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Dr.Ejaz Waris 200 points of Special Pathology you can`t afford to miss


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1.Key processes in atherosclerosis are intimal thickening and lipid accumulation.
2.Atherosclerotic plaque consists of 3 components: a)cells ,including SMCs,macrophages,and leukocytes,b)ECM and c)Intracellular and extracellular lipid.These components are arranged in central core and fibrous cap.
3.The two most important causes of aortic aneurysms are atherosclerosis and cystic medial degeneration of the arterial media.
4.ANCA are antineutrophil cytoplasmic antibodies seen in patients with vasculitis.c-ANCA are seen in Wegener’s granulomatosis and p-ANCA seen in Microscopic polyangiitis and Churg-Straus syndrome.
5.Vasculitis are divided into three types : large vessel including giant cell and takayasu’s ( granulomas),medium vessel including PAN(fibrinioid necrosis ) and Kawasaki’s disease and small vessels including Wegener’s,ChurgStrauss syndrome and Microscopic polyarteritis.
6.Lobular capillary hemangioma ( Pyogenic granuloma ) is a common oral benign tumor occurring as polypoidal form attached to mucosa.
7.Vascular immunomarkers include: CD31,CD34 and vWF.
8.Kaposi’s sarcoma is the most common AIDS associated cancer in US.The lesion is caused by KSHV and shows three morphological stages : Pact,Plaque and nodule.(PPN).
9.In Myocardial infarction,coagulation necrosis starts in 4 to 12 hrs and collagen deposition starts in 10 to 14 days.
10.Myxoma is the most common primart tumor of heart in adults and Rhabdomyoma is most commonest in children.
11.Aschoff bodies ,pathognominic of Rheumatic fever,are foci of swollen eosinophilic collagen surrounded by lymphocytes ,occasional plasma cells and plump macrophages called Anitschkow cells.
12.The thalassemia syndromes are a heterogenous group of inherited disorders caused by genetic lesions leading to decreased synthesis of either the alpha or beta globin chain of HbA.
13.Causes of enlarged lymph node include : Reactive lymph node enlargement,Infections – commonest is Tuberculosis and Malignancies which may be primary ( Lymphoma ) or metastatic.
14.Papillary carcinoma is the commonest thyroid malignancy,linked with history of childhood radiation.Diagnosis rests on nuclear features ,the nuclei typically are optically clear ( empty)-Orphan Annie appearance,show intranuclear inclusions and intranuclear grooves.
15.Scharff Bloom Richardson system grades the Breast carcinoma.It includes : a ) tubule formation ,
b ) no of mitoses and c)atypia and pleomorphism.
16.Medullary Carcinoma is linked with amyloid deposition.
17.Meningiomas are divided into 3 categories:a) simple benign type ( WHO grade 1),b)atypical –show 4 to 19 mitoses / 10HPF or show 3 of following 5 features: hypercellularity,macronucleoli,necrosis,patternless sheet like arrangement and small cell components with high N/C ratio.,c) Malignant type – more than 20 mitoses per 10 HPF or loss of differentiating features.
18.Syncitial,transitional,fibroblastic,psamommatous and secretory types fall into type 1,Clear cell and chordoid types of meningiomas fall into atypical variety and Papillary and Rhabdoid types fall into malignant variety.
19.Dukes stage C refers to involvement of lymph nodes in carcinoma of the large bowel.
20.Rosenthal fibers,eosinophilic granular bodies and microcysts are seen in low grade Pilocytic astrocytoma.
21.WHO grading of Astrocytoma include : Grade I: low grade , Grade II: Diffuse fibrillary,Grade III: Anaplastic ( mitoses and endothelial proliferation) and Grade IV : Glioblastoma Multiforme ( necrosis).
22.Leiomyomas are differentiated from leiomyosarcoma on three basis ; atypia , necrosis and number of mitoses ( < 5/10HPF: Leiomyoma,5-9/10HPF : Borderiine STUM P and > 10/10HPF: Leiomyosarcoma).
23.Synovial Sarcoma shows dual line of differentiation ( both epithelial like and spindly mesenchymal cells are seen ).
24.Reed Sternberg cell is the hall mark of Hodgkin’s Lymphoma .Immunomarker is CD 15 and CD 30.The thought of origin is post germinal center B-Cell.
25.Giant cell tumor of bone consists of Mononuclear stromal cells ( the main neoplastic element ) and evenly placed multinucleated giant cells.
26.Tophi are pathognomonic hallmark of gout,consisting of large aggregates of urate crystals surrounded by an intense inflammatory reaction of macrophages,lymphocytesand large foreign body giant cells.
27.Indian file pattern of tumor cells with monomorphic morphology is seen in Infiltrating lobular carcinoma of breast.
28.Rheumatoid nodules consist of central zone of fibrinioid necrosis surrounded by a prominent rim of epithelioid histiocytes and numerous lymphocytes and plasma cells.
29.Ewing Sarcoma (PNET) of bone consists of malignant round to oval tumor cells with cytoplasm containing glycogen.Immunomarker is CD99(MIC-2)
30.Osteosarcoma is confirmed by the presence of malignant lace like osteoid surrounded by tumor cells.
31.The histologic hall mark of Paget’s disease of bone is mosaic pattern of lamellar bone.
32.Peripheral palisading is seen in nests of tumor cells in Basal cell carcinoma ( Rodent ulcer).It is locally aggressive tumor,which rarely metastasize.Immunomarker is BER-EP4.
33.Lupus nephritis is of 6 classes : Class 1: no change , class II:
34.Malignant Melanoma shows two patterns of growth : radial and vertical.The nature and extent of the vertical growth phase determine the biologic behavious of malignant melanoma.
35.Follicular carcinoma of thyroid is confirmed by capsular and vascular invasion by tumor cells.
36.Laurens classification of gastric carcinoma include diffuse (signet ring cells) and intestinal types.
37.Adenoma is the commonest tumor Pituitary gland.
38.Fibroadenoma is commonest benign tumor of breast in young females.
39.Invasive ductal carcinoma of breast is the commonest malignant tumor of breast.
40.Carcinoid tumors common sites include small intestine and tip of appendix.The cells are monomorphic with abundant granular cytoplasm.Immunomarkers include Chromogranin and synaptophysins.
41.Chronic cholecystitis is the inflammation of gall bladder revealing subepithelial fibrosis and chronic inflammation in the lamina propria.
42.Hydatidiform mole is characterized by cystically dilated avascular chorionic villi with trophoblastic proliferation.
43.Choriocarcinoma shows no chorionic villi.
44.Panacinar emphysema is linked with alpha 1 antitrypsin deficiency.
45.Reid index is the ratio of thickness of the mucous gland layer to the thickness of the wall between the epithelium and cartilage.It is increased in Chronic bronchitis.
46.Bronchiectasis is a disease characterized by permanent dilation of bronchi and bronchioles caused by destruction of the muscle and elastic tissue resulting from or associated with chronic necrotizing infections.
47.Asbestos is linked with Mesothelioma and Bronchogenic Carcinoma.
48.Barett’s esophagus is linked with esophageal adenocarcinoma,characterized by goblet cells and villous morphology.
49.Pleomorphic adenoma is the commonest benign tumor of salivary gland.
50.Seminoma is the commonest malignant tumor of testis in adults.It is the most radiosensitive.
51.Helicobacter pylori is linked with chronic gastritis,peptic ulcer disease,gastric carcinoma and gastric MALT lymphoma.
52.Active inflammation is signified by the presence of neutrophils within the glandular and surface epithelial layer.
53.Ulcerative colitis is characterized by pseudololyps,superficial ulcers,cryptitis,crypt destruction,crypt distortion and crypt abscess formation.
54.Crohn’s disease is characterized by strictures,transmural inflammation,deep linear ulcers,sinuses and granulomas.
55.Cirrhosis of liver is characterized by nodules of variable sizes composed of benign hepatocytes and separated by thin fibrous tissue septae infiltrated by chronic inflammatory cell infiltrate.Active cirrhosis means the presence of piecemeal necrosis.
56.Knodell Score is done to evaluate the grade and stage of hepatitis comprises of : portal inflammation,piecemeal necrosis,intralobular inflammation and fibrosis.Total score is 24.
57.Metavir score is another criteria of grading and staging of liver activity.It comprises of A for activity and F for fibrosis.
58.Gleason Score is done for the grading of Prostatic adenocarcinomas.
59.Perineural invasion is depicted by prostatic and pancreatic adenocarcinomas.
60.Furrhman Grading is done for Renal cell carcinoma.
61.All patterns of Hepatocellular carcinomas have a strong propensity for invasion of vascular channels.
62.Crescents are seen in rapidly progressive glomerulonephritis,diffuse thickening of the glomerular capillary wall with silver spikes are seen in membranous glomerulonephritis and focal thickening of glomerular basement membrane with silver tram track appearance is seen in membranoproliferative glomerulonephritis.
63.Diabetic glomerulosclerosis is characterized by capillary basement membrane thickening,diffuse mesangial sclerosis ,kimmelstiel-wilson nodules (PAS positive),capsular drops and fibrin caps
64.Chronic pyelonephritis is characterized on gross examination by a corticomedullary scar and on microscopy by tubular atrophy and dilation,thyroidization and chronic interstitial inflammation.
65.Acute pyelonephritis is characterized by patchy interstitial suppurative inflammation,intratubular aggregates of neurtophils and tubular necrosis.Three complications include three P’s: Papillary necrosis,pyonephrosis and perinephric abscess.
66.Multiple Myeloma is characterized by bence jones proteinuria,cast nephropathy,hypercalcemia,hyperuricemia and light chain deposition disease.
67.Hyaline arteriosclerosis is benign hypertensive vascular change showing thickening and hyalinization of the walls with narrowed lumina of small vessels.Hyperplastic arteriosclerosis is malignant vascular hypertensive change showing fibrosis with onion skin type layering of wall.
68.Renal cell carcinoma is of 4 major types: clear cell – the most common type,papillary ,chromophobe and bellini duct carcinoma.
69.Renal cell carcinoma has the tendency to metastasize widely before giving rise to any local symptoms or signs.
70.WHO grades Transitional cell tumors into Urothelial papilloma,urothelial neoplasm of low malignant potential,low grade papillary urothelial carcinoma and high grade papillary urothelial carcinoma.
71.PT1 is for lamina propria and PT2 is for muscle wall invasion in Transitional cell tumors.
72.Seminomatous germ cell tumors are radiosensitive and chemo responsive while non seminomatous tumors are vice versa.
73.Yolk sac tumor shows Schiller Duval bodies,Granulosa cell tumor shows Call exner bodies.
74.Immature or malignant teratomas show sheets of undifferentiated cells,not seen in a benign teratoma.Teratomas in males are malignant,unless proved otherwise.
75.Alpha fetoprotein is the tumor marker of HCC and CEA is the tumor marker of carcinoma of the colon.
76.Human Papilloma Virus is the etiologic agent of Squamous cell carcinoma of the cervix ,the most common cervical carcinoma.( types 16,18,31,33).
77.Bethesda system divided into ASCUS- atypical suamous cells of undetermined significance,LSIL-low grade squamous intraepithelial lesion( Koilocytosis and mild dysplasia) and HSIL – High grade squamous intraepithelial lesion ( Moderate and severe).
78.Dysgerminoma is the counterpart of seminoma in females.
79.Tubular carcinoma of breast carries the best prognosis.
80.ER – PR postivie breast carcinomas carry better prognosis and are responsive to antiestrogen drugs.HER-2/neu positive tumors carry poor prognosis.
81.Squmaous cell carcinoma is characterized by sheets and groups of pleomorphic malignant squamous epithelial cells with hyperchromatic nuclei and pale cytoplasm.Individual cell keratinization.intracellular bridges and keratin epithelial pearls are seen.
82.Cytokeratin is the immunomarker for epithelial tumors and Vimentin is the marker for mesenchymal tumors.Desmin is positive in skeletal muscle tumors.Melan-A and HMB45 is positive for Melanomas.LCA is the universal leukocyte marker.
83.CD19,CD20 AND CD79a is positive in B-cells and CD 2,3,4,5 in T cells.
84.Adenocarcinomas are characterized by back to back glandular structures lined by pleomorphic malignant epithelial cells with hyperchromatic nuclei and eosinophilic cytoplasm.Glandular wall sharing is one of the hall mark sign of adenocarcinomas.
85.Acute appendicitis is depicted by the presence of neutrophils in the muscularis layer.
86.Small cell carcinoma of the lung shows maximum paraneoplastic syndromes – most common cushing like picture and ADH like morphology.Hypercalcemia is shown by squamous cell carcinoma of lung.
87.Hodgkin’s Lymphoma is divided into five types : one set include Lymphocyte rich,lymphocyte depletion,nodular sclerosis and mixed cellularity ( CD 15 +,CD 30 +).The separate set includes nodular lymphocyte predominance ( CD45 +).
88.Burkitt’s lymphoma carries 100% mitotic index.
89.Benign prostatic hyperplasia includes two components : Glandular and fibromuscular.DHT is the source of hyperplasia.
90.Endometriosis is the presence of normal endometrial glands,stroma and hemosiderin laden macrophages outside uterus.
91.Calretenin is the immunomarker for mesothelioma.Epithelioid and sarcomatoid types are noted in a mesothelioma.
92.Squamous cell carcinoma of lung is strongly associated with smoking.
93.PTEN is the antioncogene altered in endometrial hyperplasia and adenocarcinoma.Simple and atypical are two types of endometrial hyperplasia.EIN is the new term assoiated with endometrial hyperplasia.Endometrial carcinoma arises on two backgrounds: hormone dependent with good prognosis and vice versa with poor prognosis(clear and papillary types).
94.The primary feature of primary biliary cirrhosis is the non suppurative inflammatory destruction of medium sized intrahepatic bile ducts.90% patients are positive for antimitochondrial antibodies.
95.Hashimoto’s thyroiditis shows lymphoid follicles with germinal centers and hurthle cells.DeQuervain’s type shows presence of granulomas.
96.Pheochromocytoma is composed of polygonal to spindle shaped chromaffin cells clustered with the sustentecular cells into small nests of alveoli ( Zell ballen appearance) by a rich vascular network.

97.MEN TYPE 1 or Wermer syndrome shows abnormalities in 3 P’s : Parathyroid,pancreas and pituitary.MEN -2A or Sipple syndrome shows pheochromocytoma,medullary carcinoma thyroid and parathyroid hyperplasia.MEN2-B is same as 2A,with the exception of parathyroid involvement.
98.Round blue cell tumors of childhood include tumors with blue cell morphology with scanty cytoplasm,e.g Lymphoma,Neuroblastoma,Medulloblastoma and Retinoblastoma etc.
99.Chicken wire calcification is seen in chondroblastoma.
100.Antoni A cellular areas and Antoni B myxoid areas are seen in Schwanommas.
Few Characteristics Exclusive to Lesions – Rapid revision:
101.Peripheral Palisading – Basal cell carcinoma.
102.Pseudopalisading in tumor – GBM.
103.Whorls like arrangement – Meningioma.
104.Signet ring cells – Poorly differentiated mucin secreting adenocarcinoma.
105.Keratin pearls – Squamous cell carcinoma.
106.Verocay bodies ( Antoni A and B ) – Schwanomma.
107.Call exner bodies – Granulosa cell tumor.
108 .Psamomma bodies – Papillary carcinoma thyroid,Papillary serous ovarian tumors,Meningioma.
109.Capsular / vascular invasion – Follicular carcinoma thyroid.
110.Amyloid – Medullary carcinoma thyroid.
111.Osteoid formation – Osteosarcoma.
112.Chicken wire calcifications – chondroblastoma.
113.Schiller Duval bodies – Yolk sac tumor.
114.Indian file pattern – Lobular carcinoma breast.
115.Piecemeal necrosis – Chronic active hepatitis.
116.Mallory bodies – Alcoholic cirrhosis.
117.Stellate cells – Cardiac myxoma.
118.Oat cells – Small cell carcinoma lung.
119.Hair in tumor – Benign cystic teratoma ( dermoid cyst )
120.Reed Sternberg cells – Hodgkin’s Lymphoma.

Typical descriptions / Key Points of Few common major Lesions :

121.Carcinoid tumor : nests,aggregates and packets of monomorphic cells with round to oval nuclei and granular cytoplasm.Chromogranin positive.
122.Adenocarcinoma : Back to back closely packed gland like structures lined by pleomorphic malignant epithelial cells with hyperchromatic nuclei and eosinophilic cytoplasm.Wall sharing is noted.
123.Squamous cell carcinoma : sheets and clusters of pleomorphic malignant squamous epithelial cells with hyperchromatic nuclei and pale cytoplasm.Keratin epithelial pearls,intercellular bridges and individual cell keratinization are seen.
124.Hemangioma : Aggregates of closely arranged thin walled vascular channels lined by benign endothelium and separated by scanty fibrous stroma.
125.Angiosarcoma: Sheets of malignant oval to spindly cells with hyperchromatic nuclei.Mitoses are noted.
126.Sarcoma : Sheets of malignant oval to spindly cells with hyperchromatic nuclei .Abnormal mitoses and focal necrosis is noted in high grade sarcomas.
127.Papillary carcinoma thyroid : Papillary structures with fibrovascular cores lined by pleomorphic malignant epithelial cells with Orphan Annie nuclei.Nuclear Grooves are seen.Psamomma bodies are present.
128.Seminoma : Sheets and groups of seminoma cells with hyperchromatic vesicular nuclei and water clear cytoplasm.These tumor cells arranged in lobules separated by fibrous tissue septae infiltrated by lymphocytes.
129.Yolk sac tumor : sheets and nests of pleomorphic malignant oval to polygonal cells forming schiller duval bodies.Eosinophilic secretions are noted.
130.Meningioma : whorls and bundles of oval to fusiform to polygonal cells with regular nuclei.Psamomma bodies may also be seen.
131.Non Hodgkin’’s Lymphoma : Sheets of monotonous population of atypical lymphoid cells with hyperchromatic nuclei and scanty cytoplasm.Mitoses are noted.
132.Hodgkin’s Lymphoma : Heterogenous population of cells including lymphocytes,plasma cells,macrophages and eosinophils ( Characteristic feature).Reed Sternberg cells are hall mark.
133.Basal cell carcinoma ( Rodent ulcer ) ; Nests and groups of pleomorphic basaloid cells with hyperchromatic nuclei and scanty cytoplasm.Peripheral palisading is noted at the periphery of nests.Mitoses can be seen.
134.Malignant melanoma : Sheets of malignant oval to polygonal cells with hyperchromatic nuclei and prominent pink nucleoli.Pigment deposition is noted.
135.Ductal carcinoma breast : Ductal structures,sheets and groups of pleomorphic malignant epithelial cells with hyperchromatic nuclei and eosinophilic cytoplasm .
136.Liver cirrhosis : Nodules composed of benign hepatocytes separated by thin fibrous tissue septae.
137.Teratoma : Cystic lesion lined by benign stratified squamous epithelium and cyst wall showing hair follicles,sebaceous glands.Other types of tissue like nervous,thyroid tissue can be seen.
TYPICAL immunomarkers :
138. Cytokeratin – Carcinomas.
139.Vimentin – Sarcomas.
140.S-100 – Melanoma , nEural marker.
141.Melan – A.Malignant melanoma.
142.Desmin – Muscle marker.
143.LCA – Leukocyte common antigen – Lymphomas.
144.Chromogranin – Neuroendcrine marker ,carcinoid.
145.CD 15 & CD 30 – Reed Sternberg cells / Hodgkin’s.
146.CD19,CD20,CD79a – B cell Lymphoma Marker.
147.CD3,4,5 ,8 – T cell Lymphoma Marker.
Famous GRADING / STAGING to be Learnt by heart:
148.Bloom Richardson grading : Breast carcinoma.
149.Gleason’s Score : Carcinoma Prostate.
150.Duke’s Staging : Carcinoma colon .
151.TNM Staging of Lung.
152.Fuhrmann’s Grading : Renal cell carcinoma.
153.Knodell score : Chronic hepatitis / cirrhosis / liver activity.
154.FIGO grading / staging : Carcinoma endometrium and cervix.
155.Meningioma : WHO grading.
156.WHO grading of Astrocytoma.
157.Lauren’s Classification : carcinoma stomach.
158.Hodgkin’s Lymphoma staging. ( Ann Arbor)
Important DIFFERENTIAL DIAGNOSIS in special pathology “
159. Cold nodule thyroid : Benign hyperplastic colloid nodule,follicular adenoma,Carcinoma thyroid, thyroid cyst / nodule.
160.Enlarged cervical lymph node : Reactive lymph node enlargement ,Tuberculous lymph node,Lymphoma , Metastatic malignancy.
161.Lump Breast in 40 yrs old female : Carcinoma breast,fibrocystic disease,fibroadenoma,non specific abscess.
162.Posterior fossa brain tumors : Medulloblastoma,pilocytic astrocytoma,meningioma,schwanomma.
163.Ulcer Intestine : Tuberculosis,Typhoid,Inflammtory bowel disease,Carcinoma,Perforation.
164.Brown black pigment in liver : Haemochromatosis,Bile pigment in cholestasis,lipofuscin pigment in aging,fomalin pigment,metastatic melanoma.
165.follicle like arrangement in thyroid : Follicular adenoma,follicular carcinoma,follicular variant of papillary carcinoma thyroid.
Some other Last Points in Special Pathology not to be missed:
167.Active gastritis or colitis means presence of polymorphs .
168.crypt abscess means presence of collections of neutrophils in glands or crypts lumen.
169.Clinical outcome of a malignant tumor rests mainly on staging/lymph node invasion / mets.
170.LFT’s mean Serum billirubin,SGOT,SGPT,serum albumin,LDH.
171.RFT’s mean BUN and serum creatinine.
172.Thyroid function tests include TSH,T4,T3.
173.Cardiac Profile include : Troponin,Creatine Kinase ,LDH.
174.Lipid Profile include : Cholesterol,HDL,LDL,VLDL,Triglycerides.
175.Special Liver stains include : PAS,PAS-D,Reticulin.
176.Methenamine silver and PAS stains are done for kidney biopsies to see thickening of basement membrane of capillaries.
177.ZN stain is done to look for AFB ( Acid fast bacillus ) in Tuberculosis.
178.Van gieson and masson trichrome stains are done to look for collagen fibers / fibrosis.
179.Alcian blue is the stain used to look for mucin.
180.GMS stain is done for fungus. ( Gomori methenamine silver )
181.Sudan black and Oil Red 0 are special stains for fat.
182.Perls Prussian blue stain is used to look for iron.
183.The most frequent causes of mild anemia with hypochromia and microcytosis are iron deficiency anemia,the anemia of chronic disease and b thallesemia minor.
184.The granulomas of sarcoidosis are characteristically non caseating.
185.The hallmark of the megaloblastic anemia is the finding of megaloblastic erythroid hyperplasia in the bone marrow.
186.Nodular melanoma has two pattern of growths,horizontal and vertical.It tends to spread vertically more than horizontally.
187.The majority of salivary gland tumors occur in parotid and most common tumor is Pleomorphic adenoma.
188.Adenoid cystic carcinoma is a common malignant salivary gland tumor.
189.Biopsy is always preferable over FNAC.
190.Biopsies are of many types : Excision biopsy,Trucut biopsy,Incisional biopsy.
191.Routine histopathological stain is Haematoxylin and Eosin.
192.Routine cytological stain is Giemsa and Papanicoalau( for nucleus ).
193.Common Histo fixative is 10 % Formalin.
194.Common Cytology fixative is 95% ethyl alcohol.
195.Special stains / Immunostains are needed when diagnosis cannt be made with a Routine stain.
196.Kaiserling solution is used to keep specimens fixed in museums for long term.
197.When give Differential diagnosis of any lump always go in this order : infections,benign tumors and than malignant tumors.
198.FNAC common sites for superficial lumps – lymph nodes,salivary glands,thyroid and breast.
199.FNAC deep lumps common sites include – Liver,lung and abdominal lymph nodes.
200.FNAC of deep seated lumps need help of Ultrasound /CT.

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