Libre Pathology - User contributions [en]

Rosai-Dorfman disease

2020-06-02T15:25:18Z

Alessandro: CD68 positive

{{ Infobox diagnosis
| Name = {{PAGENAME}}
| Image = Emperipolesis_-_very_high_mag.jpg
| Width =
| Caption = Rosai-Dorfman disease. H&E stain.
| Micro = sinus histiocytosis with histiocytes have a singular large round nucleus (~2x the size of a lymphocyte) with a prominent nucleolus (visible with 10x objective); emperipolesis
| Subtypes =
| LMDDx = other specific [[histiocytoses]] ([[Langerhans cell histiocytosis]], [[Erdheim-Chester disease]]), specific infections ([[rhinoscleroma]], [[xanthogranulomatous pyelonephritis]]), [[sinus histiocytosis]]
| Stains =
| IHC = CD68 +ve, S-100 +ve, CD1a -ve
| EM =
| Molecular =
| IF =
| Gross = nodules (skin)
| Grossing =
| Site = [[skin]], [[lymph node]]s - see ''[[lymph node pathology]]''
| Assdx =
| Syndromes =
| Clinicalhx =
| Signs = fever, lymphadenopathy
| Symptoms =
| Prevalence = rare
| Bloodwork = leukocytosis with neurophilia
| Rads =
| Endoscopy =
| Prognosis = usually self-limited, benign
| Other =
| ClinDDx = lymphoma, infections with lymphadenopathy }}
'''Rosai-Dorfman disease''', abbreviated '''RDD''', is a rare [[lymph node pathology]].

It is also known as '''sinus histiocytosis with massive lymphadenopathy''',<ref name=pmid17183839>{{cite journal |author=Agarwal A, Pathak S, Gujral S |title=Sinus histiocytosis with massive lymphadenopathy--a review of seven cases |journal=Indian J Pathol Microbiol |volume=49 |issue=4 |pages=509–15 |year=2006 |month=October |pmid=17183839 |doi= |url=}}</ref> abbreviated '''SHML'''.

==General==
*Super rare.
*Prognosis - good, usually self-limited.<ref name=pmid23739703/>

Clinical findings:<ref name=pmid19668942>{{Cite journal | last1 = Landim | first1 = FM. | last2 = Rios | first2 = Hde O. | last3 = Costa | first3 = CO. | last4 = Feitosa | first4 = RG. | last5 = Rocha Filho | first5 = FD. | last6 = Costa | first6 = AA. | title = Cutaneous Rosai-Dorfman disease. | journal = An Bras Dermatol | volume = 84 | issue = 3 | pages = 275-8 | month = Jul | year = 2009 | doi = | PMID = 19668942 }}</ref><ref name=pmid23739703>{{Cite journal | last1 = Leal | first1 = PA. | last2 = Adriano | first2 = AL. | last3 = Breckenfeld | first3 = MP. | last4 = Costa | first4 = IS. | last5 = de Sousa | first5 = AR. | last6 = Gonçalves | first6 = Hde S. | title = Rosai-Dorfman disease presenting with extensive cutaneous manifestation - case report. | journal = An Bras Dermatol | volume = 88 | issue = 2 | pages = 256-9 | month = | year = | doi = 10.1590/S0365-05962013000200014 | PMID = 23739703 }}</ref>
*Fever.
*Leukocytosis with neutrophilia.
*Polyclonal gammaglobulinemia.

==Gross==
*Skin: nodules.<ref name=pmid23739703/>

Note:
*Reported at many sites.

==Microscopic==
Features:
*Sinus histiocytosis:
**Histiocytes - abundant.
***Singular large round nuclei<ref>Bailey, D. 24 August 2010.</ref> ~2x the size of resting lymphocyte.
****Prominent nucleolus - visible with 10x objective.
***Abundant cytoplasm.
*[[Emperipolesis]] (from ''Greek'': ''em'' = inside, ''peri'' = around, ''polemai'' = wander about<ref>Stedman's Medical Dictionary. 27th Ed.</ref>):
**Histiocytes contain other whole cells: neutrophils, lymphocytes, plasma cells.
***The "eaten" cell is within a vacuole;<ref>{{cite journal |author=Viswanathan P, Raghunathan K, Majhi U, Pandit RV, Shanthi R, Rajkumar T|title=Emperipolesis : an electron microscopic characteristic in RDD (Rosai-Dorfaman disease) : a case report |volume= |issue=1|pages=14-6 |year=1997 |month= |pmid= |doi= |url=http://www.ijmpo.org/article.asp?issn=0971-5851;year=1997;volume=18;issue=1;spage=14;epage=16;aulast=Viswanathan;type=0}}</ref> thus, it should have a clear halo around it.
***Thought to be related to ''peripolesis''; the attachment of a cell to another.<ref name=pmid1577151>{{cite journal |author=Lyons DJ, Gautam A, Clark J, ''et al.'' |title=Lymphocyte macrophage interactions: peripolesis of human alveolar macrophages |journal=Eur. Respir. J. |volume=5 |issue=1 |pages=59–66 |year=1992 |month=January |pmid=1577151 |doi= |url=}}</ref>

DDx:
*Other specific [[histiocytoses]]:
**[[Langerhans cell histiocytosis]].
**[[Erdheim-Chester disease]].
*Infection, e.g. [[rhinoscleroma]] (nasopharynx), [[xanthogranulomatous pyelonephritis]].
*[[Sinus histiocytosis]].
*Xanthomatous change.

===Images===
====Case 1====
<gallery>
Image:Emperipolesis_-_very_high_mag.jpg | Emperipolesis in SHML (WC)
Image:Rosai-Dorfman_disease_-_very_high_mag.jpg | Rosai-Dorfman disease (WC)
</gallery>
====Case 2====
<gallery>
Image: Rosai-Dorfman disease of parotid gland -- low mag.jpg | RDD - low mag.
Image: Rosai-Dorfman disease of parotid gland -- intermed mag.jpg | RDD - intermed. mag.
Image: Rosai-Dorfman disease of parotid gland -- high mag.jpg | RDD - high mag.
Image: Rosai-Dorfman disease of parotid gland - alt -- high mag.jpg | RDD - high mag.
Image: Rosai-Dorfman disease of parotid gland -- very high mag.jpg | RDD - very high mag.
</gallery>
====www====
*[http://path.upmc.edu/cases/case318.html RDD - case 1 - several images (upmc.edu)].
*[http://path.upmc.edu/cases/case338.html RDD - case 2 - several images of breast (upmc.edu)].
*[http://path.upmc.edu/cases/case351/micro.html RDD - case 3 - several images (upmc.edu)].
*[http://path.upmc.edu/cases/case546.html RDD - case 4 - several images (upmc.edu)].

==IHC==
Features:<ref name=pmid18504582>{{Cite journal | last1 = Hartmann | first1 = S. | last2 = Kriener | first2 = S. | last3 = Hansmann | first3 = ML. | title = [Diagnostic spectrum of reactive lymph node changes]. | journal = Pathologe | volume = 29 | issue = 4 | pages = 253-63 | month = Jul | year = 2008 | doi = 10.1007/s00292-008-1003-5 | PMID = 18504582 }}</ref>
*CD68 +ve.
*S-100 +ve.
**Useful for seeing emperipolesis.
*CD1a -ve.
**CD1a +ve in [[Langerhans cell histiocytosis]].

===Images===
<gallery>
Image:Rosai-dorfman.jpg | Rosai-Dorfman disease - S-100 showing emperipolesis (WC/AFIP)
</gallery>

==See also==
*[[Lymph node pathology]].
*[[Sinus histiocytosis]].
*[[Dermatopathic lymphadenopathy]].
*[[Histiocytoses]].

==References==
{{Reflist|2}}

[[Category:Lymph node pathology]]
[[Category:Diagnosis]]

Whipple's disease

2020-05-30T15:01:11Z

Alessandro: /* General */ typo

{{ Infobox diagnosis
| Name = {{PAGENAME}}
| Image = Whipple disease - very high mag.jpg
| Width =
| Caption = Whipple's disease. [[H&E stain]].
| Synonyms =
| Micro = rod-shaped microorganisms - typically in macrophages; lamina propria macrophages usually abundant
| Subtypes =
| LMDDx = [[mycobacterium avium complex]]
| Stains = PAS +ve (microorganisms), AFB -ve
| IHC =
| EM =
| Molecular =
| IF =
| Gross =
| Grossing =
| Site = [[duodenum]]
| Assdx =
| Syndromes =
| Clinicalhx = usu. middle aged men
| Signs = diarrhea
| Symptoms =
| Prevalence = very rare
| Bloodwork =
| Rads =
| Endoscopy =
| Prognosis = good
| Other =
| ClinDDx =
| Tx = antibiotics
}}
'''Whipple's disease''' is a rare infectious disease that is classically found in the [[duodenum]].

==General==
Etiology:
*Infection - caused by ''Tropheryma whipplei''<ref name=pmid11777846>{{cite journal |author=Liang Z, La Scola B, Raoult D |title=Monoclonal antibodies to immunodominant epitope of Tropheryma whipplei |journal=Clin. Diagn. Lab. Immunol. |volume=9 |issue=1 |pages=156?9 |year=2002 |month=January |pmid=11777846 |pmc=119894 |doi= |url=http://cvi.asm.org/cgi/pmidlookup?view=long&pmid=11777846}}</ref> a rod-shaped organism.<ref name=pmid11764080>{{Cite journal | last1 = Alkan | first1 = S. | last2 = Beals | first2 = TF. | last3 = Schnitzer | first3 = B. | title = Primary diagnosis of whipple disease manifesting as lymphadenopathy: use of polymerase chain reaction for detection of Tropheryma whippelii. | journal = Am J Clin Pathol | volume = 116 | issue = 6 | pages = 898-904 | month = Dec | year = 2001 | doi = 10.1309/7678-E2DW-HFJ5-QYUJ | PMID = 11764080 }}</ref>

Epidemiology:
*Very rare.
*Classically middle aged men.

===Clinical===
*Malabsorption (diarrhea), arthritis + others.
**Symptoms are non-specific.

Treatment:
*Antibiotics - for months and months.

==Gross==
*Pale yellow or white spots.<ref>{{Cite journal | last1 = Salkic | first1 = NN. | last2 = Alibegovic | first2 = E. | last3 = Jovanovic | first3 = P. | title = Endoscopic appearance of duodenal mucosa in Whipple's disease. | journal = Gastrointest Endosc | volume = 77 | issue = 5 | pages = 822-3; discussion 823 | month = May | year = 2013 | doi = 10.1016/j.gie.2013.01.016 | PMID = 23490230 }}</ref>

==Microscopic==
Features:<ref name=pmid15476147>{{cite journal | author=Bai J, Mazure R, Vazquez H, Niveloni S, Smecuol E, Pedreira S, Mauriño E | title=Whipple's disease | journal=Clin Gastroenterol Hepatol | volume=2 | issue=10 | pages=849?60 | year=2004 | pmid=15476147 | doi=10.1016/S1542-3565(04)00387-8}}</ref>
*Rod-shaped microorganisms - typically found in macrophages.
**Macrophages usually abundant - '''key feature''' that should raise Dx in DDx.
**Organisms periodic acid-Schiff (PAS) positive.

DDx:
*[[Mycobacterium avium complex]] (MAC) - not hole-y.
*Crushed Brunner's glands - PAS-Alcian blue stain +ve (like Whipple's disease).

===Images===
<gallery>
Image: Whipple disease - low mag.jpg | Low mag.
Image: Whipple disease - intermed mag.jpg | Intermed. mag.
Image: Whipple disease - high mag.jpg | High mag.
Image: Whipple disease - very high mag.jpg | Very high mag.
</gallery>
<gallery>
Image: Whipple disease -a- high mag.jpg | High mag.
Image: Whipple disease -a- very high mag.jpg | Very high mag.
</gallery>
<gallery>
Image:Whipple2.jpg | Whipple disease - poor quality - low mag. (WC)
</gallery>

==Stains==
*PAS +ve organisms.
*[[AFB stain]] -ve -- to r/o [[MAI]].

===Images===
*[http://www.biomedcentral.com/content/figures/1472-6823-6-3-2-l.jpg Whipple disease - PAS stain (biomedcentral.com)].
*[https://www.flickr.com/photos/euthman/6881958781/ Whipple disease - PAS (flickr.com/euthman)].

==See also==
*[[Duodenum]].
*[[Colorectal xanthomatous polyp]].

==References==
{{Reflist|2}}

[[Category:Diagnosis]]
[[Category:Duodenum]]

Dermatopathology

2020-02-21T20:38:02Z

Alessandro: two typos

'''Dermatopathology''' is the pathology of skin.

Pathology is a significant part of dermatology and dermatologists spend five years in residency. So, it is a huge area.

=Specimens=
*Shave biopsy = done for what is presumed to be benign disease - classically exophytic lesions, e.g. [[seborrheic keratosis]].
*Saucerization = scooped shave biopsy.<ref>{{Cite journal | last1 = Elston | first1 = D. | title = Practical advice regarding problematic pigmented lesions. | journal = J Am Acad Dermatol | volume = 67 | issue = 1 | pages = 148-55 | month = Jul | year = 2012 | doi = 10.1016/j.jaad.2012.04.006 | PMID = 22703907 }}
</ref>
*Punch biopsy = cylindrical piece of skin, usu. epidermis and dermis - suspicious lesions/malignant lesions, e.g. [[basal cell carcinoma]].
*Incisional biopsy = a piece of the lesion for pathologic assessment; lesion not completely removed.
*Excision = lesion cut-out with intent for complete removal - usual has a generous margin, e.g. [[malignant melanoma]] excision.
*Re-excision = done to get a wider margin ''or'' remove part of a lesion that was incompletely removed in a prior excision.
**Conservative re-excision = cut-out more with a minimal rim of normal tissue.<ref>URL: [http://www.nedermatology.com/skin-cancer-treatments.php http://www.nedermatology.com/skin-cancer-treatments.php]. Accessed on: 26 February 2013.</ref>
*[[Sentinel lymph node]] removal = a special type of lymphadenectomy usu. done for [[cancer staging|staging]], esp. [[malignant melanoma]].

=Histology=
==Layers of the skin==
[[Image:Skin.png|thumb|Schematic showing the layers and structures of skin. (WC/cancer.gov)]]
*Epidermis - outer most layer, avascular, separated from dermis by a basement membrane, epithelial tissue.
*Dermis - below the epidermis, vascular, separated from the epidermis by a basement membrane, connective tissue.

Note:
*The layer below the skin is the ''subdermis'' ([[AKA]] hypodermis, [[AKA]] subcutaneous tissue).
**It is below the dermis and consists of adipose tissue.<ref>URL: [http://histologyolm.stevegallik.org/node/119 http://histologyolm.stevegallik.org/node/119]. Accessed on: 5 November 2013.</ref>

Image:
*[http://histologyolm.stevegallik.org/node/119 Dermis and hypodermis (stevegallik.org)].

===Epidermis===
====Layers of the epidermis====
[[Image:Epidermal layers.png|thumb|right|Layers of the epidermis. (WC/Wbensmith)]]
Epidermis layers - from the surface to epidermal-dermal junction:
*Stratum corneum.
*Stratum lucidum.
**Present only in "thick" skin.<ref name=Ref_Derm1>{{Ref Derm|1}}</ref>
*Stratum granulosum.
*Stratum spinosum (aka prickle layer).
*Stratum basale (germinativum).
Mnemonic: ''Corn Lovers Grow Several Bales''.

====Cells of the epidermis====
*Keratinocytes.
**Usually eosinophilic cytoplasm - '''important feature'''.
**May have clear perinuclear halo (glycogenated keratinocytes).
**Intercellular bridges (high power) - '''key feature'''.
*Melanocytes.
**Usuallly basal location.
**Epithelioid or dendritic morphology.
**Pericellular clearing - '''key feature'''.
**Clear cytoplasm.
**+/-Pigmentation.
*Other:
**Toker cell.
**Neutrophils.
***Trilobated nuclei - 2-3 little dots - '''key feature'''.
**Lymphocytes.
***Small (round) nucleus.
***Scant/indistinct cytoplasm.
**Other foreign cells:
***[[Paget disease]]: large cells with clear cytoplasm, may cluster, above basal layer.

====Normal histology====
Features:
*Keratinocytes:
**Basal ~ 2x [[RBC]].
***May palisade focally ~ 1:2 = width: height.
*Melanocytes < 25 melanocytes / 0.5 mm of basal layer.<ref name=pmid21549242>{{Cite journal | last1 = Trotter | first1 = MJ. | title = Melanoma margin assessment. | journal = Clin Lab Med | volume = 31 | issue = 2 | pages = 289-300 | month = Jun | year = 2011 | doi = 10.1016/j.cll.2011.03.006 | PMID = 21549242 }}</ref>
*Basket weave stratum corneum (non-acral skin).

===Dermis===
Subdivided into layers:
#Papillary dermis.
#*Location: superficial - opposed to the deep aspect of the epidermis.
#*Appearance: dense, thick collagen bundles.
#Reticular dermis.
#*Location: deep - between papillary dermis and subdermis.
#*Appearance: loose connective tissue.

Images:
*[http://www.biology-online.org/user_files/Image/Anatomy/AN-fibroblastF02.gif Layers of the dermis - labelled (biology-online.org)].<ref>URL: [http://www.biology-online.org/articles/fibroblast_heterogeneity_skin_deep/figures.html http://www.biology-online.org/articles/fibroblast_heterogeneity_skin_deep/figures.html]. Accessed on: 29 March 2012.</ref>
*[http://melanoma.blogsome.com/wp-admin/images/skinstr.jpg Layers of the skin (melanoma.blogsome.com)].<ref>URL: [http://melanoma.blogsome.com/category/skin-structure/ http://melanoma.blogsome.com/category/skin-structure/]. Accessed on: 29 March 2012.</ref>

===Adnexal structures===
The top five structures of the skin:<ref>{{Ref Derm|4-8}}</ref>
{| class="wikitable sortable"
! Structure / Attribute
! Histomorphology
! Function
! [[IHC]]
! Other
! Image
|-
| '''Eccrine gland'''
| clusters of tubular structures, pale cytoplasm
| thermoregulation (cooling) - produce sweat
| [[CK7]]+, [[CEA]]+, CAM5.2+, [[EMA]]+
| ?
| ?
|-
| '''Apocrine gland'''
| apical snouts, tubular structures
| ear wax, body odor
| ?
| ?
| ?
|-
| '''Sebaceous gland'''
| clusters of cells side-by-side, pale fluffy cytoplasm
| grease hair, sexual lubrication
| ?
| assoc. with hair follicle
| ?
|-
| '''Hair follicle'''
| linear structure
| keep individual warm
| ?
| assoc. with sebaceous glands
| ?
|-
| '''Nail'''
| epidermal structure
| weapon (claw-like), look pretty?
| ?
| ?
| [http://histology.osumc.edu/histology/HumanHisto/Integumentary/Img/17B-23_001.html (osumc.edu)], [http://ctrgenpath.net/static/atlas/mousehistology/Windows/integumentary/nail20.html (ctrgenpath.net)]
|-
|}

Ducts vs. glands:<ref>HJ. 27 Feb 2009.</ref>
*Eccrine glands - spindle-shaped myoepithelial cells surround luminal cells.
*Eccrine ducts - cuboidal type subepithelial cells.

=Common terms=
==Clinical descriptors==
There are multitude of clinical descriptors - common ones are:<ref>URL: [http://www.pediatrics.wisc.edu/education/derm/text.html http://www.pediatrics.wisc.edu/education/derm/text.html]. Accessed on: 18 September 2012.</ref>
{| class="wikitable sortable"
! '''Name'''
! '''Size †'''
! '''Description'''
! '''Other'''
! '''Image'''
|-
| Macule
| <= 10 mm
| flat + change of colour
| if > 10 mm --> patch
| [[Image:Macule_and_Patch.svg|thumb|center|150px| Macule (WC)]]
|-
| Patch
| > 10 mm
| flat + change of colour
| if <= 10 mm --> macule
| [[Image:Macule_and_Patch.svg|thumb|center|150px| Patch (WC)]]
|-
| Papule
| <= 10 mm
| raised
| if > 10 mm --> nodule
| [[Image:Papule_and_Plaque.svg|thumb|center|150px| Papule (WC)]]
|-
| Nodule
| > 10 mm
| raised
| if <= 10 mm --> papule
| [[Image:Nodules.svg|thumb|center|150px| Nodule (WC)]]
|-
| Plaque
| > 10 mm
| raised, flat-top
| plateau-like
| [[Image:Papule_and_Plaque.svg|thumb|center|150px| Plaque (WC)]]
|-
| Vesicle
| <= 10 mm
| raised, fluid filled
| if > 10 mm --> bulla
| [[Image:Vesicles_and_Bulla.svg |thumb|center|150px| Vesicle (WC)]]
|-
| Bulla
| > 10 mm
| raised, fluid filled
| if <= 10 mm --> vesicle
| [[Image:Vesicles_and_Bulla.svg |thumb|center|150px| Bulla (WC)]]
|}
Note:
* † Definitions vary -- some authors use a 5 mm cut-off.

==Histologic descriptors==
Dermatopathology doesn't have intuitive terms, e.g. thickening of the stratum spinosum isn't ''spinosum hyperplasia''. The terms have to committed to memory.

===Common terms in a table===
{| class="wikitable sortable"
! Term
! Meaning
! Reference
|-
|Acanthosis
| thickening of the prickle layer (stratum spinosum) of epidermis
| <ref>[http://dictionary.reference.com/browse/acanthosis http://dictionary.reference.com/browse/acanthosis]</ref>
|-
|Acantholysis
| loss of intercellular connections in the epidermis
|
|-
|Dyskeratosis
| abnormal keratinization, often refers to keratinization below the stratum granulosum; keratinization above may be abnormal (dependent on body site)
|
|-
|Parakeratosis
| retention of nuclei in the stratum corneum, normal in mucous membranes
|
|-
|Spongiosis
| epidermal intercellular edema; cells appear to have a clear halo around 'em
| <ref>{{Ref PBoD|1230}}</ref>
|-
|Basketweave stratum corneum
| appearance of the normal stratum corneum; presence in the context of pathology suggests an acute process
|
|-
|Compact hyperkeratosis
| stratum corneum layer is dense and thickened; this suggests a chronic process
| <ref>URL: [http://dermnetnz.org/pathology/pathology-glossary.html http://dermnetnz.org/pathology/pathology-glossary.html]. Accessed on: 8 August 2012.</ref>
|-
| Hyperkeratosis
| thickened stratum corneum - also see ''compact hyperkeratosis'' and ''basketweave stratum corneum''
|
|-
|Epidermotropism †
| intraepithelial lymphocytes in [[CTCL]]; how to remember: epidermotropis''m'' = ''m''alignant
| <ref name=pmid20132423>{{Cite journal | last1 = Fung | first1 = MA. | title = 'Epidermotropism' vs. 'exocytosis' of lymphocytes 101: definition of terms. | journal = J Cutan Pathol | volume = 37 | issue = 5 | pages = 525-9 | month = May | year = 2010 | doi = 10.1111/j.1600-0560.2010.01515.x | PMID = 20132423 }}</ref>
|-
|Exocytosis †
| intraepithelial lymphocytes in benign conditions
| <ref name=pmid20132423>{{Cite journal | last1 = Fung | first1 = MA. | title = 'Epidermotropism' vs. 'exocytosis' of lymphocytes 101: definition of terms. | journal = J Cutan Pathol | volume = 37 | issue = 5 | pages = 525-9 | month = May | year = 2010 | doi = 10.1111/j.1600-0560.2010.01515.x | PMID = 20132423 }}</ref>
|-
|Orthokeratosis
| anuclear keratin layer is present (stratum corneum) - seen in normal skin; ''ortho-'' means ''correct''
| <ref>URL: [http://www.medilexicon.com/medicaldictionary.php?t=63448 http://www.medilexicon.com/medicaldictionary.php?t=63448]. Accessed on: 13 March 2013.</ref><ref>URL: [http://dictionary.reference.com/browse/ortho- http://dictionary.reference.com/browse/ortho-]. Accessed on: 13 March 2013.</ref>
|}
Note:
* † These definitions are not universally accepted. ''Epidermotropism'' is sometimes used in the context of benign disease.<ref name=pmid9537476>{{Cite journal | last1 = Fung | first1 = MA. | last2 = LeBoit | first2 = PE. | title = Light microscopic criteria for the diagnosis of early vulvar lichen sclerosus: a comparison with lichen planus. | journal = Am J Surg Pathol | volume = 22 | issue = 4 | pages = 473-8 | month = Apr | year = 1998 | doi = | PMID = 9537476 }}</ref>

Image:
*[http://commons.wikimedia.org/wiki/File:Spongiotic_dermatitis_%282%29_Dyshidrotic_.JPG Spongiosis (WC)].

===Others terms===
*Crust = epithelial elements, blood.

Image:
*[http://www.eplasty.com/article_images/eplasty10e60_fig3.gif Crust (eplasty.com)].<ref>URL: [http://www.eplasty.com/index.php?option=com_content&view=article&id=492&catid=171:volume-10-eplasty-2010&Itemid=121 http://www.eplasty.com/index.php?option=com_content&view=article&id=492&catid=171:volume-10-eplasty-2010&Itemid=121]. Accessed on: 16 October 2012.</ref>

=Skin diseases=
==Neoplasms==
{{main|Dermatologic neoplasms}}

===Malignant===
Skin cancer is very common. The basic DDx of a malignant skin lesion is:
*[[Squamous cell carcinoma]] (SCC).
*[[Basal cell carcinoma]] (BCC).
*[[Malignant melanoma]].
*Metastases.

==Non-malignant disease==
{{main|Non-malignant skin disease}}
Non-malignant skin disease is common. It is the domain of dermatologists. It can be scary for general anatomical pathologists because the differential diagnosis is often broad, and, it's generally not something the general anatomical pathologist sees a lot of.

===Subarticles===
*[[Dermal cysts]], e.g. [[epidermal cyst]], [[pilar cyst]].
*[[Epidermal necrosis]], e.g. [[erythema multiforme]], [[toxic epidermal necrolysis]].
*[[Inflammatory skin diseases]].
**[[Bullous diseases]], e.g. [[pemphigus vulgaris]].
**[[Panniculitis]].

=Common entities in tables=
==Non-malignant non-cystic - very common==
{| class="wikitable sortable" style="margin-left:auto;margin-right:auto"
! Entity
! Key histologic feature
! Other features
! Clinical
! Stains/IHC
! DDx
! Other
! Image
|-
| [[Seborrheic keratosis]] (SK)
| horn cysts (intraepidermal collections of keratin)
| hyperkeratosis, brown granular material at the DE junction, sharply demarcated
| stuck on appearance
| none
| [[fibroepithelial polyp]]
| Leser–Trélat sign = many SKs in malignancy
| [[Image:Seborrheic_keratosis_(1).jpg |thumb|center|150px| SK (WC)]]
|-
| [[Dermatofibroma]]
| fibrous bundles esp. at edge of lesion
| "dirty fingers" = acanthosis + basal keratinocyte hyperpigmentation
| +/-trauma Hx
| CD34-, Factor XIIIa+
| [[DFSP]]
| very common
| [[Image:SkinTumors-P9280848.jpg|thumb|center|150px|DF (WC)]]
|-
| [[Fibroepithelial polyp]] (skin tag)
| on a stalk (epithelium on 3+ sides)
| no horn nests, no hyperkeratosis
| raised lesion
| none
| [[seborrheic keratosis]]
| very common
| [[Image:SkinTumors-P9250819.jpg|thumb|center|150px|Skin tag (WC)]]
|-
| [[Lipoma]]
| mature adipocytes - uniform size
| var. of size may be seen, should prompt search for lipoblasts
| mobile subcutaneous mass
| S100 (???)
| [[liposarcoma]]
| variants: angiolipoma (blood vessels), myolipoma (muscle)
| [[Image: Lipoma -- high mag.jpg|thumb|center|150px|Lipoma (WC)]]
|-
| [[Cicatrix]] (dermal scar)
| dense collagen bundles running parallel to DE junction, loss of dermal papillae
| loss of adnexal structures, +/-[[giant cells]], +/-foreign material, +/-inflammatory cells
| site of previous trauma/surgery
| usu. none; S-100 (to exclude melanoma)
| residual disease, [[hypertrophic scar]], (desmoplastic) [[melanoma]]
|
| [[Image:ScarHistology.JPG |thumb|center|150px| Scar (WC)]]
|- 
|}

==Non-malignant non-cystic - common==
{| class="wikitable sortable" style="margin-left:auto;margin-right:auto"
! Entity
! Key histologic feature
! Other features
! Clinical
! Stains/IHC
! DDx
! Other
! Image
|-
| [[Neurofibroma]]
| bland spindle cells
| mast cells, mixed with collagen, assoc. with a nerve
| may be associated with [[neurofibromatosis]], esp. plexiform type
| S100+, GFAP+
| neurotized [[melanocytic nevus]]
| may develop into [[MPNST]]
| [[Image:Neurofibroma_%281%29.jpg |thumb|center|150px| Neurofibroma (WC)]]
|-
| [[Keratoacanthoma]]
| keratin plug, glassy pink cytoplasm, pushing downward growth
| minimal/no nuclear atypia
| grow rapidly then involute
| none
| [[squamous cell carcinoma]]
| some don't believe in the entity
| [[Image:Skin_keratoacanthoma_whole_slide.jpg |thumb|center|150px| Keratoacathoma (WC)]]
|-
| [[Molluscum contagiosum]]
| suprabasilar cells with abundant granular eosinophilic cytoplasm
| small peripheral nucleus
| polypoid lesion; mushroom-like (?)
| none (?)
| DDx (?)
| favourite exam case
| [[Image:Molluscum_contagiosum_high_mag.jpg |thumb|center|150px|Molluscum contagiosum (WC)]]
|-
| [[Verruca vulgaris]]
| hypergranulosis (thick granular layer) + keratohyaline granules
| hyperkeratosis (thick s. corneum), acanthosis (thick s. spinosum), rete ridges lengthened (~7-10x normal), large vessels at DE junction, koilocytic change (???)
| raised lesions, classically on hand
| none (p16+?)
| [[squamous cell carcinoma of the skin|squamous cell carcinoma]]
| caused by [[HPV]]
| [[Image:Verruca_vulgaris_-_very_low_mag.jpg |thumb|center|150px| Verruca vulgaris (WC)]]
|-
| [[Condyloma acuminatum]]
| koilocytes
| parakeratosis, long folded rete ridges (papillomatosis) - pseudopapillary look
| genital lesion
| none (p16+)
| [[fibroepithelial polyp]]
| caused by [[HPV]]
| [[Image:Anal_condyloma_%282%29.jpg |thumb|center|150px| Condyloma acuminatum (WC)]]
|-
| [[Granuloma annulare]]
| dermal palisading [[granuloma]] around necrotic collagen
| mucin in centre of lesion, (peripheral) lymphocytes, usu. more superficial than necrobiosis lipoidica
| benign, self-limited
| none (CD68?)
| [[necrobiosis lipoidica]], [[rheumatoid nodule]], [[epithelioid sarcoma]]
| Other ?
| [[Image:Granuloma_annulare_-_add_-_high_mag.jpg |thumb|center|150px| GA (WC)]]
|-
| [[Necrobiosis lipoidica]]
| dermal palisading [[granuloma]] around necrotic collagen, plasma cells
| mucin in centre of lesion, (peripheral) chronic inflammatory cells
| may be assoc. [[diabetes mellitus]]
| none (CD68?)
| [[granuloma annulare]], [[rheumatoid nodule]]
| histology identical to ''necrobiosis lipoidica diabeticorum''
| [http://www.drmihm.com/cases/casefigure.cfm?figID=942&CaseID=53 (drmihm.com)]
|-
| [[Angiofibroma]]
| fibrotic dermis, dilated capillaries
| enlarged (stellate fibroblasts)
| dome-shaped - face, boys & nosebleeds ([[nasopharyngeal angiofibroma]])
| Stains/IHC
| DDx
| may be associated with [[tuberous sclerosis]]
| [[Image:Nasopharyngeal angiofibroma - 2 - high mag.jpg|thumb|150px|Angiofibroma (WC)]]
|-
| [[Keloid]]
| thick collagen bundles - surrounded by paler staining fibroblasts
| replaces adnexal structures
| site of previous trauma, esp. in blacks
| none
| [[dermatofibroma]] (???)
| [[hypertrophic scar]]
| [[Image:Keloid_-_high_mag.jpg|thumb|center|150px|Keloid (WC)]]
|-
| [[Eccrine poroma]]
| abundant basaloid cells with (small) ductal structures
| incloses islands of sclerotic stroma with edema
| erythematous lesions
| Stains/IHC ?
| DDx ?
| Other ?
| [[Image:SkinTumors-P7150495.JPG|thumb|center|150px|EP (WC)]]
|-
| [[Syringoma]]
| bilayered ducts, occasionally tadpole like shape
|
| usu. close to [[eyelid]]
| Stains/IHC ?
| DDx ?
| Other ?
| [http://dermatology.cdlib.org/144/tumors/axillary_syringoma/2.jpg (cdlib.org)]
|-
| [[Chondroid syringoma]] (mixed tumour of skin)
| [[chondromyxoid stroma]], epithelial component
| epithelial component in nests with eosinophilic cytoplasm, round/ovoid nuclei with nucleoli
| Clinical ?
| Stains/IHC ?
| DDx ?
| related to [[pleomorphic adenoma]] (???)
| Image ?
|-
| [[Angiokeratoma]]
| ectatic superficial dermal vessels + overlying hyperkeratosis
| -
| may be seen in [[Fabry disease]]
| Stains/IHC ?
| [[venous lake]]
| Other ?
| [[Image:Angiokeratoma_-_low_mag.jpg |thumb|center|150px| Angiokeratoma (WC)]]
|- 
|}

==Non-malignant non-cystic - children==
{| class="wikitable sortable" style="margin-left:auto;margin-right:auto"
! Entity
! Key histologic feature
! Other features
! Clinical
! Stains/IHC
! DDx
! Other
! Image
|-
| [[Pilomatricoma]]
| anucleate squamous cells (ghost cells), giant cells
| bland basaloid cells
| common in children
| none
| [[squamous cell carcinoma of the skin|squamous cell carcinoma]]
| mutations of CTNNB1 gene
| [[Image:Pilomatrixoma_-_intermed_mag.jpg |thumb|center|150px| Pilomatrixcoma (WC)]]
|-
| [[Juvenile xanthogranuloma]] (JXG)
| Touton giant cells - multi-nucleated cells where nuclei are distributed around the cell periphery forming a ring
| abundant cytoplasm
| children
| CD68+, CD1a-, CD207-
| [[Langerhans cell histiocytosis]]
| may be seen in adults, known as '''adult xanthogranuloma'''
| [[Image:Juvenile_xanthogranuloma_-_high_mag.jpg |thumb|center|150px| JXG (WC)]]
|}

==Non-malignant cystic==
{| class="wikitable sortable" style="margin-left:auto;margin-right:auto"
! Entity
! Key histologic feature
! Other features
! Clinical
! Stains/IHC
! DDx
! Other
! Image
|-
| [[Epidermal cyst]]
| cyst lined by squamous epithelium '''with''' a granular layer
| keratinous debris, no skin adnexal structures
| cyst
| none
| [[pilar cyst]], [[dermoid cyst]]
| Other?
| [[Image:Epidermal inclusion cyst -- high mag.jpg |thumb|center|150px| Epidermal inclusion cyst (WC)]]
|-
| [[Pilar cyst]] (trichilemmal cyst)
| cyst lined by squamous epithelium '''without''' a granular layer
| keratinous debris
| cyst
| none
| [[epidermal cyst]]
| Other?
| [[Image:Trichilemmal_cyst_-_very_high_mag.jpg |thumb|center|100px| Pilar cyst (WC)]]
|-
| [[Steatocystoma]]
| cyst lined by squamous epithelium with a corrugated eosinophilic lining
| epidermis has '''no''' granular layer
| cyst
| none
| [[dermoid cyst]], follicular cyst
| Other?
| [[Image:Steatocystoma_-_high_mag.jpg |thumb|center|150px| Steatocystoma (WC)]]
|-
| [[Dermoid cyst]]
| cyst lined by keratinizing squamous epithelium with adnexal structures
| adnexal structure = hair, sebaceous gland, sweat glands
| cyst
| none
| [[epidermal cyst]]
| may be seen in the [[ovary]]
| [http://webeye.ophth.uiowa.edu/eyeforum/cases-i/case115/larger/Figure4.jpg (uiowa.edu)]
|}

==Pre-malignant==
{| class="wikitable sortable" style="margin-left:auto;margin-right:auto"
! Entity
! Key histologic feature
! Other features
! Clinical
! Stains/IHC
! DDx
! Other
! Image
|-
| [[Actinic keratosis]]
| epidermal atypia, esp. (basal) nuclear enlargement
| var. of nuclear size, shape and staining, parakeratosis (important in early lesions); does ''not'' involves adnexal epithelium and follicular epithelium
| yellow-brown scaly
| none
| [[squamous carcinoma]], [[Bowen disease]]
| seen with [[solar elastosis]]
| [[Image:Actinic_Keratosis,_H%26E.jpg |thumb|center|150px| AK (WC)]]
|-
| [[Bowen disease]] (squamous cell carcinoma in situ)
| epidermal atypia, esp. suprabasal nuclear enlargement
| var. of nuclear size, shape and staining; usually full thickness involvement; involve adnexal epithelium and follicular epithelium
|
| none
| [[squamous carcinoma]], [[actinic keratosis]]
| typically seen with solar elastosis
| [[Image:Bowen_disease_%281%29.jpg |thumb|center|100px| Bowen's disease (WC)]]
|}

==Common malignant==
{| class="wikitable sortable" style="margin-left:auto;margin-right:auto"
! Entity
! Key histologic feature
! Other features
! Clinical
! Stains/IHC
! DDx
! Other
! Image
|-
| [[Basal cell carcinoma]] (BCC)
| basaloid cells with peripheral palisading, artificial cleft
| [[myxoid]] stroma
| raised, pearly, telangiectasia
| usu. none req., [[CK5/6]]+
| [[trichoepithelioma]], [[basaloid squamous cell carcinoma]]
| assoc. [[nevoid basal cell carcinoma syndrome]], [[Bazex syndrome]]
| [[Image:Basal cell carcinoma - high mag.jpg| thumb| center|150px|BCC (WC)]]
|-
| [[Squamous cell carcinoma]] (SCC)
| nuclear enlargement, eosinophilic cytoplasm, central nucleus
| small nucleolus, intercellular bridges
| flaky appearance
| usu. none req., p63+, HMWK+
| [[keratoacanthoma]], [[Paget disease]] ([[EMPD]] & [[PDB]]), [[malignant melanoma]], Toker cell hyperplasia
| Other
| [[Image:Oral_cancer_%281%29_squamous_cell_carcinoma_histopathology.jpg|thumb|center|150px|SCC (WC)]]
|-
| [[Malignant melanoma]]
| spindle and/or epithelioid morphology +/-nuclear atypia (esp. nucleoli)
| mitoses (esp. deep), +/-pigment, +/-nested arch., asymmetry, upward spread (into epidermis), epithelioid m. deep, +/-single cells, +/-sheets of cells
| ABCD = Asymmetry, Borders poor demarc., Colour dark, Diameter large
| S100+, Melan A+, HMB-45+, microphthalmia+, tyrosinase+
| [[melanocytic lesions]] esp. [[Spitz nevus]], [[Bowen's disease]]
| may be familial, [[dysplastic nevus]]
| [[Image:Malignant_melanoma_%281%29_at_thigh_Case_01.jpg |thumb|center|150px|Melanoma (WC)]]
|- 
|}

==Less common malignant==
{| class="wikitable sortable" style="margin-left:auto;margin-right:auto"
! Entity
! Key histologic feature
! Other features
! Clinical
! Stains/IHC
! DDx
! Other
! Image
|-
| [[Kaposi sarcoma]]
| vascular spindle cell lesion
| [[hyaline globules]] (intracytoplasmic)
| often HIV/AIDS
| [[HHV-8]]
| [[Masson's hemangioma]], [[angiosarcoma]], [[Kaposiform hemangioendothelioma]]
| stages: patch stage, plaque stage, nodular stage, exophytic, infiltrative, lymphadenopathic
| [[Image:Kaposi_sarcoma_low_intermed_mag.jpg |thumb|center|150px| Kaposi sarcoma (WC)]]
|-
| [[Cutaneous T-cell lymphoma]] (includes ''mycosis fungoides'')
| single lymphocytes in epidermis ("lymphocyte exocytosis")
| lymphocyte nests in the epidermis ("Pautrier microabscesses"), short arrays of lymphocytes along the basal layer of the epidermis ("epidermotropism")
| Clinical
| CD45, CD4
| B cell lymphoma (?)
| Other
| [[Image:Cutaneous_T-cell_lymphoma_-_intermed_mag.jpg |thumb|center|150px| CTCL (WC)]]
|-
| [[Atypical fibroxanthoma]]
| dermal lesion with marked nuclear atypia
| multinucleated cells, mitoses, vacuolated cytoplasm
| old men, head and neck
| p63-, 34betaE12-, S100-, desmin-
| sarcomatoid squamous carcinoma, [[melanoma]], [[leiomyosarcoma]]
| some classify this as '''benign'''; thought to be related to [[undifferentiated pleomorphic sarcoma]]
| [[Image:SkinTumors-P9280874.jpg|thumb|center|150px| AFX (WC)]]
|-
| [[Merkel cell carcinoma]]
| neuroendocrine nuclear features (stippled chromatin, no nucleolus), scant cytoplasm
| +/-nuclear moulding, usu. intermediate cell size
| Merkel cell polyomavirus associated, usu. head & neck or extremities
| CK20+, EMA+
| cutaneous [[Ewing sarcoma]], [[basal cell carcinoma]], (dermal) [[lymphoma]], metastatic small cell carcinoma (e.g. [[Lung tumours#Small cell carcinoma|lung]])
| rare, aggressive
| [[Image:Merkel_cell_carcinoma_-_very_high_mag.jpg |thumb|center|100px| MCC (WC)]]
|-
| [[Dermatofibrosarcoma protuberans]] (DFSP)
| spindle cell tumour with storiform pattern, tumour often contains adipocytes
| dermal tumour with preserved adnexal structures
| locally aggressive
| CD34+, factor XIIIa-
| [[dermatofibroma]], [[solitary fibrous tumour]] (usu. deeper)
| rarely metastases, characteristic [[translocation]]: t(17;22)(q22;q15) COLA1/PDGFB; may transform to [[fibrosarcoma]]
| [[Image:Storiform_pattern_-_intermed_mag.jpg |thumb|center|150px| DFSP (WC)]]
|- 
|}

=Presentations=
==Leukoplakia==
{{Main|Leukoplakia}}

DDx:<ref>{{Ref PBoD|1065}}</ref>
*Vitiligo (loss of pigment).
*Inflammation.
**Chronic dermatitis.
**[[Psoriasis]].
*Neoplasia.
**[[Vulvar intraepithelial neoplasia]].
**[[Invasive_breast_cancer#Paget.27s_disease|Paget disease]].
**Invasive carcinoma.
*Other.
**[[Lichen sclerosus]].
**[[Lichen simplex chronicus]].

=Skin disease and systemic conditions=
==Tabular list==
{| class="wikitable sortable" style="margin-left:auto;margin-right:auto"
! Entity
! Disease/syndrome
! Key histologic feature
! Image
|-
| [[Acanthosis nigricans]]
| [[diabetes mellitus]], malignancy
| basal cell hyperpigmentation, hyperkeratosis, prominent rete ridges
| [http://dermatology.cdlib.org/149/reviews/acanthosisnigricans/higgins.html (cdlib.org)]
|-
| [[Trichilemmoma]]
| [[Cowden disease]]
| "hyperkeratosis"
| [http://ccr.cancer.gov/staff/images/9033_12822_Lee_1520.jpg (cancer.gov)]<ref>URL: [http://ccr.cancer.gov/staff/gallery.asp?profileid=12822 http://ccr.cancer.gov/staff/gallery.asp?profileid=12822]. Accessed on: 14 December 2011.</ref>
|-
| [[Angiokeratoma]]
| [[Fabry disease]]
| hyperkeratosis + vessels in superficial dermis
| [http://commons.wikimedia.org/wiki/File:Angiokeratoma_-_low_mag.jpg (WC)]
|-
| [[Dermatitis herpetiformis]]
| [[Celiac disease]]
| subepidermal [[bullous disease]], papillary abscesses
| [http://www.lampyris101.com/L101/gallery1/12_JPG.html (lampyris101.com)]
|-
| [[Angiofibroma]]
| [[tuberous sclerosis]]
| fibrotic dermis + dilated blood vessels
| [http://www.drdittmar.lu/images/sce/angiofibroma-s.jpg (drdittmar.lu)]
|-
| [[Sebaceous adenoma]]
| [[Muir-Torre syndrome]]
| abundant sebaceous glands with abn. arch.
| [http://commons.wikimedia.org/wiki/File:Sebaceous_adenoma_-_low_mag.jpg (WC)]
|-
| [[Seborrheic keratosis]], multiple with explosive onset
| Leser–Trélat sign (malignancy)
| horn cysts, hyperkeratosis
| [http://commons.wikimedia.org/wiki/File:IMG_1724.JPG gross (WC)], [http://commons.wikimedia.org/wiki/File:Seborrheic_keratosis_%281%29.jpg micro. (WC)]
|- 
|}

==Acanthosis nigricans==
===General===
Associated with:
*[[Diabetes mellitus]].<ref>URL: [http://www.emedicine.com/derm/topic1.htm http://www.emedicine.com/derm/topic1.htm], URL: [http://dermatlas.med.jhmi.edu/derm/indexDisplay.cfm?ImageID=1943559504].</ref>
*Malignancy.<ref name=Ref_PCPBoD8|596>{{Ref PCPBoD8|596}}</ref>

===Microscopic===
Features (memory device ''BPH''):<ref name=Ref_PCPBoD8|596>{{Ref PCPBoD8|596}}</ref>
*Basal cell hyperpigmentation.
*Prominent rete ridges.
*Hyperkeratosis.

DDx:
*[[Seborrheic keratosis]] - typically has more hyperkeratosis, pseudohorn cysts.

Images:
*[http://dermatology.cdlib.org/149/reviews/acanthosisnigricans/higgins.html AN (cdlib.org)].

==Others==
*[[Dermatitis herpetiformis]]: gluten enteropathy ([[celiac disease]]), [[thyroid]] disease, intestinal [[lymphoma]].<ref name=Ref_TN2007_D23>{{Ref TN2007|D23}}</ref>
*[[Pemphigus vulgaris]]: [[thymoma]], myasthenia gravis, malignancy.<ref name=Ref_TN2007_D23>{{Ref TN2007|D23}}</ref>

===Lipoid proteinosis===
<gallery>
File:3767 dp sl 1.png |Lipoid proteinosis (A)
File:3767 dp sl 2.png |Lipoid proteinosis (B)
</gallery>
A. Inner labial biopsy shows subepithelial hyalinized pink/red material, about blood vessels and in general. B. The particularly glassy appearance of the material in areas is evident at high power.

===Xanthogranuloma in scrotal skin.===
<gallery>
File:DP16MR17 sl 1.png| Xanthogranuloma in scrotal skin. (A)
File:DP16MR17 sl 2.png| Xanthogranuloma in scrotal skin. (B)
File:DP16MR17 sl 3.png| Xanthogranuloma in scrotal skin. (C)
File:DP16MR17 sl 4.png| Xanthogranuloma in scrotal skin. (D)
</gallery>
A. Pseudoepitheliomatous hyperplasia seemingly forms a dermal mass. B. Parakeratosis tops epidermis. C. Neutrophils lie in the center of the apparent mass. D. Diagnostic xanthoma cells lie in dermal papillae.

===Silicone granuloma===
<gallery>
File:DP13AP17 sl1.png| Silicone granuloma (A)
File:DP13AP17 sl2.png| Silicone granuloma (B)
File:DP13AP17 sl3.png| Silicone granuloma (C)
File:DP13AP17 sl4.png| Silicone granuloma (D)
</gallery>
A. The dermis resembles Swiss cheese. B. Macrophages, some with more than one nucleus, accompany empty ovoid spaces. C. Some macrophages resemble Teuton body giant cells. D. An admixture of lymphocytes is not at all unusual.

====Histoplasmosis in skin====
<gallery>
File:DP20AP17 sl 1.png| Dermal histoplasmosis (A)
File:DP20AP17 sl 2.png| Dermal histoplasmosis (B)
File:DP20AP17 sl 3.png| Dermal histoplasmosis (C)
File:DP20AP17 sl 4.png| Dermal histoplasmosis (D)
</gallery>
A. Extending from papillary dermis into dermis is a chronic, blue inflammatory infiltrate. B. The infiltrate comprises lymphocytes, plasma cells, and macrophages. C. At the edge of the biopsy pink strews inflammatory cells; this pink invasion of inflammation, so to speak, is a good place to look for organisms. D. High power reveals sometimes budding yeast forms in clear spaces.

===Herpes Zoster===
<gallery>
File:5.049889044 sl 1.png| Changes of herpes zoster (A)
File:5.049889044 sl 2.png| Changes of herpes zoster (B)
File:5.049889044 sl 3.png| Changes of herpes zoster (C)
File:5.049889044 sl 4.png| Changes of herpes zoster (D)
</gallery>
Changes of herpes zoster in lower right abdominal skin of a 48 yo Hispanic man. A. Note the edema at the dermoepidermal junction along with a focal separation at the left as well as the inflamed superficial and deep blood vessels. B,C. Careful examination along the junction uncovers smudged chromatin diagnostic of viral infection. D. Vasculitis associated changes include extravasated neutrophils with nuclear dust, as well as pervascular macrophages, lymphocytes and occasional eosinophils.

=References=
{{reflist|2}}

[[Category:Dermatopathology]]

Talk:Case 50

2020-02-21T20:22:44Z

Alessandro: Created page with "Looks like a duplicate of Case_34! ~~~~"

Looks like a duplicate of [[Case_34]]! [[User:Alessandro|Alessandro]] ([[User talk:Alessandro|talk]]) 15:22, 21 February 2020 (EST)

Malignant melanoma

2019-10-15T09:56:46Z

Alessandro: fix typo

{{ Infobox diagnosis
| Name = {{PAGENAME}}
| Image = Melanoma40x.JPG
| Width =
| Caption = Malignant melanoma. [[H&E stain]].
| Micro = melanocytic differentiation (e.g. pigment), abnormal architecture, lack of maturation, +/-nuclear atypia - esp. nucleoli, +/-upward scatter of melanocytes, +/-asymmetry of pigmentation
| Subtypes =
| LMDDx = [[dysplastic nevus]], [[Spitz nevus]], [[common nevus]] (nevoid melanoma), [[atypical fibroxanthoma]], (spindle cell) [[squamous cell carcinoma]], [[leiomyosarcoma]], [[serous carcinoma]], [[clear cell sarcoma]], others
| Stains = melanin
| IHC = S-100, Melan A, HMB-45, MITF, tyrosinase
| EM = melanosomes
| Molecular = +/-[[BRAF mutation]]
| IF =
| Gross =
| Grossing =
| Site = [[skin]] (usu. sun exposed areas), oral mucosa, others
| Assdx =
| Syndromes = familial melanoma
| Clinicalhx =
| Signs = ABCDE <nowiki>=</nowiki> asymmetrical, border irregular, colour (black), diameter (>6 mm), evolving (growing)
| Symptoms =
| Prevalence = common
| Bloodwork =
| Rads =
| Endoscopy =
| Prognosis = good to very poor (dependent on stage)
| Other =
| ClinDDx = pigmented skin lesions, esp. [[melanocytic lesions]]
| Tx = wide excision if possible
}}
{{ Infobox external links
| Name = Melanoma in situ
| EHVSC = 10171
| pathprotocols =
| wikipedia =
| pathoutlines =
}}
'''Malignant melanoma''', also '''melanoma''', is an aggressive type of skin cancer that can be diagnostically challenging for pathologists.

It fits into the larger category of [[melanocytic lesions]] which includes many benign entities, a number of which can be difficult to distinguish from melanoma.

==General==
*Known as the great mimicker in pathology; it may look like many things.

===Pathologic prognostic factors===
Pathologic predictors for a poor prognosis:<ref>URL: [http://www.cap.org/apps/docs/committees/cancer/cancer_protocols/2011/SkinMelanoma_11protocol.pdf http://www.cap.org/apps/docs/committees/cancer/cancer_protocols/2011/SkinMelanoma_11protocol.pdf]. Accessed on: 29 March 2012.</ref>
*Tumour thickness (Brewslow thickness) > 1 mm.
*Mitotic rate >1/mm^2.
*Ulceration.
*Regression - >75% of tumour.
*Microsatellitosis - nest of tumour cells > 0.05 mm size, separated from primary tumour >=0.3 mm and <= 2 cm.
*[[In transit metastasis]].
*[[Lymphovascular invasion]].
*[[Perineural invasion]].
*Lack of [[tumour infiltrating lymphocytes]] (TILs).{{fact}}

===Clinical===
Serologic predictors of a poor prognosis:
*Lactate dehydrogenase (LDH) > 200-225 U/L.
*Alumin < 35 g/L.

Epidemiology:
*Strong association with sun exposure.
*Typically Caucasians.
**Blacks rarely get melanoma. When they do it is often on the palms or soles.<ref>{{Ref APBR|362 Q49}}</ref><ref name=pmid17373156>{{Cite journal | last1 = Byrd-Miles | first1 = K. | last2 = Toombs | first2 = EL. | last3 = Peck | first3 = GL. | title = Skin cancer in individuals of African, Asian, Latin-American, and American-Indian descent: differences in incidence, clinical presentation, and survival compared to Caucasians. | journal = J Drugs Dermatol | volume = 6 | issue = 1 | pages = 10-6 | month = Jan | year = 2007 | doi = | PMID = 17373156 }}</ref>

==Gross==
Memory device ''ABCDE'':<ref name=Ref_Derm466>{{Ref Derm|466}}</ref>
*Asymmetric.
*Borders (irregular).
*Colour (black - variable in lesion).
*Diameter (larger than 6 mm).
*Evolving (change with time).

==Microscopic==
===Metastatic/non-skin===
Features (non-skin):
*Classic appearance of melanoma:
**Loosely cohesive; mix of small nests of cells, single cells.
***Nests often have clefting with surrounding tissue.
**Mix of spindle cells and epithelioid cells:
***+/-Occasional large binucleated cells.
***Cytoplasm with brown pigment (melanin).
***Prominent (large) red nucleoli (like in ''serous carcinoma'' of the ovary).
***Marked nuclear pleomorphism - variation in cell size, shape & staining (like in ''serous carcinoma'' of the ovary).
***[[Nuclear pseudoinclusions]] (like in ''papillary thyroid carcinoma'').

Notes:
*Can look almost like anything.
**Like it is said that [[sarcoidosis]] is in every internal medicine DDx... melanoma is every pathologic DDx
*May have no nuclear atypia.
**[[Diagnosis]] is based on architecture (upward spread in the epidermis, single cells, asymmetry).

====DDx====
*Carcinoma.
**[[Serous carcinoma]] - both serous carcinoma and melanoma have a large [[nucleolus]].
*Sarcoma - as may have spindle cells.
**[[Clear cell sarcoma]] ([[AKA]] melanoma of the soft parts).
**[[Metaplastic carcinoma]].
**[[Spindle cell squamous carcinoma]].
**Epithelioid [[angiosarcoma]].
*Lymphoma.
*Other [[melanocytic lesions]].

Images:
*[http://path.upmc.edu/cases/case378.html Desmoplastic melanoma - several images (upmc.edu)].

===Skin===
Features (skin):
#Melanocytic differentiation:
#*Pigmentation (melanin).
#*Nuclear pseudoinclusion.
#*Gray cytoplasm.
#*Clear (artefactual) halo around cells.
#Architecture:
#*Sheeting - '''diagnostic'''.
#*Asymmetry of architecture - as judged from low power magnification.
#Lack of maturation - see below.
#+/-[[Nuclear atypia]] - esp. nucleoli.
#*May be seen in a [[Spitz nevus]].
#+/-Upward scatter of melanocytes [[AKA]] intraepidermal ascent - "cannonball" appearance.
#*No diagnostic significance in the following cases:
#**Acral sites - see: ''[[Acral nevus]]''.
#**Histologic evidence of trauma.
#***Thick dense ''stratum corneum''.
#+/-Asymmetry of pigmentation.

Maturation - with depth:
*Cells get smaller.
*Mitoses decrease.
*Pigmentation decreases.
*Nests get smaller.

Memory device '''CMPA''': '''C'''ells, '''M'''itoses, '''P'''igment, '''A'''ggregates of cells (nests).

DDx:
*Epithelioid cell forms:
**[[Spitz nevus]] - especially difficult.
***Key differences: maturation and symmetry.
**[[Melanocytic nevus]] - especially:
***[[Dysplastic nevus]].
*Spindle cell forms:
**Spindle cell squamous carcinoma.
**[[Atypical fibroxanthoma]].
**[[Leiomyosarcoma]].
**[[Dermal scar]].
**[[Blue nevus]].

=====Images=====
======www======
*[http://path.upmc.edu/cases/case429.html Malignant melanoma - several images (upmc.edu)].
======MIS======
<gallery>
Image: Malignant melanoma in situ -- very low mag.jpg | MIS - very low mag. (WC/Nephron)
Image: Malignant melanoma in situ -- low mag.jpg | MIS - low mag. (WC/Nephron)
Image: Malignant melanoma in situ -- intermed mag.jpg | MIS - intermed. mag. (WC/Nephron)
Image: Malignant melanoma in situ -- high mag.jpg | MIS - high mag. (WC/Nephron)
Image: Malignant melanoma in situ - alt -- very high mag.jpg | MIS - very high mag. (WC/Nephron)
</gallery>

====Regression of melanoma====
{{Main|Tumour regression}}
=====General=====
*Complete regression without metastases estimated to be 10-20%.<ref name=pmid11459861/>
**Common ~25% of cases.<ref name=pmid11459861>{{Cite journal | last1 = Printz | first1 = C. | title = Spontaneous regression of melanoma may offer insight into cancer immunology. | journal = J Natl Cancer Inst | volume = 93 | issue = 14 | pages = 1047-8 | month = Jul | year = 2001 | doi = | PMID = 11459861 | URL = http://jnci.oxfordjournals.org/content/93/14/1047.full }}</ref>
*Complete regression and partial regression >75% of the lesion are a poor prognostic feature.<ref name=pmid16446717>{{Cite journal | last1 = Crowson | first1 = AN. | last2 = Magro | first2 = CM. | last3 = Mihm | first3 = MC. | title = Prognosticators of melanoma, the melanoma report, and the sentinel lymph node. | journal = Mod Pathol | volume = 19 Suppl 2 | issue = | pages = S71-87 | month = Feb | year = 2006 | doi = 10.1038/modpathol.3800517 | PMID = 16446717 }}</ref>

Note:
*[[Melanocytic lesions]] in general, ''not'' only melanoma, may regress.<ref name=Ref_Derm476>{{Ref Derm|476}}</ref><ref name=pmid21029398>{{Cite journal | last1 = Speeckaert | first1 = R. | last2 = van Geel | first2 = N. | last3 = Vermaelen | first3 = KV. | last4 = Lambert | first4 = J. | last5 = Van Gele | first5 = M. | last6 = Speeckaert | first6 = MM. | last7 = Brochez | first7 = L. | title = Immune reactions in benign and malignant melanocytic lesions: lessons for immunotherapy. | journal = Pigment Cell Melanoma Res | volume = 24 | issue = 2 | pages = 334-44 | month = Apr | year = 2011 | doi = 10.1111/j.1755-148X.2010.00799.x | PMID = 21029398 }}</ref>
=====Microscopic=====
Features - all required:
*No melanocytes.
*Melanophages.
*Fibrosis.
*Thinned epidermis.
*Telangiectatic vessels.
*Lymphocytes.

====Metastatic versus primary====
Primary lesions should have:
*Epidermal involvement.

Metastatic lesions classically have:
*Tumour angiotropism (tumours cells cluster around vessels).
*Intravascular invasion.
*No epidermal component.

Note:
*Histology is '''not definitive''' for metastatic melanoma vs. primary melanoma; epidermal involvement may be seen in mets.
**IHC (like histology) is ''not definitive''.<ref name=pmid15272532>{{Cite journal | last1 = Guerriere-Kovach | first1 = PM. | last2 = Hunt | first2 = EL. | last3 = Patterson | first3 = JW. | last4 = Glembocki | first4 = DJ. | last5 = English | first5 = JC. | last6 = Wick | first6 = MR. | title = Primary melanoma of the skin and cutaneous melanomatous metastases: comparative histologic features and immunophenotypes. | journal = Am J Clin Pathol | volume = 122 | issue = 1 | pages = 70-7 | month = Jul | year = 2004 | doi = 10.1309/FUQH-92B0-3902-5LHG | PMID = 15272532 }}</ref>
**History/clinical is important for differentiation.

====Margin assessment====
{{Main|Surgical margin}}
=====General=====
*Adequate distance dependent on tumour stage - see ''[[Surgical_margins#Adequate_margins_by_tumour|surgical margin]]'' article.
*Margin assessment is notoriously difficult as there are numerous mimics of melanoma in situ:<ref name=pmid21549242>{{Cite journal | last1 = Trotter | first1 = MJ. | title = Melanoma margin assessment. | journal = Clin Lab Med | volume = 31 | issue = 2 | pages = 289-300 | month = Jun | year = 2011 | doi = 10.1016/j.cll.2011.03.006 | PMID = 21549242 }}</ref>
*#Melanocytic hyperplasia (considered to be on a continuum with melanoma) may be due to:
*#*Light exposure.
*#*Peritumoral-effect.
*#*Previous biopsy.
*#[[Solar lentigo]].
*#Lichenoid reactions.

=====Microscopic=====
Features of [[MIS]]:<ref name=pmid21549242/>
#Pagetoid spread of melanocytes.
#Junctional or intraepidermal melanocytic nests.
#Three of more contiguous melanocytes in the basal layer.
#Increased numbers of basal melanocytes ( > 25 melanocytes / 0.5 mm of basal layer).
#Marked cytologic atypia - multinucleated cells.
#Adenxal involvement.

Lame mnemonic ''MARGIN'':
*'''M'''arked cytologic atypia.
*'''A'''dnexal involvement.
*'''R'''ow of melanocytes.
*'''G'''ravity defying melanocytes (Pagetoid spread).
*'''I'''ncreased basal melanocytes.
*'''N'''ests of melanocytes.

=====Assessment/reporting of margins=====
*There is no general agreement on how to report margins in melanoma.

It is suggested that one should:
#Try to tease apart melanoma cells from benign melanocytes.
#*Use the ''MARGIN'' mnemonic above.
#**Melanocytes with nuclear atypia = melanoma cells.
#Report the clearance of the nearest melanoma cell to the margin.
#*Positive margin = melanoma cell is touching ink.
#*Very close is reported as "clearance < 0.1 mm".
#Use [[immunostain]]s to assist the assessment of difficult cases:
#*MiTF is considered the preferred marker.
#*MART-1 (Melan A) is considered to overestimate melanocytes; it should ''not'' be used.<ref name=pmid21797920>{{Cite journal | last1 = Kim | first1 = J. | last2 = Taube | first2 = JM. | last3 = McCalmont | first3 = TH. | last4 = Glusac | first4 = EJ. | title = Quantitative comparison of MiTF, Melan-A, HMB-45 and Mel-5 in solar lentigines and melanoma in situ. | journal = J Cutan Pathol | volume = 38 | issue = 10 | pages = 775-9 | month = Oct | year = 2011 | doi = 10.1111/j.1600-0560.2011.01763.x | PMID = 21797920 }}</ref>
#*S-100 also marks follicular dendritic cells; it is ''not'' a preferred marker.

====Breslow thickness====
*[[AKA]] ''maximum tumour thickness''.
*Depth measured from [[stratum granulosum]] to deepest intradermal tumour cell - predictive of survival.<ref name=Ref_PCPBoD8>{{Ref PCPBoD8|595}}</ref>

=====Tumour stage=====
Melanoma staging is based primarily on the Breslow thickness:<ref>{{Cite journal | last1 = Nowecki | first1 = ZI. | last2 = Rutkowski | first2 = P. | last3 = Michej | first3 = W. | title = The survival benefit to patients with positive sentinel node melanoma after completion lymph node dissection may be limited to the subgroup with a primary lesion Breslow thickness greater than 1.0 and less than or equal to 4 mm (pT2-pT3). | journal = Ann Surg Oncol | volume = 15 | issue = 8 | pages = 2223-34 | month = Aug | year = 2008 | doi = 10.1245/s10434-008-9965-3 | PMID = 18506535 }}</ref><ref>URL: [http://www.cap.org/apps/docs/committees/cancer/cancer_protocols/2013/SkinMelanoma_13protocol_3300.doc http://www.cap.org/apps/docs/committees/cancer/cancer_protocols/2013/SkinMelanoma_13protocol_3300.doc]. Accessed on: 2 January 2014.</ref>
*pT1 <= 1.0 mm.
**pT1a: no ulceration, <1 mitoses/mm2.
**pT1b: ulceration present ''or'' >=1 mitoses/mm2.
*pT2 1.01 mm to 2.0 mm.
**pT2a: no ulceration.
**pT2b: ulceration present.
*pT3 2.01 mm to 4.0 mm.
**pT3a: no ulceration.
**pT3b: ulceration present.
*pT4 >4.0 mm.
**pT4a: no ulceration.
**pT4b: ulceration present.

=====Clark level=====
*[[AKA]] ''anatomic level''.
*''Not'' as reproducible as ''Breslow thickness''. It is not used for this reason.

Anatomic level - definition:
*I = epidermis only ([[AKA]] melanoma in situ).
*II = extends into [[papillary dermis]] but does '''not''' fill or expand.
*III = fills and expands papillary dermis.
*IV = extends into reticular dermis.
*V = extends into subdermis.

====Subtypes====
{| class="wikitable sortable" style="margin-left:auto;margin-right:auto"
! Subtype name
! Key feature
! Microscopic additional
! DDx
! Image
! Notes/other
|-
| Melanoma in situ
| confined to epidermis, nuclear atypia
| melanocyte enlargement, nuclear hyperchromasia, +/- melanocytes above suprapapillary plate (above basal layer) = "Pagetoid spread"
| melanocytic hyperplasia, pagetoid Spitz nevus, [[dysplastic nevus]]<ref name=pmid15953373>{{Cite journal | last1 = Farrahi | first1 = F. | last2 = Egbert | first2 = BM. | last3 = Swetter | first3 = SM. | title = Histologic similarities between lentigo maligna and dysplastic nevus: importance of clinicopathologic distinction. | journal = J Cutan Pathol | volume = 32 | issue = 6 | pages = 405-12 | month = Jul | year = 2005 | doi = 10.1111/j.0303-6987.2005.00355.x | PMID = 15953373 }}</ref>
| [http://path.upmc.edu/cases/case97/micro.html (upmc.edu)], [http://commons.wikimedia.org/wiki/File:Lentigo_maligna_-_high_mag.jpg (WC)]
| ''lentigo maligna'' (LM) is melanoma in situ<ref name=pmid16681656>{{Cite journal | last1 = McKenna | first1 = JK. | last2 = Florell | first2 = SR. | last3 = Goldman | first3 = GD. | last4 = Bowen | first4 = GM. | title = Lentigo maligna/lentigo maligna melanoma: current state of diagnosis and treatment. | journal = Dermatol Surg | volume = 32 | issue = 4 | pages = 493-504 | month = Apr | year = 2006 | doi = 10.1111/j.1524-4725.2006.32102.x | PMID = 16681656 }}</ref> on sun damaged skin; LM should '''not''' be confused with ''lentigo maligna melanoma'' (LMM)
|-
| Malignant melanoma - superficial spreading type
| atypical melanocytes at all levels of epidermis + dermis
| atypical dermal melanocytes single, in cluster or sheets
| compound melanocytic nevus
| Image?
| Notes/other?
|-
| Malignant melanoma - lentiginous type
| atypical melanocytes prominent along basal keratinocytes + in dermis
| nuclear atypia
| melanoma in situ
| Image?
| ''lentigo maligna melanoma'' (LMM) = lentiginous malignant melanoma with sun damage{{fact}}
|-
| Malignant melanoma - nodular type
| dermal large nodule/sheet
| nuclear atypia; may not be prominent in epidermis
| metastatic melanoma
| Image?
| Notes/other?
|-
| Malignant melanoma - desmoplastic-neurotropic type [[AKA]] desmoplastic melanoma
| large atypical spindle cells, between collagen
| predominantly dermal, +/-lymphocytes (nodules or infiltrating)<ref>URL: [http://path.upmc.edu/cases/case378/dx.html http://path.upmc.edu/cases/case378/dx.html]. Accessed on: 1 June 2012.</ref>
| [[pleomorphic undifferentiated sarcoma]] (MFH), [[scar]], [[dermatofibroma]], [[DFSP]], [[leiomyosarcoma]], desmoplastic [[Spitz nevus]], sclerosing [[blue nevus]]
| [http://path.upmc.edu/cases/case378.html (upmc.edu)]
| IHC: rarely S100-, generally Melan A- & HMB-45-; subdivided into ''mixed desmoplastic melanoma'' and ''pure desmoplastic melanoma''
|-
| Malignant melanoma - nevoid type
| prominent nucleoli, deep mitoses - '''high power diagnosis'''
| mimics nevus at low power; "push" elastic fibers downward (unlike benign nevi)
| (benign) nevus
| Image?
| deep HMB-45+
|-
| Malignant melanoma - spitzoid type
| nested pattern, nuclear atypia, no maturation (large deep cells)
| [[NC ratio]] increased (vs. Spitz)
| [[Spitz nevus]]
| Image?
| Notes/other?
|}

====Subtypes in short====
{| class="wikitable sortable" style="margin-left:auto;margin-right:auto"
! Subtype name
! Key feature
|-
| in situ
| confined to epidermis, unlike all others
|-
| superficial spreading
| above basal layer
|-
| lentiginous
| along basal keratinocytes
|-
| nodular
| nodular dermal lesion
|-
| desmoplastic-neurotropic
| atypical dermal spindle cells
|-
| nevoid
| nevus-like at low power
|-
| spitzoid
| mimics Spitz nevus (at DE junction)
|}

==[[Electron microscopy]]==
*[[Melanosomes]].

Image(s):
*[http://www.nature.com/nrm/journal/v8/n10/fig_tab/nrm2258_F1.html Melanosomes (nature.com)].

==Stains==
*''[[Fontana-Masson stain]]'', stains melanin.<ref>URL: [http://education.vetmed.vt.edu/curriculum/VM8054/labs/Lab2/Examples/exfontana.htm http://education.vetmed.vt.edu/curriculum/VM8054/labs/Lab2/Examples/exfontana.htm]. Accessed on: 5 May 2010.</ref>
**May be useful to differentiate melanin from other brown stuff (e.g. lipofuscin, hemosiderin).

==[[IHC]]==
===Standard panel===
#S-100 +ve.
#*Negative staining pretty much excludes the diagnosis.
#HMB-45 +ve -- especially deep, often patchy.
#Melan A (MART-1) +ve.

Notes:
*The standard panel above (S100, HMB-45, MART-1) is also positive in other lesions, e.g. ''[[cellular blue nevus]]''.
*Melan A tends to overestimate the number of melanocytes.<ref name=pmid21797920>{{Cite journal | last1 = Kim | first1 = J. | last2 = Taube | first2 = JM. | last3 = McCalmont | first3 = TH. | last4 = Glusac | first4 = EJ. | title = Quantitative comparison of MiTF, Melan-A, HMB-45 and Mel-5 in solar lentigines and melanoma in situ. | journal = J Cutan Pathol | volume = 38 | issue = 10 | pages = 775-9 | month = Oct | year = 2011 | doi = 10.1111/j.1600-0560.2011.01763.x | PMID = 21797920 }}</ref>
**Counting the cell bodies may give an accurate result.{{fact}}
*S-100 marks melanocytes and follicular dendritic cells.

===Threshold panel===
When one it sure it is melanocytic... but unsure whether it is melanoma:
*HMB-45 +ve deep melanocytes.
**In benign lesions deep (mature) melanocytes are negative.
*Ki-67.

===Sentinel lymph node panel===
{{Main|Sentinel lymph node}}
Three sets of the following (12 slides in total):
*[[H&E stain|H&E]].
*S-100.
*MART-1.
*HMB-45.

Notes:
*Positive in approximately 20% of cases - based on one series.<ref name=pmid24455276>{{cite journal |author=Teixeira V, Vieira R, Coutinho I, ''et al.'' |title=Prediction of sentinel node status and clinical outcome in a melanoma centre |journal=J Skin Cancer |volume=2013 |issue= |pages=904701 |year=2013 |pmid=24455276 |pmc=3886376 |doi=10.1155/2013/904701 |url=}}</ref>
**Strongly dependent on T-stage (T1 ~5%, T2 ~11%, T3 ~28%, T4 ~47%).

===Others===
*SOX10 +ve -- useful for differentiate from excision scar.<ref name=pmid20653825>{{cite journal |author=Ramos-Herberth FI, Karamchandani J, Kim J, Dadras SS |title=SOX10 immunostaining distinguishes desmoplastic melanoma from excision scar |journal=J. Cutan. Pathol. |volume=37 |issue=9 |pages=944–52 |year=2010 |month=September |pmid=20653825 |doi=10.1111/j.1600-0560.2010.01568.x |url=}}</ref>
**SOX-10 = pan-schwannian and melanocytic marker.
*[[CD99]] +ve.

*Melanoma cocktail (HMB-45, MART-1).<ref name=pmid18360125>{{cite journal |author=Jani P, Chetty R, Ghazarian DM |title=An unusual composite pilomatrix carcinoma with intralesional melanocytes: differential diagnosis, immunohistochemical evaluation, and review of the literature |journal=Am J Dermatopathol |volume=30 |issue=2 |pages=174–7 |year=2008 |month=April |pmid=18360125 |doi=10.1097/DAD.0b013e318165b8fe |url=}}</ref>
*Microphthalmia (MITF) - easy to interpret as it is a nuclear stain.<ref>{{OMIM|156845}}</ref><ref name=pmid16899407>{{Cite journal | last1 = Levy | first1 = C. | last2 = Khaled | first2 = M. | last3 = Fisher | first3 = DE. | title = MITF: master regulator of melanocyte development and melanoma oncogene. | journal = Trends Mol Med | volume = 12 | issue = 9 | pages = 406-14 | month = Sep | year = 2006 | doi = 10.1016/j.molmed.2006.07.008 | PMID = 16899407 }}</ref>
*Tyrosinase.<ref name=pmid17227112>{{Cite journal | last1 = Roma | first1 = AA. | last2 = Magi-Galluzzi | first2 = C. | last3 = Zhou | first3 = M. | title = Differential expression of melanocytic markers in myoid, lipomatous, and vascular components of renal angiomyolipomas. | journal = Arch Pathol Lab Med | volume = 131 | issue = 1 | pages = 122-5 | month = Jan | year = 2007 | doi = 10.1043/1543-2165(2007)131[122:DEOMMI]2.0.CO;2 | PMID = 17227112 }}</ref>
*WT1 usually +ve<ref name=pmid17927581>{{cite journal |author=Wilsher M, Cheerala B |title=WT1 as a complementary marker of malignant melanoma: an immunohistochemical study of whole sections |journal=Histopathology |volume=51 |issue=5 |pages=605–10 |year=2007 |month=November |pmid=17927581 |doi=10.1111/j.1365-2559.2007.02843.x |url=}}</ref> - not commonly used.

==Molecular==
* Commonly have [[BRAF mutation]]s.<ref name=pmid12460918>{{Cite journal | last1 = Brose | first1 = MS. | last2 = Volpe | first2 = P. | last3 = Feldman | first3 = M. | last4 = Kumar | first4 = M. | last5 = Rishi | first5 = I. | last6 = Gerrero | first6 = R. | last7 = Einhorn | first7 = E. | last8 = Herlyn | first8 = M. | last9 = Minna | first9 = J. | title = BRAF and RAS mutations in human lung cancer and melanoma. | journal = Cancer Res | volume = 62 | issue = 23 | pages = 6997-7000 | month = Dec | year = 2002 | doi = | PMID = 12460918 }}
</ref>
* Desmoplastic melanoma has the highest number of mutations (62 per megabase).<ref>{{Cite journal | last1 = Shain | first1 = AH. | last2 = Garrido | first2 = M. | last3 = Botton | first3 = T. | last4 = Talevich | first4 = E. | last5 = Yeh | first5 = I. | last6 = Sanborn | first6 = JZ. | last7 = Chung | first7 = J. | last8 = Wang | first8 = NJ. | last9 = Kakavand | first9 = H. | title = Exome sequencing of desmoplastic melanoma identifies recurrent NFKBIE promoter mutations and diverse activating mutations in the MAPK pathway. | journal = Nat Genet | volume = 47 | issue = 10 | pages = 1194-9 | month = Oct | year = 2015 | doi = 10.1038/ng.3382 | PMID = 26343386 }}</ref>
**The high number of (C>T) transitions suggest UV radiation as main cause.
**Approx. 15% of the cases have NFKBIE amplifications.

==Sign out==
===Melanoma in situ===
<pre>
Skin Lesion, Left Upper Back, Re-excision:
- Melanoma in situ, completely excised.
-- Surgical clearance 8 millimetres.
- Dermal scar.
- Solar elastosis.

Comment:
The case was partially reviewed with Dr. X; he agrees melanoma in situ is present.
</pre>

====Block letters====
<pre>
SKIN LESION, MID-MIDDLE BACK, PUNCH BIOPSY:
- MELANOMA IN SITU, NEAREST (LATERAL) MARGIN APPROXIMATELY 1 MM -- WIDE RE-EXCISION SHOULD BE DONE.

COMMENT:
The lesion is characterized by mild nuclear atypia and marked architectural complexity.
It has lamellar fibrosis and multiple foci of complex rete ridge bridging and pagetoid
spread of melanocytes. Mitotic activity is seen focally.
</pre>

<pre>
SKIN LESION, MID BACK, EXCISION:
- LENTIGO MALIGNA (SOLAR ELASTOSIS AND MELANOMA IN SITU), MARGIN CLEARANCE < 0.1 MM.

COMMENT:
This lesion should be re-excised.
</pre>

<pre>
SKIN LESION, MID BACK, EXCISION:
- MELANOMA IN SITU AND SOLAR ELASTOSIS (LENTIGO MALIGNA), MARGIN CLEARANCE 2 MM.

COMMENT:
The presence of melanoma in situ is confirmed with immunostaining (HMB-45, MITF).

This lesion should be re-excised.
</pre>

====At least MIS====
<pre>
LEFT THUMB NAIL, AVULSION AND NAIL MATRIX BIOPSY:
- AT LEAST MALIGNANT MELANOMA IN SITU.

COMMENT:
The quantity of diagnostic material is suboptimal.

The limited number of lesional cells stain as follows:
POSITIVE: S-100, HMB-45, MITF, Melan A.

An internal review confirms the impression of at least melanoma in situ.
</pre>

====Micro====
The sections show hair-bearing skin with atypical melanocytes confined to the epidermis.
The melanocytes scatter upwards (focally), have confluent growth and nucleoli, and involve
the adnexal structures. Occasional large multi-nucleated melanocytes, with their nuclei
arranged around the cell periphery, are present. Mitotic activity is not apparent. Extensive solar elastosis is present.

The lesion is very close to the margin (<0.1 mm clearance).

===Invasive melanoma===
<pre>
SKIN LESION, LEFT LOWER BACK, SHAVE BIOPSY:
- INVASIVE MALIGNANT MELANOMA.
-- AT LEAST pT3a.
-- 6 MITOSES/MM*MM.
-- DEEP AND LATERAL MARGINS POSITIVE, WIDE RE-EXCISION SHOULD BE DONE.
-- PLEASE SEE TUMOUR SUMMARY.
-- PLEASE SEE COMMENT.

COMMENT:
The morphologic impression is confirmed by immunostains; the tumour is POSITIVE for
S-100, HMB-45, and MART-1.
</pre>

==See also==
*[[Dermatopathology]].
*[[Dermatologic neoplasms]].
*[[Cytopathology]].
*[[Melanocytic lesions]].

==References==
{{reflist|2}}

==External links==
*[https://www.youtube.com/watch?v=_4jgUcxMezM Dear 16-year-old me - DCMFCanada (youtube.com)].

[[Category:Dermatopathology]]
[[Category:Diagnosis]]

Condyloma acuminatum

2019-03-05T17:24:36Z

Alessandro: typo

'''Condyloma acuminatum''', also '''genital wart''', is a common benign pathology of the genital region ([[vulva]], [[penis]], perineum).

The Bethesda system includes ''condyloma acuminatum'' in [[LSIL]].<ref>{{Ref GP|143}}</ref>

==General==
*Due to [[human papillomavirus]] (HPV).
**Transmission: sexual, non-sexual, horizontal (mother to child).<ref name=Ref_APBR280>{{Ref APBR|280 Q29}}</ref>
***Should raise the suspicion of child abuse.

Note:
*Related to [[verruca vulgaris]] (common wart).

Clinical DDx:
*[[Molluscum contagiosum]].<ref>URL: [http://emedicine.medscape.com/article/781735-differential http://emedicine.medscape.com/article/781735-differential]. Accessed on: 5 July 2013.</ref>

==Microscopic==
Features:
*Koilocytes.<ref name=pmid11860848>{{Cite journal | last1 = Huang | first1 = Z. | last2 = Yang | first2 = S. | last3 = Li | first3 = Q. | last4 = Yan | first4 = P. | last5 = Li | first5 = L. | title = [Evaluation the pathological diagnostic values of koilocyte in condyloma acuminatum]. | journal = Zhonghua Liu Xing Bing Xue Za Zhi | volume = 22 | issue = 1 | pages = 58-60 | month = Feb | year = 2001 | doi = | PMID = 11860848 }}</ref>
**Cells with an enlarged nucleus and perinuclear clearing.
*Papillomatosis.<ref>{{Ref WMSP|204}}</ref>
**Papillomatosis = surface elevation due to dermal papillae enlargement.<ref>{{Ref PBoD|1230}}</ref>
*+/-Parakeratosis.

DDx:
*[[Classic vulvar intraepithelial neoplasia]] - architecture different.

===Images===
<gallery>
Image:Condyloma_acuminatum_-_low_mag.jpg | Condyloma acuminatum - low mag. (WC)
Image:Condyloma_acuminatum_-_very_high_mag.jpg | Condyloma acuminatum - very high mag. (WC)
Image:Anal_condyloma_%282%29.jpg | Condyloma acuminatum - 2. (WC)
Image:Anal_condyloma_%284%29.jpg | Condyloma acuminatum - 3. (WC)
</gallery>

==Sign out==
<pre>
Submitted as "Penile Wart", Excision:
- Condyloma acuminatum (genital wart).
</pre>

====Block letters====
<pre>
SKIN LESION ("VULVAR WART"), VULVA, EXCISION:
- CONDYLOMA ACUMINATUM (GENITAL WART).
</pre>

<pre>
LABIA MINORA, BIOPSY:
- CONDYLOMA/LOW-GRADE SQUAMOUS INTRAEPITHELIAL LESION (LSIL).
-- NEGATIVE FOR HIGH-GRADE DYSPLASIA.
</pre>
===Seborrheic keratosis-like===
<pre>
Submitted as "Penile Wart", Excision:
- Consistent with condyloma acuminatum (genital wart) with
seborrheic keratosis-like features.
</pre>

====Block letters====
<pre>
SKIN LESION, PERINEUM, BIOPSY:
- SEBORRHEIC KERATOSIS-LIKE CONDYLOMA ACUMINATUM (GENITAL WART).
</pre>

===Without viral cytopathic changes===
<pre>
VULVAR LESIONS (x3), EXCISION:
- SQUAMOUS HYPERPLASIA WITH HYPERORTHOKERATOSIS WITHOUT VIRAL CYTOPATHIC EFFECT,
COMPATIBLE WITH CONDYLOMA (x3).
- NEGATIVE FOR MALIGNANCY.
</pre>

===Micro===
The sections show a polypoid fragment of skin with epithelium on three sides, acanthosis, hyperkeratosis and parakeratosis. Koilocytic changes (mild nuclear enlargement, perinuclear clearing) are seen focally. There is mild basilar nuclear enlargement and hyperchromasia. The epithelium shows maturation to the surface and a granular layer is present.

====Seborrheic keratosis-like====
The sections show skin with acanthosis with papillomatous features (round bulbous rete ridges, acanthosis with penetrating fibrovascular cores) pseudohorn cysts, parakeratosis and hyperkeratosis. There is no significant basal nuclear atypia. There are no mitoses and no melanocytic nests. There is mild dermal inflammation. There is no solar elastosis. Pigment incontinence is present focally.

==See also==
*[[Vulva]].
*[[Penis]].

==References==
{{Reflist|2}}

[[Category:Vulva]]
[[Category:Diagnosis]]

Lichen sclerosus

2019-03-04T14:55:33Z

Alessandro: typos

{{ Infobox diagnosis
| Name = {{PAGENAME}}
| Image = Lichen_sclerosus_-_high_mag.jpg
| Width =
| Caption = Lichen sclerosus. [[H&E stain]].
| Synonyms = balanitis xerotica obliterans (old term for lesion on glans penis)
| Micro = fibrosis of dermis with loss of adnexal structures - '''key feature''', loss of the rete ridges, (severe) [[hyperkeratosis]], inflammation - often with eosinophils
| Subtypes =
| LMDDx = [[morphea profunda]], [[differentiated vulvar intraepithelial neoplasia]], [[lichen planus]], cutaneous [[amyloidosis]], [[malignant melanoma]] with regression
| Stains =
| IHC =
| EM =
| Molecular =
| IF =
| Gross =
| Grossing =
| Site = [[vulva]], [[penis]], [[urethra]]
| Assdx = [[differentiated vulvar intraepithelial neoplasia]], [[vulvar squamous cell carcinoma]]
| Syndromes =
| Clinicalhx =
| Signs =
| Symptoms = pruritus
| Prevalence =
| Bloodwork =
| Rads =
| Endoscopy =
| Prognosis = chronic, benign
| Other =
| ClinDDx =
}}
{{ Infobox external links
| Name = {{PAGENAME}}
| EHVSC = 9993
| pathprotocols =
| wikipedia =
| pathoutlines =
}}
'''Lichen sclerosus''' is a relatively common chronic condition classically associated with the [[vulva]]. On the vulva is also known as ''chronic atrophic vulvitis''.

On the glans [[penis]] it was referred to as '''balanitis xerotica obliterans''', abbreviated '''BXO'''.<ref name=pmid12602704>{{cite journal |author=Finkbeiner AE |title=Balanitis xerotica obliterans: a form of lichen sclerosus |journal=South. Med. J. |volume=96 |issue=1 |pages=7–8 |year=2003 |month=January |pmid=12602704 |doi= |url=}}</ref><ref name=pmid24268357>{{Cite journal | last1 = Stewart | first1 = L. | last2 = McCammon | first2 = K. | last3 = Metro | first3 = M. | last4 = Virasoro | first4 = R. | title = SIU/ICUD Consultation on Urethral Strictures: Anterior urethra-lichen sclerosus. | journal = Urology | volume = 83 | issue = 3 Suppl | pages = S27-30 | month = Mar | year = 2014 | doi = 10.1016/j.urology.2013.09.013 | PMID = 24268357 }}</ref>

==General==
*Associated with [[differentiated vulvar intraepithelial neoplasia]] - '''important'''.
**Approximately 50% of [[vulvar cancer]] associated with lichen sclerosus.

Clinical:
*Pruritus -> leads to scratching.
*Chronic condition.
*Usu. post-menopausal women.
*May lead to labial fusion.

Treatment:
*Steroids - high dose initially, then a maintenance therapy to prevent relapse.

Notes:
*'''Mixed vulvar dystrophy''' = lichen sclerosus + squamous cell hyperplasia.<ref name=pmid9491669>{{Cite journal | last1 = Kini | first1 = U. | title = Squamous cell carcinoma of the vulva in association with mixed vulvar dystrophy. A brief report with review of literature. | journal = Indian J Cancer | volume = 34 | issue = 2 | pages = 92-5 | month = Jun | year = 1997 | doi = | PMID = 9491669 }}</ref>

==Microscopic==
Features:<ref>URL: [http://www.pathologyoutlines.com/vulva.html#lichensclerosis http://www.pathologyoutlines.com/vulva.html#lichensclerosis]. Accessed on: 19 April 2011.</ref>
*Loss of rete ridges.
*Severe [[hyperkeratosis]].
**Hyperkeratosis = stratum corneum thickened.
*Fibrosis of the superficial dermis with loss of adnexal structures - '''key feature'''.
**Superficial dermis appears pale and homogeneous (distinct collagen bundles are lost).<ref>URL: [http://www.webpathology.com/image.asp?n=2&Case=538 http://www.webpathology.com/image.asp?n=2&Case=538]. Accessed on: 25 August 2011.</ref>
*Lichenoid inflammatory infiltrate - often with eosinophils; may destroy the dermal-epidermal junction leading to blister formation.
**May be prominent - in the ''inflammatory phase'' of the disease.<ref name=pmid9537476>{{Cite journal | last1 = Fung | first1 = MA. | last2 = LeBoit | first2 = PE. | title = Light microscopic criteria for the diagnosis of early vulvar lichen sclerosus: a comparison with lichen planus. | journal = Am J Surg Pathol | volume = 22 | issue = 4 | pages = 473-8 | month = Apr | year = 1998 | doi = | PMID = 9537476 }}</ref>

Notes:
*May have [[angiokeratoma]]-like changes.<ref name=pmid19187108>{{Cite journal | last1 = Luzar | first1 = B. | last2 = Neil | first2 = SM. | last3 = Calonje | first3 = E. | title = Angiokeratoma-like changes in extragenital and genital lichen sclerosus. | journal = J Cutan Pathol | volume = 36 | issue = 5 | pages = 540-2 | month = May | year = 2009 | doi = 10.1111/j.1600-0560.2008.01091.x | PMID = 19187108 }}</ref>

DDx:
*[[Morphea profunda]] - deep fibrosis.
*[[Differentiated vulvar intraepithelial neoplasia]] - commonly co-exists with lichen sclerosus.
*[[Lichen planus]] (LP) - esp. for the ''inflammatory phase of lichen sclerosus''.
**LP has wedge shaped hypergranulosis, lacks basilar [[exocytosis]], no epidermal atrophy.<ref name=pmid9537476/>
*Cutaneous [[amyloidosis]] - classically has "cracked" appearance.
*[[Malignant melanoma]] with regression - esp. for the ''inflammatory phase of lichen sclerosus''.
*[[Mycosis fungoides]] - the inflammatory infiltrate of lichen sclerosis can closely mimic mycosis fungoides (which almost never presents in a genital area).<ref name=pmid14631186>{{Cite journal | last1 = Citarella | first1 = L. | last2 = Massone | first2 = C. | last3 = Kerl | first3 = H. | last4 = Cerroni | first4 = L. | title = Lichen sclerosus with histopathologic features simulating early mycosis fungoides. | journal = Am J Dermatopathol | volume = 25 | issue = 6 | pages = 463-5 | month = Dec | year = 2003 | doi = | PMID = 14631186 }}</ref>

====Images====
<gallery>
Image:Lichen_sclerosus_-_low_mag.jpg | Lichen sclerosus - low mag. (WC/Nephron)
Image:Lichen_sclerosus_-_high_mag.jpg | Lichen sclerosus - high mag. (WC/Nephron)
Image:Lichen_sclerosus_-_very_high_mag.jpg | Lichen sclerosus - very high mag. (WC/Nephron)
</gallery>
www:
*[http://www.flickr.com/photos/euthman/2329061374/in/set-72057594114099781 Lichen sclerosus + syringoma (flickr.com)].
*[http://www.webpathology.com/image.asp?n=2&Case=538 Lichen sclerosus (webpathology.com)].

==Sign out==
<pre>
VULVA, BIOPSY:
- LICHEN SCLEROSUS.
</pre>

<pre>
FORESKIN, CIRCUMCISION:
- LICHEN SCLEROSUS.
</pre>

Note:
*''BXO'' afflicts the glans penis.

===Micro===
====Inflammatory phase of lichen sclerosus====
The sections show skin with a lymphoplasmacytic predominant interface dermatitis with hyperkeratosis. Spongiosis is present. Scattered inflammatory cell are found with the basal aspect of the epidermis; however, they do not form clusters. No mitotic activity is appreciated.

Focal hypergranulosis and focal parakeratosis is present. Numerous Civatte bodies are identified.

The focal hypergranulosis is not wedge-shaped. There are no pointed rete ridges. There is no basal squamatization.

====Sclerotic phase of lichen sclerosus====
The sections show skin with loss of the rete ridges, hyperkeratosis and marked fibrosis of the superficial dermis. Few, scattered lymphocytes are seen in the dermis.

A granular layer is present. There is no basal nuclear atypia. There is no acanthosis.

====Sclerotic phase of lichen sclerosus with active inflammation====
The sections show skin with loss of the rete ridges, a thin epidermis, hyperkeratosis and marked fibrosis of
the superficial dermis. Numerous lymphocytes are seen scattered between the collagen fibres
in the deeper aspect of the dermis.

A granular layer is present. There is no basal nuclear atypia.

==See also==
*[[Vulva]].
*[[Penis]].
*[[Plasma cell vulvitis]].
*[[Plasma cell balanitis]].

==References==
{{Reflist|2}}

[[Category:Diagnosis]]
[[Category:Vulva]]
[[Category:Gynecologic pathology]]

CSF cytopathology

2019-02-20T08:06:39Z

Alessandro: typo

'''CSF cytopathology''' is a subset of [[CNS cytopathology]], which is a subset of [[cytopathology]].

This article deals only with cerebrospinal fluid (CSF) cytopathology. An introduction to cytopathology is in the ''[[cytopathology]]'' article.

In many institutions, CSF specimens get triaged/rapidly assessed as:
#They are small specimens ~ usually 1-10 ml.
#The procedure to obtain them is non-trivial, i.e. not pleasant for the patient and not risk free.
#Lymphoma is a common malignancy of malignancies found in the CSF.

In many institutions, all CSF specimens are ''stat''.
==Cerebrospinal fluid==
==Normal==
*Paucicellular.
*<12/3 cells
*protein is around 15-40 mg/dl
Gobs of anuclear material:
*Protein vs. white matter.
*Ocassionally arachnoid cap cell-

Bark-like flaky material:
*Contaminant.

Fluffy/smudged large cells (~2-3x RBC dia.) with an indistinct nucleus:
*Degenerated white cells.
**Should prompt a comment about "degeneration", if the population is dominant.

===Routine processing===
*Cytospin - if no abnormality at triage.
**The cellularity of the cytospin will appear to be increased (artifact).

===Images===
<gallery>
File:4 vials of human cerebrospinal fluid.jpg | Normal CSF fluid is clear. (WC/James Heilman)
File:CSF normal cytology.jpg | Normal CSF cytology Pappenheim specimen. (WC/jensflorian)
</gallery>

==Hemorrhage==
*Xanthochromatous specimen
**Can be artificial -> due punctuation injuries or rifampin medication.<ref name="pmid7125611">{{Cite journal | last1 = Liggett | first1 = SB. | last2 = Berger | first2 = JR. | last3 = Hush | first3 = J. | title = Cerebrospinal fluid xanthochromia with rifampin. | journal = Ann Neurol | volume = 12 | issue = 2 | pages = 228-9 | month = Aug | year = 1982 | doi = 10.1002/ana.410120240 | PMID = 7125611 }}</ref>
**Can be seen in newborn -> due to increased bilirubin levels.
**Best seen when looking from top through the tube. <ref name="pmid3981778">{{Cite journal | last1 = Bremer | first1 = HL. | title = Identification of xanthochromia. | journal = JAMA | volume = 253 | issue = 17 | pages = 2496 | month = May | year = 1985 | doi = | PMID = 3981778 }}</ref>
**pink (free hemoglobin directly after bleeding) to yellow (bilirubin after one day).

===Cytology===
*Mostly RBC.
*Neutrophils can be increased.
*+/-Erythro- and Siderophages (usu. after 3-4d).

<gallery>
File:XanthochromeCSF.jpg | Xanthochromatous CSF (WC/Dschafar)
File:Siderophage_CSF_cytology.jpg | A siderophage (WC/jensflorian)
</gallery>

==Acute bacterial meningitis==
{{Main|Meningitis}}
===Cytology===
*Neutrophils - none should be present normally.<ref name=Ref_APBR681>{{Ref APBR|681 (Q25)}}</ref><ref>MUN. 4 November 2010.</ref>
**If the tap is traumatic (i.e. fibrin is present) the finding may be uninterpretable.
**Neutrophils may be present in early exsudative phase of viral meningitis.
*Cell count usually above 1000/µl.
<gallery>
File:CSF_pleocytosis_neutrophils.jpg | CSF (Pappenheim stain) with numerous neutrophils indicating a purulent meningitis (WC/jensflorian)
File:CSF S capitis 2013-11-08.JPG | Streoptococcal meningitis in a neonate with ventriculoperitoneal shunt (WC/Paulo Henrique Orlandi Mourao)
File:Gram Stain Anthrax.jpg | Gram-positive Anthrax bacteria in a CSF specimen (WC/TenOfAllTrades).
</gallery>

DDx:
*[[TBC]]
*Fungal meningitis

==Viral meningitis==
{{Main|Meningitis}}
===General===
*Positive viral culture.
**HSV
**CMV
**Enterovirus
**HIV

===Cytology===
*Pleocytosis (usu. 10-1000 cells/µl).
*Polymorphous population of lymphocytes.<ref name=Ref_APBR681/>
* Activated lymphocytes.
* Plasma cells (sometimes bi- and multinuclear).
* Occ. mitoses.
* Activated (vacuolated) monocytes.

<gallery>
File:Hiv_meningeoencephalitis_csf_pleocytosis.jpg | Lymphocytic plecoytosis in HIV meningeoencephalitis
File:HSV1_encephalitis_CSF_specimen.jpg | Activated lymphocytes in HSV1 encephalitis
</gallery>

==Mollaret's meningitis==
===General===
*Rare aseptic meningitis.
*Suspected to be caused by HSV1 and HSV2.<ref name=emed1169489>[http://emedicine.medscape.com/article/1169489-overview http://emedicine.medscape.com/article/1169489-overview]</ref>

Clinical:
*Recurrent meningismus, headache, +/-fever.<ref name=emed1169489/>

===Cytology===
Features:
*Mollaret cells - described as ''monocytoid cells''<ref name=Ref_APBR681/> (look like monocytes<ref>[http://www.mondofacto.com/facts/dictionary?monocytoid+cell http://www.mondofacto.com/facts/dictionary?monocytoid+cell]</ref> - but do not phagocytose), and ''large endothelial cells''.<ref name=emed1169489/>
**Features - large cells with: abundant cytoplasm, footprint-shaped" nucleus.
**Mollaret cells ''not'' pathognomonic.<ref name=emed1169489/>
*Mixed population of inflammatory cells<ref name=Ref_APBR681/> (PMNs, monocytes, plasma cells, lymphocytes); usually lymphocyte predominant.<ref name=emed1169489/>

Image:
*[http://www.cmaj.ca/cgi/content/full/174/12/1710-a Mollaret cells (cmaj.ca)].

==Meningeosis neoplastica==
===CNS lymphoma===
Histology:<ref name=Ref_APBR681>{{Ref APBR|681 (Q25)}}</ref>
*Too many cells - ''key feature''.
**Not diagnostic... but should raise suspicion.
*Single cells (as typical of lymphoma/leukemia).
*Large lymphocytes - >2x RBC diameter.
*+/-Nuclear atypia.
**Radial segmentation - a completely cleaved nucleus/quasi-binucleation.

Notes:
*Massive karyorrhexis (nuclear fragmentation) is suggestive of lymphoma<ref name=Ref_APBR681>{{Ref APBR|681 (Q25)}}</ref> - not common.

<gallery>
File:NHL b-cell meningiosis.jpg | CSF cytology of a diffuse large B-cell non hodgkin lymphoma. Atypical cells are larger and have a basophilic cytoplasm (WC/jensflorian).
File:CSF Lymphoma on CSF cytospin cluster of blastoid cells 3.jpg | Blastoid cells in a CNS lympoma (WC/Prof. Erhabor Osaro)
</gallery>

===Meningeal carcinomatosis (Meningeosis carcinomatosa)===
Histology:
*abnormal cell size / giant multinuclear cells.
*unusual nuclear/cytoplasm ratio.
*hyperchromatic nuclei.
*prominent nucleoli.
*atypical mitoses.
*cell clustering.

Notes:
*cell count can be normal.
*accompanied by granulocytes and monocytes.

<gallery>
File:Meningeosis carcinomatosa.jpg | Lung adenocarcinoma cells in CSF (WC/Marvin101).
File:Leptomeningeal metastasis.jpg | Atypical mitosis in epithelial cells in CSF (WC/jensflorian).
File:Meningiosis carcinomatosa.jpg | Leptomeningeal carinomatois (WC/jensflorian).
</gallery>

===Non-lymphoid, non-epithelial neoplasm===
*Non-lymphoid, non-epithelial neoplasms are rarely found in the CSF.
*[[Ependymoma]]s and [[medulloblastoma]]s have a higher rate of dissemination than other primary brain tumors.

Meningeosis gliomatosa ([[Astrocytoma]]/[[Glioblastoma]]):
*May vaguely resemble a neuroendocrine tumour:
**Small cell clusters.
**Nuclear moulding.
**Cells somewhat larger than small cell carcinoma.
**Scant cytoplasm.
<gallery>
File:Bild 01Meningeosis gliomatosa 20x GFAP.jpg | GFAP IHC in a CSF specimen highlighting glioma cells (WC/Marvin101).
</gallery>

==CNS fungal infections==
*Cryptococcus is the most common.<ref name=Ref_APBR682>{{Ref APBR|682}}</ref>

==Cryptococcosis==
{{Main|Cryptococcosis}}
*[[AKA]] cryptococcus infection

===General===
*Usu. immunocompromised host.

===Microscopic===
Microscopic appearance:
*Yeast:<ref name=Ref_APBR682>{{Ref APBR|682}}</ref>
**Round/ovoid 5-15 micrometres.
**Thick mucopolysacchardie capsule + refractile centre.
***"Target-like" shape/"bull's eye" appearance.
**"Tear drop-shapped" budding pattern (useful to differentiate from Blastomyces, [[Histoplasma]]).

Images:
*[http://commons.wikimedia.org/wiki/File:Cryptococcus.jpg Cryptococcus in lung FNA - Field stain (WC)].
*[http://commons.wikimedia.org/wiki/File:Cryptococcosis_of_lung_in_patient_with_AIDS._Mucicarmine_stain_962_lores.jpg Crytococcosis - mucicarmine stain (WC)].
*[http://commons.wikimedia.org/wiki/File:Cryptococcosis_of_lung_in_patient_with_AIDS_Methenamine_silver_stain_963_lores.jpg Crytococcosis - methenamine silver stain (WC)].
<gallery>
File:Cryptococcus_neoformans_using_a_light_India_ink_staining_preparation_PHIL_3771_lores.jpg | Ink preparation of Cryptococcosis (CDC/Dr. Leanor Haley)
</gallery>

==See also==
*[[CNS cytopathology]].
*[[Cytopathology]].
*[[Basics]].
*[[Neuropathology]].

==References==
{{reflist|2}}

[[Category:Cytopathology]]

Stomach

2019-02-13T12:56:20Z

Alessandro: /* Stomach versus intestine */ correct typo

[[Image:Gray1051.png|thumb|300px|A drawing of the stomach.]]
'''Stomach''' is an important organ for pathologists. It is often inflamed and may be a site that cancer arises from. Gastroenterologists often biopsy the organ. Surgeons take-out the organ. It connects the [[esophagus]] to the [[duodenum]]. An introduction to gastrointestinal pathology is in the ''[[gastrointestinal pathology]]'' article.

=Normal stomach=
==Gross anatomy==
*Cardia - first part of the stomach; joins with [[esophagus]].
*Fundus - superior portion - not attached directly to the esophagus.
*Body - contains parietal cells.
*Pylorus - distal (think ''pyloric stenosis''); it joins with the [[duodenum]].
**[[AKA]] antrum.

===Image===
<gallery>
Image:Illu_stomach.jpg | Stomach anatomy (WC)
</gallery>

==Microscopic==
===Foveolar cells versus intestinal goblet cells===
*Intestinal goblet cells - clear mucin.
*Foveolar cells - eosinophilic contents.

===Stomach versus intestine===
A tabular comparison:<ref>ALS. 4 Feb 2009.</ref> 
{| class="wikitable sortable"
! Feature
! Intestine
! Stomach
|-
|Spacing
|Goblets cell - spaced
|Foveolar cells - beside one another
|-
|Morphology of epithelial cells
|columnar
|tall columnar (Champagne flute)
|-
|Vesicle at luminal surface
|touching/small opening
|wide open
|-
|PAS-D
| -ve (???)
| +ve<ref>{{Cite journal | last1 = Rubio | first1 = CA. | title = Gastric duodenal metaplasia in duodenal adenomas. | journal = J Clin Pathol | volume = 60 | issue = 6 | pages = 661-3 | month = Jun | year = 2007 | doi = 10.1136/jcp.2006.039388 | PMID = 16837629 | PMC = 1955048 | url = http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1955048/ }}</ref>
|-
|Villin stain<ref name=pmid2459839>{{cite journal |author=Osborn M, Mazzoleni G, Santini D, Marrano D, Martinelli G, Weber K |title=Villin, intestinal brush border hydrolases and keratin polypeptides in intestinal metaplasia and gastric cancer; an immunohistologic study emphasizing the different degrees of intestinal and gastric differentiation in signet ring cell carcinomas |journal=Virchows Arch A Pathol Anat Histopathol |volume=413 |issue=4 |pages=303–12 |year=1988 |pmid=2459839 |doi= |url=}}</ref><ref>{{Cite journal | last1 = Braunstein | first1 = EM. | last2 = Qiao | first2 = XT. | last3 = Madison | first3 = B. | last4 = Pinson | first4 = K. | last5 = Dunbar | first5 = L. | last6 = Gumucio | first6 = DL. | title = Villin: A marker for development of the epithelial pyloric border. | journal = Dev Dyn | volume = 224 | issue = 1 | pages = 90-102 | month = May | year = 2002 | doi = 10.1002/dvdy.10091 | PMID = 11984877 }}</ref>
| +ve
| -ve
|-
|Images
|[http://commons.wikimedia.org/wiki/File:Tubular_adenoma_2_high_mag.jpg Tubular adenoma - goblet cells on right of image (WC)]
|[http://www.microscopy-uk.org.uk/mag/imgaug01/Fig8.jpg Gastric biopsy (microscopy-uk.org.uk)], [http://commons.wikimedia.org/wiki/File:Gastric_signet_ring_cell_carcinoma_histopatholgy_%282%29_PAS_stain.jpg Stomach with cancer - PAS (WC)], [http://commons.wikimedia.org/wiki/File:Normal_gastric_mucosa_intermed_mag.jpg Stomach (WC)]
|}

Notes:
*Intraepithelial lymphocytes in the gastric mucosa have a clear halo around 'em.<ref>Sternberg H4P 2nd Ed., P.484</ref>
*Memory device: '''F'''oveolar cells have '''f'''riends, i.e. they are close to other foveolar cells.

===Gastric antrum versus gastric body===
{| class="wikitable sortable"
! Cell
! Body
! Antrum
! Histology
! Image
|-
| '''Parietal cell'''
| abundant
| few or none
| parietal cells: intensely eosinophilic cytoplasm
| [[Image:Normal_gastric_mucosa_intermed_mag.jpg|thumb|center|60px|Parietal cells. (WC)]]
|-
| '''Chief cell'''
| present
| absent
| chief cells: basophilic cytoplasm, [[IHC]]: +ve for ''pepsinogen I''
| [[Image:Chief_cells.JPG|thumb|center|100px|Chief cells. (WC)]]
|-
| '''G cell'''
| absent
| present
| fried egg appearance (clear cytoplasm, round nucleus); look at high power - usu. middle 1/3 of gland,<ref>URL: [http://www.lab.anhb.uwa.edu.au/mb140/CorePages/GIT/git.htm http://www.lab.anhb.uwa.edu.au/mb140/CorePages/GIT/git.htm]. Accessed on: 3 December 2010.</ref> IHC: +ve for ''gastrin''.
| [[Image:G_cell_hyperplasia_-_very_high_mag.jpg|thumb|center|60px|G cell hyperplasia. (WC)]]
|-
| '''Surface'''
| flat
| blunted villi
| antrum is somewhat duodenum-like
| [[Image:Normal_gastric_mucosa_intermed_mag.jpg |thumb|center|60px|Body - flat. (WC)]]
|-
| '''Gastric glands / mucosa'''
| thick
| thin
| not so useful for discrimination
| [http://commons.wikimedia.org/wiki/File:Normal_gastric_mucosa_intermed_mag.jpg body - thick], [http://www.wjgnet.com/1007-9327/full/v16/i4/WJG-16-445-g001.htm body & antrum]
|}
Notes:
*G cells may superficially resemble intraepithelial lymphocytes.
**G cell nucleus is usu. perfectly round and slightly larger (diameter of 12 micrometers?) than a lymphocyte nucleus (diameter ~ 9-10 micrometers?).

===Sign out===
====Short version====
<pre>
Stomach, Biopsy:
- Antral-type gastric mucosa within normal limits.
</pre>

<pre>
Stomach, Biopsy:
- Body and antral-type gastric mucosa within normal limits.
</pre>

<pre>
Stomach, Biopsy:
- Antral-type gastric mucosa within normal limits.
- NEGATIVE for Helicobacter-like organisms.
</pre>

=====Block letters=====
<pre>
STOMACH, BIOPSY:
- BODY AND ANTRAL-TYPE GASTRIC MUCOSA WITHIN NORMAL LIMITS.
</pre>

<pre>
STOMACH, BIOPSY:
- BODY AND ANTRAL-TYPE GASTRIC MUCOSA WITHIN NORMAL LIMITS.
- NEGATIVE FOR HELICOBACTER-LIKE ORGANISMS.
</pre>

<pre>
STOMACH, BIOPSY:
- ANTRAL-TYPE GASTRIC MUCOSA WITHIN NORMAL LIMITS.
- NEGATIVE FOR HELICOBACTER-LIKE ORGANISMS.
</pre>

====Long version====
<pre>
STOMACH, BIOPSY:
- BODY/ANTRAL-TYPE GASTRIC MUCOSA.
- INFLAMMATION: ABSENT.
- ATROPHY: ABSENT.
- INTESTINAL METAPLASIA: ABSENT.
- HELICOBACTER-LIKE ORGANISMS: NOT IDENTIFIED WITH ROUTINE STAINS.
- NEGATIVE FOR DYSPLASIA AND NEGATIVE FOR MALIGNANCY.
</pre>

====Sleeve gastrectomy====
{{Main|Sleeve gastrectomy}}

=Introduction=
==Useful stains for stomach==
*[[Cresyl violet stain]]<ref>[http://www.histology-world.com/stains/stains.htm http://www.histology-world.com/stains/stains.htm]</ref> - used to find H. pylori.<ref name=pmid10210995>{{cite journal |author=Goggin N, Rowland M, Imrie C, Walsh D, Clyne M, Drumm B |title=Effect of Helicobacter pylori eradication on the natural history of duodenal ulcer disease |journal=Arch. Dis. Child. |volume=79 |issue=6 |pages=502-5 |year=1998 |month=December |pmid=10210995 |pmc=1717771 |doi= |url=http://adc.bmj.com/cgi/pmidlookup?view=long&pmid=10210995}}</ref>
*[[Alcian blue stain]] - used to find mucin<ref>[http://www.histology-world.com/stains/stains.htm http://www.histology-world.com/stains/stains.htm]</ref> which is present in intestinal metaplasia
**Other mucins stains:<ref>[http://www.histology-world.com/stains/stains.htm http://www.histology-world.com/stains/stains.htm]</ref> mucicarmine, [[PAS]], [[PAS-D stain|PASD]] (doesn't stain glycogen)

==Things to look for...==
*Parietal cells (indicate you're in the body of the stomach) - pink (eosinophilic) cytoplasm.
**Lack of parietal cells -- DDx: Bx of antrum (pylorus), Bx of cardia, pernicious anemia.
*Goblet cells = intestinal metaplasia.
*Architectural distortion of gastric glands - suspect cancer.
*Signet ring cells = (usually) gastric carcinoma.
**Can be ''very'' easy to miss in some biopsies.
*Inflammation + small bacteria = suspect H. pylori gastritis.

=Some patterns=
==Gastric atrophy==
===General===
*Has a wide differential diagnosis.

===Microscopic===
Can take three general forms:
#Intestinal metaplasia - see ''intestinal metaplasia'' section.
#Pseudopyloric metaplasia; gastric body looks like gastric antrum.
#*Characterized by ''foveolar hyperplasia''.
#Cell loss without replacement.
#*Clue is deep inflammation in the body.

==Plasma cells in the stomach==
DDx of plasmacytosis:
*[[Plasma cell neoplasm]].
*[[Syphilis]].
*Chronic [[gastritis]].

==Granulomatous gastritis==
*Usual DDx of granulomatous disease (see ''[[Basics]]'' article):
**DNF AAII:
***Drugs, Neoplasms, Foreign body, Autoimmune, Allergic, Infectious, Idiopathic.

Important ones:
*Autoimmune - [[Crohn's disease]].
*Infectious - [[Tuberculosis]].
*Idiopathic - [[Sarcoidosis]].

=Non-neoplastic disease=
==Peptic ulcer disease==
*Abbreviated ''PUD''.
:For duodenal manifestations see ''[[Peptic duodenitis]]''.
===General===
*Benign.

Complications:
*Hemorrhage.
*Obstruction.
*Perforation - can be fatal.

Etiology - typically:<ref name=pmid19683340>{{Cite journal | last1 = Malfertheiner | first1 = P. | last2 = Chan | first2 = FK. | last3 = McColl | first3 = KE. | title = Peptic ulcer disease. | journal = Lancet | volume = 374 | issue = 9699 | pages = 1449-61 | month = Oct | year = 2009 | doi = 10.1016/S0140-6736(09)60938-7 | PMID = 19683340 }}</ref>
*[[Helicobacter pylori]].

===Gross===
Features:
*Typically in the [[duodenum]]; duodenum:stomach = ~4:1.
**Epithelial defect with punched-out edges (suggestive of a benign process).

Note:
*Heaped edges - suggestive of [[stomach cancer|cancer]].

====Endoscopic image====
<gallery>
Image:Deep_gastric_ulcer.png | Gastric ulcer. (WC)
</gallery>

===Microscopic===
Features:
*Loss of epithelium.
*Inflammation.
*+/-Helicobacter organisms - ''see [[Helicobacter gastritis]]''.

==Gastritis==
{{Main|Gastritis}}
{{Main|Chronic gastritis}}
{{Main|Acute gastritis}}

==Helicobacter gastritis==
{{Main|Helicobacter gastritis}}

==Intestinal metaplasia of the stomach==
{{Main|Intestinal metaplasia of the stomach}}

==Inflammatory bowel disease and the stomach==
:See ''[[inflammatory bowel disease]]''.
*Histopathologic findings are usually non-specific.
*Conventional thinking ''was'' upper GI involvement = [[Crohn's disease]]; this is changing.<ref name=pmid20962621>{{cite journal |author=Lin J, McKenna BJ, Appelman HD |title=Morphologic findings in upper gastrointestinal biopsies of patients with ulcerative colitis: a controlled study |journal=Am. J. Surg. Pathol. |volume=34 |issue=11 |pages=1672–7 |year=2010 |month=November |pmid=20962621 |doi=10.1097/PAS.0b013e3181f3de93 |url=}}</ref>

===Endoscopic/gross===
Features - Crohn's:<ref name=Ref_GLP80>{{Ref GLP|80}}</ref>
*+/-Linear fissures, erosions, ulcers, cobblestoning.
*May mimic ''[[linitis plastica]]''.

===Microscopic===
Features:<ref>Kirsch R. 13 December 2010.</ref>
*Focal inflammation.
**Common finding - non-specific.
*+/-[[Granulomas]].

Note:
*Granulomas in Crohn's gastritis present 7-34% of the time.<ref name=Ref_GLP80>{{Ref GLP|80}}</ref>

====Images====
<gallery>
Image: Crohn's gastritis -- low mag.jpg | CG - low mag. (WC)
Image: Crohn's gastritis -- intermed mag.jpg | CG - intermed. mag. (WC)
Image: Crohn's gastritis -- high mag.jpg | CG - high mag. (WC)
Image: Crohn's gastritis -- very high mag.jpg | CG - very high mag. (WC)
</gallery>

=Miscellaneous=
This is a grab bag of stuff seen in the stomach. Some of it is quite rare.
==Gastric antral vascular ectasia==
{{Main|Gastric antral vascular ectasia}}

==Reactive gastropathy==
{{Main|Reactive gastropathy}}

==Autoimmune metaplastic atrophic gastritis==
*[[AKA]] ''autoimmune gastritis''.
{{Main|Autoimmune metaplastic atrophic gastritis}}

==Collagenous gastritis==
{{Main|Collagenous gastritis}}

==Gastritis cystitis profunda==
*[[AKA]] ''Gastritic cystica profunda''.{{fact}}
===General===
*May be associated with glandular proliferation as well.<ref>URL: [http://www.springerlink.com/content/u2v2525241754557/ http://www.springerlink.com/content/u2v2525241754557/] Accessed on: 19 November 2010.</ref> (???)
*Super rare.
*Similar to ''[[cystitis cystica]]''.

===Microscopic===
Features:
*Cystic spaces lined by foveolar epithelium.

==Ménétrier's disease==
{{Main|Ménétrier's disease}}

==Gastric xanthoma==
*Abbreviated ''GX''.
*[[AKA]] ''xanthelasma''.
*[[AKA]] ''stomach lipidosis''.
{{Main|Gastric xanthoma}}

==Gastric ischemia==
:''Gastric necrosis'' redirects here.
===General===
*Rare.
*May arise due to:
**Small bowel obstruction.<ref name=pmid18209748>{{Cite journal | last1 = Steen | first1 = S. | last2 = Lamont | first2 = J. | last3 = Petrey | first3 = L. | title = Acute gastric dilation and ischemia secondary to small bowel obstruction. | journal = Proc (Bayl Univ Med Cent) | volume = 21 | issue = 1 | pages = 15-7 | month = Jan | year = 2008 | doi = | PMID = 18209748 | PMC = 2190544}}</ref>
**Therapeutic embolization.<ref name=pmid22020717/>

===Microscopic===
Features:
*+/-Pseudomembrane formation.<ref name=pmid21360426>{{Cite journal | last1 = Herman | first1 = J. | last2 = Chavalitdhamrong | first2 = D. | last3 = Jensen | first3 = DM. | last4 = Cortina | first4 = G. | last5 = Manuyakorn | first5 = A. | last6 = Jutabha | first6 = R. | title = The significance of gastric and duodenal histological ischemia reported on endoscopic biopsy. | journal = Endoscopy | volume = 43 | issue = 4 | pages = 365-8 | month = Apr | year = 2011 | doi = 10.1055/s-0030-1256040 | PMID = 21360426 }}</ref>
*[[Necrosis]] of the epithelium lining the gastric pits.

Image:
*[https://www.thieme-connect.com/media/endoscopy/2011S02/097cl2.jpg Gastric necrosis (thieme-connect.com)].<ref name=pmid22020717>{{Cite journal | last1 = Papanikolaou | first1 = IS. | last2 = Foukas | first2 = PG. | last3 = Sioulas | first3 = A. | last4 = Beintaris | first4 = I. | last5 = Panagopoulos | first5 = P. | last6 = Karamanolis | first6 = G. | last7 = Panayiotides | first7 = IG. | last8 = Dimitriadis | first8 = G. | last9 = Triantafyllou | first9 = K. | title = A case of gastric ischemic necrosis. | journal = Endoscopy | volume = 43 Suppl 2 UCTN | issue = | pages = E342 | month = | year = 2011 | doi = 10.1055/s-0030-1256795 | PMID = 22020717 }}</ref>

==Portal hypertensive gastropathy==
*Abbreviated ''PHG''.
{{Main|Portal hypertensive gastropathy}}

==Amyloidosis of the stomach==
*[[AKA]] ''gastric amyloidosis''.
{{Main|Amyloidosis}}
===General===
*Very rare.
*Etiologies: various - see [[amyloidosis]].

===Gross/endoscopy===
*Red/swollen gastric folds.<ref name=pmid22863214>{{Cite journal | last1 = Kamata | first1 = T. | last2 = Suzuki | first2 = H. | last3 = Yoshinaga | first3 = S. | last4 = Nonaka | first4 = S. | last5 = Fukagawa | first5 = T. | last6 = Katai | first6 = H. | last7 = Taniguchi | first7 = H. | last8 = Kushima | first8 = R. | last9 = Oda | first9 = I. | title = Localized gastric amyloidosis differentiated histologically from scirrhous gastric cancer using endoscopic mucosal resection: a case report. | journal = J Med Case Rep | volume = 6 | issue = 1 | pages = 231 | month = | year = 2012 | doi = 10.1186/1752-1947-6-231 | PMID = 22863214 | PMC = 3438062 | URL = http://www.jmedicalcasereports.com/content/6/1/231 }} </ref>

Endoscopic DDx:
*[[Stomach cancer]].<ref name=pmid14606114>{{Cite journal | last1 = Wu | first1 = D. | last2 = Lou | first2 = JY. | last3 = Chen | first3 = J. | last4 = Fei | first4 = L. | last5 = Liu | first5 = GJ. | last6 = Shi | first6 = XY. | last7 = Lin | first7 = HT. | title = A case report of localized gastric amyloidosis. | journal = World J Gastroenterol | volume = 9 | issue = 11 | pages = 2632-4 | month = Nov | year = 2003 | doi = | PMID = 14606114 }}</ref><ref name=pmid22814919>{{Cite journal | last1 = Sawada | first1 = T. | last2 = Adachi | first2 = Y. | last3 = Akino | first3 = K. | last4 = Arimura | first4 = Y. | last5 = Ishida | first5 = T. | last6 = Ishii | first6 = Y. | last7 = Endo | first7 = T. | title = Endoscopic features of primary amyloidosis of the stomach. | journal = Endoscopy | volume = 44 Suppl 2 UCTN | issue = | pages = E275-6 | month = | year = 2012 | doi = 10.1055/s-0032-1309750 | PMID = 22814919 | URL = https://www.thieme-connect.com/DOI/DOI?10.1055/s-0032-1309750 }}</ref>

===Microscopic===
Features:
*Lamina propria expanded by amorphous paucicellular material.

Image:
*[http://www.jmedicalcasereports.com/content/6/1/231/figure/F5 Stomach amyloidosis (jmedicalcasereports.com)].<ref name=pmid22863214/>

===Stains===
*[[Congo red stain]] +ve.

==Eosinophilic gastritis==
{{Main|Eosinophilic gastritis}}

==Proton pump inhibitor effect==
*Abbreviated ''PPI effect''.
{{Main|Proton pump inhibitor effect}}

=Gastric polyps=
Similar to colonic polyps - see [[intestinal polyps]].

DDx polyp (similar to colon & rectum):
*Hyperplastic - most common, characterised by abundant elongated foveola + glands.
*[[Hamartomatous polyps|Hamartomatous]] - weriod stuff.
*[[Inflammatory fibroid polyp]] - inflammation, [[myxoid stroma]].
*[[Fundic gland polyp]] - cystic dilation, flat epithelium.
*[[Gastric adenoma]] - polypoid [[gastric dysplasia]].

==Inflammatory fibroid polyp==
{{Main|Inflammatory fibroid polyp}}

==Hyperplastic polyp of the stomach==
{{Main|Hyperplastic polyp of the stomach}}

==Fundic gland polyp==
{{Main|Fundic gland polyp}}

=Neoplastic=
The spectrum from benign to malignant is divided into five:<ref name=pmid10680883>{{Cite journal | last1 = Rugge | first1 = M. | last2 = Correa | first2 = P. | last3 = Dixon | first3 = MF. | last4 = Hattori | first4 = T. | last5 = Leandro | first5 = G. | last6 = Lewin | first6 = K. | last7 = Riddell | first7 = RH. | last8 = Sipponen | first8 = P. | last9 = Watanabe | first9 = H. | title = Gastric dysplasia: the Padova international classification. | journal = Am J Surg Pathol | volume = 24 | issue = 2 | pages = 167-76 | month = Feb | year = 2000 | doi = | PMID = 10680883 }}</ref>
#Benign.
#Indefinite for gastric epithelial dysplasia.
#Low-grade gastric epithelial dysplasia.
#High-grade gastric epithelial dysplasia.
#Gastric carcinoma.

==Gastric dysplasia==
:''Gastric adenoma'' directs here.
*[[AKA]] ''gastric columnar dysplasia''.
===General===
*Lesions that protrude into the lumen ''and'' are macroscopically apparent are known as: ''adenomas''.<ref name=pmid10680883>{{Cite journal | last1 = Rugge | first1 = M. | last2 = Correa | first2 = P. | last3 = Dixon | first3 = MF. | last4 = Hattori | first4 = T. | last5 = Leandro | first5 = G. | last6 = Lewin | first6 = K. | last7 = Riddell | first7 = RH. | last8 = Sipponen | first8 = P. | last9 = Watanabe | first9 = H. | title = Gastric dysplasia: the Padova international classification. | journal = Am J Surg Pathol | volume = 24 | issue = 2 | pages = 167-76 | month = Feb | year = 2000 | doi = | PMID = 10680883 }}</ref>
*Polypoid forms are grouped various ways.<ref name=pmid18384215>{{Cite journal | last1 = Park | first1 = do Y. | last2 = Lauwers | first2 = GY. | title = Gastric polyps: classification and management. | journal = Arch Pathol Lab Med | volume = 132 | issue = 4 | pages = 633-40 | month = Apr | year = 2008 | doi = 10.1043/1543-2165(2008)132[633:GPCAM]2.0.CO;2 | PMID = 18384215 | url=http://www.archivesofpathology.org/doi/full/10.1043/1543-2165(2008)132%5B633:GPCAM%5D2.0.CO;2 }}</ref>

====Grading====
Like in the colon - they are divided into:
*Low grade.
*High grade.

====Subclassification====
One subclassification:<ref>URL: [http://surgpathcriteria.stanford.edu/gitumors/gastric-adenoma/printable.html http://surgpathcriteria.stanford.edu/gitumors/gastric-adenoma/printable.html]. Accessed on: 18 December 2012.</ref>
*Intestinal: goblet cells or [[Paneth cell]]s.
**Not associated with FAP.
*Gastric: foveolar epithelium.
**Associated with [[familial adenomatous polyposis]] (FAP).

===Microscopic===
*Histologic criteria similar to columnar dysplasia in the [[esophagus]].
**The threshold is much lower than in the colon and rectum.

====Foveolar type====
Features:
*Hyperchromasia at the surface - '''key feature'''.
*Cytoplasm with (shortened) champagne flute-like luminal aspect (apical mucin caps).
*Nuclear changes:
**Hyperchromasia.
**Enlargement.
*No intestinal metaplasia.

DDx:
*[[Gastric carcinoma]].
*[[Reactive changes]].

====Intestinal type====
Features - intestinal:
*[[Intestinal metaplasia of the stomach|Intestinal metaplasia]].
*Hyperchromasia of cytoplasm.
*Nuclear changes:
**Loss of nuclear polarity.
**Increased [[NC ratio]].
**Elongation of nucleus and pseudostratification.

DDx:
*[[Gastric carcinoma]].
*[[Reactive changes]].
*[[Intestinal metaplasia of the stomach|Intestinal metaplasia]].

=====Images=====
<gallery>
Image:Gastric_adenoma_(1).jpg | Gastric adenoma. (WC/KGH)
Image:Gastric_adenoma_(2).jpg | Gastric adenoma. (WC/KGH)
</gallery>
www:
*[http://www.sciencedirect.com/science/article/pii/S1756231710001878 Gastric polyps - several images (sciencedirect.com)].
*[http://www.archivesofpathology.org/doi/pdf/10.1043/1543-2165%282008%29132%5B633%3AGPCAM%5D2.0.CO%3B2 Gastric polyps - several images (achivesofpathology.org)].

====Grading====
=====Low-grade gastric dysplasia=====
Features:
*Nuclear changes:
**Nuclear crowding/pseudostratification with hyperchromasia.
**Elongation of nuclei (cigar-shaped nuclei).
**Nuclear stratification intact; nuclei close to the basement membrane.
*Architecture:
**Focal irregularities in the glandular contours.

Negatives:
*No desmoplasia.
*No necrosis.
*No surface maturation.

DDx:
*Indefinite for dysplasia.
*High-grade gastric columnar dysplasia - see below.
**The threshold is much lower than in the colon and rectum!

Images:
*[http://path.upmc.edu/cases/case431.html Low-grade gastric columnar dysplasia - several images (upmc.edu)].
*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3204467/figure/F4/ Gastric low-grade dysplasia (nih.gov)].<ref name=pmid22076218>{{Cite journal | last1 = Kushima | first1 = R. | last2 = Kim | first2 = KM. | title = Interobserver Variation in the Diagnosis of Gastric Epithelial Dysplasia and Carcinoma between Two Pathologists in Japan and Korea. | journal = J Gastric Cancer | volume = 11 | issue = 3 | pages = 141-5 | month = Sep | year = 2011 | doi = 10.5230/jgc.2011.11.3.141 | PMID = 22076218 }}</ref>
=====High-grade gastric dysplasia=====
Features:
*Nuclear changes:
**Round hyperchromatic nuclei.
**Loss of normal nuclear stratification.
*Architecture:
**Irregularities in the glandular contours.
**Back-to-back glands.
**+/-Cribriforming of the glands.
**+/-Necrosis.

Negatives:
*No [[desmoplasia]].

DDx:
*Low-grade gastric columnar dysplasia.
*[[Gastric adenocarcinoma]].

=====Images=====
<gallery>
Image:High_grade_gastric_dysplasia_-_low_mag.jpg | High grade gastric dysplasia - low mag. (WC/Nephron)
Image:High_grade_gastric_dysplasia_-_very_high_mag.jpg | High grade gastric dysplasia - very high mag. (WC/Nephron)
</gallery>
www:
*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3404600/figure/F8/ Gastric high-grade dysplasia - probably (nih.gov)].<ref name=pmid22188910>{{Cite journal | last1 = Correa | first1 = P. | last2 = Piazuelo | first2 = MB. | title = The gastric precancerous cascade. | journal = J Dig Dis | volume = 13 | issue = 1 | pages = 2-9 | month = Jan | year = 2012 | doi = 10.1111/j.1751-2980.2011.00550.x | PMID = 22188910 }}</ref>
*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3204467/figure/F7/ Gastric high-grade dysplasia - probably (nih.gov)].
*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3204467/figure/F6/ Gastric high-grade dysplasia (nih.gov)].<ref name=pmid22076218/>

===Sign out===
====Indefinite for dypslasia====
<pre>
STOMACH, ANTRUM, BIOPSIES:
- ANTRAL-TYPE MUCOSA INDEFINITE FOR DYSPLASIA WITH MODERATE CHRONIC INFLAMMATION.
- EXTENSIVE INTESTINAL METAPLASIA.
- NEGATIVE FOR HELICOBACTER-LIKE ORGANSIMS.
- NEGATIVE FOR MALIGNANCY.
</pre>

====Intestinal type====
<pre>
STOMACH, ANTRUM, BIOPSIES:
- ANTRAL-TYPE MUCOSA WITH FOCUS OF LOW-GRADE DYSPLASIA (INTESTINAL TYPE).
- EXTENSIVE INTESTINAL METAPLASIA.
- MODERATE CHRONIC INFLAMMATION.
- NEGATIVE FOR HELICOBACTER-LIKE ORGANSIMS.
- NEGATIVE FOR MALIGNANCY.
</pre>

====Foveolar type====
<pre>
STOMACH POLYP, EXCISION:
- ADENOMATOUS POLYP, FOVEOLAR TYPE.
- NEGATIVE FOR HIGH-GRADE DYSPLASIA.
- NEGATIVE FOR HELICOBACTER-LIKE ORGANISMS.
</pre>

====Foveolar type with high-grade dysplasia====
<pre>
STOMACH POLYP, EXCISION:
- LARGE ADENOMATOUS POLYP (FOVEOLAR TYPE) WITH HIGH-GRADE DYSPLASIA.
- NEGATIVE FOR MALIGNANCY.
</pre>

==Gastric neuroendocrine tumour==
*[[AKA]] ''neuroendocrine tumour of the stomach''.
===General===
*Behaviour dependent on the subtype.
*Uncommon.

====Overview of subtypes====
Divided into four types:<ref>URL: [http://www.cap.org/apps/docs/committees/cancer/cancer_protocols/2011/StomachNET_11protocol.pdf http://www.cap.org/apps/docs/committees/cancer/cancer_protocols/2011/StomachNET_11protocol.pdf]. Accessed on: 29 March 2012.</ref>
{| class="wikitable sortable"
!Tumour type
!Relative prevalence
!Multifocality
!Tumour size
!Typical location
!Clinical
!Other
!Histology
|-
|Type 1
| ~75%
| yes
| small (5-10 mm)
| body
| benign typically, female:male ~ 4:1, 50-60 years
| chronic atrophic gastritis - usu. autoimmune
| WDNET, WDNEC
|-
|Type 2
| rare
| yes
| small ~15 mm
| body
| aggressive, ~50 years old
| assoc. [[MEN I]], hyperchlorhydia
| WDNEC, WDNET
|-
|Type 3
| 10-15%
| no
| small and large
| variable location
| aggressive if >2.0 cm, males > females
| normal gastrin levels
| WDNET
|-
|Type 4
| extremely rare
| no
| large
| variable location
| aggressive (mets usu. at time of Dx), males > females
| elevated gastrin d/t parietal cell dysfunction
| PDNEC
|-
|}
Notes:
*WDNET = well-differentiated neuroendocrine tumour.
*WDNEC = well-differentiated neuroendocrine carcinoma.
*PDNEC = poorly-differentiated neuroendocrine carinoma.

===Microscopic===
:''See [[neuroendocrine tumours]]''

=Neoplastic rare=
==Gastric calcifying fibrous tumour==
{{Main|Calcifying fibrous tumour}}

=Gastric cancer=
*[[Gastrointestinal stromal tumour]] (GIST).
*[[Gastric adenocarcinoma]].
*[[MALT lymphoma]].

==Gastric lymphoma==
{{main|MALT lymphoma}}
===General===
*Associated with helicobacter infection.<ref name=pmid19273142>{{Cite journal | last1 = Mbulaiteye | first1 = SM. | last2 = Hisada | first2 = M. | last3 = El-Omar | first3 = EM. | title = Helicobacter Pylori associated global gastric cancer burden. | journal = Front Biosci | volume = 14 | issue = | pages = 1490-504 | month = | year = 2009 | doi = | PMID = 19273142 }}
</ref>
*Usually ''MALT lymphoma'' (mucosa-associated lymphoid tissue lymphoma).

===Microscopic===
Features:
*Sheets of lymphoid cells.
*"[[Lymphoepithelial lesion]]" - gastric crypts invaded by a monomorphous population of lymphocytes.<ref>Bailey, D. 6 August 2010.</ref>
**Features:
**# Cluster of lymphocytes - three cells or more - '''key feature'''.
**#* Single lymphocytes don't count.
**# Clearing around the lymphocyte cluster.
**Associated with MALT lymphoma;<ref name=pmid1452124>{{Cite journal | last1 = Papadaki | first1 = L. | last2 = Wotherspoon | first2 = AC. | last3 = Isaacson | first3 = PG. | title = The lymphoepithelial lesion of gastric low-grade B-cell lymphoma of mucosa-associated lymphoid tissue (MALT): an ultrastructural study. | journal = Histopathology | volume = 21 | issue = 5 | pages = 415-21 | month = Nov | year = 1992 | doi = | PMID = 1452124 }}</ref> however, not specific.

DDx:
*Reactive lymphoid hyperplasia.
*[[Syphilis]].<ref name=pmid20021615>{{Cite journal | last1 = Kim | first1 = K. | last2 = Kim | first2 = EJ. | last3 = Kim | first3 = MJ. | last4 = Song | first4 = HJ. | last5 = Lee | first5 = YS. | last6 = Jung | first6 = KW. | last7 = Yu | first7 = E. | title = Clinicopathological features of syphilitic gastritis in Korean patients. | journal = Pathol Int | volume = 59 | issue = 12 | pages = 884-9 | month = Dec | year = 2009 | doi = 10.1111/j.1440-1827.2009.02462.x | PMID = 20021615 }}</ref><ref name=pmid7661178>{{Cite journal | last1 = Long | first1 = BW. | last2 = Johnston | first2 = JH. | last3 = Wetzel | first3 = W. | last4 = Flowers | first4 = RH. | last5 = Haick | first5 = A. | title = Gastric syphilis: endoscopic and histological features mimicking lymphoma. | journal = Am J Gastroenterol | volume = 90 | issue = 9 | pages = 1504-7 | month = Sep | year = 1995 | doi = | PMID = 7661178 }}</ref>

===IHC===
*Panker -- most useful.

Others:
*CD3 (T cells) - scatter positivity.
*[[CD20]] (B cells) +ve.
*CD138 (plasma cells).
*kappa, lambda -- often one is predominant, suggesting clonality.
*BCL2 +ve.

===Treatment===
*Triple therapy (two antibiotics, proton pump inhibitor (PPI)).<ref name=pmid19532131>{{Cite journal | last1 = Zullo | first1 = A. | last2 = Hassan | first2 = C. | last3 = Andriani | first3 = A. | last4 = Cristofari | first4 = F. | last5 = De Francesco | first5 = V. | last6 = Ierardi | first6 = E. | last7 = Tomao | first7 = S. | last8 = Morini | first8 = S. | last9 = Vaira | first9 = D. | title = Eradication therapy for Helicobacter pylori in patients with gastric MALT lymphoma: a pooled data analysis. | journal = Am J Gastroenterol | volume = 104 | issue = 8 | pages = 1932-7; quiz 1938 | month = Aug | year = 2009 | doi = 10.1038/ajg.2009.314 | PMID = 19532131 }}</ref>
*Surgery - if triple therapy fails.

Review paper: PMID 16950858.

==Hereditary gastric cancer==
Several syndromes are associated with gastric cancer:<ref>{{Cite journal | last1 = Sereno | first1 = M. | last2 = Aguayo | first2 = C. | last3 = Guillén Ponce | first3 = C. | last4 = Gómez-Raposo | first4 = C. | last5 = Zambrana | first5 = F. | last6 = Gómez-López | first6 = M. | last7 = Casado | first7 = E. | title = Gastric tumours in hereditary cancer syndromes: clinical features, molecular biology and strategies for prevention. | journal = Clin Transl Oncol | volume = 13 | issue = 9 | pages = 599-610 | month = Sep | year = 2011 | doi = | PMID = 21865131 }}</ref>
{| class="wikitable sortable"
! Disease
! Gene
! Histology
! Other
|-
| [[Hereditary diffuse gastric cancer syndrome|Hereditary diffuse gastric cancer (HDGC) syndrome]]
| CDH1 (E-cadherin)<ref>{{OMIM|192090}}</ref>
| diffuse - more specifically [[signet ring cell carcinoma]]
| most important; assoc. [[invasive lobular carcinoma]]<ref name=pmid9537325>{{Cite journal | last1 = Guilford | first1 = P. | last2 = Hopkins | first2 = J. | last3 = Harraway | first3 = J. | last4 = McLeod | first4 = M. | last5 = McLeod | first5 = N. | last6 = Harawira | first6 = P. | last7 = Taite | first7 = H. | last8 = Scoular | first8 = R. | last9 = Miller | first9 = A. | title = E-cadherin germline mutations in familial gastric cancer. | journal = Nature | volume = 392 | issue = 6674 | pages = 402-5 | month = Mar | year = 1998 | doi = 10.1038/32918 | PMID = 9537325 }}</ref>
|-
| [[Lynch syndrome]]
| MSH2, MLH1, others
| ?
| colorectal carcinoma, endometrial carcinoma
|-
| [[Familial adenomatous polyposis]]
| APC
| ?
| adenomatous polyps
|-
| [[Peutz-Jeghers syndrome]]
| STK11
| ?
| stomach hamartomas - not precursor
|-
| [[Li-Fraumeni syndrome]]
| TP53 (p53)
| ?
| [[AKA]] SBLA syndrome = sarcomas, breast, brain, leukemia, laryngeal, lung, adrenocortical carcinoma
|-
| Familial breast and ovarian cancer 2<ref name=omim600185>{{OMIM|600185}}</ref>
| [[BRCA2]]
| ?
| ?
|}

==Gastric carcinoma==
:Includes ''gastric adenocarcinoma''.
{{Main|Gastric carcinoma}}

=See also=
*[[Esophagus]].
*[[Duodenum]].
*[[Granulation tissue]].
*[[Intestinal polyps]].

=References=
{{reflist|2}}

[[Category:Gastrointestinal pathology]]

Disordered proliferative endometrium

2019-02-13T12:41:41Z

Alessandro: /* General */

{{ Infobox diagnosis
| Name = {{PAGENAME}}
| Image = Disordered proliferative endometrium -- low mag.jpg
| Width =
| Caption = Disordered proliferative endometrium. [[H&E stain]].
| Synonyms =
| Micro = proliferative endometrial glands (pseudostratified nuclei + mitoses) with focally abnormal glands (glands >2x normal size; irregular shape -- typically with inflection points; >4 glands involved (dilated)), +/-stromal condensation, gland-to-stromal ratio normal, not within an endometrial polyp
| Subtypes =
| LMDDx = [[proliferative phase endometrium]],[[simple endometrial hyperplasia]], [[benign endometrial polyp]]
| Stains =
| IHC =
| EM =
| Molecular =
| IF =
| Gross =
| Grossing =
| Site = [[endometrium]]
| Assdx =
| Syndromes =
| Clinicalhx =
| Signs =
| Symptoms =
| Prevalence =
| Bloodwork =
| Rads =
| Endoscopy =
| Prognosis = benign
| Other =
| ClinDDx =
| Tx = followup - re-biopsy
}}
'''Disordered proliferative endometrium''', abbreviated '''DPE''', is an abnormal [[endometrium|endometrial]] finding with some features of [[simple endometrial hyperplasia]].

==General==
*Association: anovulation.
*Benign - can be grouped with ''normal''.<ref name=pmid18580308>{{Cite journal | last1 = Sherman | first1 = ME. | last2 = Ronnett | first2 = BM. | last3 = Ioffe | first3 = OB. | last4 = Richesson | first4 = DA. | last5 = Rush | first5 = BB. | last6 = Glass | first6 = AG. | last7 = Chatterjee | first7 = N. | last8 = Duggan | first8 = MA. | last9 = Lacey | first9 = JV. | title = Reproducibility of biopsy diagnoses of endometrial hyperplasia: evidence supporting a simplified classification. | journal = Int J Gynecol Pathol | volume = 27 | issue = 3 | pages = 318-25 | month = Jul | year = 2008 | doi = 10.1097/PGP.0b013e3181659167 | PMID = 18580308 }}</ref>

Treatment:
*Progesterone<ref name=pmid16873562>{{Cite journal | last1 = McCluggage | first1 = WG. | title = My approach to the interpretation of endometrial biopsies and curettings. | journal = J Clin Pathol | volume = 59 | issue = 8 | pages = 801-12 | month = Aug | year = 2006 | doi = 10.1136/jcp.2005.029702 | PMID = 16873562 }}</ref> versus observation.<ref name=pmid17090792>{{Cite journal | last1 = Ely | first1 = JW. | last2 = Kennedy | first2 = CM. | last3 = Clark | first3 = EC. | last4 = Bowdler | first4 = NC. | title = Abnormal uterine bleeding: a management algorithm. | journal = J Am Board Fam Med | volume = 19 | issue = 6 | pages = 590-602 | month = | year = | doi = | PMID = 17090792 | url = http://www.jabfm.org/content/19/6/590.full }}</ref>

Image:
*[http://www.jabfm.org/content/19/6/590/F8.expansion.html Treatment algorithm based on endometrial biopsy results (jabfm.org)].<ref name=pmid17090792/>

==Microscopic==
Features:<ref name=Ref_PBoD1080>{{Ref PBoD|1080 and 1082}}</ref>
*Proliferative type endometrium with:
**Cystic dilation of glands focally that do not have (glandular) secretions - '''key feature'''.
***Glands >2x normal size - usually 3-4x normal.
***Irregular shape, e.g. gland contour has inflection points.
***Greater than four glands involved (dilated).
*+/-Stromal condensation -- balls of stromal tissue, aka "blue balls" (due to breakdown of endometrium).

Notes:
*Dilated glands often have tubal metaplasia.{{fact}}
*Eosinophilic syncytial metaplasia - common.
**Features: abundant eosinophilic cytoplasm, mild nuclear atypia +/-loss of nuclear stratification, no mitoses).

DDx:
*[[Proliferative phase endometrium]].
**Glands: straight, tubular, tall pseudostratified columnar cells, mitotic figures, no vacuolation, no mucus secretion, abundant mitoses.
**Stroma: cellular, stroma (spindle cells), mitoses.
*[[Simple endometrial hyperplasia]] without atypia - architectural atypia diffuse.
*[[Benign endometrial polyp]] - may have gland dilation.
*[[Anovulatory endometrium]] - some consider this a synonym, see ''[[relation to disordered proliferative endometrium]]''.

===Images===
<gallery>
Image: Disordered proliferative endometrium -- low mag.jpg | DPE - low mag.
Image: Disordered proliferative endometrium -- intermed mag.jpg | DPE - intermed. mag.
Image: Disordered proliferative endometrium - alt -- intermed mag.jpg | DPE - intermed. mag.
Image: Disordered proliferative endometrium -- high mag.jpg | DPE - high mag.
Image: Disordered proliferative endometrium - alt -- high mag.jpg | DPE - high mag.
</gallery>
<gallery>
Image:Endometrial_stromal_condensation_high_mag.jpg | Endometrial stromal condensation - high mag. (WC/Nephron)
</gallery>
www:
*[http://www.sciencedirect.com/science/article/pii/S0740257010000997#fig15 DPE (sciencedirect.com)].
*[http://www.sciencedirect.com/science/article/pii/S0740257010000997#fig18 DPE (sciencedirect.com)].
*[http://www.glowm.com/resources/glowm/uploads/1225247516_03-50291-007_small.jpg DPE (glowm.com)].<ref name=glowm>URL: [http://www.glowm.com/index.html?p=glowm.cml/section_view&articleid=235 http://www.glowm.com/index.html?p=glowm.cml/section_view&articleid=235]. Accessed on: 11 December 2012.</ref>
*[http://www.hsc.stonybrook.edu/gyn-atlas/UT3431B.htm DPE (stonybrook.edu)].

==Sign out==
<pre>
ENDOMETRIUM, BIOPSY:
- DISORDERED PROLIFERATIVE ENDOMETRIUM.
</pre>

====With endocervix====
<pre>
ENDOMETRIUM, BIOPSY:
- DISORDERED PROLIFERATIVE ENDOMETRIUM.
- BENIGN ENDOCERVICAL MUCOSA.
</pre>

====Waffle a bit====
<pre>
ENDOMETRIUM, BIOPSY:
- COMPATIBLE WITH DISORDERED PROLIFERATIVE ENDOMETRIUM (FRAGMENTS OF PROLIFERATIVE
ENDOMETRIUM WITH EVIDENCE OF SHEDDING AND VERY RARE GLAND DILATION).
- VERY SCANT STRIPPED ENDOCERVICAL EPITHELIUM WITHOUT APPARENT PATHOLOGY.
- NEGATIVE FOR ENDOMETRIAL HYPERPLASIA.
- NEGATIVE FOR MALIGNANCY.
</pre>

<pre>
ENDOMETRIUM, CURETTAGE:
- PROLIFERATIVE ENDOMETRIUM, FOCALLY WITH GLAND DILATION AND SMALL BLOOD
VESSELS, SEE COMMENT.
- NEGATIVE FOR HYPERPLASIA AND NEGATIVE FOR MALIGNANCY.

COMMENT:
A fibrotic stroma is not present. The findings may represent a remnant of the previously
excised endometrial polyp or disordered proliferative endometrium. Follow-up is suggested.
</pre>

===Micro===
The sections show a well-sampled endometrium. Mitotic figures are identified within the
glands and stroma. Irregular, moderately enlarged glands are seen (only) in one of several
fragments; most of the endometrial glands are round, regular and small.

No stromal condensation is apparent. No secretions are in the glands.

There are no back-to-back glands. No nuclear atypia is apparent. No thick-walled blood
vessels are apparent.

==See also==
*[[Endometrium]].
*[[Simple endometrial hyperplasia]].
*[[Waffle diagnosis]].

==References==
{{Reflist|2}}

[[Category:Endometrium]]
[[Category:Diagnosis]]

Secretory phase endometrium

2019-02-13T12:37:53Z

Alessandro: /* Micro */

{{ Infobox diagnosis
| Name = {{PAGENAME}}
| Image = Secretory phase endometrium -- intermed mag.jpg
| Width =
| Caption = Secretory phase. [[H&E stain]].
| Micro = dependent on day post-ovulation - see microscopic
| Subtypes =
| LMDDx = [[endometrial hyperplasia with secretory changes]], [[endometrium with hormonal changes]],[[proliferative phase endometrium]]
| Stains =
| IHC =
| EM =
| Molecular =
| IF =
| Gross =
| Grossing =
| Site = [[endometrium]]
| Assdx =
| Syndromes =
| Clinicalhx =
| Signs =
| Symptoms =
| Prevalence =
| Bloodwork =
| Rads =
| Endoscopy =
| Prognosis =
| Other = normal finding
| ClinDDx =
}}
'''Secretory phase endometrium''', abbreviated '''SPE''', is a common diagnosis in [[endometrium|endometrial]] specimens.

==General==
*Secretory phase = luteal phase.
**Gynecologists prefer the ovarian descriptor, i.e. ''luteal phase''; pathologists go by what they see, i.e. ''Secretions'' in the (endometrial) glands.

==Gross==
*Thickened endometrium.

==Microscopic==
===Early secretory phase===
Features - post-ovulatory day 1-5:<ref name=Ref_DCHH237>{{Ref DCHH|237}}</ref>
*Glands: secretory vacuoles.
**First basal to the epithelial nuclei (infranuclear vacuoles).
**Then apical to the epithelial nuclei (supranuclear vacuoles).
*Mitoses may be present - common when vacuoles are subnuclear.

===Mid secretory phase===
Features - post-ovulatory day 6-8:<ref name=Ref_DCHH237>{{Ref DCHH|237}}</ref>
*Glands: Mucus in glands.
*Stroma: Edema (empty space around the glands).

===Late secretory phase===
Features - post-ovulatory day 9-12:<ref name=Ref_DCHH237>{{Ref DCHH|237}}</ref>
*Stroma:
**Spiral arterioles.
**Predecidual changes -- mnemonic ''NEW'':
**#Nucleus central.
**#Eosinophilic cytoplasm '''key feature''' (may be subtle to the novice).
**#Well-defined cell borders.

===Premenstrual===
*Stroma: [[neutrophil]]s, scattered lymphocytes, stromal balls ("blue balls"); "stromal condensation".
*Glands: [[apoptosis]] at the base of the gland.<ref>Colgan T. 22 June 2009.</ref>

Notes:
*Stromal condensation (stromal balls) - premenstrual - stromal cells tightly packed together; nuclei molded together like in small cell tumours.<ref>GAG. 6 Oct 2009.</ref>
*Gland-to-stroma ratio is increased in late secretory phase and menstruation.<ref>URL: [http://www.pathologyoutlines.com/topic/uteruspatternapproach.html http://www.pathologyoutlines.com/topic/uteruspatternapproach.html]. Accessed on: 6 December 2012.</ref>
*Endocervical epithelium (ECE) has a morphology similar to the epithelium of secretory phase endometrium (SPE):
**ECE - grey foamy appearing cytoplasm.
**SPE - eosinophilic cytoplasm.
***Most useful feature to differentiate ECE and SPE is the accompanying stroma.

DDx:
*[[Endometrial hyperplasia with secretory changes]].
*[[Endometrium with hormonal changes]].
*[[Proliferative phase endometrium]] - may have some changes of secretory endometrium; <50% of glands have subnuclear vacuoles ''or'' <50% of cells in the glands have subnuclear vacuoles.<ref name=Ref_EMB14>{{Ref EMB|14}}</ref>

===Images===
<gallery>
Image: Early secretory phase endometrium -- intermed mag.jpg | Early SPE - intermed. mag. (WC)
Image: Early secretory phase endometrium -- high mag.jpg | Early SPE - high mag. (WC)
Image: Early secretory phase endometrium -- very high mag.jpg | Early SPE - very high mag. (WC)
</gallery>
<gallery>
Image: Secretory phase endometrium -- low mag.jpg | Late SPE - low mag. (WC)
Image: Secretory phase endometrium -- intermed mag.jpg | Late SPE - intermed. mag. (WC)
Image: Secretory phase endometrium -- high mag.jpg | Late SPE - high mag. (WC)
</gallery>
<gallery>
Image:Endometrium_Secretory-Type_Endometrium_10x1.JPG | Early secretory phase endometrium. (WC)
Image:Endometrium_Secretory_20x1.jpg | Early secretory phase endometrium. (WC)
Image:Endometrial_stromal_condensation_high_mag.jpg | Endometrial stromal condensation. (WC/Nephron)
</gallery>

==Sign out==
<pre>
ENDOMETRIUM, BIOPSY:
- SECRETORY PHASE ENDOMETRIUM.
</pre>

<pre>
ENDOMETRIUM, ASPIRATION:
- SECRETORY PHASE ENDOMETRIUM.
</pre>

<pre>
ENDOMETRIUM, CURETTAGE:
- SECRETORY PHASE ENDOMETRIUM.
</pre>

<pre>
ENDOMETRIUM, BIOPSY:
- SECRETORY PHASE ENDOMETRIUM, EARLY.
</pre>
===With additional stuff===
<pre>
ENDOMETRIUM, BIOPSY:
- SECRETORY PHASE ENDOMETRIUM.
- SCANT ENDOCERVICAL MUCOSA WITHIN NORMAL LIMITS.
</pre>

<pre>
ENDOMETRIUM, BIOPSY:
- SECRETORY PHASE ENDOMETRIUM.
- ENDOCERVICAL MUCOSA AND STRIPPED ENDOCERVICAL EPITHELIUM WITHIN NORMAL LIMITS.
</pre>

<pre>
ENDOMETRIUM, BIOPSY:
- SECRETORY PHASE ENDOMETRIUM.
- BENIGN SUPERFICIAL EXOCERVICAL EPITHELIUM.
- SCANT BENIGN ENDOCERVICAL EPITHELIUM.
</pre>

===Evidence of shedding===
<pre>
ENDOMETRIUM, CURETTAGE:
- SECRETORY PHASE ENDOMETRIUM WITH FINDINGS SUGGESTIVE OF SHEDDING (EPITHELIAL
APOPTOSIS, INFLAMMATORY CELLS - ESPECIALLY NEUTROPHILS).
- BENIGN EXOCERVICAL AND ENDOCERVICAL MUCOSA.
</pre>

===Micro===
The sections show endometrium with a normal gland-to-stroma ratio. The glands are mildly dilated, tortuous and have mucus within them. The glandular epithelium is simple and non-pseudostratified. The stroma is edematous and has a decidual reaction. No mitotic activity is apparent.

==See also==
*[[Endometrium]].

==References==
{{Reflist|2}}

[[Category:Diagnosis]]
[[Category:Endometrium]]

Suture material

2019-02-11T13:17:32Z

Alessandro: /* Microscopic */

'''Suture material''' is occasionally seen under the [[microscope]]. It is usually easy to identified and typically polarizes.

==General==
*Suture are often used to orient a specimen<ref name=pmid23287819>{{Cite journal | last1 = Volleamere | first1 = AJ. | last2 = Kirwan | first2 = CC. | title = National survey of breast cancer specimen orientation marking systems. | journal = Eur J Surg Oncol | volume = 39 | issue = 3 | pages = 255-9 | month = Mar | year = 2013 | doi = 10.1016/j.ejso.2012.12.008 | PMID = 23287819 }}</ref> and/or mark the true [[surgical margin]].<ref name=pmid7544556>{{Cite journal | last1 = Seitz | first1 = SE. | last2 = Foley | first2 = GL. | last3 = Marretta | first3 = SM. | title = Evaluation of marking materials for cutaneous surgical margins. | journal = Am J Vet Res | volume = 56 | issue = 6 | pages = 826-33 | month = Jun | year = 1995 | doi = | PMID = 7544556 }}</ref>

==Microscopic==
Features:
*Glassy appearance - sharply circumscribed.
*+/-Tearing surrounding tissue.
*+/-Foreign body-type [[granuloma]]s with multinucleated giant cells.
**Seen only if the suture has been in place for at least several days.

===Images===
<gallery>
Image:Solitary_fibrous_tumour_low_mag.jpg | Suture material adjacent to a [[solitary fibrous tumour|SFT]].
Image:Suture_micrograph.jpg | Suture material.
</gallery>

==See also==
*[[Histology artifacts]].
*[[Foreign material]].
*[[Granuloma]].

==References==
{{Reflist|2}}

[[Category:Basics]]

Pathology links

2019-02-10T22:20:05Z

Alessandro: /* Tests/Quizes */

[[Image:Broad_chain_closeup.jpg|thumb|right|325px|Don't feel chained... here are links to other sites.]]
The following is a collection of '''pathology links'''.

==Histology==
*[http://www.lab.anhb.uwa.edu.au/mb140/ Blue histology (uwa.edu.au)] - a very good site for histology.
*[http://peir.path.uab.edu/wiki/Histologic Pathology Education Instructional Resource - Histologic (path.uab.edu)] - an introduction to histology with good figures.

==Cytology==
*[http://www.cytologystuff.com/ (cytologystuff.com)] - Cytology images, quizzes, and teaching site.
*[http://www.eurocytology.eu/en/course/3/virtualslides (eurocytology.eu)] - Cervical Cytology Virtual Slides.
*[http://www.cytology-iac.org/educational-resources/virtual-slide-library (ctology-iac.org)] Virtual Slide Library - The International Academy of Cytology.

==General - pathology==
*[http://www.pathologyoutlines.com/ Pathology Outlines] - a good general resource if you have a good handle on the basics - though may be frustrating to navigate.
*[http://pathlabmed.typepad.com/ The Daily Sign-Out (pathlabmed.typepad.com)].
*[http://www.pathologystudent.com/ Pathology Student (pathologystudent.com)] - advertisement free pathology information.
*[http://www.pathguy.com/ The Pathology Guy (pathguy.com)].
*[http://www.pathologynotes.com/ Pathology Notes (pathologynotes.com)].
*[http://granuloma.homestead.com/ Atlas of Granulomatous Diseases by Yale Rosen (granuloma.homstead.com)].
*[http://commons.wikimedia.org/wiki/Category:Images_from_Department_of_Pathology,_Calicut_Medical_College Calicut Medical College - Department of Pathology (wikimedia.org)].
*[http://medicalschoolpathology.com/ Medical School Pathology (medicalschoolpathology.com)] - a full pathology course by Dr. John Minarcik.
*[http://pathology911.com/ Pathology 911 (pathology911.com)] - has some nice [http://pathology911.com/pathosnap/ pathology cases].
*[http://drdoubleb.com/checklists/ Tumor Automatized Reporting Systems (drdoubleb.com/checklists/)].

==Molecular pathology of tumours==
*[http://atlasgeneticsoncology.org/ Atlas of Genetics and Cytogenetics in Oncology and Haematology (atlasgeneticsoncology.org)].

==Interesting pathologists==
*[http://web2.airmail.net/uthman/ Ed Uthman (airmail.net)].

==Tests/Quizzes==
*[http://library.med.utah.edu/WebPath/EXAM/IMGQUIZ/quizsidx.html Quizzes with images (med.utah.edu)] - nice small set of images.
*[http://path.upmc.edu/cases/ Online case studies (path.upmc.edu)] - a large set of really nice cases with, unfortunately, mostly crappy low resolution images.
*[http://www.pathologypics.com/FlashCards.aspx Flash cards (pathologypics.com)] - a quiz.
*[http://apps.pathology.jhu.edu/sp Cases at Johns Hopkins (jhu.edu)] - recommended.

===Oklahoma===
*[http://moon.ouhsc.edu/kfung/jty1/opaq/Command/PQ-Welcome-M.htm Pathology quizzes (ouhsc.edu)] - a set of quizzes.
*[http://moon.ouhsc.edu/kfung/jty1/CytoLearn/CytoQuiz/CQ-001-M.htm Cytopathology (ouhsc.edu)].

===India===
*[http://www.histopathology-india.net/PathQuiz.htm A series of surgical pathology cases (histopathology-india.net)] - this site unfortunately has low resolution images.
*[http://www.apconquiz.com/ More Indian quizes (apconquiz.com)].

==Autopsy==
*[http://www.le.ac.uk/pa/teach/va/welcome.html The virtual autopsy (le.ac.uk)] - a set of cases with descriptions of the findings where one is challenged to find the cause of death.

==Staining==
*[http://library.med.utah.edu/WebPath/ Internet Pathology Laboratory of Medical Education (med.utah.edu)].
**[http://library.med.utah.edu/WebPath/HISTHTML/MANUALS/MANUALS.html Stains manual] - nice description of stains.

*[http://en.wikipedia.org/wiki/Main_Page Wikipedia (wikipedia.org)].
**[http://en.wikipedia.org/wiki/Wikipedia:WikiProject_Medicine/Pathology_task_force Pathology task force].

==Micrograph - collections==
*[http://pathorama.ch/ Micrographs from Switzerland (pathorama.ch)].
*[http://www.pubcan.org/index.php?type=about PubCan (pubcan.org)] - a site with information about tumours sponsored by the World Health Organization - unfortunately difficult to navigate.
*[http://www.pathpedia.com/Education/eAtlas/Cases.aspx eAltas (pathpedia.com)].
*[http://radiology.uchc.edu/eatlas/ eAtlas of Pathology (radiology.uchc.edu)].
*[http://cnup.uropat.org/ European Network of Uropathology - Canadian page (uropat.org)].
**[http://enup.org/image-archive/ ENUP image archive (enup.org)].
*[http://www.fujita-hu.ac.jp/~tsutsumi/index.html Pathology of Infectious Diseases (fujita-hu.ac.jp)].
*[http://peir.path.uab.edu/library/ PEIR - a collection of images from the University of Alabama (peir.path.uab.edu)].
*[http://www.virtualpathology.leeds.ac.uk/ Virtual Pathology at Leeds (leeds.ac.uk)].
*[http://imagebank.hematology.org/ American Society of Hematology Image Bank (imagebank.hematology.org)].

===Flickr===
*[http://www.flickr.com/photos/euthman/sets/72057594114099781/ Ed Uthmans's "Specimens" (flickr.com)].
*[http://www.flickr.com/photos/jian-hua_qiao_md/sets/?&page=1 Jian-Hua Qiao photo collection (flickr.com)].
*[http://www.flickr.com/photos/dramnani/ Ramnai's photostream (flickr.com)] - presumably [http://www.uro.com/physicians/dharam-m-ramnani-md/ Dharam Ramnani (uro.com)].
*[http://www.flickr.com/photos/lunarcaustic/ Lunar caustic (flickr.com)] - high quality images.

===Virtual slide boxes===
*[http://www.path.uiowa.edu/virtualslidebox/nlm_histology/content_index_db.html U of I (uiowa.edu)].
*[http://www.papsociety.org/atlas/displayimage.php?album=38&pos=4 Papanicolaou society (papsociety.org)].
*[http://www.pathxchange.org/ A large virtual slide collection (pathxchange.org)].
*[http://rosaicollection.org/index.cfm Rosai Collection (rosaicollection.org)].
*[https://eliph.klinikum.uni-heidelberg.de/atlas/ Institute of Pathology Heidelberg (eliph.klinikum.uni-heidelberg.de/atlas)].
*[http://www.virtualpathology.leeds.ac.uk/ Virtual Pathology at the University of Leeds (virtualpathology.leeds.ac.uk)].
*[http://cancer.digitalslidearchive.net/ Cancer Digital Slide Archive /Emory University (http://cancer.digitalslidearchive.net/)].
*[https://digitalpathologyassociation.org/whole-slide-imaging-repository/ DPA's Slide Imaging Repository (digitalpathologyassociation.org/whole-slide-imaging-repository)].
*[http://slidetutor.upmc.edu/ Interactive dermpath slides, University of Pittsburgh (slidetutor.upmc.edu)].

==Associations==
*[http://www.dgp-berlin.de/ Deutschen Gesellschaft für Pathologie].
*[http://cap-acp.org/ Canadian Association of Pathologists (CAP)].
**[https://mypathologist.ca/ mypathologist.ca] - a slick web site that explains pathology in simple terms.
*[http://www.uscap.org/ United States and Canadian Academy of Pathology (USCAP)].
**[http://www.cap.org/apps/cap.portal?_nfpb=true&cntvwrPtlt_actionOverride=/portlets/contentViewer/show&_windowLabel=cntvwrPtlt&cntvwrPtlt{actionForm.contentReference}=committees/cancer/cancer_protocols/protocols_index.html&_pageLabel=cntvwr CAP cancer checklists].
*[http://www.cap.org/apps/cap.portal College of American Pathologists (CAP)].
*[http://www.canp.ca/ Canadian Association of Neuropathologists (canp.ca)].
*[https://www.cytopathology.org/ American Society of Cytopathology (ASC)].
*[https://www.digitalpathologyassociation.org/ Digital Pathology Association (DPA)].
*[http://slap-patologia.org/ Latin American Society of Pathology (SLAP)].
*[http://ampatologia.org/ Mexican Association of Pathologists (AMP)].

==Pathology mailing lists==
*[http://www.mailman.srv.ualberta.ca/mailman/listinfo/patho-l Patho-l (ualberta.ca)] - an international mailing list in existence since 1994.

==Other wikis==
{{Main|Wikis}}

==Other==
*[http://www.sharinginhealth.ca/site/about.html Sharing in Health (sharinginhealth.ca)].
*[http://www.cancerview.ca Cancer view Canada (cancerview.ca)] - a collection of information about cancer care in Canada.

==See also==
*[[Pathology books]].
*[[Basics]].

[[Category:Pathology links]]

Prostate gland

2019-02-10T19:21:47Z

Alessandro: added a word for clarity

[[Image:Prostatelead.jpg|thumb|right|200px|The prostate gland and its surrounding structures. (WC/NCI)]]
The '''prostate gland''' adds juice to the sperm. In old men it creates a lot of problems... [[nodular hyperplasia]] (commonly called BPH or [[benign prostatic hyperplasia]]) and cancer (usually adenocarcinoma).

[[Prostate cancer]] is such a big topic it is dealt with in its own article.

The female homologue of the prostate gland is considered to be Skene's gland.<ref name=pmid8522254>{{Cite journal | last1 = Dodson | first1 = MK. | last2 = Cliby | first2 = WA. | last3 = Pettavel | first3 = PP. | last4 = Keeney | first4 = GL. | last5 = Podratz | first5 = KC. | title = Female urethral adenocarcinoma: evidence for more than one tissue of origin? | journal = Gynecol Oncol | volume = 59 | issue = 3 | pages = 352-7 | month = Dec | year = 1995 | doi = 10.1006/gyno.1995.9963 | PMID = 8522254 }}</ref>

=Normal prostate gland=
==Anatomy==
Divided into three zones:<ref name=pmid2456702>{{Cite journal | last1 = McNeal | first1 = JE. | title = Normal histology of the prostate. | journal = Am J Surg Pathol | volume = 12 | issue = 8 | pages = 619-33 | month = Aug | year = 1988 | doi = | PMID = 2456702 }}
</ref>
#Peripheral zone - posterior aspect, palpable with digit.
#*Classic location for [[prostate cancer|cancer]].
#Central zone - considered resistant to disease.
#Transition zone - usual location for [[nodular hyperplasia of the prostate|nodular hyperplasia]].

==Histology==
*Glands have two cell layers (similar to glands in breast).
**Second cell layer may be difficult to see (like in breast).
*Epithelium in glands is "folded" or "tufted".
**Very important - helps to differentiate from Gleason pattern 3.
*Luminal epithelium often clear cytoplasm.
*Single nucleus.

Benign normal:
*Corpora amylacea.
**Round/ovoid-eosinophilic bodies -- with laminations (layered appearance).
**In gland lumina.
**Usually in benign glands - but cannot be used to exclude cancer.<ref name=pmid15309020>{{cite journal |author=Christian JD, Lamm TC, Morrow JF, Bostwick DG |title=Corpora amylacea in adenocarcinoma of the prostate: incidence and histology within needle core biopsies |journal=Mod. Pathol. |volume=18 |issue=1 |pages=36–9 |year=2005 |month=January |pmid= |doi=10.1038/modpathol.3800250 |url=}}</ref>
**Very common.
**These should be differentiated from ''eosinophilic proteinaceous debris'' - which is associated with cancer.

Negatives:
*No nucleoli present (if you see nuclei think: cancer, HGPIN, reactive changes, basal cell hyperplasia).
*No mitoses - these are uncommon... even in high grade prostate cancer.

Notes:
*Tufted epithelium is a strong indicator of benignancy; however two uncommon prostate cancer variants typically have tufted epithelium:
**[[Pseudohyperplastic adenocarcinoma]].
**[[Foamy gland carcinoma]].

====Images====
<gallery>
Image:Corpora_amylacea_low_mag.jpg | Benign prostate with corpora amylacea - low mag. (WC/Nephron)
Image:Corpora_amylacea_high_mag.jpg | Benign prostate with corpora amylacea - high mag. (WC/Nephron)
</gallery>

==IHC of normal prostate==
Normal prostate:
*[[AMACR]] -ve (mark epithelial cells).
*[[CK5/6]] +ve,<ref name=pmid19605815>{{Cite journal | last1 = Trpkov | first1 = K. | last2 = Bartczak-McKay | first2 = J. | last3 = Yilmaz | first3 = A. | title = Usefulness of cytokeratin 5/6 and AMACR applied as double sequential immunostains for diagnostic assessment of problematic prostate specimens. | journal = Am J Clin Pathol | volume = 132 | issue = 2 | pages = 211-20; quiz 307 | month = Aug | year = 2009 | doi = 10.1309/AJCPGFJP83IXZEUR | PMID = 19605815 }}</ref> p63 +ve, HMWCK +ve (mark basal cells).
*PSA ([[prostate-specific antigen]]) +ve, PSAP ([[prostatic-specific acid phosphatase]]) +ve.

==Sign out==
===Staining slightly abnormal - morphology not definitely abnormal===
<pre>
COMMENT:
Very focal AMACR staining is seen; this is interpreted as negative, in the
context of no definite cytologic changes. The basal cells appear to be
preserved in all of the tissue sampled.
</pre>

===Compatible with previous biopsy===
<pre>
COMMENT:
Siderophages are seen in several cores; this is compatible with the history
of a previous biopsy.
</pre>

=Other accessory glands=
==Bulbourethral gland==
*[[AKA]] ''Cowper's gland''.
{{Main|Bulbourethral gland}}

==Seminal vesicles==
{{Main|Seminal vesicles}}

=Specimens=
*[[Prostate core biopsy]] - done transrectal.
*[[Prostate chips]] (from a ''transurethral resection of the prostate'', abbreviated ''TURP'') - usu. done for [[nodular hyperplasia of the prostate gland]]; may be done in the context of obstructing cancer.
*[[Radical prostatectomy]] - includes the [[seminal vesicles]].
*[[Radical cystoprostatectomy]] - includes the [[urinary bladder]] and [[seminal vesicles]].<ref>URL: [http://www.cancer.gov/dictionary?cdrid=446218 http://www.cancer.gov/dictionary?cdrid=446218]. Accessed on: 23 February 2012.</ref>

=Approach=
*Know the common diagnoses well.
*Core biopsies - scan the slides with the 10x objective.

==Common diagnoses==
*Benign.
**[[Atrophy of the prostate|Atrophy]] - may resemble adenocarcinoma - typically not reported.
**[[Adenosis of the prostate|Adenosis]] - may resemble adenocarcinoma - typically not reported.
*[[Prostate adenocarcinoma]].
*[[HGPIN]] (high-grade prostatic intraepithelial neoplasia) - prostate adenocarcinoma precursor lesion.
*[[ASAP]] (atypical small acinar proliferation) - used if you have a few abnormal appearing glands... but can't decide between prostate adenocarcinoma & benign.
*Chronic inflammation.
*Acute inflammation - can result in an elevated PSA and may have prompted the biopsy you're looking at.
*[[Nodular hyperplasia of the prostate]]; [[AKA]] ''benign prostatic hypertrophy'' (BPH).
**Not diagnosed on needle biopsies.
**''BPH'' is technically incorrect -- the process is a hyperplasia.
***Hyperplasia = proliferation of cells, hypertrophy = enlargement of cells.
****How to remember? A. '''P'''rostate... hyper'''P'''lasia.

=Clinical history=
{{Main|Prostate specific antigen}}
*[[PSA]] (serum).
** >10 ng/mL worrisome for prostate cancer.
** Normal is age dependent - increases with age, usu. cut-off ~ 4 ng/mL.
*HIFU = ''High Intensity Focused Ultrasound'' - an ablation procedure for prostate cancer.<ref>URL: [http://www.internationalhifu.com/what-is-hifu-mainmenu-132.html http://www.internationalhifu.com/what-is-hifu-mainmenu-132.html]. Accessed on: 15 June 2010.</ref>

=Benign changes and remnants=
==Adenosis of the prostate gland==
*[[AKA]] ''atypical adenomatous hyperplasia of the prostate gland'' (or ''atypical adenomatous hyperplasia'').
{{Main|Adenosis of the prostate gland}}

==Basal cell hyperplasia of the prostate==
{{Main|Basal cell hyperplasia of the prostate}}

==Atrophy of the prostate==
*[[AKA]] ''atrophy''.
*[[AKA]] ''prostatic atrophy''.
*[[AKA]] ''atrophy of the prostate gland''.
{{Main|Atrophy of the prostate gland}}

==Mesonephric remnant of the prostate gland==
{{Main|Mesonephric remnant of the prostate gland}}

=Benign conditions=
==Prostatic nodular hyperplasia==
*[[AKA]] ''nodular hyperplasia of the prostate''.
*AKA ''benign prostatic hyperplasia'' (abbreviated BPH).
*AKA ''benign prostatic hypertrophy''.
**This is a misnomer. It is ''not'' a hypertrophy.
{{Main|Nodular hyperplasia of the prostate}}

==Acute inflammation of the prostate gland==
{{ Infobox external links
| Name = {{PAGENAME}}
| EHVSC = 10176
| pathprotocols =
| wikipedia =
| pathoutlines =
}}
*[[AKA]] ''prostate gland with acute inflammation''.
===General===
*A may lead to an increase in the PSA and prompt biopsy.

Note:
*"[[Prostatitis]]" is considered a clinical diagnosis.
**Cases are signed out as "acute inflammation".
***Some pathologists do not comment on the presence (or absence) of inflammation.

===Microscopic===
Features:
*[[Neutrophil]]s within the glands, between the epithelial cells ''or'' within the stroma - '''key feature'''.
*+/-Chronic inflammation (lymphocytes) within the surrounding stroma.

DDx:
*[[Prostatic infarction]].

====Image====
<gallery>
Image:Acute_inflammation_of_prostate.jpg| Prostate with acute inflammation. (WC/Nephron)
</gallery>
===Sign out===
<pre>
G. PROSTATE, LEFT LATERAL SUPERIOR, BIOPSY:
- BENIGN PROSTATE TISSUE;
- FOCAL ACUTE INFLAMMATION.
</pre>

<pre>
G. PROSTATE, LEFT LATERAL SUPERIOR, BIOPSY:
- BENIGN PROSTATE TISSUE;
- FOCAL ACUTE AND CHRONIC INFLAMMATION.
</pre>

==Chronic inflammation not otherwise specified==
===General===
*Common.
*Non-specific finding.
*Etiology usually not apparent on histomorphology.

===Microscopic===
Features:
*Lymphocytes within the glands, between the epithelial cells ''or'' within the stroma - '''key feature'''.

Notes:
*Rare scattered lymphocytes are common, especially in the central portion of the gland.
*"Focal" one field with a 2.2 mm diameter involved.

====Image====
<gallery>
Image:Inflammation_of_prostate.jpg | Prostate with chronic inflammation. (WC/Nephron)
</gallery>
===Sign out===
<pre>
G. PROSTATE, LEFT LATERAL SUPERIOR, BIOPSY:
- BENIGN PROSTATE TISSUE;
- FOCAL CHRONIC INFLAMMATION.
</pre>

<pre>
F. PROSTATE, RIGHT MEDIAL MIDZONE, BIOPSY:
- BENIGN PROSTATE TISSUE;
- CHRONIC INFLAMMATION.
</pre>

Note:
*Opinion is divided on whether this finding should be reported.
**Advocates for reporting inflammation say "[i]t is just reporting what you see and may explain the bump in PSA."
**Naysayers opine that "[i]t may provide false assurance that no cancer is present."

==Granulomatous prostatitis==
{{Main|Granulomatous prostatitis}}

==Prostatic infarct==
*[[AKA]] ''prostatic [[infarction]]''.
===General===
*Rare < 0.1% of core biopsies.<ref name=pmid11023099>{{Cite journal | last1 = Milord | first1 = RA. | last2 = Kahane | first2 = H. | last3 = Epstein | first3 = JI. | title = Infarct of the prostate gland: experience on needle biopsy specimens. | journal = Am J Surg Pathol | volume = 24 | issue = 10 | pages = 1378-84 | month = Oct | year = 2000 | doi = | PMID = 11023099 }}</ref>
*Can mimic cancer - [[urothelial carcinoma]].<ref name=pmid11023099/>
*Prostate usually large.

===Microscopic===
Features:
*Classic findings of [[necrosis]]:
**Karyolysis (loss of nuclei), karyorrhexis (frag. of nuclei), pyknosis (small shrunken nuclei).
*+/-Squamous metaplasia of prostate gland epithelium.

Notes:
*Corpora amylacea - help... call it benign.
*Glands maintain normal spacing.

DDx:
*[[Urothelial carcinoma]] with squamous differentiation.

Image:
*[http://www.sciencephoto.com/media/258565/enlarge Prostatic thrombosis (sciencephoto.com)].

=Preneoplastic changes and atypical changes=
==High-grade prostatic intraepithelial neoplasia==
*Abbreviated as ''HGPIN''.
*May be referred to as ''prostatic intraepithelial neoplasia'', abbreviated ''PIN''.
{{Main|High-grade prostatic intraepithelial neoplasia}}

==Atypical small acinar proliferation==
*Abbreviated ''ASAP''.
*[[AKA]] ''suspicious for carcinoma''.<ref>THvdK. 19 June 2010.</ref>
**''ASAP'' is preferred as it does not contain the word ''carcinoma'' and, thus, cannot be misread as ''carcinoma'', i.e. positive for malignancy.
{{Main|Atypical small acinar proliferation}}

=Prostate cancer=
{{Main|Prostate cancer}}
This is a big topic that is dealt with in its own article.

=See also=
*[[Urothelium]].
*[[Genitourinary pathology]].

=References=
{{reflist|2}}

[[Category: Genitourinary pathology]]