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

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FIGURE 25.2 Accessing the spinal cord

Removing the cord within the vertebral column: this

method is used if there is a suspicion of spinal cord infarct

as it preserves the cord blood supply (but the body must be

reconstructed with a broomstick and crossbars). Method

is as for the anterior approach but instead of cutting the

pedicles you cut through the ribs close to the spine, cut

through the sacroiliac region to free the sacrum and dis-

sect the whole spine from the soft tissue severing any

atlantoaxial connections. Fix the whole thing then access

the cord by laminectomy as in the posterior approach.

Avoid crush artefacts: whatever method is used, do not

kink or sharply bend the cord during removal or ﬁxation

(if a long enough ﬁxative container is not available, bisect

the cord after making an opening in the dura – never cut

through cord and dura together).

Maintain a knowledge of the levels (by tying a suture to

L1 prior to removing the cord, by preserving the dentate

ligament when opening the dura at the time of cut-up and

by counting back to the distinctive roots of T1 [T1 has

the last large roots distal to the cervical enlargement and

has unequal-sized anterior and posterior roots, unlike T2,

with posterior bigger than anterior and each bigger than

the roots of T2]).

Muscles for ?Myopathy

Take samples from: digastric (both anterior and posterior belly separately), tongue, larynx / pharyngeal

muscles, sternocleidomastoid, diaphragm, biceps / triceps, small hand muscles and vastus lateralis.

Lay the sample out on a labelled card until they are a little dry (to stick to the card) then ﬁx. Take

transverse and longitudinal sections for histology.

Nerves for ?Neuropathy

Sample the ulnar, femoral and sural ± autonomic ganglia. Fix and section as for muscles (vide supra)

If ? MND take spinal cord, muscles (as above) and examine brain stem cranial nerve nuclei (NB: III,

IV and VI are usu. spared in MND)

Parathyroid Glands

These are soft, ovoid and browny-yellow.

Dissect the posterolateral grooves between the oesophagus and thyroid.

Upper pair are usu. midway down the posterior border of the thyroid.

Lower pair are usu. just beneath the inferior margin of the thyroid.

Conducting System of the Heart

Refer to Figure 4.6 on p. 39 and to the instructions below

Indications: complete AV block not explained by IHD, suspected congenital conducting system defects,

conﬁrmation of tumour/sarcoid involvement (e.g. 1

◦

mesothelioma of the AV node or mets)

ECG correlation and input of an expert cardiac pathologist is advisable before dissection because some

specialist dissections may be necessary (e.g. complete radial serial sectioning of both AV rings is

indicated in some pre-excitation syndromes – see specialist texts in the Bibliography)

The basic dissection may be performed on the fresh heart or after intact ﬁxation (ﬂush out blood / clots,

stuff chambers with formalin-soaked cotton wool and immerse whole in formalin)

All the blocks require serial sectioning and stain with Masson’s trichrome and H&E →100s of sections

Open the right atrium anterolaterally (do not join-cut the venae cavae as usual) and identify the crista

terminalis – the internal crest between the ridged anterior atrial muscle and the smooth posterior muscle

continuous with the venae cavae. Take a rectangular block of the crista as it arches over the junction

between the atrial appendage and the SVC. The SA node (‘pacemaker’) is usu. in the anterolateral

part but may be more extensive (= ‘horseshoe node’). Serial sectioning for histology is done from

anterolateral to posteromedial.

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Identify the triangle of Koch (the AV node is within its apex, near the medial attachment of the septal cusp

of the tricuspid valve) and membranous septum (it contains the AV bundle of His) – transillumination

may help. Take a rectangular block to include these two areas and part of the subjacent muscular septum

(containing left and right bundle branches) to include the septal papillary muscle (the latter is usu. a

group of little papillae rather than a single muscle). Divide this rectangle into top and bottom halves.

For histology, serially section the top half longitudinally (perpendicular to the plane of the valve ring)

and the bottom half transversely (across the septum).

The ‘moderator band’ is a bridging piece of trabeculae carnae near the bottom of the septum that reaches

across to the anteroinferior wall of the RV at the root of the anterior papillary muscle. It contains the

distal part of the right bundle branch of the conducting system.

Femur

Incise the skin from medial to lateral across the patella anteriorly and continue up the lateral thigh.

Transect the patella, clear the muscles from the femur inferiorly and divide the medial, lateral and

cruciate ligaments of the knee joint.

Clear the muscles upto the hip, incise the hip joint capsule around the femoral neck and swing the

femur laterally till the head pops out of the acetabulum. The femur can now be removed.

Slice the femur longitudinally to reveal extent of red marrow. Alternatively, chisel segments from

proximal mid and distal parts by cutting parallel vertical slices mid way into the shaft at these points

and then chisel across to give a semicircular segment from each location (this may be done without

having to remove the femur completely).

Biliary Tract

Open the lateral duodenum and squeeze the GB to locate the ampulla and demonstrate patency.

Mobilise the GB and cut down on the cystic duct then open it to the CBD.

Open up the left and right hepatic ducts and continue down the CBD.

Remove the intact GB and open it into a clean container – don’t spill the bile.

Air Embolism

! Consider this prior to PM: it alters the order and nature of dissection to avoid artefactual air bubbles.

Venous

Open the abdomen ﬁrst, ﬁll it with water and inspect IVC for bubbles.

Make a surgical window in the chest to expose the praecordium (avoid removing the whole sternum or

cutting the 1

rib because this will damage the subclavian).

Open the pericardial sac, inspect the epicardial veins, ﬁll the sac with water and insert the needle of a

water-ﬁlled syringe body (no plunger) into the RV – look for bubbles.

Frothy blood in the right heart may occur with large air embolism.

Arterial

This may follow thoracic surgery (e.g. CABG) or any trauma to the pulmonary veins.

The key is to demonstrate bubbles in the vessels of the meninges (in situ) or base of brain.

The cranium must be opened without damaging the meninges.

The internal carotid and basilar arteries must only be cut after clamping them – then remove the brain.

Inspect the vessels of the circle of Willis for bubbles (while immersing the brain under water).

Others

Oesophageal Varices: tie the oesophagus high in the chest before cutting it. Remove oesophagus in

continuity with stomach. Open the distal stomach, remove its contents and insert grasping forceps into

the stomach (via this incision) to the top of oesophageal portion then grasp and pull the oesophagus

down into the stomach to evert it and inspect for varices.

Renal disease / Hypertension: look for accessory renal arteries.

Hiatus Hernia: you need to keep the diaphragm intact to demonstrate this.

Small Intestine: always check the 1

part of the duodenum for ulcers.

Intestinal ischaemia / embolism: dissect down to the superior mesenteric artery to inspect its branches.

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Normal Weights and Measures in Adults

TABLE 25.1 Normal values in adults

Weights (g) Male Female

Heart

290–440 230–390

Pericardium 20–50 ml 20–50 ml

Right Lung

†

420–900 340–750

Left Lung

‡

370–800 290–640

Pleura (each) 50 ml 50 ml

Liver 1280–2070 1110–1840

Kidneys (each) 120–200 100–170

Testis (each) 20–30 –

Prostate 15@20 yrs to –

40@80 yrs

Spleen (∝ age) 70–240 60–220

Pancreas

100–180 90–160

Adrenals (each) 6–8 6–8

Thyroid

††

10–40 10–30

Parathyroids (all together) 116–124 mg 137–147 mg

Brain 1200–1600 1100–1500

cbs/wb 0.12 0.12

for males the heart is 0.45% body weight (0.4% for females).

Formalin ﬁxation increases heart weight by ≈ 6%

†

oldersources forthe rightlung weightsuggest 400–500g(M),

350–450g (F)

‡

older sources for the left lung weight suggest 330–450g (M),

300–400g (F)



PM splenic weight rangeis wide: upto 350g being acceptable

with physiological atrophy down to 40g

older sources for pancreatic weight suggest 70–100g (M),

60–90g (F).

††

the lower end of this range occurs in the very young and the

very old.

Table 25.1 was compiled from various

sources (see Bibliography). Values for

heart, lungs, liver, kidneys, spleen, pancreas

and thyroid were calculated from recent data

by Lorin de la Grandmaison et al. (2001) on

Caucasians who died within 1 hour of injury

and had no detected disease.

The range shown in the table is ± 1SD

about the mean, rounded to the nearest 10g.

For Normal distributions, 95% of cases lie

between 1.96 x SD either side of the mean

so the actual ranges are very wide indeed.

I have tried to illustrate variation between

sources in the footnotes. Variation in lung

weights may be due to differing amounts

of agonal pulmonary oedema in otherwise

healthy patients.

Heart weights were not found to correlate

with height in females (contrary to older

data) but many organ weights depend on

BMI (as measured post mortem), age, exer-

cise history, etc.

All these complexities should be considered

when interpreting your ﬁndings, especially

when your conclusions have medicolegal

implications.

See tables 25.2 and 25.3 for cardiac mea-

surements

TABLE 25.2 Cardiac wall thickness

Cardiac Wall Thickness

Right Atrium 2–2.5 mm

Left Atrium 2–2.5 mm

Right Ventricle

(1cm below pulm. valve, at conus) 2–3 mm

Left Ventricle

(1cm below posterior leaﬂet of mitral) 12–15 mm

TABLE 25.3 Cardiac valve circumference

Valve Circumference

‡‡

Tricuspid 11–13 cm

Pulmonary 8–9 cm

Mitral 9–11 cm

Aortic 7–8 cm

‡‡

measured linearly with valve cut open

Fulton’s Method for Separating the Left and Right Ventricle

Demonstrates isolated ventricular hypertrophy (esp. RVH) and ratios may be esp. useful where inter-

preting total heart weight is difﬁcult (e.g. in some paediatric / perinatal settings) – Figure 25.3

FIGURE 25.3 The Fulton method

◦

cut off the atria and all valves (scissors)

◦

trim and scrape all the epicardial fat off

◦

with broad-bladed scissors place one blade

on the septum and cut the RV off the septum

as shown in the ﬁgure without leaving a ridge

of muscle behind. Also cut off all muscle pro-

truding from the septum into the RV cavity.

The free wall of the RV and any protruding

muscle thus trimmed constitute the RV mass (RVm). The LV and septum constitute the LV mass (LVm).

The RVmand LVmare weighed separately and used to assess Fulton’s criteria for normality/hypertrophy

as below

Fulton’s series was small, none were >65 years old and M & F data were pooled. However they are considered reasonable (NB:

large/active − but healthy − people may have higher values).

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Normality: requires all of the following:

◦

(LVm + RVm) < 250g

◦

RV m < 65g

◦

LV m <190g

◦

LVm:RVm is between 2.3:1 and 3.3:1

RVH:RVm≥ 80g or, in isolated RVH, LVm:RVm <2:1

LV H :LVm≥ 225g

Pomerance and Davies (1975) report normal ranges for:  LV m = 84–195g (M); 73–181g (F)

 RV m = 26–73g (M); 24–65g (F)

Perinatal Autopsy (a Procedure)

In practice, the precise method varies depending on the clinicoradiologicalHx and any suspected anomalies.

FIGURE 25.4 Perinatal body

incision

1. external examination, weights and measures, babygram +/ speciﬁc

radiography

2. skin incision (see Figure 25.4 – take section of cord, measure subcu-

taneous fat thickness)

3. check for pneumothorax

4. check internal connection of cord vessels:

a) check umbilical vein then cut it

b) incise skin around other side of cord then lay it caudally with

umbilical arteries and urachal remnant attached

5. check rotation of gut and identify gonads. If sex differs from the request form phone this result through

urgently so parents can be informed (for correct naming on the gravestone, etc.)

6. remove plastron at cartilages anterior to the costochondral joints from bottom up. Take the thymus

7. Is there blood-stained ﬂuid in the serous cavities? (a sign of maceration)

8. remove intestines and take samples of rectum, ileum and jejunum for histology

9. check the venous drainage of the lungs into the heart in situ and the inferior veins into the IVC

10. neck – sample part of tongue in mouth

11. Rokitansky removal of organs (i.e. thoracic and abdominal organs removed together en bloc)

12. probe the oesophagus into stomach, open the oesophagus and strip it off

13. separate the heart and lung block

14. dissect the heart (samples for histology should include septum and papillary muscle):

fossa ovalis ±

foramen ovale

coronary sinus

FIGURE 25.5 Medial aspect

of Rt atrium

a) join-cut the IVC – SVC

b) cut along the AV border

c) examine the fossa ovalis and coronary sinus (see Figure 25.5)

d) cut down the septum on RV and examine the tricuspid

e) probe up the pulmonary artery into the ductus arteriosus

f) cut along the pulmonary artery to examine the pulmonary valve

g) connect the pulmonary veins on the left atrium and cut along

the AV border

h) cut down septum into the LV and examine the mitral valve

i) probe up aorta and cut along the probe to examine the aortic valve

j) remove the heart and weigh it

k) take a longitudinal section of right and left ventricle to include papillary muscles

l) take a transverse section of septum

15. cut down the tracheobronchial tree

16. remove, weigh, examine and sample lungs (combined weight is used for lungs:body ratio)

17. cut the trachea at the level of the thyroid

18. remove the diaphragm (and sample it) – take care not to destroy the adrenals

19. separate the kidneys from the liver-spleen-stomach

20. remove and weigh the adrenals (together) and sample them

21. weigh the kidneys (separately)

22. sample the psoas muscle

incising the thoracic cavity under water works but allows any pleural ﬂuid also to escape and allows water in to dilute and

contaminate intrapleural contents should microbiology be required. To overcome this, use a sterile needle and syringe partly ﬁlled

with sterile water. Insert the needle into the cavity and pneumothorax will cause bubbles to rise in the syringe. A babygram (whole

body X-ray) may also give warning of pneumothorax

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23. sample the left and right lobes of the liver

24. sample the stomach, spleen and gonads

25. sample a costochondral junction (and sample some other growth plates if ? skeletal dysplasia)

26. remove the brain and examine the cranium, falx, venous sinuses and meninges

a) coronal skin incision from ear to ear over posterior fontanelle, reﬂect to eyebrows and base

b) make longitudinal nicks in the dura at the lateral aspects of the anterior fontanelle

c) extend nicks to create bilateral bone ﬂaps – bend back and cover edges with a wet towel

d) examine the tentorium and falx cerebri (use gravity and wet scalpel handle to shift the brain)

e) remove the central strip of bone

Weight ratios

◦

fetal:placental – for IUGR (normal values are 1:1 at 14/40 to ≈ 7:1 at 40–44/40)

◦

brain:liver – for asymmetric IUGR (deﬁned as ≥5; normal range is 2.5–3.5)

◦

lungs:body – pulmonary hypoplasia is ≤0.015 before 28/40 or <0.012 after 28/40 (in the absence of

complicating factors like hydrops, general IUGR, pneumonia, etc.), radial alveolar counts also help

(count the n˜o. of alveoli or septa transected by a line from a resp. bronchiole to the nearest acinar

margin – see Cooney and Thurlbeck, 1982).

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Index of General Terms 395

Index of General Terms

3D clusters (in cytology)

mesothelial 360

urine 365

adenocarcinoma 361



-antitrypsin 157

acantholytic squamous cell carcinoma

285

acanthoma 282, 283, 292

accessory auricles 199

acetic acid artefact 357

achalasia of the cardia 135

achondroplasia 330

acinar cell carcinoma/dysplasia 177

acinar zones (of liver) 156

acinic cell carcinoma 132, 369

acquired immunodeﬁciency

syndrome (AIDS, see also HIV)

165, 306–7, 346–7, 364

acral naevus 288

acrodermatitis enteropathica 304

ACTH 275, 278

actinic

keratosis 283

lentigo 288–9

reticuloid 299

Actinomyces spp. 343–344, 22, 239,

357, 371

acute

cholecystitis 173–4

diffuse proliferative

glomerulonephritis 202

disseminated encephalomyelitis 183

endometriosis 239

febrile neutrophilic dermatosis 300

haemorrhagic leucoencephalitis 183

haemorrhagic

leucoencephalomyelitis 183

haemorrhagic leucoencephalopathy

183

hepatitis 158–9

lymphoblastic leukaemia 16, 97,

101, 103–5, 228, 253

myeloid leukaemia 103,

4, 16, 99–104, 107–8, 123, 300

pancreatitis 175

pouchitis 147

pyelonephritis 206

radiation effects 305

rheumatic fever 76–7

tubular necrosis 206

villitis 63

adamantinoma 335

adenocarcinoma 91–2, 219, 361

basal cell 130–1

bronchial 369–70

ductal 176

endometrioid 92

invasive 234–5

minimal deviation 235

polymorphous low grade 131

prostatic 220, 222, 224

adenoid

basal carcinoma 234

basal epithelioma 234

cystic carcinoma 131, 369

pharyngeal tonsil 38

adenoma 130–1, 200

adrenocortical 275–6

basal cell 130–1, 223

bile duct 172

bronchioalveolar 91

Brunner’s gland 142

canalicular 131

duct 264

dysplasia 149–50

ﬂat 149–50

follicular 268–9

gastric 138

hepatocellular 169–70

hyalinising trabecular 271

malignum 235

metanephric 216

microcystic 177

nephrogenic 218

of the nipple 259–60

parathyroid 274

Pick’s 227

pleomorphic salivary 130, 368

polypoidal 149–50

renal 216

serous microcystic 177

serrated 149–50

sporadic 149–50

adenomatous

hyperplasia (lung) 91

hyperplasia (prostate) 220–1

nodules (liver) 171

polyps 138, 149–50, 220

adenomyoma

atypical polypoid 239, 242

biliary tree 173

gallbladder 174

uterus 239

adenosarcoma 242–3

tamoxifen and 238, 254

vs. endometrial stromal tumours 242

vs. granulosa cell tumour 249

adenosis

atypical apocrine 262, 373

microglandular 262

prostate 220–1

sclerosing (breast) 262

sclerosing (prostate) 221

sclerosing (salivary) 134

vaginal 232

adenosquamous carcinoma (ASC) 92

ADH 258–9

adipose 313–15

adiposis dolorosa 281

adnexal tumours 292–4

adrenal medullary chromafﬁn

paraganglioma 276

adrenal pathology 53–4, 275–7, 383

adrenocortical adenoma 275–6

adrenocortical carcinoma (ACC)

275–6

adrenocorticotrophic hormone

(ACTH) 275, 278

adult

granulosa cell tumour 249

large bile duct obstruction 164

renal tumours 49

respiratory distress syndrome 383

T-cell leukaemia 115–16

advanced practitioners 359

adventitious bursa 342

AFP 19

age-related changes 68, 75, 196–7,

201

age-related macular degeneration

(AMD) 196–7

Agenda for Change 24–5

aggressive

angiomyxoma 317

osteoblastoma 335

AIDS cholangiopathy 165

AIDS-associated malignancies

347

AIDS-deﬁning illnesses (ADI) 346,

364

AIN 152

air embolism 390

Albers-Sch¨onberg marble bone

disease 330

Alcian blue 12

alcoholic

ﬁxatives 7

gastropathy 137

hepatitis 157

steatohepatitis 157

alimentary tract 126–55

alkaline phosphatase (ALP) 11, 15,

53, 332, 336, 337

ALL 16, 97, 101, 103–5, 228, 253

allograft rejection see transplants

alopecia 295

ALP 11, 15, 53, 332, 336, 337

Alport’s disease 205

alveolar

capillary dysplasia 56

pathology 58

radial counts 393

soft part sarcoma 323

Alzheimer’s disease 181

AMD 196–7

ameloblastic ﬁbroma 128–9

ameloblastoma 128

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

JWBK208-IND-II December 14, 2007 13:30 Char Count= 0

Index of General Terms 396

AML 103, 4, 16, 99–104, 107–8, 123,

300

amnion nodosum 63

ampulla of Vater 46

amputation neuroma 317

amyloid 11

angiopathy 72

colonic 146

eye 194

skin 300

tumour 94, 194

anal canal 152

anal intra-epithelial neoplasia (AIN)

152

analgesic nephropathy 206

anaphylaxis 382

anaplastic

astrocytoma 185

carcinoma 272, 368

large cell lymphoma 105, 109, 116

meningioma 186

myeloma 109

oligo/oligoastrocytoma 186

seminoma 225

Wilms’ tumour 60

anatomy 36–43

ancillary techniques 362–3

ancillary tests 387

androgen blockade therapy 224

aneurysmal bone cysts (ABC) 331,

333

aneurysms 72–3

angina 75

angioblastoma of Nakagawa 319

angiocentric

lymphoid proliferations 91

T-cell lymphoma 115

angiodysplasia 148

angiofollicular lymph node

hyperplasia 119–20

angiography 386

angioimmunoblastic

lymph node reaction 115

lymphadenopathy with

dysproteinaemia 115

T-cell lymphoma 115

angiokeratoma circumscriptum 285

angioleiomyolipoma 314

angiolipoma 313

angiolymphoid hyperplasia with

eosinophilia 318

angiomatosis 319–23

angiomyoﬁbroblastoma 317

angiomyolipoma 216, 314

angiomyxoma 317–18

angiosarcoma 320–1

ankylosing spondylitis 194

anti-rejection drug toxicity 209–10

antibodies

anticardiolipin 351

antiphospholipid antibody

syndrome 61–2, 351

layering methods 9

site selective 363

anticardiolipin antibody 351

antigens 19, 107–9

antiphospholipid antibody syndrome

61–2, 351

aortic dissection 73

aphthae 126–7, 144–5

apical granuloma 128

apocrine carcinoma 293

aponeuroses 323–4

appendix 46, 152

applied anatomy 36–43

appraisals 32

arachnoid nodules 94

ARDS 383

Arias-Stella reaction 232, 236, 237,

253

arrhythmogenic right ventricular

dysplasia (ARVD) 78, 385

artefact(s)

acetic acid 357

air bubbles (vs. air embolism) 390

alcohol ﬁxation 7

birefringent particles (in synovial

ﬂuid) 375

capsule/halo (in Histoplasma) 345

cirrhosis and 161

cracks (in FCL) 112

crush (in carcinoid/SmCC/spinal

cord) 93, 389

dyscohesion (in breast FNA) 371,

373

dysplasia vs. 136

erosion vs. 127

FNA / needle track 265, 269

formalin ﬁxation (unbufferred) 7,

383

frozen section 4

ice crystal (in muscle) 43, 189

iodine (and CIN) 233

liver 156

mercurial ﬁxation 16

nuclear clearing (due to

biotin/ﬁxation) 267, 270, 272

RBCs in alveoli 87

retraction (in lacunar cells) 4, 117

sampling (in muscle Bx) 189

sclerosing HCC (footnote) 171

sickling of RBCs 383

smearing (vs. vascular invasion) 205

spindling (in Ewing’s) 336

tangiential sectioning 205

thick section (syncytial knots) 61

arterial

dissection 73

embolism 390

pathology 68, 69

pulmonary hypertension 88

arteriohepatic dysplasia 164

arterioles/arteriolosclerosis 68, 69

arteriosclerosis 68

arteritis 44, 69, 70

arthritis 340–1

articular pathology 339–42

ARVD 78, 385

ASAP/ASAPUS 222

asbestos bodies 86, 48, 371

asbestosis 85–6

ascending cholangitis 166–7

ASH 157

Askin tumour of chest wall 58

Aspergillus spp. 22, 345, 370

asthma 86

astrocytoma 185

asymptomatic proteinuria 201

atherosclerotic aneurysms 72

atrophy 358

atypical

acinar cell nodules 177

adenomatous hyperplasia 91, 220–1

adenomatous nodules 171

decubital ﬁbroplasia 311

ductal hyperplasia 258–9

ﬁbroxanthoma 325

haemangioma of the breast 320

hyperplasia 51, 238

lipoma 313

lobular hyperplasia 262

nodular proliferations in a

congenital naevus 288

polypoid adenomyoma 239

small acinar proliferations 222

vascular lesions post radiotherapy

320

aural polyp 199, 319

autoimmune

diseases 86–7

hepatitis 161

pancreatitis 175

plexopathy 154

sialadenitis 132–3

autopsy 3, 23, 377–94

limited 386–7

performance

recommendations/guidance 378

perinatal 392–3