EMR

Contents

• MNG• Hashimoto’s Thyroiditis • Graves Disease• Papillary CA Thyroid• Medullary CA Thyroid• Mucinous Cystadenoma• Serous Cystadenoma• Dermoid Cyst• Simple cystic endometrial hyperplasia • Atypical endometrial hyperplasia• Endometrial polyp• Adenomyosis • Leimyoma• Leimyosarcoma• H. mole• Retained products of conception• Dysgerminoma• Cryptorchidism• Fibrocystic Disease• Fibroadenoma• Invasive Ductal CA Breast

Multinodular GoiterMultinodular goiter-

colloid present in follicles, tall columnar cells lining follicles, follicular hyperplasiaDegenerating changes- necrosis, hemorrhage, fibrosis

Case:Diffuse neck swelling, iodine deficient diet, mostly females, resident of hilly areas, pressure symptoms- dysphagia, dyspnea

Hashimoto’s ThyroiditisExtensive infiltration of parenchyma by inflammatory cells (lymphocytes and plasma cells)Atrophic thyroid folliclesNormal low cuboidal epithelium replaced by eosinophilic hurthle cells.

Case:Woman with hypothyroidism, thyroid peroxidase antibodies positive.

Graves’ Disease1. Moth eaten appearance

of colloid2. Crowding and

hypertrophy of tall columnar cells

Case:Woman with exophthalmos, hyperthyroidism symptoms, TSIs positive

Papillary CA thyroidPapillary CA thyroid-

Orphan Annie nuclei, psammoma bodies

Case:H/O radiation to head/neck, mets to cervical lymphnodes

Medullary CA ThyroidPolygonal cells forming nests, follicles and trabeculae.A cellular amyloid deposits derived from altered calcitonin molecules secreted by neoplastic cells.

Case:Male, with familial MEN Syndrome, mets present.

Mucinous Cystadenoma OvaryMucinous cystadenoma ovary

Mucin secreting cystsMucinous pleomorphic cells

Case:U/L pelvic massAbdominal painPseudomyxoma peritoneiiGross specimen, increased mucin production

Serous cystadenoma ovarySerous cystadenoma ovary

Pleomorphic atypical cellsNests of tumor cellsPsammoma bodiesTall columnar cells

Case:B/L ovarian massesGross: smooth glistening surface, septa

Dermoid CystID points:1.Dermal appendages2. Stratified squamous epithelium

Case:Young girl, with pelvic pain, radiological evidence of calcification in pelvic mass

Simple Cystic HyperplasiaID points:1. Dilated endometrial

glands2. Increased gland to stroma

ratio

Case: Woman with excessive

estrogen: PCOD, obesity etc

Atypical Endometrial HyperplasiaID points:1. Distorted endometrial

glands2. Crowding of glands3. Loss of cellular polarity

Case:Woman < 40-50 yrs, obese,

HRT, post-menopausal, vaginal bleeding

Endometrial PolypEndometrial polyp

Endometrium resembling basalis wih small muscular arteriesCystically dilated endometrial glands (finger like projections)

Case:Woman with intermittent vaginal spotting

AdenomyosisID points:1. Endometrial glands in

myometrium2. Reactive hypertrophy of

myometrium

Case:Young female with enlarged

uterus, dysmenorrhea, menorrhagia

LeimyomaLeimyoma

Whorls of smooth muscle fibersSpindle cells

Case:Woman with menorrhagia, increased frequency, multipara

Squamous Cell CA CervixSquamous cell CA cervix

Keratin pearlsFull thickness epithelium involvedNeoplastic fragments in stroma

Case:Young woman, multiple sexual partners, repeated HPV infections, young age at first intercourse, abnormal Pap smear report

LeimyosarcomaLeimyosarcoma

Cigar shaped cellsIncreased mitotic figuresNecrosisHyperchromatic nuclei

Case:Menorrhagia, mets, pelvic adhesions leading to symptoms

H. MoleHyaditiform mole

Swollen villiEdematous avascular stromaMultinucleated syncytiotrophoblasts

Case:Pregnant lady with very high HCG levels, large for date gestation, passage of grape-like clusters

Retained products of conceptionRetained products of conception

Fetal RBCsChorionic villi

Case:Incomplete abortion

DysgerminomaID points:polygonal uniform looking seminoma cells, lymphocytic infiltrateFibrous septa

Case: Young male with hard unilateral testicular mass, localized to the testes.

CryptorchidismCryptorchidism

Interstitial fibrosisThickened tubular basement membrane

Case:Young male with empty scrotal sac

Fibrocystic DiseaseApocrine change in cells lining ducts.Dilation of ducts, normal lining of ducts.

Case:Asymptomatic woman with U/L palpable breast mass.

FibroadenomaFibroadenoma breast-

increased stroma, star-shaped intracanalicular ductsDucts lined by normal cells

Case:Young female, in reproductive age group, cyclical breast pain or increase in mass size, freely mobile mass, increases in size during pregnancy/menstrual cycle

Invasive Ductal CA breastInfiltrating ducts.Ducts lined by single layer of cells.Pleomorphic nuclei.Stroma shows dense desmoplasia.

Case:Woman with palpable breast mass, nipple discharge, peau’d orange appearance of breast, axillary lymphnodes +, mets present.

Invasive CA breastBreast CA-

Increased N/C ratio, pleomorphic, undifferentiated cells

Case:Old woman, with mets, axillary nodes palpable, nipple retraction

KUB

Contents

• Kidney Necrosis• Chronic pyelonephritis• Membranous GN• Crescenteric GN• Glomerulonephritis• Renal Cell CA• Transitional Cell CA Bladder• BPH• Prostate CA

Kidney necrosisAttenuation of epithelial cellsPresence of casts in lumina of tubules and collecting ducts.Interstitial edema.

Case:Patient with ARF, drug induced or shock-induced, DIC

Chronic PyelonephritisHyaline like deposit in glomeruli.Abudant chronic inflammatory cells.

Case:Patient with recurrent kidney infections, UTI, renal scarring, chronic renal failure, TIN.

Membranous GNGlomeruli are large.Proliferation of mesangial cells.Glomerular capillaries show tram track apperance.

Case: Nephrotic Syndrome S/S

Crescenteric GNDeposition of protein like material in Bowman’s space.Proliferation of cells in parietal layer of Bowman’s capsule.

Case:Patient presenting with ARF, with Goodpasture’s, Wegener;s, SLE etc.

Glomerolunephritis

Membranous glomerulonephritis

Thickening of basement membraneNeutrophils

Case:30-50 yr old male with nephrotic syndrome

Focal Segmental Glomerulosclerosis

Some glomeruli/part of glomeruli show sclerosis.Matrix proliferation.Protein depostion.Some glomeruli totally sclerosed.

Case:Nephrotic Syndrome S/S:Hyperlipidemia, lipiduria, proteinurea > 3.5 g/day, children/adults. Not responsive to steroids.

Renal Cell CARenal cell carcinoma

Vacuolated or lipid-laden appearance of cells (clear cells)Scant stromaClear, granular cytoplasmBizarre nuclei with giant cells.

Case:Painless hematuria, flank pain, palpable mass

Transitional Cell CA BladderTransitional cell carcinoma

Transitional cells are arranged in 8-10 layersForm papillae, having fibrovascular core

Case:Old man with painless hematuria, working in naphthylene/rubber industry

Benign Prostatic HyperplasiaBenign prostatatic hyperplasia-

increased fibrous stroma, double layers of cells lining ducts, corpora amylasia

Case:Old man with increased hesitancy, frequency, poor stream and smoothly enlarged prostate on DRE

Prostate CAProstate CA-

single layer of cuboidal cells lining ducts, back to back arrangement of glands

Case:Old man with back pain, mets, urinary frequency, hesitancy, poor stream

RES

Contents

• Nasal Polyp• Nasopharyngeal CA• Laryngitis• Tonsillitis• Pneumonia• Granulomatous inflammation• Bronchoalveolar CA• Small Cell CA• Sq. Cell CA

Nasal PolypNasal polyp

Pseudostratified columnar epitheliumEosinophils and fibroblasts

Case: Patient of allergy, with U/L nasal obstruction

Nasopharyngeal CA

Nasopharyngeal CALarge epithelial cells with indistinct bordersCells with prominent eosinophilic nucleoliLymphocytes surrounding syncytial cells.

Case:Chinese man with nasal obstruction, cranial nerve palsies, enlarged cervical nodes

LaryngitisNeutrophilsCongestionHyperemiaStratified squamous epithelium

Case:High fever, hoarseness of voice

TonsillitisLymphnode lined by stratified squamous epithelium.Proliferation of germinal centers, infiltration of reactive lymphocytes.

Case:Child with sore throat, cervical lymphadenopathy, high grade fever, odynophagia

PneumoniaAlveolar architecture intact. Distended alveolar spacesVascular congestionLeukocytic infiltrate

Case:Patient with cough, sputum, high grade fever, chest pain, crackles

Granulomatous InflammationEpitheloid cellsRim of fibroblastsMultinucleated giant cellsNecrotic center

Case:TB? (caseous necrosis) Sarcoidosis? Cat-Scratch Disease?

Alveolar Cell CA LungAlveolar carcinoma

Atypical columnar epithelial cellsHobnailing of nucleiLining the alveoli projecting towards the lumen, intervening stroma is not infilterated by the tumor.

Case:Non-smoker, usually female, central mass

Small Cell CA LungSmall cell carcinoma of lung/ Oat cell CA

Undifferentiated neoplasm of primitive appearing cellsCells are flat shaped, with scant cytoplasmTheir size is approximately double to that of a lymphocyte.

Case:Paraneoplastic syndrome, ACTH, Growth hormone, ADH high related symptoms

Squamous Cell Ca LungSquamous cell carcinoma of lung

Well-differentiated squamous carcinoma of the lung, shows keratin pearl formation.Cells show atypia and loss of intercellular junctions.

Case:Smoker, male, central mass in chest, late mets to liver, bone, adrenals

GIT

Contents

• Pleomorphic Adenoma (Parotid)• Barret’s esophagus• Sq. Cell CA esophagus• Gastritis• H. Pylori (Chronic gastritis)• Stomach CA (diffuse)• Celiac Disease• Crohn’s Disease• Ulcerative Colitis• Adenomatous Polyp• Colorectal CA• Carcinoid Tumor• Acute appendicitis• Chronic cholecystitis• Cholestatis• Fatty liver• Chronic hepatitis• Cirrhosis• Hepatocellular CA

Pleomorphic adenomaPleomorphic adenoma

CartilageNeoplastic acinusConnective tissue & adipose cellsApparently encapsulated

Case:Patient with swelling over angle of jaw.

Barret’s EsophagusSquamous to columnar (intestinal) metaplasiaGoblet cellsChronic inflammatory cells.

Case:Long standing GERD

Squamous CA esophagusSquamous cell CA esophagus

Keratin pearlsStratified squamous epithelium

Case:Patient of achalasia, with weight loss, dysphagia to solids, cough and formation of tracheo-esopheal fistulae, hemoptysis

GastritisChronic gastritis

Plasma cells with lymphocytesAtrophy of epithelial lining

Case:Patient with retrosternal burning, NSAID use, hyperparathyroidism, steroid use

H. PyloriSpiral rod shaped organism seen in superficial cells of stomach mucosaIntestinal metaplasiaChronic inflammatory cells

Case:Patient not responding to PPI regimen, fecal antigen postive, urease breath test positive, feco-oral transmission

CA Stomach (Diffuse)Signet ring cells permeating mucosa of stomach wallLarge mucin lobes

Case:Long standing peptic ulcer disease, weight loss, anemia, supraclavicular lymphnode (virchow’s node), signs of obstruction, hematemesis, melena

Celiac DiseaseCeliac disease

Absence of microvilliIntraepithelial lymphocytesInflammatory infiltrateFlattening of villiVascular degeneration of epitheliumCrypt hyperplasia

Case:Child with chronic diarrhea, weight loss and intolerance to wheat, rye, barley products

Crohn’s DiseaseCrohn’s disease

Granulomatous inflammationTransmural damageLinear ulcers

Case:Male, melena, fistula formation, mouth ulcers, can involve any part of GIT, mostly ileum

Ulcerative ColitisUlcerative colitis

Mucosal ulcerationInflammatory cells

Crypt abscessesEpithelial metaplasiaDiffuse inflammatory process limited to mucosa and superficial submucosa.

Case:Acutely sick patient, melena, megacolon, joint pains, gallbladder problems, commonly involves colon, increased chances of malignancy

Adenomatous PolypAdenomatous polyp

Epithelial proliferative dysplasiaStalk covered by normal epitheliumNeoplastic epithelium forming branching glands

Case: Pt with melena, family history of colorectal problems, undergoing colonoscopy. May present with symptoms of hypokalemia and hypoalbuminemia.

Colorectal CAColorectal CA (adenocarcinoma of colon)

Signet ring cells invading bowel wallIntracellular mucinNeoplastic glands in muscularis

Case:Old man with anemia, obstruction, melena, altered bowel habits

Carcinoid TumorCarcinoid tumor

Solid nest of monotonous appearing cells with small uniform nucleiCells with pink cytoplasm and round-oval stippled nucleusInfrequent mitoses

Case:Flushing, diarrhea, bronchospasm, mucoid stool

Acute appendicitisAcute appendicitis

Star-shaped lumenSuperficial ulcerationNeutrophils and pus cellsCongested blood vesselsHypertrophied muscles

Case:Patient with tenderness in RIF.

Chronic cholecystitisChronic cholecystitis-

subserosal fibrosis, lymphoplasmacytic infiltrate

Case:Female, forties, fat, flatulence, bloating, fatty meal intolerance

CholestasisAccumulation of bile pigment in liver parenchymaDilated bile canaliculiFoamy appearance (feathery degeneration)Apoptotic bodies visible.

Case:Jaundice, pruritis, elevated ALP, bilirubin

Fatty LiverSmall droplets of fat in hepatocytes.Perivenular and perisinusoidal fibrosis present.

Case:Obese patient with long standing diabetes, metabolic syndrome, alcoholic, hyperlipidemia

Chronic HepatitisChronic hepatitis-

collagen fibers, fibrous tissue inflammatory cells in portal tractsSteatosisLiver architecture preserved

Case:K/C Hep B or C, alcoholic, taking hepatotoxic drugs

CirrhosisCirrhosis

Bridging fibrous septaNodulesTotal disruption of liver architecture

Case:Long standing liver disease, alcoholic, encephalopathy, asterixis, spider angioma, ascites

Hepatocellular CAHepatocellular CA

Dilated sinusoidal spaceMalignant hepatocytes

Case:Patient of chronic liver disease with signs of decompensation and worsening ascites, melena, hematesis, bloody ascites etc.

Bones, Soft Tissue & Skin

Contents

• Osteochondroma• Osteosarcoma• Sq. Cell CA Skin

OsteochondromaOsteochondroma

Hyaline cartilageFibrous perichondrium

Case:Patient with sudden onset of pain in knee due to nerve impingement

OsteosarcomaCoarse lace like pattern of neoplastic bone laid by malignant cells.Large hyperchromatic nuclei of neoplastic cells.

Case:Young boy with painful knee, lung mets, Xray findings of Codman’s triangle, sun burst appearance.

Sq. Cell CA SkinLobules of squamous cells with glassy cytoplasm undergoing keratinization. (keratin pearls)

Case:Man with everted ulcer on lip, face, arm (sun exposed area) or everted ulcer developing in long standing scars (burns etc)

CVS

AtherosclerosisLipid core Fibrous cap of atheromatous plaqueThickening of tunica media

Case:Patient of HTN, IHD with chest pain

HEM

Contents

• Iron deficiency Anemia• Thalessemia• Megaloblastic anemia• Burkitt’s Lymphoma• Hodgkin’s Lymphoma• NHL

Iron Deficiency AnemiaIron deficiency anemia

Microcytic, hypochromic RBCsTarget cells distort into pencil cells

Case:Pregnant female, child with worm infestation, woman with fibroids

ThalessemiaThalessemia

Basophilic stipplingNucleated RBCsMicrocytic, hypochromic RBCs

Case:Child- failure to thrive, multiple transfusion history, hepatosplenomegaly, chipmunk facies, skull showing hair on end appearance on xray, consanguineous marriage

Megaloblastic anemiaMegaloblastic anemia

Hypersegmented nuclei in neutrophilsImmature RBCs and WBCs

Case:Adult woman, with C/O peripheral neuropathy, fatigue, psychiatric disturbances, vegetarian or post-op gastrectomy

Burkitt’s Lymphoma•Intermediate sized lymphocytes with round to oval nucleus•Macrophages with clear cytoplasm (starry sky appearance)

Case:African child with mass/swelling in the jaw or retroperitoneum

Hodgkin’s LymphomaRS cells in a reactive inflammatory background consisting of lymphocytes, eosinophils and granulocytes.

Case:Patient with multiple swelling in neck and axillary region associated with malaisa, night sweats, low grade fever

NHL LymphomaLymphocytes

Case:Patient with malaise, low grade fever, lymphadenopathy, hepatosplenomegaly, in contiguous involvement of lymphnodes.