Tadrous P.J. Diagnostic criteria handbook in histopathology: a surgical pathology vade mecum

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VIN vulval intraepithelial neoplasia

viz. ‘namely’

VMAT-2 vesicular monoamine transporter 2

vMC von Meyenburg Complex(es)

VOD veno-occlusive disease

VSD ventriculoseptal defect

VZV varicella-zoster virus

w.r.t. with respect to

WCC white cell count

WDC Workforce Development

Confederation

WDHA watery diarrhoea, hypokalaemia and

achlorhydria syndrome

WDTC well-differentiated thymic carcinoma

WG Wegener’s Granulomatosis

WHAFFT worrisome histological alterations

following FNA of the thyroid

WHO World Health Organisation

WLE wide local excision

WT1 Wilms’ tumour 1 (gene / Ab)

XL X-linked (heredity)

YST yolk sac tumour

ZE Zollinger-Ellison

ZF zona fasciculata

ZG zona glomerulosa

ZN Ziehl Neelsen

Zn zinc

ZR zona reticularis

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General Bibliography and Suggested Reading

At the end of each chapter the bibliography lists sources for the information in this book and gives

suggestions for further reading. Because some sources have contributed to most chapters, I list them here

rather than repeat them at the end of every chapter:

Fletcher, C.D.M. (ed) (2000) Diagnostic Histopathology of Tumors,2

edn, Churchill Livingstone, London. [3

ed. 2007]

Frisman, D.M., http://www.immunoquery.com/(accessed March 2007)

Mills, S.E., Carter, D., Greenson, J.K., Oberman, H.A., Reuter, V.E. and Stoler, M.H. (eds) (2004) Sternberg’s Diagnostic Surgical Pathology,4

edn, Lippincott Williams & Wilkins, Philadelphia.

MacSween, R.N.M. and Whaley, K. (eds) (1992) Muir’s Textbook of Pathology,13

edn, Edward Arnold, London.

Weidner, N., Cote, R.J., Suster, S, Weiss, L.M. (eds) (2003) Modern Surgical Pathology,1

edn, Saunders, Philadelphia.

I have also drawn on the following series (in addition to other journals and publications of ofﬁcial organi-

sations). References to the speciﬁc articles are given at the end of each chapter:

Recent Advances in Histopathology

Progress in Pathology

Current Diagnostic Pathology

Pathology journals: Histopathology; American Journal of Surgical Pathology; American Journal of Clinical Pathology; Modern Pathology; Journal of

Clinical Pathology; Journal of Pathology, etc.

Visit the Book’s Web Site

www.pathbook.com

The problem with paper textbooks is that they go out of date as soon as the manuscript leaves the author.

In order to counteract this I have set up a users’ web site with the intention that updates can be made

available and any errata corrected as they are found. The web site has the added advantage of allowing all

the readership to contribute their comments and suggestions for improvements and additions.

Below is shown one of the pages from the site.

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Index to Grading and Classiﬁcation Systems

Neoplasia

Site: Lesion / System Page

Adrenal: adrenocortical carcinoma 275–276

Adrenal: neuroblastoma 59

Any: carcinoid 279, 139–

140, 152

Any: histiocytoses 286

Bladder: TCC 219, 365

Bone marrow: AML 103

Bone marrow: mastocytosis 102

Bone marrow: multiple myeloma 104

Bone: chondrosarcoma 339

Bone: giant cell tumour 335

Bone: osteosarcoma 336

Breast: carcinoma 260

Breast: core biopsy (B1 – B5) 265

Breast: DCIS 258–259

Breast: FNA (C1 – C5) 371

Breast: NPI 260

Breast: phyllodes 262–263

Cervix: CGIN 234–235

Cervix: CIN 233–234

Cervix: dyskaryosis 356

Cervix: FIGO staging 233

Cervix: SCC 234

CNS: gliomas / meningiomas 185–186

CNS: olefactory neuroblastoma 184

Colon: adenocarcinoma 151

Colon: adenoma dysplasia 149–150

Colon: dysplasia in CIBD / DALM 150–151

Colon: Haggitt and Kikuchi stage 151

Endometrium: adenocarcinoma 240

Endometrium: stromal tumours 242

Eye: melanocytosis (Zimmerman) 198

Eye: melanoma (Callender) 198

Gallbladder: carcinoma 174

GIT: dysplasia general 127

GIT: dysplasia Vienna System 127

GIT: GIST 141

Head and neck: carcinoma 44

Head and neck: NPC 81, 44

Head and neck: olfactory NB 184

Kidney: Fuhrman grading 218

Kidney: RCC papillary 217

Kidney: Wilms’ Tumour Stage 60

Larynx: carcinoma 44, 38–39

Liver: dysplasia and nodules 170–171

Liver: HCC 171

Lung: adenocarcinoma 91

Lung: angiocentric lymphoid

proliferations

Lung: MALT lymphoma 91

Lung: mucoepidermoid carcinoma 92, 132

Lung: SCC 92

Lymphoreticular: AITCL 115

Lymphoreticular: follicular

lymphoma

111

Lymphoreticular: Hodgkin’s

(NSHL)

117

Lymphoreticular: MALT lymphoma 112

Oesophagus: carcinoma 136

Oesophagus: dysplasia 135–136

Oral: ameloblastoma 128

Oral: carcinoma 44

Oral: squamous dysplasia 129

Ovary: FIGO staging 244

Ovary: mucinous / endometrioid 246

Ovary: serous 245

Ovary: teratoma immature 252

Ovary: universal (Shimizu) 248

Pancreas: adenocarcinoma 176

Pancreas: PanIN 175

Penis: SCC (Broders’ grade) 284

Pituitary: adenomas 278

Prostate: Gleason grade 222

Prostate: PIN 221

Salivary Gland: carcinoma ex PSAd 130

Salivary Gland: mucoepidermoid 132, 92

Skin: apocrine carcinoma 293

Skin: Clark’s levels 291

Skin: dysplasia (melanocytic) 289

Skin: LyP Willemze Types 299

Skin: SCC (Broders’ grade) 284

Skin: smooth muscle tumours 309

Skin: vascular lesions (ISSVA) 57

Soft tissue: angiosarcoma 320

Soft tissue: ﬁbrosarcoma 312

Soft tissue: general (NCI/FNCLCC) 327,

52–53

Soft tissue: liposarcoma 314

Soft tissue: malignant SFT 324

Soft tissue: myxoﬁbrosarcoma 312

Soft tissue: smooth muscle tumours 309

Soft tissue: synovial sarcoma 323

Stomach: adenocarcinoma 138–139

Stomach: dysplasia 138

Stomach: ECL-cell carcinoids 140

Testis: MRC Prognostic score 226

Thymus: thymoma 95–96

Thyroid: carcinoma 53

Thyroid: FNA (Thy1 – Thy5) 367

Uterus: FIGO staging 240

Uterus: smooth muscle tumours 241–242

Vagina: VAIN 233–234

Vulva: FIGO staging 232

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Non-Neoplastic Conditions

Any: cryoglobulins 350

Any: hypersensitivity 350

Bone marrow: cellularity 99

Bone marrow: myeloﬁbrosis 102

Bone marrow: reticulin ﬁbrosis 99

Brain: dementia and Braak stage 181

Breast: CCL 262

Breast: receptors H-Score 260–261

Breast: receptors Quick Score 260–261

Breast: Herceptest

Score 260

Eye: melanocytosis (Zimmerman) 198

GIT: gastritis 137

GIT: ileoanal pouchitis score 147

Heart: acute cardiac death (Davies) 386

Heart: Tx rejection (acute) grading 78

Joints: periprosthetic membrane 341

Kidney: lupus nephritis (SLE) 204

Kidney: stage and grade (inﬂam

) 201

Kidney: tubulitis 208

Kidney: Tx humoural rejection 209

Kidney: Tx rejection (Banff ’97) 209

Liver: hepatitis C (RCP/BSG) 160

Liver: hepatitis grade (HAI) 161

Liver: iron 156

Liver: methotrexate (Roenigk) 168

Liver: PSC and PBC staging 162

Liver: reticulin ﬁbrosis stage 161

Liver: steatosis 157

Liver: Tx rejection (Banff RAI) 165–166

Lung: asbestosis 86

Lung: CCAM / CAM / CPAM 82–83

Lung: coal worker’s pneumoconiosis 85

Lung: NSIP 84

Lung: pulmonary ﬁbrosis 86

Oesophagus: Barrett’s typing 135

Oral: odontogenic cysts 127–128

Skin: GVHD / GVHR 306

Skin: vascular lesions (ISSVA) 57

Testis: Johnsen’s score 212

Dating

Chorionic villi following IUD 62

Endometrium 236–237

MI 75

Thrombus 73, 10

Frozen Section Index

Site: Condition Page

Any: artefacts 4

Any: mitotic counts 7

Any: rapid H&E method 10–11

Any: signet ring carcinoma d/dg 139, 214

Bone: osteosarcoma imprints 336

Brain: tumours (incl. smears) 187–188,

Breast 265–266

GIT: gastric adenoCA vs. carcinoid 140

GIT: CIBD 144

Inguinal: lymphadenectomy 39

(Fig. 4.5)

Joints: prosthesis revision 341

Kidney: tumours / cysts 218

Larynx 82

Liver: AdenoCA vs.vMC/BD

adenoma

164, 172

Liver: BD lesions vs. cholangioCA 173

Liver: biliary atresia (Kasai) 164

Liver: steatosis 165

Liver: Tx (donor liver) 165

Lung 95

Lymph Node: inclusions / sentinel 118

Ovary: tumours / cysts 253, 251,

254

Pancreas: adenocarcinoma d/dg 176, 175,

174

Pancreas: endocrine tumour d/dg 178–179

Parathyroid 274

Peritoneum: deposits (gynae) 251, 254

Pituitary: tumours 278–279

Skin: incl. Mohs’ surgery 48

Testis: tumours / nodules 228

Thyroid 273

Reader’s Index

Use this space to make your own handy reference / bookmark list

Topic Page

xxvi

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cdh

olf

ins

put

spl

phg

sic

phg

collateral sulcus

cdt

put

cla

iculum

cdt

fimbria

CA1,2,3

CA4

lgn

A5A3P1P4

dorsal

ventral

superior

inferior

Cb1 Cb2

Cb3

Cb4

Lobar Boundaries Cerebral Blood Supply Cerebral Boundary Zones

Cerebellar Boundary Zone

The Hippocampus

TWS

Key

Cerebral Blood Supply

red anterior cerebral artery

green middle cerebral artery

blue posterior cerebral artery

Cerebral Boundary Zones

cyan boundary zone between the

posterior & middle cerebral

yellow anterior & middle cerebral

magenta anterior & posterior cerebral

TWS triple watershed region

Cerebellar Boundary Zones

cyan boundary between medial &

lateral branches of the

posterior inferior cerebellar

artery

yellow superior & posterior inferior

magenta anterior inferior & posterior

inferior

Slice Numbers

A5 fifth slice anterior to the

mammillary bodies (mb)

A3 third slice anterior to the mb

P1 first slice posterior to the mb

P4 fourth slice posterior to the mb

Cb1 left paramedian sagittal slice

of the cerebellum

Cb2 right paramedian sagittal slice

of the cerebellum

Cb3 horizontal slice through the

cerebellum just caudal to the

midpoint

Cb4 horizontal slice through the

cerebellum more caudally

than Cb3

ic internal capsule

ins insula

lgn lateral geniculate nucleus

mb mammillary body

phg parahippocampal gyrus

pg pineal gland

ps pituitary stalk

put putamen

rn red nucleus

sic superior & inferior

colliculi

sn substantia nigra

spl corpus callosum (splenium)

th thalamus

u uncus

Anatomical Landmarks

a anterior commissure

aq aqueduct of Sylvius

CA cornu ammonis (CA1 =

Sommer's sector)

cc corpus callosum (body)

cdh caudate nucleus (head)

cdt caudate nucleus (tail)

cg cingulate gyrus

cla claustrum

cp choroid plexus

f fornix (anterior column)

ge corpus callosum (genu)

gp globus pallidus

HF hippocampal fissure

ht hypothalamus

caudate

1. Corpus striatum (striate body) = putamen

2. Claustrum globus pallidus

3. Amygdaloid body

4. some clinicians might add: subthalamic nuclei &

substantia nigra

(NB: the caudate + putamen = the neostriatum,

sometimes just called 'the striatum' - do not confuse

with the 'corpus striatum' or that part of the visual

cerebral cortex called the area striata = striate cortex)

Blood Supply:

This is mainly from perforating branches of the

middle & posterior cerebral arteries e.g. the lateral

striate arteries that arise close to the origin of the

middle cerebral & enter the brain via the anterior

perforated substance at the base of the brain lateral

to the optic chiasm.

The Basal Ganglia

Lobar Boundaries

cyan occipital lobe

yellow frontal lobe

magenta parietal lobe

grey temporal lobe

1. central sulcus

2. lateral sulcus

3. parieto-occipital sulcus

4. calcarine sulcus

L1. a line joining 3 to the

pre-occipital notch

notch formed by the (the

petrous temporal bone)

L2. a line from the end of 2

to the midpoint of L1

L3. a line from the pre-occipital

notch to the anterior end of 4

FIGURE 4.1

Diagnostic Criteria Handbook in Histopathology: A Surgical Pathology Vade Mecum. Paul J. Tadrous



2007 by John Wiley & Sons, Ltd. ISBN: 978-0-470-51903-5

color-plates December 8, 2007 16:39 Char Count= 0

Optic nerve is nasal

& inferior to the mid point

The closest muscle to the optic nerve

is temporal and inferior to the mid point.

Superior oblique is

temporal & superior

(tendinous insertion)

LEFT

RIGHT

Long ciliary

arteries lie

horizontally

(Inferior oblique: muscular insertion, overlies the macula)

FIGURE 4.2

IIA IIB

III

VII

Key to Anatomical Landmarks:

1. jugular fossa

2. posterior border of submandibular salivary gland

3. inferior border of the digastric

4. mid-digastric tendon

5. internal jugular vein (anterior and posterior borders)

6. inferior border of the hyoid bone

7. anterior border of trapezius

8. accessory nerve (spinal part)

9 posterior / lateral border of sternocleidomastoid

10. inferior border of cricothyroid cartilage

11. posterior border of anterior scalene

12. superior border of manubrium sterni

Structures included in a Radical Neck Dissection:

A. LN from levels I-IV (at least)

B. submandibular salivary gland

C. internal jugular vein

D. sternocleidomastoid

E. accessory nerve (spinal part)

the last three are optional in a modified radical

Anatomical landmarks 2, 4, 5 & 9 are particularly

helpful in defining the levels in a radical neck

dissection specimen, as is the point at which the

omohyoid passes deep to the sternocleidomastoideus

(marks the dividing line between level III & IV).

FIGURE 4.3

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Nasopharynx

Oropharynx

Laryngopharynx

(= Hypopharynx)

cervical

oesophagus

sphenoid to lower border

of back of soft palate.

It contains the

'postnasal space'.

to upper border of

epiglottis (incl. the

posterior 1/3 of tongue)

to lower border of

cricoid cartilage (incl.

the post-cricoid

area)

sphenoid

Pharynx

= a funnel connecting the nasal & oral cavities to the oesophagus. The

anterior limits = back of nasal septum, palatoglossal fold, sulcus terminalis (& the

opening to the larynx). It is divided

into nasal, oral & laryngeal parts:

Tonsils of Waldeyer's Ring:

pharyngeal (= 'adenoids')

tubal

palatine (= 'tonsils')

lingual

palatoglossal fold

ppf

lgef

mgef

aef

cricothyroid ligament

thyrohyoid membrane

hb pf

cune

corn

aryt

oblique line (attachment for

sternothyroid, thyrohyoid &

inferior constrictor muscles)

arch of cc

lamina of cc

tracheal cartilage

Strap Muscles

(not illustrated)

= musculi infrahyoides

a) sternohyoid b) omohyoid c) thyrohyoid d) sternothyroid

tongue

lgef

ppf

vcvc

mgef

superior

cornu of tc

lamina

of tc

vbf vcf

(respiratory lining

& underlying

mucous glands)

(squamous lining

& none / rare

mucous glands)

greater

cornu

of hb

vcf

vbf

vbl

tgl

vcl

Fibroelastic

Membrane:

ctl

superior

cornu

of tc

inferior

cornu

of tc

Key to Figure:

Muscles

1. genioglossus

2. geniohyoid

3. aryepiglottic

4. oblique arytenoid

5. transverse arytenoid

6. posterior cricoarytenoid

7. vocalis

Anatomical Landmarks

ac anterior commissure

aef aryepiglottic fold

aryt arytenoid cartilage

s saccule (= sinus of

Morgagni = appendix

ventriculi laryngis)

st sulcus terminalis

tb tubercle of epiglottis

tc thyroid cartilage

tgl thyroglottic ligament

v ventricle

vbf vestibular fold

(= false vocal cord)

vbl vestibular ligament

vc vallecula(e)

vcf vocal fold

(= true vocal cord)

vcl vocal ligament

vp vallate papilla(e)

aef

aryt

4, 5

pes

mgef

corn

deep base of tongue

Larynx (Spaces)

supraglottic

(green)

paraglottic

(infraglottic

part)

Reinke's (yellow)

subglottic

pre-epiglottic

paraglottic

(supraglottic

part)

hel

cc cricoid cartilage

ce conus elasticus

corn corniculate cartilage

ctl cricothyroid ligament

cune cuneiform cartilage

eg epiglottis

hb hyoid bone

hel hypoepiglottic ligament

lgef lateral glossoepiglottic fold

mgef median glossoepiglottic fold

pes pre-epiglottic space

pf piriform fossa

(= piriform sinus)

ppf palatopharyngeal fold

qm quadrangular membrane

Larynx (Regions)

1cm

}

Glottic

Subglottic

(begins 1cm below the

level of the true vocal cords)

(the glottis = the true vocal

cords & both commissures)

Supraglottic

(the 'epilarynx' = suprahyoid epiglottis,

aryepiglottic folds & arytenoids: i.e.

the region above the green line)

FIGURE 4.4

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pubic

symphysis

anterior superior

iliac spine

inguinal

ligament

iliac vessels:

common

internal

external

limits of dissection for

inguinal lymphadenectomy:

modified

standard

fossa ovalis (filled with

the loose cribriform fascia)

great saphenous vein

superficial fascia

(= subcutaneous fat

of Camper plus deeper

membranous layer

of Colles)

deep fascia

(fascia lata)

CR node

region of superficial

inguinal nodes

Points to Note:

•

The femoral artery begins as

the continuation of the external iliac

at the midpoint between the anterior

superior iliac spine & pubic symphysis.

•

The fossa ovalis here refers to the

saphenous opening in the fascia lata.

•

The external iliac nodes are shown

in grey.

•

The deep inguinal nodes (in the

fossa ovalis) are shown in yellow and

one is constant, labelled as 'CR Node',

at the medial high point of the femoral

vein (= Cloquet's node of Rosenm

üller).

•

The superficial inguinal nodes lie near

Colles' fascia, are arranged in vertical

& horizontal groups and total upto 25.

The lateral part of the horizontal group

receive lymph from the lower back.

The region marked 'SN' is where the

sentinel nodes of penile

are found.

•

The modified lymphadenectomy field

is that of Catalona and is a saphenous

vein-sparing method with fewer complic-

ations used prophylactically in clinically

node negative patients - but may be

converted to the standard radical

dissection if positive nodes are found

(incl. by the use of frozen section).

FIGURE 4.5

Key (View of heart from the right)

1. Rt. atrial appendage

2. fossa ovalis

3. coronary sinus

4. eustachian valve (of IVC), the continuation of which

(shown as a dotted grey line) overlies the tendon of Todaro

5. annulus (attachment) of the septal cusp of the tricuspid

6. triangle of Koch (base = 3, sides = 4 & 5)

7. septal cusp of tricuspid

8. membranous septum

9. septal papillary muscle(s)

10. moderator band

SVC

IVC

aorta

position of

crista terminalis

strip to be taken

for SA node

block to be taken

for AV node & His bundle

block to be taken

for left & right

bundle branches

FIGURE 4.6

Pancreatic Components

1. Head (to the Rt. of the Lt. border of the SMV)

2. Uncinate process of the head

3. Body (between the head & the Lt. border of the aorta )

4. Tail (to the Lt. of the Lt. border of the aorta)

Left gastric

ophageal

che

Short gastric arteries

ight & Left gastroepiploics

Inferior mesenteric vein

(joining the splenic vein)

IVC

Superior mesenteric vein (SMV)

and artery

Hepatic arteries

Portal Vein

Common bile duct

Gastroduodenal artery

(goes behind D1)

Superior and Inferior

pancreaticoduodenal

arteries

Porta Hepatis Contents

1. Portal veins (Lt. & Rt.)

2. Hepatic ducts (Lt. & Rt.)

3. Hepatic arteries (Lt. & Rt.)

4. LNs (draining liver & gallbladder)

Operative Specimens (Pancreas)

Whipple's:

1. head of pancreas

2. distal bile ducts & gallbladder

3. duedenum

4. stomach (distal 2/3)

Pylorus-preserving pancreaticoduodenectomy:

1.- 3. above

Total pancreaticoduodenectomy:

as for subtotal ± spleen

Sub-total pancreaticoduodenectomy:

+ body of pacreas

± stomach

1.- 3. above

Distal pancreatectomy:

body & tail of pancreas ± spleen

Branches of the Coeliac Axis

1. Lt. gastric artery

2. Splenic

3. Hepatic

Lt. gastroepiploic

pancreatic branches

short gastrics

Rt. & Lt. hepatic

gastroduodenal

Rt. gastric

Rt. gastroepiploic

superior

pancreaticoduodenal

Main Vessels Labelled

FIGURE 4.7

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Normal

Proximal gastrectomy with gastric tube reconstruction

Proximal gastrectomy with direct oesophageal anastomosis

Total gastrectomy

CUT HERE

Billroth 1 (Hofmeister anastomosis) Billroth 2

Colon

Gastric bypass

Total gastrectomy

Distal gastrectomy

Choledochojejunostomy

Billroth 2 Anterior gastrojejunostomy

CUT HERE

FIGURE 4.8

falciform ligament

gallbladder

caudate lobe

hepatic artery &

portal vein branches

IVC

hepatic veins

ANTERIOR VIEW

POSTERIOR VIEW SUPERIOR VIEW

hepatic veins (projected)

left

middle

right

IVC

FIGURE 4.9

SMA

IMA

ILEO

RIGHT

MIDDLE

LEFT

SIGMOID

SUPERIOR

RECTAL

Key to Arteries:

1. ileocolic

2. right colic

3. middle colic

4. left colic

5. sigmoid

6. superior rectal

NB: The IMA arises

≈

4 cm

above the aortic bifurcation

and may be small.

Operation Vascular Ties

Rt. hemicolectomy

ileocolic, Rt. colic ± mid colic

Transverse colectomy midcolic ± Lt. colic

Lt. hemicolectomy

Lt. colic, sigmoid, ± superior rectal

Anterior resection / APR

superior rectal

FIGURE 4.10

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Bladder

PZ PZ

A S E

A P E X

Internal

urethral

meatus

External

urethral

sphincter

Urethral crest and

Verumontanum

(with openings for

ejaculatory ducts

& prostatic utricle)

Ampulla of vas deferens

Seminal vesicle

Fascia of Denonvilliers with its

median (longitudinal smooth) muscular

thickening - ! not rectal muscularis propria

Adipose

Neurovascular

bundle (capsular invasion

is most common in the

regions of nerve penetration

at the superior and inferior

pedicles)

Glands

Main

Submucosal

Periurethral

(= mucosal)

P O S T E R I O R

Apex

Base

Posterior View

Attachment of

bladder base

Internal

urethral

meatus

Anterior View

Attachment of

rectum

Oblique

transverse

slice of the

superior half

Cowper's

bulbourethral

gland

FIGURE 4.11

Ventral

Dorsal

FIGURE 4.12

(anterior

peritoneal

reflection)

(posterior ovarian pedicle)

3. (anterior round ligaments

with forcep marks)

UTERUS ANTEROLATERAL VIEW

FIGURE 4.13