tt
o
oo c
ccu
uub
bbo
ooi
ii d
dda
aal
ll c
cce
eel
ll l
ll s
ss
-
-- M
MMo
oos
sst
tt o
oof
ff t
tt h
hhe
ee f
ff o
ool
ll l
ll i
ii c
ccl
ll e
ees
ss c
cco
oon
nnt
tt a
aai
ii n
nn c
cco
ool
ll l
ll o
ooi
ii d
dd.
.. M
MMa
aan
nny
yy o
oof
ff t
tt h
hhe
ee f
ff o
ool
ll l
ll i
ii c
ccl
ll e
ees
ss a
aar
rre
ee c
ccy
yys
sst
tt i
ii c
cca
aal
ll l
ll y
yy
d
ddi
ii l
ll a
aat
tt e
eed
dd a
aan
nnd
dd s
sso
oom
mme
ee o
oof
ff t
tt h
hhe
eem
mm s
ssh
hho
oow
ww r
rre
eec
cce
een
nnt
tt h
hha
aae
eem
mmo
oor
rrr
rrh
hha
aag
gge
ee w
wwi
ii t
tt h
hhi
ii n
nn t
tt h
hhe
ee l
ll u
uum
mmi
ii n
nna
aa

Q2: Correlate the gross appearance of the specimen with the clinical
presentation & the histological features.
-
-- E
EEn
nnl
ll a
aar
rrg
gg
e
eed
dd t
tt h
hhy
yyr
rro
ooi
ii d
dd
d
ddu
uue
ee t
tt o
oo a
aac
ccc
ccu
uum
mmu
uul
ll a
aat
tt i
ii o
oon
nn o
oof
ff c
cco
ool
ll l
ll o
ooi
ii d
dd
-
-- A
AAt
tt t
tt a
aac
cch
hh t
tt o
oo t
tt r
r
ra
aac
cch
hhe
eea
aa
m
mmo
oov
vve
ee w
wwi
ii t
tt h
hh s
ssw
wwa
aal
ll l
ll o
oow
wwi
ii n
nng
gg
-
-- C
CCu
uut
tt s
ssu
uur
rrf
ff a
aac
cce
ee a
aap
ppp
ppe
eea
aar
rre
eed
dd g
gge
eel
ll a
aat
tt
i
iin
nno
oou
uus
ss &
&& g
ggl
ll i
ii s
sst
tt e
een
nni
ii n
nng
gg d
ddu
uue
ee t
tt o
oo c
cco
ool
ll l
ll o
ooi
iid
dd c
cco
oon
nnt
tt e
een
nnt
tt

Q3: List the possible complication that may arise as a result of this goitre
-
-- C
CCo
oos
ssm
mme
eet
tt i
ii c
cca
aal
ll l
ll
y
yy u
uun
nna
aac
ccc
cce
eep
ppt
tt a
aab
bbl
ll e
ee
-
-- A
AAb
bbn
nno
oor
rrm
mma
aal
ll t
tt h
hhy
yyr
rro
ooi
ii d
dd h
hho
oor
rrm
mmo
oon
nne
ee p
ppr
rro
ood
ddu
uuc
cct
tt i
ii o
oon
nn (
((r
rra
aar
rre
e
e)
))
-
-- R
RRi
ii s
ssk
kk o
oof
ff c
cca
aar
rrc
cci
ii n
nno
oom
mma
aa (
((s
ssm
mma
aal
ll l
ll )
))
-
-- D
DDi
ii f
ff f
ff i
ii c
ccu
uul
ll t
tt i
ii e
ees
ss i
ii n
nn s
ssw
wwa
aal
ll l
ll o
oow
wwi
ii n
nn
g
gg,
,, b
bbr
rre
eea
aat
tt h
hhi
ii n
nng
gg
-
-- C
CCo
oom
mmp
ppr
rre
ees
sss
ssi
ii o
oon
nn o
oof
ff l
ll a
aar
rrg
gge
ee v
vve
ees
sss
sse
eel
ll s
ss i
ii n
nn n
nne
eec
cck
kk &
&& u
uup
ppp
ppe
e
er
rr t
tt i
ii s
sss
ssu
uue
ees
ss
-
-- C
CCo
oom
mmp
ppr
rre
ees
sss
ss r
rre
eec
ccu
uur
rrr
rre
een
nnt
tt l
ll a
aar
rry
yyn
nng
gge
eea
aal
ll n
nne
eer
rrv
vve
ee


Slide 29B Thyroid - Follicular adenoma (H&E x 40)
This slide of thyroid shows part of a well encapsulated tumour consisting of thyroid
follicle that lying back to back. These follicles are small to mediumsized, lined by
cuboidal to columnar epitheliumand some of themcontain colloid. The capsule is
made of fairy thick fibrous tissue and there is no capsular infiltration by tumour cells
nor is there any vascular permeation. Outside the capsule is seen normal thyroid
tissue consisting of colloid-filled follicle lined by flattened or cuboidal epithelium.

Case 2: Ms Malini, 1 35 year old cashier, presented with a solitary nodular swelling
in the left side of the neck which her colleagues had noticed for the past
month. The swelling moved with swallowing. Thyroid scan showed a cold
nodule. A diagnosis of follicular neoplasm was made on Fine Needle
Aspiration Cytology (FNAC). Thyroidectomy was performed. This is a
representative histological section.

Q1: What is the clinical significance of a solitary thyroid nodule?
-
-- O
OOn
nnl
ll y
yy <
<< 1
11%
%% i
ii s
ss m
mma
aal
ll i
ii g
ggn
nna
aan
nnt
tt
YEAU MING SONG
MBBS 2008/2013
-
-- M
MMo
oos
sst
tt a
aar
rre
ee a
aad
dde
een
nno
oom
mma
aa
n
nno
oon
nn-
-- t
tt e
een
nnd
dde
eer
rr,
,, n
nno
oon
nn-
--n
nne
eeo
oop
ppl
lla
aas
sst
tt i
ii c
cc

Q2: Identify the cellular changes & identify the capsule.
-
-- T
TTh
hhe
ees
sse
ee
f
ff o
ool
ll l
ll i
ii c
ccl
ll e
ees
ss a
aar
rre
ee s
ssm
mma
aal
ll l
ll t
tt o
oo m
mme
eed
ddi
ii u
uum
mm s
ssi
ii z
zze
eed
dd,
,, l
ll i
ii n
nne
eed
dd b
bby
yy c
ccu
uub
bbo
ooi
ii d
dda
aal
ll t
tt o
o
o
c
cco
ool
ll u
uum
mmn
nna
aar
rr e
eep
ppi
ii t
tt h
hhe
eel
ll i
ii u
uum
mm a
aan
nnd
dd s
sso
oom
mme
ee o
oof
ff t
tt h
hhe
eem
mm c
cco
oon
nnt
tta
aai
ii n
nn c
cco
ool
ll l
ll o
ooi
ii d
dd
-
-- T
TTh
hhe
ee c
cca
aap
pps
ssu
uul
ll e
ee i
ii s
ss m
mma
aad
dde
ee o
oof
ff f
ff a
aai
iir
rry
yy t
tt h
hhi
ii c
cck
kk f
ff i
ii b
bbr
rro
oou
uus
ss t
tt i
ii s
sss
ssu
uue
ee a
aan
nnd
dd t
tt h
hhe
eer
r
re
ee i
ii s
ss n
nno
oo
c
cca
aap
pps
ssu
uul
ll a
aar
rr i
ii n
nnf
ff i
ii l
ll t
tt r
rra
aat
tt i
ii o
oon
nn b
bby
yy t
ttu
uum
mmo
oou
uur
rr c
cce
eel
ll l
ll s
ss n
nno
oor
rr i
ii s
ss t
tt h
hhe
eer
rr
e
ee a
aan
nny
yy v
vva
aas
ssc
ccu
uul
ll a
aar
rr
p
ppe
eer
rrm
mme
eea
aat
tt i
ii o
oon
nn
-
-- O
OOu
uut
tt s
ssi
ii d
dde
ee t
tt h
hhe
ee c
cca
aap
pps
ssu
uul
ll e
ee i
ii s
ss s
sse
eee
een
nn n
n
no
oor
rrm
mma
aal
ll t
tt h
hhy
yyr
rro
ooi
ii d
dd t
tt i
ii s
sss
ssu
uue
ee c
cco
oon
nns
ssi
ii s
sst
tt i
ii n
nng
gg o
oof
ff c
cco
ool
ll l
ll o
ooi
iid
dd-
--
f
ff i
ii l
ll l
ll e
eed
dd f
ff o
ool
ll l
ll i
ii c
ccl
ll
e
ee l
ll i
ii n
nne
eed
dd b
bby
yy f
ff l
ll a
aat
tt t
tt e
een
nne
eed
dd o
oor
rr c
ccu
uub
bbo
ooi
ii d
dda
aal
ll e
eep
ppi
ii t
tt h
hhe
eel
ll i
ii u
uum
mm.
..
-
-- F
FFo
ool
ll l
ll i
ii c
ccu
uul
ll a
aar
rr c
cce
eel
ll l
ll s
ss a
aar
rre
ee p
ppa
aac
cck
kke
eed
dd,
,, w
wwe
eel
ll l
ll -
-- s
ssp
ppa
aac
cce
ee n
nnu
uuc
ccl
ll e
eeu
uus
ss

Q3: Define neoplasm. What is the significance of the diagnosis of follicular
neoplasm in FNAC?
-
-- C
CCa
aan
nn d
ddi
ii f
ff f
ff e
eer
rre
een
nnt
tt i
ii a
aat
t
t e
ee b
bbe
eet
tt w
wwe
eee
een
nn f
ff o
ool
ll l
ll i
ii c
ccu
uul
ll a
aar
rr &
&& p
ppa
aap
ppi
ii l
ll l
ll a
aar
rry
yy n
nne
eeo
oop
ppl
ll a
aas
ssm
mm
-
-- C
CCa
aan
nn
t
tt d
ddi
ii f
ff f
ff e
eer
rre
ee
n
nnt
tt i
ii a
aat
tt e
ee b
bbe
eet
tt w
wwe
eee
een
nn b
bbe
een
nni
ii g
ggn
nn &
&& m
mma
aal
ll i
ii g
ggn
nna
aan
nnt
tt
-
-- T
TTe
een
nnd
dd t
tt o
oo m
mme
eet
tt a
aas
sst
tt a
aas
ssi
ii s
ss t
tt h
hhr
r
ro
oou
uug
ggh
hh b
bbl
ll o
ooo
ood
dd s
sst
tt r
rre
eea
aam
mm t
tt o
oo l
ll u
uun
nng
ggs
ss,
,, b
bbo
oon
nne
ee &
&& l
ll i
ii v
vve
eer
rr.
..
S
SSu
uur
rrg
ggi
ii c
cca
aal
ll e
eex
xxc
cci
ii s
ssi
ii
o
oon
nn.
.. A
AAf
ff t
tt e
eer
rr s
ssu
uur
rrg
gge
eer
rry
yy,
,, t
tt r
rre
eea
aat
tt w
wwi
ii t
tt h
hh t
tt h
hhy
yyr
rro
ooi
ii d
dd h
hho
oor
rrm
mmo
oon
nne
ee


Slide 29C thyroid - papillary carcinoma (H&E x 40)
This slide shows tumour with a papillary architecture. The papillae have
fibrovascular cores and lined by cuboidal to columnar cells with a high nuclear-
cytoplasmic ratio. The nuclei of most of these cells show an optically clear
appearance. There is also nuclear overlapping seen. In some areas the papillae are
projecting into colloid filled cystic space. Some of these spaces contain erythrocytes
and haemosiderin-laden macrophage. Scattered through the tumour are calcified
spherules (psammoma bodies). Unlike the follicular adenoma (slide 29B), this
tumour is not encapsulated.

Case 3: Nadia, a 22 year old university student & active sports women decided to
go for a medical check up as her volley ball tournament was coming up
soon. On examination, there was a mild enlargement of the right lobe of the
thyroid gland as well as 2 enlarged lymph nodes in the right cervical region.
Investigations were done & subsequently a Thyroidectomy was performed.
This is a histological section.

Q1: What investigations were done in this case?
F
FFN
NNA
AAC
CC (
((F
FFi
ii n
nne
ee N
NNe
eee
eed
ddl
ll e
ee A
AAs
ssp
ppi
ii r
rra
aat
tt i
ii o
oon
nn C
CCy
yyt
tt o
ool
ll o
oog
ggy
yy)
))

Q2: Identify the various cellular changes seen in this section
-
-- T
TTu
uum
mmo
oou
uur
rr
w
wwi
ii t
tt h
hh p
ppa
aap
ppi
ii l
ll l
ll a
aar
rry
yy a
aar
rrc
cch
hhi
ii t
tt e
eec
cct
tt u
uur
rre
ee (
((p
ppr
rro
ooj
jj e
eec
cct
tt i
ii n
nng
gg f
ff i
ii n
nng
gge
eer
rrs
ss)
)) w
wwi
ii t
tt h
hh
f
ff i
ii b
b
br
rro
oov
vva
aas
ssc
ccu
uul
ll a
aar
rr c
cco
oor
rre
ees
ss
-
-- P
PPr
rre
ees
sse
een
nnc
cce
ee o
oof
ff P
PPs
ssa
aam
mmm
mmo
oom
mma
aa b
bbo
ood
ddi
ii e
ees
ss
-
-- L
LLi
ii n
nni
ii n
nng
gg e
ee
p
ppi
ii t
tt h
hhe
eel
ll i
ii u
uum
mm a
aar
rre
ee c
ccu
uub
bbo
ooi
ii d
dda
aal
ll &
&& c
cco
ool
ll u
uum
mmn
nna
aar
rr c
cce
eel
ll l
ll s
ss w
wwi
ii t
tt h
hh
N
NN:
:: C
CC r
rra
aat
tt i
ii o
oo
-
-- N
NNo
oo c
cca
aap
pps
ssu
uul
ll e
ee
-
--
O
OOr
rrp
pph
hha
aan
nn A
AAn
nnn
nni
ii e
ee e
eey
yye
ee
n
nnu
uuc
ccl
ll e
eei
ii

Q3: Why are the right cervical lymph nodes enlarged in this patient?
C
CCe
eer
rrv
vvi
ii c
cca
aal
ll l
ll y
yym
mmp
pph
hh n
nno
ood
dde
ee m
mme
eet
tt a
aas
sst
tt a
aas
ssi
ii s
ss


Chapter 13 : Reproductive System & Breast
YEAU MING SONG
MBBS 2008/2013

38A Leiomyoma (H&E x 20)

Case 1: Mrs. Vijaya, 1 35 year old lady married for 8 years, presented to the
infertility clinic for primary infertility. She complained of irregular periods
which were heavy at times. She was otherwise well. Ultrasound showed a
well defined mass in the fundus of the uterus. The mass was intramural in
location. Other investigations were normal. Hysterectomy was performed.
This is a representative section of the lesion in the hysterectomy specimen.

Q1: Identify the cellular pattern as labeled above in the histological section
provided.
W
WWh
hho
oor
rrl
ll e
eed
dd b
bbu
uun
nnd
ddl
ll e
ees
ss o
oof
ff s
ssm
mmo
ooo
oot
tt h
hh m
mmu
uus
ssc
ccl
ll e
ee c
cce
eel
ll l
ll s
ss

Q2: Name other possible modes of presentation of this condition
T
TTo
oor
rrs
ssi
ii o
oon
nn,
,, p
ppe
eed
ddu
uun
nnc
ccu
uul
ll a
aat
tt e
eed
dd

Q3: List the possible complications of this condition
-
-- R
RRa
aar
rre
eel
ll y
yy u
uun
nnd
dde
eer
rrg
ggo
oo m
mma
aal
ll i
ii g
ggn
nna
aan
nnt
tt c
cch
hha
aan
nng
gge
ees
ss
-
-- R
RRe
eed
dd d
dde
e
eg
gge
een
nne
eer
rra
aat
tt i
ii o
oon
nn,
,, c
ccy
yys
sst
tt i
ii c
cc d
dde
eeg
gge
een
nne
eer
rra
aat
tt i
ii o
oon
nn,
,, p
ppo
oos
sst
tt -
-- p
ppa
aar
rrt
tt u
uum
mm h
hha
aae
eem
mmo
oor
rrr
rrh
hha
aag
gge
ee
-
-- F
FFe
eet
tt a
aal
ll m
mma
aal
ll p
ppr
rre
ees
sse
een
nnt
tt a
aat
tt i
ii o
oon
nn,
,, s
ssp
ppo
oon
nnt
tt a
aan
nne
eeo
oou
uus
ss a
aab
bbo
oor
rrt
tt i
ii o
oon
nn


38E Large Cell Keratinizing Squamous Cell Carcinoma (H&E x 10)

38E Large Cell Keratinizing Squamous Cell Carcinoma (H&E x 40)

Case 2: Mrs. Velu a 48 year old widow presented to the GP clinic for PAP smear
after listening a radio health talk show. She did not complain of any
Stromabeing
infiltrated
YEAU MING SONG
MBBS 2008/2013
symptoms. General examination revealed no abnormalities. On vaginal
examination the GP saw a fungating mass measuring 1cmin diameter in the
posterior lip of the cervix. Mrs. Velu was referred to the O&G department
on an urgent basis.

Q1: What other symptoms may a patient with a similar condition present
with?
-
-- I
II r
rrr
rre
eeg
ggu
uul
ll a
aar
rr v
vva
aag
ggi
ii n
nna
aal
ll b
bbl
ll e
eee
eed
ddi
ii n
nng
gg
-
-- L
LLe
eeu
uuk
kko
oor
rrr
rrh
hhe
eea
aa,
,, d
ddy
yys
ssu
uur
rri
ii a
aa
-
-- V
V
Vi
ii r
rri
ii l
ll i
ii s
ssm
mm
-
-- P
PPa
aai
ii n
nnf
ff u
uul
ll c
cco
ooi
ii t
tt u
uus
ss (
((b
bbl
ll e
eee
eed
ddi
ii n
nng
gg)
))
-
-- M
MMi
ii c
cct
tt u
uur
rri
ii t
tt i
ii o
oon
nn

Q2: Describe the macroscopic & microscopic findings
M
MMa
aac
ccr
rro
oo:
:
: P
PPo
ool
ll y
yyp
ppo
ooi
ii d
dd,
,, f
ffu
uun
nng
gga
aat
tt i
ii n
nng
gg,
,, e
eex
xxo
oop
pph
hhy
yyt
tt i
ii c
cc m
mma
aas
sss
ss o
oor
rr a
aas
ss a
aan
nn u
uul
ll c
cce
eer
rra
aat
tt i
ii v
vve
ee,
,,

i
ii n
nnf
ff i
ii l
ll t
tt r
rra
aat
tt i
ii v
vve
ee t
tt u
uum
mmo
oor
rr
M
MMi
ii c
ccr
rro
oo:
:: e
eep
ppi
ii t
tt h
hhe
eel
ll i
ii a
aal
ll c
cce
eel
ll l
ll s
ss

Q3: What are the risk factors of this disease?
-
-- M
MMu
uul
ll t
tt i
ii p
ppl
ll e
ee s
sse
eex
xx p
ppa
aar
rrt
tt n
nne
eer
rrs
ss
-
-- E
EEa
aar
rrl
ll y
yy s
sse
eex
xx i
ii n
nnt
tt e
eer
rrc
cco
oou
uur
rrs
sse
ee
-
-- F
FFr
rre
eeq
qqu
uue
een
nnt
tt c
cco
ooi
ii t
tt u
uus
ss
-
-- N
N
Nu
uul
ll l
ll i
ii p
ppa
aar
rro
oou
uus
ss
Explain the pathogenesis of this disease
H
HHP
PPV
VV
l
ll o
oow
ww g
ggr
rra
aad
dde
ee

h
hhi
iig
ggh
hh g
ggr
rra
aad
dde
ee
i
ii n
nnt
tt e
eeg
ggr
rra
aat
tt e
ee i
ii n
nn D
DDN
NNA
AA
t
tt u
uum
mmo
oor
rr p
ppr
rro
oog
ggr
rre
ees
sss
ssi
ii o
oon
nn

Q4: Mrs. Velu is a widow. Does this contribute to a delay in diagnosis in any
way?
W
WWi
ii d
ddo
oow
ww
n
nno
oo i
ii n
nnt
tt e
eer
rrc
cco
oou
uur
rrs
sse
ee,
,, n
nno
oo e
eea
aar
rrl
ll y
yy s
ssi
ii g
ggn
nn
O
OOt
tt h
hhe
eer
rrw
wwi
ii s
sse
ee,
,, p
ppo
oos
sst
tt -
-- c
cco
ooi
ii t
tt a
aal
ll b
bbl
ll e
eee
eed
ddi
ii n
nng
gg,
,, p
ppa
aai
ii n
nnf
ffu
uu
l
ll c
cco
ooi
ii t
tt u
uus
ss


15A Fibroadenoma (H&E x 20)

Case 3: Cik Ling a 24 year old secretary presented to the surgical clinic
complaining of discovering a lump in her left breast on self examination.
This was the first time she had performed breast self-examination (BSE) &
was not sure of her findings. Her increased awareness of breast lumps was
because her elder sister had recently been diagnosed with breast cancer.

Q1: Described the macro & microscopic features seen in this slide
M
MMa
aac
ccr
rro
oo:
:: H
HHo
oom
mmo
oog
gge
een
nno
oou
uus
ss i
ii n
nn a
aap
ppp
ppe
eea
aar
rra
aan
nnc
cce
ee
D
DDi
ii s
ssc
ccr
rre
eet
tt e
ee,
,, f
ff i
ii r
rrm
mm,
,, f
f
f r
rre
eee
eel
ll y
yy m
mmo
oov
vva
aab
bbl
ll e
ee n
nno
ood
ddu
uul
ll e
ee,
,, e
een
nnc
cca
aap
pps
ssu
uul
ll a
aat
tt e
eed
dd,
,, g
ggr
rra
aay
yyi
ii s
ssh
hh w
wwh
hhi
ii t
tt e
ee
M
MMi
ii c
ccr
rro
oo:
:: P
PPr
rro
ool
ll i
ii f
ff e
eer
rra
aat
tt i
ii o
oon
nn o
oof
ff b
bbo
oot
tt h
hh g
ggl
ll a
aan
nnd
ddu
uul
ll a
aar
rr &
&& s
sst
tt r
rro
oom
mma
aal
ll e
eel
ll e
eem
mme
een
nnt
tt s
ss (
((b
bbi
ii p
pph
hha
aas
s
si
ii c
cc /
//
m
mmi
ii x
xxe
eed
dd t
tt u
uum
mmo
oor
rr)
))
L
LLo
ooo
oos
sse
eel
ll y
yy c
cce
eel
ll l
ll u
uul
ll a
aar
rr f
ff i
ii b
bbr
rro
oos
ssi
ii s
ss s
sst
tt r
rro
oom
mma
aa i
ii n
nn w
wwh
hh
i
ii c
cch
hh a
aar
rre
ee s
sse
eee
een
nn b
bbr
rra
aan
nnc
cch
hhi
ii n
nng
gg
d
ddu
uuc
cct
tt a
aal
ll s
sst
tt r
rru
uuc
cct
tt u
uur
rre
ees
ss t
tt h
hha
aat
tt a
aar
rre
ee c
cco
oom
mmp
ppr
rre
ees
sss
s
se
eed
dd i
ii n
nnt
tt o
oo s
ssl
ll i
ii t
tt -
-- l
ll i
ii k
kke
ee s
ssp
ppa
aac
cce
ee
(
((i
ii n
nnt
tt r
rra
aac
cca
aan
nna
aal
ll i
ii c
ccu
uul
ll a
aar
rr)
))

Q2: What should the surgeon advise & do for Cik Ling?
T
TTr
rri
ii p
ppl
ll e
ee a
aas
sss
sse
ees
sss
s
sm
mme
een
nnt
tt
c
ccl
ll i
ii n
nni
ii c
cca
aal
ll ,
,, m
mma
aam
mmm
mmo
oog
ggr
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aam
mms
ss,
,, F
FFN
NNA
AAC
CC &
&& r
rre
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mmo
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vve
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mmp
pp

Q3: What is the significance of finding a breast lump in the case of Cik Ling?
F
FFa
aam
mmi
ii l
ll y
yy h
hhi
ii s
sst
tt o
oor
rry
yy (
((g
gge
een
nne
eet
tt i
ii c
cc i
ii n
nnh
hhe
eer
rri
ii t
tt a
aan
nnc
cce
ee)
))
YEAU MING SONG
MBBS 2008/2013

15E Infiltrating Ductal Carcinoma (H&E x 10)

Case 4: Puan Hasnah a 48 year old housewife presented to the surgical clinic for a
medical check as the skin around her right areola appeared reddish. On
examination the surgeon noted a lump measuring 2cmx 2 cm. She was
immediately sent for a mammogramwhich was reported as malignant. An
FNAC was done & reported as malignant.

Q1: Describe the histopathological changes seen in this slide.
-
-- L
LLy
yym
mmp
pph
hha
aat
tt i
ii c
cc i
ii n
nnv
vva
aas
ssi
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nn
-
-- V
VVa
aas
ssc
ccu
uul
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aar
rr p
ppe
eer
rrm
mme
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aat
tt i
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nn
-
-- F
FFi
ii b
bbr
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tt r
rro
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mma
aa i
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nn
-
-- P
PPl
ll e
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mmo
oor
rrp
pph
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mma
aal
ll i
ii g
ggn
nna
aan
nnt
tt c
cce
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ll l
ll s
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wwi
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tt h
hh a
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b
bbu
uun
nnd
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nnt
tt c
ccy
yyt
tt o
oop
ppl
lla
aas
ssm
mm
-
-- V
VVe
ees
ssi
ii c
ccu
uul
ll a
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rr n
nnu
uuc
ccl
ll e
eei
ii w
wwi
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tt h
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ppr
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oom
mmi
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ll e
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ol
ll i
ii
-
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FFr
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qqu
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een
nnt
tt m
mmi
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tt o
oot
tt i
ii c
cc f
ff i
ii g
ggu
uur
rre
ees
ss
-
-- F
FFo
oor
rrm
mmi
ii n
nng
gg s
ssm
mma
aal
ll l
ll /
// l
ll a
aar
rrg
gge
ee c
ccl
ll u
uu
s
sst
tt e
eer
rrs
ss &
&& g
ggl
ll a
aan
nnd
ddu
uul
ll a
aar
rr d
ddu
uuc
cct
tt a
aal
ll s
sst
tt r
rru
uuc
cct
tt u
uur
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ees
ss
-
-- S
SSo
oom
mme
ee c
cco
oom
mme
eed
ddo
oo p
ppa
aat
tt t
tt e
eer
rrn
nn (
((l
ll a
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rrg
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tt u
uub
bbu
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wwi
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tt h
hh c
cce
een
nnt
tt r
rra
aal
ll n
nne
eec
ccr
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ssi
ii s
ss)
))

Q2: List the macroscopic changes seen in carcinoma of the breast
-
-- G
GGr
rri
ii t
tt t
tt y
yy,
,, r
rro
ooc
cck
kk h
hha
aa
r
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yyi
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ii n
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ff i
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tt r
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tt i
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mma
aas
sss
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-
-- Y
YYe
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ll l
ll o
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wwi
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hh-
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wwh
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cch
hha
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l
l k
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kks
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cch
hha
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tt e
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-
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EEx
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tt e
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ff i
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ss)
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tt y
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Q3: List the risk factors of breast cancer
-
-- P
PPr
rro
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nng
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dd e
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sst
tt r
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Chapter 14 : CNS
CP.CILS/PAT/Ph2Session12/13
1

Jabatan Patologi
Fakulti Perubatan Universiti Malaya

Phase II (MBBS) Session 2012/2013

CP.CILS 14: Central Nervous System

1. Nerve 32B:




Mrs Tan is a 56-year-old housewife who complained of progressive hearing
loss and tinnitus in her right ear for 6 months. Contrast-enhanced CT scan
showed a 1cm tumour in the right cerebello-pontine angle. Microsurgery
was performed and the tumour was removed.
a) Describe the microscopic appearance of the tumour.
b) What is your diagnosis?
c) Name a heredity condition that maybe associated with this lesion.


CP.CILS/PAT/Ph2Session12/13
2
2. Meninges 34A:





Mrs Tina is a 76-year-old retired school teacher with recent
complaints of seizures. Plain CT scan of the head showed a dural
tumour over the temporal lobe compressing the brain, which was
excised.

a) Describe the microscopic appearance of the tumour.
b) What is the most likely diagnosis?
c) What other complications are associated with this condition?


CP.CILS/PAT/Ph2Session12/13
3
3. Meninges 34B:





Adina, a 6-year-old girl, was admitted with history of fever and
headache. Cerebrospinal fluid examination showed many
neutrophils. She passed away before treatment was started. A
Postmortem examination of the brain was performed.

a) Describe the microscopic appearance.
b) What is the provisional diagnosis?
c) What are the possible aetiological factors?




CP.CILS/PAT/Ph2Session12/13
4

4. Brain 35A:





Mr Boon was a 66-year-old businessman with a history of
hypertension and chronic smoking. While having dinner, he suddenly
complained of headache and developed hemiparesis. He soon lost
consciousness and died a few days later. Postmortem brain tissue
was obtained for examination.

a) Describe the microscopic appearance of the biopsy tissue.
b) What is your diagnosis?
c) Explain the possible pathogenesis of this condition in this
particular patient?


CP.CILS/PAT/Ph2Session12/13
5



5. Brain 35D:





Mr Subra, an 86-year-old retired policeman, presented with
headache and problems with speech and memory for 3 months.
Magnetic resonance imaging (MRI) revealed an enhancing cystic
lesion in the left temporal lobe. Partial resection of this left temporal
mass was performed.

a) Describe the microscopic appearance of the lesion.
b) What is your diagnosis?
c) How would you grade this type of lesion?
Chapter 15 : Diseases of Bones and Joints
YEAU MING SONG
MBBS 2008/2013

Slide 37A Bone - Giant cell tumour (osteoclastoma) (H&E x10)
This slide shows a tumour composed of mononucleated and multinucleated giant
cells. The mononucleated cells show pale pink cytoplasmand oval vesicular nuclei
which are fairly uniformin appearance. The multinucleated cells show nuclei that are
similar in appearance to the nuclei of the mononucleated cells. A few mitotic figures
can be seen. There is no osteoid or bone formation by the tumour cells. There is no
normal bone seen in this section.

Case 1: A 32 year old woman, presented with a 2 month history of pain around the
lower portion of her right knee. Examination showed signs of local swelling.
Roentgenograms revealed a well-defined, eccentric and lytic radiolucent
lesion in the proximal tibia involving the metaphysis and epiphysis
extending to the subchondral bone end plate of the articular surface. There
was a notable absence of sclerotic rimming & the presence, instead, of
moth-eaten destruction (arrows) & trabeculation.
Microscopic examination of the surgical resection specimen revealed a
lesion represented by the section shown.

Q1: Describe the characteristic features of this cellular lesion, identifying
the neoplastic cells & state its alternative name

Q2: On the basis of the microscopic presence of giant cells, what other
possible differentials may be considered?

Q3: What is the clinical course of the disease?


37B Bone Osteomyelitis (H&E x20)

Case 2: A 57 year old chronic diabetic male presented at the out patient clinic with
complaints of a dull, throbbing pain over the left lower leg, of a weeks
duration.
Local examination showed a poorly healed ulcer over the anteromedial
aspect of the distal third of the limb close to the ankle. There were also
other trophic changes of the surrounding skin imparting a generally
unhealthy appearance. There was no apparent swelling.
Roentgenograms revealed a lytic focus in the distal tibia surrounded by well
defined sclerotic margin.
The examined biopsy specimen yielded microscopic sections such as that
shown above.

Q1: Describe the microscopic features seen

YEAU MING SONG
MBBS 2008/2013
Q2: Discuss the common routes of infection in Osteomyelitis & the common
clinical scenario which you may encounter in our local setting

Q3: Name (a) common neoplastic condition(s) which may mimic an
infection of bone

Q4: Apart from pyogenic Osteomyelitis name one other type of
Osteomyelitis which is commonly considered

Q5: How does age influence the location of the infective focus within a
particular bone?


37D Bone Osteosarcoma (H&E x 20)

Case 3: A 16 year old boy presented with sudden excruciating pain around the
upper portion of his right knee during basketball practice. On further
probing, he also disclosed that he had felt progressively increasing pain in
the knee for the past 1 months.
Examination showed some degree of swelling around the knee &
considerable tenderness.
Roentgenograms showed a fairly large destructive mixed densely sclerotic
& lytic tumour in the metaphysis of the femur, exhibiting permeative
margins, a sunburst pattern & a Codmans triangle.
Microscopic examination of an open biopsy specimen showed a fairly
cellular tumour as depicted above.

Q1: Described the microscopic features seen in the section & identify the
diagnostic prerequisite. Discuss other features which may be expected

Q2: Discuss the pathogenesis of this tumour

Q3: What would be the usual main course of management for this patient?

Q4: Discuss the different types of classification of the tumour


37F Bone Osteochondroma (H&E x 5)

Case 4: A 25 year old bricklayer was brought to the hospital, complaining of knee
pain after he slipped & fell at work.
Examination showed mild inflammatory changes around the knee.
Roentgenograms revealed a characteristic pedunculated mushroom shaped
bony outgrowth (exostoses) arising fromthe surface of the distal femur.
YEAU MING SONG
MBBS 2008/2013
Microscopic examination of the excisional specimen showed typical
features

Q1: Discuss other salient radiographic features of this benign bone tumour

Q2: Describe the gross & microscopic features seen, including other
expected details

Q3: What is the risk, if any, of malignant development?


Histopathology slide description
Slide 1A Aorta - Atherosclerosis
The aorta showing an artheromatous plaque which is bulging slightly into the luminal
aspect of the vessel. The centre of plaque shows heamorrhage. The luminal aspect of
plaque shows a fibrous cap with cholesterol clefts and the deeper part shows foam
cells (lipid laden macrophages) and smooth muscle cells.

Slide 1C - Coronory Artery - Thrombosis
In this section you see adipose tissue, cardiac muscle, 2 veins and 3 arteries. The
cross section of one of the arteries shows a recent thrombus almost filling the lumen.
The thrombus is composed of erythrocytes and leucocytes. Platelets are not clearly
visible as they are incorporated into thrombus the part of the thrombus adjacent to
the endothelium is compose of fibrin adherent to the endothelium. There is also
some congestion and haemorrhage seen in intima.



Slide 2D Heart - Rheumatic carditis
The slide of the heart shows a picture of pancarditis. The endocardim is heavily
inflamed with numerous lymphocytes, scattered eosinophils, polymorphs and a few
plasma cells. The characteristic features are the necrosis surrounded by collections of
anitschkow cells(plump activated histiocytes)and Aschoff giant cells. The anitschkow
cells have abundant , amhophilic cytoplasm and central round to oval nuclei in which
the chromatin is dispersed in a wavy slender ribbon resembling a
caterpillar(caterpillar cells). The Aschoff giant cells are multinucleated histiocytes
with similar nuclei as described in aniscthkow cells. A few aschoff giant cells and
other inflammatory cells are also seen in the myocardium and pericardium.


Slide 2E Heart - Recent and healed infarct
The slide shows cardiac muscle. The recent and the old infarct are at opposite ends
of section. The area of recent infarct shows foci of dropout of cardiac muscle fibres
and these areas are filled with inflammatory cells, mainly polymorphs. The cardiac
muscle around these areas of dropout shows absence of nuclei and muscle
striations and stain very brightly eosinophilic.some of larger areas of cardiac muscle
dropout show, in addition to polymorphs, lymphocytes, granulation
tissue(indicating that healing has commended). Around this area of granulation
tissue many of the cardiac fibres show golden brown pigment(possibly lipofuchsin).
What has been described so far constitutes the recent infarct. Proceed to the other
end of the section and you will see large areas of dropout of cardiac muscles
occupied by fibrous tissue(healed infarct). Some of the cardiac muscle round these
areas show large and deep staining nuclei.

Slide 2H - Heart - old myocardial infarct
The slide shows endocardium , myocardium and pericardium. The pericardium
consists of fibrofatty tissue while the endocardium consist of fibrous tissue .the
myocardial region shows variably sized areas of muscle fibre dropout occupied by
fibrous tissue. Some of these smaller foci of fibrous tissue are seen in the
subendocardial myocardium(close to the endocardium). Some muscle fibres around
the fibrotic areas show very large nd deeply-staining nuclei.

Slide 2I Heart - Recent infarct
The slide show a section of the heart showing recent infarction. This is a very early
infarct showing subendocardial foci of congestion and haemorrhage in areas of
cardiac muscle dropout. Hemorrhage and congestion are also seen in other areas of
myocardium and in some of them you can also see inflammatory cells(mainly
polmorphs)
Along with a few histiocytes. Cardiac muscle fibres around this congested area show
absence of nuclei and striations.

Slide 3A Nose - Nasal polyp
In this slide you see polypoid fragments of tissue lined by pseudostratified ciliated
columnar epithelium. The underlying tissue shows oedema and inflammatory cell
infiltration consisting of eosinophils ,lymphocytes and plasma cells. There are many
blood vessels seen and also mucous glands, some cartilage and bone.

Slide 3C Nasopharynx - Carcinoma
The slide shows 3 fragments of tissue, one partly lined by squamous epithelium. The
underlying tissue in the two large fragments is heavily inflamed with numerous
plasma cells, lymphocytes and a few eosinophils. Sheets and islands of tumour cells
are seen infiltrating this tissue. These tumour cells are large with pale pink
cytoplasm and pale staining large nuclei and macro-nucleoli. Part of the two large
fragments and the entire small fragment show deep pink areas in which no nuclei are
stained(ischemic necrosis).


Slide 6C Lung - Lobar pneumonia
The section shows lung tissue with congested alveoli all of which are filled with
neutrophils and histiocytes with erythrocyte. The alveolar septae are
widened and congested bronchi or normal alveoli are seen.

Slide 6E Lung - Miliary tuberculosis
The slide shows lung tissue with pleural absence at one end. Some of the alveoli
show pink proteinacous materials in the lumen(oedema fluid). A few bronchi are
visible. Tuberculous are seen consisting of central caseation and
circumscribed clusters of epitheliod cells, Langhans giant cells and lymphocytes.

Slide 6H Lung - Hyaline membrane ________se
This slide of lung shows congestion . Some of the respiratory
bronchioles , alveolar ducts and alveoli are lined by thick pink hyaline
membrane(which is made up of fibrin and cell debris derived from necrotic alveolar
lining cells).

Slide 6I Lung - Bronchiectasis
The slide shows lung with several bronchi showing mucous gland and cartilage in the
wall. The bronchi are .Beneath the bronchial epithelium, inflammatory
cells(mainly monocytes)are seen. At one focus near one end of the section the
bronchial lining is desquamated with necrotic material, erythrocytes an leucocytes in
the lumen and the wall of the bronchus is heavily inflamed and the lumina of some of
them are filled with inflammatory cells. Some lung tissue is seen which shows foci of
oedema and consolidation.


Slide 6P Lung - Small cell carcinoma
This slide of lung shows tumor tissue, some normal lung tissue and a lymph node in
which a lot of anthracotic (carbon) pigment is seen. The tumor is composed of small
hyperchromatic cell ( slightly larger tan lymphocytes) with scanty cytoplasm, round
to oval nuclei and mild to moderate pleomorphism. Some cells are spindle-shaped or
polygonal. These cells are arranged in loose clusters that show neither glandular nor
squamous differentiation and are incompletely divided by fibrous tissue septae which
contain blood vessels. This is the classic oat cell pattern







Slide 7G - Lymph node - Non Hodgkins lymphoma
This slide shows a lymph node with complete loss of nodal architecture. The lymph
node is replaced by a more or less homogenous population of lymphoid cells that
show scanty cytoplasm and vesicular nuclei, some of which are cleaved. One or more
nucleoli can be seen and mitotic figures are numerous. Some small lymphocytes are
scattered in between these cells.

Slide 7K - Lymph node - Metastatic adenocarcinoma
This slide shows a lymph node which partly replaced b tumour consisting of glands of
varying sized that are lined by tall columnar cells with vesicular nuclei. In between
the glands, some amount of fibrous tissue is seen and part of the uninvolved node is
also seen which shows lymphoid follicles.

Slide 9A Skin - histoplasmosisthis slide
This slide of skin shows an area of ulceration with exhuberant granulation tissue
consisting of blood vessels, polymorphs and histiocytes which contain numerous
yeast forms of histoplasma capsulatum. The yeast forms measure about 2-4 mm in
diameter and in H+E stained sections appear as central dot like structures
surrounded by a clear halo which represents the capsule. In the PAS stained slide the
yeast form and the capsule are well demonstrated in deep magenta colour. The
histiocytes containing yeast forms are also seen in the superficial dermis in the
adjacent non-ulcerated part of skin.


Slide 9G skin - malignant melanoma
The slide shows skin with a small area of ulceration. The superficial part of this ulcer
is composed of inflammatory exudate and fibrin. Underneath this and extending
vertically downwards into the deep part of the dermis also extending laterally
underneath the intact non-ulcerated epidermis u can see a tumour composed of
spindle cells. These spindle cells are large and shows pleomorphic vesicular nuclei
with prominent nucleoli. Mainly multinucleated tumour cells are seen and within the
cytoplasm of some of the cells dark brown melanin pigment is present. These cells
form interconnecting fascicles. Mitotic activity is very high. The cells in the superficial
part of the dermis are the ones that show pigmentation while the deeper part of the
tumour is not pigmented. This tumour is an example of the spindle cell variety of
melanoma.

Slide 9H skin - Squamous papilloma
The slide shows skin with the raised area that is composed of thickened (acanthotic)
epidermis that is thrown up into papillary processes (papillolatosis) and increased
thick keratin layers (hyperkeratosis). The underlying dermis is heavily inflamed.


Slide 9K Skin - Basal cell carcinoma
The slide shows skin with an area of ulceration and under this ulcer is seen a tumour
consisting of deeply basophilic cells that are extending down into the dermis in the
form of large and medium-sized anastomosing sheets. The individual cells are
medium-sized with round to oval fairly uniform looking nuclei that are vesicular. The
cytoplasm is indistinct. The peripheral layer of cells in all these sheets and clusters
shows a palisading pattern. All these tumor cells have a resemblance to the basal
cells of the epidermis. Many cells show mitotic figures. As you move towards the
uninvolved part of the skin you will notice that this tumor is continuous with the
lower part of the epidermis.

Slide 9N Skin - leprosy
This slide of skin shows atrophy of the rete pegs and thinning of the epidermis. In
the dermis there are numerous collections of cells with clear to vacuolated cytoplasm
and oval vesicular nuclei(these are lipid laden macrophage or lepra cells). In the
superficial part of the dermis these lepra cells are arranged around vessels, while in
the deeper part of the dermis they are seen to be surrounding adnexal structures
such as sweat ducts and sebaceous glands. There is however a free(small)
uninvolved zone of dermis just beneath the epidermis.

Slide 9N Skin - Leprosy stained with acid-fast bacilli stain
The slide demonstrate numerous acid-fast lepra bacilli within the lepra cells.


Slide 11A Kidney - Acute tubular necrosis
This slide shows kidney tissue in which most of the glomeruli and some of the
tubules appear normal. Many of the tubules show pink eosinophilic appearance with
absence of nuclei(necrotic tubules).

Slide 11B Kidney - Infarct
This slide shows kidney with an area of coagulative necrosis in which most of the
tubules, glomeruli and interstitial tissue have lost their nuclei and appear deep pink.
The uninvolved kidney around the area of coagulative necrosis shows marked
congestion. Some of you may have sections in which the margin between the area of
infarction and the uninvolved kidney tissue is ill defined but can be recognized by
marked congestion of kidney tissue which involves medium-sized and large blood
vessels, associated with an filtration of an acute inflammatory cells.

Slide 11D Kidney - Acute on chronic pyelonephritis
This slide of kidney shows one of the calyces at one end. There is a heavy infiltrate
of lymphoid cells under the transitional epithelium lining the calyx. As you proceed
towards the renal parenchyma you will note that there is patchy inflammatory cells
infiltration of the interstitium consisting of lymphocytes and polymorphs. Some of the
tubules in these inflamed areas contain polymorphs in their lumen. Uninvolved
tubules shows hypertrophy. Thyroidization is not obvious in this section. Occasional
glomeruli show hyalinization. The end of the section that is opposite to the calyceal
end shows the renal capsule with the underlying kidney tissue showing interstitial
inflammatory cells and areas of tubular atrophy.


Slide 11J Kidney - Diabetic glomerulosclerosis
This slide of kidney shows many of the glomeruli with hyaline mesangial nodules of
varying sizes. Some of these nodules are surrounded by patent capillary loops while
others show extensive nodular glomerulosclerosis completely oblitering the
glomerular tuft. Accompanying changes of benign nephrosclerosis are also seen
such as hyaline arterioslerosis and fibrous thickening of the parietal layer of the
Bowmans capsule. Patchy infiltrates of chronic inflammatory cells are seen in the
interstitium associated with foci of tubular atrophy while other areas show
hypertrophy.

Slide 11N Kidney - adenocarcinoma
This slide shows kidney in which a small amount of kidney tissue (mainly tubules
showing hyaline casts)I visible. Over the rest of the section the kidney is replaced by
a tumour composed of large cells with abundant clear to pink cytoplasm and
medium-sized
round to oval vesicular nuclei with prominent nucleoli. These cells are arranged in
sold pattern and trabeculae(cord-like pattern)and also papillo-glandular pattern.
Some

Slide 11O Kidney Wilms tumour
This slide shows normal kidney tissue on one side and tumour tissue on the other
side. The tumour is separated from the normal kidney by a fibrous pseudocapsule.
The tumour consist of small cells that are round, oval or slightly spindle-shaped.
These cells have scanty cytoplasm and oval hyperchromatic nuclei. These cells
attempt to form tubular and glomeruloid structure. Around these structures the cells
are dispersed in a diffuse manner and resemble stromal cells. Mitotic figures are
seen. Some of you may have section in which most of the tumour is very well
differentiated and dominated by tubular structures while the diffuse areas are scanty.

Slide 11P Kidney Tuberculosis
This slide of kidney shows multiple tuberculous granulomas which consist of a central
area of caseation surrounded by epithelioid cells, Langhans giant cells and
lymphocytes. Some of the granulomas also show nuclear debris in the caseous
centres (karyorrhectic debris of polymorphs).


Slide 11S Kidney Amyloidosis Congo Red
This slide of kidney shows amyloid in the glomeruli, around blood vessels and in
peritubular location staining red in color (with polarizing microscope, this is seen as
yellow-green birefringence).

Slide 11S Kidney Hypertension
This slide of kidney shows marked narrowing of small and medium-sized arteriolar
lumina owing to thickening and hyalinization of their walls (this hyaline material
consists of plasma protein, lipids and basement membrane material). Some of the
glomeruli show shrinkage of the tuft or even hyalinization. Areas of interstitial
scarring and tubular atrophy are seen. There is a patchy chronic inflammatory
infiltration of the interstitium.

Slide 12B Urinary bladder Transitional cell carcinoma
This slide shows smooth muscle wall lined by neoplastic transitional epithelium which
consists of 7 10 layers of transitional cells that have a fairly uniform appearance
with oval

Slide 15D Breast Traumatic fat necrosis
This slide shows adipose tissue in which are seen numerous lipid-laden macrophages
(foam cells) and some of them are multinucleated (Touton giant cells). Areas
offibroblastic proliferation with fibrous tissue are presenting between the fat cells.
Slide 15E Breast Infiltrating ductal carcinoma
The slide shows breast tissue in which only occasional normal lobules can be seen.
The rest of the section shows tumour. This tumour is made up of pleomorphic
malignant cells with abundant cytoplasm, vesicular nuclei with prominent nucleoli
and frequent mitotic figures. These cells are forming small and large solid clusters as
well as glandular, ductal structures are cribriform patterns. Some of the large tubular
structures are lined by malignant cells that show central necrosis (cornedo pattern).
The area of tumour adjoining the normal breast tissue shows tumour emboli in
vessels (vascular permeation). Some of you have slides in which the tumour cells are
markedly hyperchromatic, and tend to be spindle-shaped owing to large amounts of
fibrous tissue being produced around the clusters of tumour cells (desmoplasia).
Here the tumour is poorly differentiated and is mainly seen as cords, sheets and
strands and interconnecting trabeculae with abundant fibrous tissue. This is the
classical scirrhous type of breast carcinomawhich is the most common type of
invasive breast carcinoma. However at the periphery which is the growing edge of
the tumour and where there is less fibrous tissue to compress the tumour islands,
you can see large ductal structures lined by multilayered tumour cells with necrotic
material in the lumen (comedo pattern).

Slide 15F Breast Medullary carcinoma
The slide shows only tulour and no normal breast tissue is seen. The tumour consists
of pleomorphic cells with large vesicular nuclei and one or more nucleoli present in
syncytial (sheet like) pattern with no attempts at forming glandular or tubular
structures. Mitotic activity is very high and a few multinucleated tumour cells are
seen. The desmoplastic reaction (which is so striking in scirrhous carcinoma), is not
seen in medullary carcinoma. In between these sheets of tumour cells, numerous
lymphocytes are present. This is a typical medullary carcinoma with lymphocytes. It
is the lymphoid infiltration that probably give this tumour a distinctly better
prognosis than the usual type of scirrhous carcinoma.

Slide 16A Ovary Benign cystic teratoma
This slide shows cystic spaces of varying sizes. Some of them are lined by epidermis
with keratin in the cyst lumen and sebaceous glands and hair follicles in the wall of
the cyst, (evidence of ectodermal differentiation). Other spaces are lined by flattened,
ciliated columnar or mucin-secreting epithelium (evidence of endodermal
differentiation). In the walls of some of these cyst, lymphoid aggregates and
cartilage or osteoid can be seen and fibrous tissue, smooth muscle and adipose
tissue are also present (mesodermal differentiation). A few ganglion cells are seen
and glial tissue is also present (ectodermal differentiation).

Slide 17A Uterus Leiomyoma
The slide shows a well circumscribed tumour consisting of interlacing bundles of
smooth muscle cells that are spindle-shaped or elongated. The nuclei are uniform in
appearance and there is no increase in mitotic activity. Some areas of hyalinization
of muscle fibers are seen.

Slide 17F Uterus Choriocarcinoma
The slide shows uterine smooth muscle on one side and on the other side the
endometrial cavity is seen to be lined by a tumour that is markedly haemorrhagic
and necrotic. The tumour cells are of 2 types cytotrophoblast, which show large pale
nuclei with one or more nucleoli and pale pink to vacuolated cytoplasm, and
syncytiotrophoblasts which are multinucleated cells with hyperchromatic nuclei. Many
of these cells are in mitosis. These trophoblastic cells are similar to the cells lining
normal chorionic villi. However in choriocarcinoma chorionic villi are never seen.

Slide 21D Salivary gland Mixed parotid tumour
This slide shows normal salivary gland tissue on one side and lymph node at the
other end. In between these two there is a well encapsulated tumour. This tumour
consist of various types of elements thrown together giving it the name of mixed
parotid tumour or pleomorphic salivary adenoma. The predominant cells are small
and monotonous in appearance with ovoid or spindle nuclei and indistinct cytoplasm.
These cells are arranged in a diffuse pattern as well as in cords and trabeculae. Here
and there these cell form glandular spaces which contain pink secretory material.
Some of the larger spaces are filled with keratin and group of keratinizing squamous
cells are present. All that we have describe till now was evidence of epithelial
differentiation. However also seen in this tumour are myxoid areas of connective
tissue. The myxoid tissue is loose pale blue in colour and show a few spindle cells
that resemble the Whartons jelly seen in umbilical cord. This myxoid tissue in some
foci shows cartilaginous metaplasia. The myxo-chondroid tissue is evidence of
mesenchyml differentiation. Mixed parotid tumour is essentially a biphasic tumour.

Slide 23A Stomach Chronic peptic ulcer
This slide of stomach shows an area of ulceration. The superficial part of the ulcer
shows erythrocytes, leucocytes and fibrin. Deeper down we can see an area of
granulation tissue characterized by numerous proliferating small vessels, surrounded
by inflammatory cells (lymphocytes, eosinophils, plasma cells and polymorphs) and a
few fibroblast. Note that in the areas of ulceration the muscularis mucosa have been
destroyedand that the ulcer is sitting directly on the muscularis propia. The
inflammation extends into the superficial portion of the muscularis propia. The zone
of scar tissue is not seen in this section.vthe serosa shows many congested vessels.


Slide 23C Stomach Adenocarcinoma (diffuse variety)
This slide of stomach shows an area of ulceration of the mucosa. This area is
occupied by poorly differentiated malignant tumour composed of cells that are
medium sized with vesicular nuclei and one or more nucleoli. Many signet ring cells
are seen and there is high mitotic activity. These cells are diffusely infiltrating the
wall of stomach right from the mucosa through the muscle coat, here and there
splaying and splitting the muscle coat. These cells are forming large emboli in
lymphatic spaces. The tumour cells are also seen extending into the submucosa and
the lamina propia of the diffuse variety of adenocarcinoma of the stomach which is
also known as linnitis plastica owing to the leather bottle type of gross appearance
(thickening of the entire wall of the stomach due to tumour infiltration). This variety
of gastric carcinoma has a worse prognosis than the well-differentiated intestinal
variety.


Slide 25B Small intestine Tuberculosis
This slide shows small intestine with granulomas of varying sizes in the submucosa
and extending down and into the muscle coat. These granulomas consists of pale
epithelioid with a few Langhans giant cells. The larger granulomas show central
areas of caseation. This is a faded slide and the staining is pale.


Slide 27B Liver - Chronic passive congestion
This slide of liver shows congestion and hemorrhage in zone 3 (around the central
veins), faty change in zone 2 and normal hepatocytes in zone 1(periportal zone).
Some of you have sectios in which the fatty change is absentor is very minimal.
These sections show a few hepatocytes in zone with fine cytoplasmic fat vacuoles.
Many of the hepatocytes appear quite normal.

Slide 27C Liver - Cholangiocarcinoma
This slide of liver showing infiltration by tumor that consists of malignant cells
arranged in tubuloglandular pattern as well as solid cords. The tumor cells are pale
staining with abundant cytoplasm and vesicular nuclei. There is one large focus of
tumor in the section and occasional small satellite foci. Some of the glandular lumina
formed by the tumour cells contain pink secretory material (mucin). The rest of the
liver tissue looks fairly normal with focal fatty change only.



Slide 27L Liver - Cirrhosis
This slide shows liver tissue which is divided into pseudolobules of varying sizes by
the presence of fibrous bands which separate the lobules. The pseudolobules cosist
of hepatocytes which show frequent binucleation (evidence of regenerative activity).
Tey also show focal nuclear pleomorphism with macronucleoli (evidence of liver cell
dysplasia). The fibrous tissue contains many proliferating bile ducts and some
chronic inflammatory infiltrates. Some of the large vessels show calcification.

Slide 27P Liver - metastatic adenocarcinoma
This slide of liver shows a large tumour deposit. The tumour consists of pleomorphic
cells with deep staining nuclei and frequent mitosis arranged in tubuloglandular
pattern. Many of the glandular lumina contain pink secretory material (possibly
mucin). The surrounding liver cells appear quite normal.

Slide 27S Liver - Haemosiderosis
This slide of liver shows golden to dark brown pigment within the cytoplasm of the
portal tract macrophages, cytoplasm of the hepatocytes. There is also focal fatty
change present.
A special stain for iron shows up the iron pigment in Prussian blue colour (Prussian
blue reaction for iron). Now the iron can be seen very clearly within the parenchymal
cells, Kupffer cells and the portal tract

Slide 27A Liver - Abscess
At one end of the section you can see liver tissue under the Glissons capsule, with
yhe portal tracts widened by inflammatory infiltrate that consists of mainly
lymphocytes along with a few eosinophils. At the opposite end of the section there is
necrotic tissue with inflammatory cells and abundant nuclear debris. These
inflammatory cells include polymorphs, lympohocytes, eosinophils, histiocytes
(macrophage) and a few amoebic trophozoites. (these are large and round with small
pale nuclei and ingested RBCs within their cytoplasm). In one area of necrotic tissue
there are numerous plasma cell. At the interphase between the necrotic focus and
the liver tissue there is a wide zone of inflammatory granulation tissue spanning 2-3
low power fields.

Slide 28B Pancreas - fat necrosis
This slide shows viable and necrotic pancreatic tissue. The necrotic area shows a
pattern of coagulative necrosis. There is also haemorrhage and necrosis of the
peripancreatic fatty tissue with some bluish granular areas (calcification). There are
focal inflammatory infiltrates in the fatty tissue. Some of u have sections n which
autolytic changes are seen in the pancreas.

Slide 29A Thyroid - Thyrotoxicosis
This slide shows thyroid tissue consisting of thyroid follicles of varying sized lying
back to back. Many of the larger ones contain colloid. The follicular lining epithelium
varies from cuboidal to low columnar. In some foci scalloping of colloid is seen at the
margins of follicular cells. A few collection of lymphoid cells and occacional lymphoid
follicles are seen. The classical histological pattern of thyrotoxicoxis (such as increase
in the height of the lining epithelium, increase in the number of cells, pseudopapillary
pattern of piling up of follicular epithelium, increased vascularity and lack of colloid),
are not seen because of preoperative medication with iodine, which promotes colloid
storage, devascularisation and involution of gland.



Slide 29D Thyroid - Medullary carcinoma with amyloid
This slide shows normal thyroid follicles at the periphery with intervening lymphoid
collections and an infiltrative tumour composed of organoid nests, cords and
tuberculae of tumour cells that are interested by fibrous tissue septae that contain
blood vessels. Masses of pink amorphous material are seen in some foci which
represents amyloid.


Slide 29F Thyroid - Hashimotos disease
The slide shows thyroid tissue which contains numerous lymphoid follicles and many
of them show active enlarged germinal centers. The remaining thyroid follicles are
mostly lined by Hurtle cells which show abundant eosinophilic cytoplasm (oncocytes,
Askanazy cells).

Slide 31B Eye - Retinoblastoma
This slide shows an eyeball in which the cornea, sclera, iris, lens and a small portion
of normal retina can be identified. Most of the retina is however replaced by a
tumour that consists of small round undifferentiated hyperchromatic cells with scanty
cytoplasm, that show focal rosette pattern and areas of calcification.


Slide 32A Nerve - Neurofibroma
This slide shows a tumour composed of spindle cells arranged in wavy thin fascicles.
There is no nuclear pleomorphism, hyperchromasia or increased mitotic activity.

Slide 32B Nerve - Neurilemmoma
This slide shows a tumour consisting of spindle cells that are arranged in fascicles
with nuclear palisading (Antoni A pattern). Some areas are loose and not so cellular.
However the myxoid and cystic change seen in the Antoni B pattern is not very
obvious in this section. Some of you have slides that are faded.

Slide 33A Synovium - Rheumatoid arthritis
The slide of synovium shows villous hypertrophy with oedema and thickening. The
villi are lined by hyperplastic synovial cells. The villous stroma is infiltrated by
numerous lymphocytes and plasma cells and shows increases vascularity. A few
lymphoid follicles are also seen in the villous stroma.

Slide 34A Meninges - Meningioma
This slide shows a tumour consisting of whorled clusters of cells and scanty
intervening fibrovascular stroma. The individual tumour cells are uniform with
abundant eosinophilic cytoplasm and small vesicular nuclei. Many calcified spherules
(psammoma bodies) are seen and globular foci of hyalinization are also present.

Slide 34B Meninges - Meningitis
The slide of brain shows marked congestion and inflammatory infiltration of
meninges with numerous polymorphs.

Slide 34C Meninges - Tuberculous meningitis with tuberculoma of brain
This slide shows brain tissue with dilated congested meningeal blood vessels and a
heavy infiltration of the meninges by inflammatory cells which are mainly
lymphocytes and histocytes along with collections of epithelioid cells that are not
forming well defined granulomas. Other areas of the section show a caseating
granulomatous reaction within the adjacent brain tissue. Here you can see extensive
caseation surrounded by Langerhans giant cells, epithelioid cells and lymphocytes.

Slide 35A Brain - Infarct
This slide of brain shows areas of liquefactive necrosis infiltrated by cells with foamy
vacuolated cytoplasm filled with phagocytic debris (gitter cells/compound granular
corpuscles). The adjacent brain tissue shows oedema and congestion.

Slide 35C Brain - oligodendroglioma
The slide shows a cellular tumour composed of astrocytes that show increased in
nuclear size and mild nuclear pleomorphism. The cytoplasm of the cells is pink and
presents a fibrillary appearance at places.

Slide 35D Brain - Glioblastoma multiforme
The slide shows a very cellular tumour composed of round, polygonal, spindle and
giant cells, many of which show highly pleomorphic and bizarre nuclei. Many of the
cells are in mitosis and extensive areas of necrosis are seen. On one side a small
amount of uninvolved brain tissue is seen.

Slide 35I Brain - Cryptococcus
This slide of brain shows numerous yeast forms of Cryptococcus in the Virchow-Robin
spaces and also in the meninges. In the PAS-stained section you can see the
cryptococci staining deep pink. The Cryptococcus shows a thick capsule and
relatively paler staining hollow centre. The shape varies from round to pear shape.
Occasional budding yeast forms are seen.