cpcils with answers

8/12/2019 CPCils With Answers

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CPCils With Answers


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Chapter 1 : Cell Injury


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YEAU MING SONGMBBS 2008/2013

Slide 27D Liver - Fatty change (H&E x 10)This slide of liver shows extensive areas of fatty change in which you can seemacrovesicular cytoplasmic vacuoles which are large and clear owing toaccumulation of lipids and this is compressing and displacing the nucleus of thehepatocytes to the periphery of the cell. There is therefore a striking resemblance toadipose tissue cells. Areas of congestion are also seen with pigment in the sinusoids.The portal tracts show sparse inflammatory infiltrates.

Case 1: This is a section of liver of a 25 year old Chinese male engineer who had 6 beers at a bar. Despite being drunk, he ignored his friends advice to take ataxi home, and sped off on his Harley Davidson bike. He crashed into alamp post and at the A&E unit he was found to be dead on arrival.

Q1: What do you expect the liver to look like grossly? E E E nnn lll aaa r r r ggg eee , , , y y y eee lll lll ooo www , , , ggg r r r eee aaa sss y y y &&& sss ooo f f f t t t

Q2: What do you seen in section of his liver? N N N uuu ccc lll eee iii aaa r r r eee d d d iii sss p p p lll aaa ccc eee d d d p p p eee r r r iii p p p hhh eee r r r aaa lll lll y y y C C C lll eee aaa r r r lll iii p p p iii d d d vvvaaa ccc uuu ooo lll eee iii nnn sss iii d d d eee p p p aaa r r r eee nnn ccc hhh y y ymmmaaa lll ccc eee lll lll sss ccc y y y t t t ooo p p p lll aaa sss mmm

Q3: How would you classify this liver injury? Is it reversible or irreversible?F F F aaa t t t t t t y y y ccc hhh aaa nnn ggg eee , , , R R R eee vvveee r r r sss iii bbb lll eee iii nnn j j j uuu r r r y y y

Intracellular accumulations of a variety of materials can occur in response to cellularinjury. Here is fatty metamorphosis (fatty change) of the liver in which derangedlipoprotein transport from injury (most often alcoholism) leads to accumulation oflipid in the cytoplasm of hepatocytes.

Liver Necrosis in amoebic abscess Large are of necrosis in liver parenchyma Necrotic tissue is pale in colour, structureless & friable loss of norm

architecture Irreversible change


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Slide 7C - Lymph node Coagulative necrosis (H&E x 20)

Case 2: This section shows a large area of coagulative necrosis. This typeof necrosis is seen in tuberculosis where it is also know ascaseation necrosis.

Q1: What are the morphological characteristics of necrotic tissue?DDDeee aaa d d d ccc eee l l l l l l sss , , , bbb aaa sss iiiccc t t t iii ssssssuuu eee aaa r r r ccchhh iii t t t eee ccc t t t uuu r r r eee iii sss p p p r r r eee sss eee r r r v v v eee d d d , , , f f f iii r r r mmm t t t eee x x x t t t uuu r r r eee , , , d d d eee nnn aaa t t t uuu r r r aaa t t t iiiooo nnn ooo f f f sss t t t r r r uuu ccct t t uuu r r r aaa l l l p p p r r r ooo t t t eee iiinnn sss &&& eee nnn z z z y y y mmm eee sss sss ooo bbb l l l ooo ccc k k k sss p p p r r r ooo t t t eee ooo l l l y y y sss iiisss ooo f f f d d d eee aaa d d d ccc eee l l l l l l sss , , , eee ooo sss iiinnn ooo p p p hhh iiil l l iii ccc , , , aaa nnn uuu ccc l l l eee aaa t t t eee ccc eee l l l l l l sss , , , iii nnn f f f l l l aaa mmm mmm aaa t t t ooo r r r y y y iii nnn f f f iii l l l t t t r r r aaa t t t eee ( ( ( nnn eee uuu t t t r r r ooo p p p hhh iii l l l sss ) ) )

Q2: How would you classify this type of injury? Is it reversible orirreversible?

I I I r r r r r r eee vvveee r r r sss iii bbb lll eee

Q3: Name other types of necrosis. L L L iii qqq uuu eee f f f aaa ccc t t t iii vvveee nnn eee ccc r r r ooo sss iii sss , , , ggg aaa nnn ggg r r r eee nnn ooo uuu sss nnn eee ccc r r r ooo sss iii sss , , , ccc aaa sss eee ooo uuu sss nnn eee ccc r r r ooo sss iii sss , , , f f f aaa t t t nnn eee ccc r r r ooo sss iii sss , , , f f f iii bbb r r r iii nnn ooo iii d d d nnn eee ccc r r r ooo sss iii sss

Microscopic, caseous necrosis is characterized by acellular pink areas of necrosis, asseen here at the upper right, surrounded by a granulomatous inflammatory process.

Lung Caseation necrosis in tuberculosis Apex of lung, an area of necrosis & a cavity seen Necrotic tissue is cream in colour, structureless, cheesy & crumbles easily Caseation necrosis is a form of coagulative necrosis found in tuberculosis Irreversible change


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Slide 11Q Kidney Amyloidosis (H&E x 10)This slide of kidney shows amyloid deposits in a glomeruli, around the tubules,around the blood vessel and in the interstitium. The glomerular (amyloid) depositsare mainly in the mesangium and around the capillary basement membrane wherethey appear as pink acellular material. The extent of involvement of glomeruli isvariable with some showing only mild or segmental involvement while others showalmost complete obliteration of the glomerular tuft by confluent masses ofinterlacing mesangial amyloid deposits. Around the blood vessels, the amyloiddeposits appear as broad pink bands of acellular material.

Case 3: This is a section of a kidney from a patient who suffered from leprosy for20 years and finally died from multi-organ failure

Q1: What is this hyaline material seen in the kidney? A A A mmm y y y lll ooo iii d d d

Q2: Where is this hyaline material located? D D D eee p p p ooo sss iii t t t sss iii nnn ggg lll ooo mmmeee r r r uuu lll iii ((( iii nnn t t t hhh eee mmm eee sss aaa nnn ggg iii uuu mmm &&& aaa r r r ooo uuu nnn d d d t t t hhh eee ccc aaa p p p iii lll lll aaa r r r y y y bbb aaa sss eee mmmeee nnn t t t mmmeee mmm bbb r r r aaa nnn eee ))) , , , aaa r r r ooo uuu nnn d d d t t t uuu bbb uuu lll eee sss , , , aaa r r r ooo uuu nnn d d d bbb lllooo ooo d d d vvveee sss sss eee lll &&& iii nnn t t t hhh eee iii nnn t t t eee r r r sss t t t iii t t t iii uuu mmm

Q3: What would you see if you polarized the section stained with CongoRed?

R R R eee d d d --- ggg r r r eee eee nnn bbb iii r r r eee f f f r r r iii nnn ggg eee nnn ccc eee

This Congo Red stain reveals orange-red deposits of amyloid, which is an abnormalaccumulation of breakdown products of proteinaceous material that can collectwithin cells & tissues

Kidney - Infarct Wedged-shaped areas of infarction are present These areas of necrosis are pale, lack form & are sharply demarcated from the

adjacent viable tissue. Irreversible change


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Slide 24A Appendix Acute appendicitis (H&E x 10)This slide shows complete destruction of the appendiceal mucosa and glands andinfiltration of the entire wall of the appendix by polymorphs. The mucosa iscompletely necrotic and inflammation extends into the periappendicial fatty tissue(periappendicitis).

Case 1: This is a section of the appendix of a second year medical student who presented with right iliac fossa pain, fever & nausea.

Q1: Identify & name the inflammatory cells seen in the sectionPPP ooo lll y y y mmm ooo r r r p p p hhh ooo nnn uuu ccc lll eee aaa r r r nnn eee uuu t t t r r r ooo p p p hhh iii lll sss , , , eee ooo sss iii nnn ooo p p p hhh iii lll sss

Q2: What type of inflammation is this? A A A ccc uuu t t t eee iii nnn f f f lll aaa mmm mmm aaa t t t iii ooo nnn

Q3: Explain the pathogenesis of this type of inflammationOOO bbb sss tttr r r uuu ccc ttt iiiooo nnn bbb yyy f f f eee ccc aaa llliiittt hhh (((hhh aaa r r r ddd sss tttooo nnn yyy mmm aaa sss sss ooo f f f f f f eee ccc eee sss ))) ,,, ggg aaa llllllsss tttooo nnn eee ,,, tttuuu mmm ooo r r r ooo r r r bbb aaa llllll ooo f f f www ooo r r r mmm sss (((OOO xxxyyyuuu r r r iiiaaa sss iiisss vvveee r r r mmm iiiccc uuu lllaaa r r r iiisss ))) ccc ooo nnn ttt iiinnn uuu eee ddd sss eee ccc r r r eee ttt iiiooo nnn ooo f f f mmm uuu ccc iiinnn ooo uuu sss f f f llluuu iiiddd bbb uuu iiilllddd uuu ppp iiinnn ttt r r r aaa llluuu mmm iiinnn aaa lll ppp r r r eee sss sss uuu r r r eee ccc ooo llllllaaa ppp sss eee ooo f f f ddd r r r aaa iiinnn iiinnn ggg vvveee iiinnn sss ooo bbb sss ttt r r r uuu ccc ttt iiiooo nnn &&& iiisss ccc hhh eee mmm iiiccc iiinnn j j juuu r r r yyy r r r eee sss uuu lllttt f f f lllaaa vvvooo r r r bbb aaa ccc ttteee r r r iiiaaa lll ppp r r r ooo llliiif f f eee r r r aaa ttt iiiooo nnn www iiittthhh iiinnn f f f lllaaa mmm mmm aaa tttooo r r r yyy eee ddd eee mmm aaa &&& eee xxxuuu ddd aaa ttt iiiooo nnn f f f uuu r r r ttt hhh eee r r r ccc ooo mmm ppp r r r ooo mmm iiisss iiinnn ggg bbb lllooo ooo ddd sss uuu ppp ppp lllyyy

Microscopically, acute appendicitis is marked by mucosal inflammation andnecrosis. Here, the mucosa shows ulceration and undermining by an extensiveneutrophilic exudate.

Appendix Acute appendicitis Appendix is swollen (cellular & fluid exudates) & reddish ( vascularity)

Acute inflammatorycellular exudates


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Compare this with normal appendix

Slide 10B - Skeletal muscle Abscess (H&E x 10)This slide shows skeletal muscle bundles on one side and fibrous tissue on the other.In between these 2 there is a large area occupied by numerous polymorphs. Some ofthe polymorphs are necrotic and in between the polymorphs, capillaries can be seen.These polymorphs are also separating the collagen bundles and infiltrating betweenthem. At one focus the polymorphs are going in between the skeletal muscle fibres.

Case 2: A 50 year old man who is known diabetic, complained of pain & swellingin left leg. On examination the swelling was red. Warm & tender. This is asection through the swelling

Q1: Explain the pathogenesis of this lesion? M M M iii ccc r r r ooo aaa nnn ggg iii ooo p p p aaa t t t hhh y y y bbb lll ooo ooo d d d f f f lll ooo www ccc eee lll lll sss d d d iii eee ((( iii sss ccc hhh eee mmm iii aaa ))) ggg lll uuu ccc ooo sss eee bbb aaa ccc t t t eee r r r iii aaa ggg r r r ooo wwwt t t hhh aaa bbb sss ccc eee sss sss ((( sss eee p p p sss iii sss )))

Q2: What is the main inflammation cell seen here? N N N eee uuu t t t r r r ooo p p p hhh iii lll sss

Q3: List the cardinal feature of inflammation & correlate them with thepathological changes

R R R uuu bbb ooo r r r ((( r r r eee d d d ))) vvvaaa sss ooo d d d iii lll aaa t t t iii ooo nnn bbb lll ooo ooo d d d f f f lll ooo www

D D D ooo lll ooo r r r ((( p p p aaa iii nnn ))) bbb r r r aaa d d d y y y k k k iii nnn iii nnn T T T uuu mmmooo r r r ((( sss wwweee lll lll iii nnn ggg ))) eee d d d eee mmm aaa , , , eee x x xuuu d d d aaa t t t eee C C C aaa lll ooo r r r ((( wwwaaa r r r mmm t t t hhh ))) vvvaaa sss ooo d d d iii lll aaa t t t iii ooo nnn F F F uuu nnn ccc t t t iii ooo lll aaa eee sss aaa ((( lll ooo sss sss ooo f f f f f f uuu nnn ccc t t t iii ooo nnn )))

Liver Fatty change Liver is diffusely enlarge, yellowish & feels greasy


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Slide 7C - Lymph node Tuberculosis (H&E x 10 & x 20)

This slide shows a lymph node with its nodal architecture preserved over only part ofcortex where lymphoid follicles are visible. The rest of node shows loss ofarchitecture due to large areas of cheesy (caseation) necrosis. Around these areas ofcaseation necrosis epithelioid cell granulomas are seen, some of which showLanghans giant cells while others show central necrosis in the centre of the nodealso show a lot of nuclear debris which appears as purple staining dots of variablesizes. The capsule is thickened over part of node and near this area the capsule isinfiltrated by lymphocytes, plasma cell, eosinophilis and polymorphs and somecaseating granulomas (periadenitis).

Case 4: A 29 year old Bangladeshi waiter presented with cough, night sweats and aswelling at the right neck region of 2 months duration. Chest X-ray showedapical cavitation & the Mantoux skin test was positive. A biopsy of rightcervical lymph node was done

Q1: Identify & name the characteristic pathological lesion seen in thissectionGGG r r r aaa nnn uuu lll ooo mmmaaa --- t t t y y y p p p iii ccc aaa lll nnn eee ccc r r r ooo sss iii sss iii nnn mmmiii d d d d d d lll eee ((( ccc aaa sss eee aaa t t t iii ooo nnn ))) --- uuu nnn ccc lll eee aaa r r r ccc eee lll lll mmm eee mmm bbb r r r aaa nnn eee --- r r r iii mmm mmm eee d d d bbb y y y eee p p p iii t t t hhh eee lll iii ooo iii d d d hhh iii sss t t t iii ooo ccc y y y t t t eee sss --- L L L aaa nnn ggg hhh aaa nnn sss mmmuuu lll t t t iii nnn uuu ccc lll eee aaa t t t eee d d d GGG iii aaa nnn t t t ccc eee lll lll sss ((( t t t y y y p p p iii ccc aaa lll hhh ooo r r r sss eee sss hhh ooo eee sss hhh aaa p p p eee )))

M M M uuu lll t t t iii nnn uuu ccc lll eee aaa t t t eee d d d GGG iii aaa nnn t t t ccc eee lll lll --- f f f ooo r r r mmm eee d d d bbb y y y f f f uuu sss iii ooo nnn ooo f f f mmm uuu lll t t t iii p p p lll eee eee p p p iii t t t hhh eee lll iii ooo iii d d d mmmaaa ccc r r r ooo p p p hhh aaa ggg eee sss

Q2: Draw a schematic diagram of this lesion & label its components


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The focal nature of granulomatous inflammation is demonstrated in this microscopicsection of lung in which there are scattered granulomas in the parenchyma. This iswhy the chest radiograph with tuberculosis or other granulomatous diseases is oftendescribed as "reticulonodular". A biopsy could miss such lesions from sampling error,too. Giant cells are a "committee" of epithelioid macrophages. Seen here aretwo Langhans type giant cells in which the nuclei are lined up around the periphery

of the cell. Additional pink epithelioid macrophages compose most of the rest of thegranuloma.
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Chapter 3 : Repair


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Slide 9E skin - Granulating wound (H&E x 4)The slide shows skin with an area of ulceration in the centre. On both ends of theulcer the epidermal lining can be seen. The ulcer shows a superficial zone of fibrinand inflammatory exudates and under this is a zone of granulation tissue whichconsists of capillaries of varying sizes. Polymorphs, plasma cells, lymphocytes anddeeper down, fibroblasts are also seen. The area of granulation tissue also shows alot of pink fluid like material (possibly plasma) that has probably oozed out of theleaky vessels of granulation tissue. The dermis underneath the intact skin on bothsides of the ulcer is also inflamed with many plasma cells and proliferating vessels.Some underlying adipose tissue (subcutaneous tissue) also seen.

Case 1: Imagine that a section through a surgical wound is taken. This is the tissueyou would see within the first week of the healing process.

Q1: Identify and name the tissue seen in the sectionU U U lll ccc eee r r r ggg r r r aaa nnn uuu lll aaa t t t iii ooo nnn t t t iii sss sss uuu eee

Q2: Name the components of this tissueF F F iii bbb r r r ooo uuu sss t t t iii sss sss uuu eee , , , vvvaaa sss ccc uuu lll aaa r r r t t t iii sss sss uuu eee , , , ooo eee d d d eee mmmaaa , , , mmmaaa ccc r r r ooo p p p hhh aaa ggg eee sss , , , lll y y ymmm p p p hhh ooo ccc y y y t t t eee sss , , ,

p p p ooo lll y y y mmm ooo r r r p p p hhh sss , , , p p p lll aaa sss mmmaaa ccc eee lll lll sss , , , f f f iii bbb r r r ooo bbb lll aaa sss t t t sss

Q3: List the stages of healing

111 ))) A A A ccc uuu t t t eee iii nnn f f f lll aaa mmmmmmaaa t t t iii ooo nnn 222 ))) PPP r r r ooo lll iii f f f eee r r r aaa t t t iii ooo nnn &&& mmm iii ggg r r r aaa t t t iii ooo nnn 333 ))) A A A nnn ggg iii ooo ggg eee nnn eee sss iii sss 444 ))) S S S ccc aaa r r r f f f ooo r r r mmmaaa t t t iii ooo nnn 555 ))) R R R eee mmmooo d d d eee lll iii nnn ggg

Healing of inflammation often involves ingrowths of capillaries and fibroblasts. Thisforms granulation tissue. Here, an acute myocardial infarction is seen healing. Thereare numerous capillaries, and collagen is being laid down to form a scar. Non-infarcted myocardium is present at the far le ft.At high magnification, granulation tissue has capillaries, fibroblasts, and a variable

amount of inflammatory cells (mostly mononuclear, but with the possibility of somePMN's still being present).
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Slide 1D Heart - Organizing Thrombus in Auricle (H&E x 4 & x 10)The slide shows cardiac muscle around a central irregular heamorrhagic space. Thisspace is partly lined by endothelium and around the areas of hemorrhage , thin wall

capillaries of varying sizes (some uncanalized) are proliferating along withinflammatory cells (constituting granulation tissue). The cardiac muscle adjacent tothe endothelium shows mild hydropic changes. One or two more hemorrhage-filledluminal spaces surrounded by cardiac muscle are also seen which, in some slides ,show organizing thrombi as described above.

Case 2: This is an example of thrombosis in the auricle of the heart. The formationof a fibrin clot gradually leads to blockage of the heart chamber.

Q1: Explain how the process of repair can improve this condition R R R eee p p p aaa iii r r r bbb y y y ccc ooo nnn nnn eee ccc t t t iii vvveee t t t iii sss sss uuu eee sss aaa ccc uuu t t t eee iii nnn f f f lll aaa mmmmmmaaa t t t iii ooo nnn mmm iii ggg r r r aaa t t t iii ooo nnn p p p r r r ooo lll iii f f f eee r r r aaa t t t iii ooo nnn ooo f f f f f f iii bbb r r r ooo bbb lll aaa sss t t t sss f f f ooo r r r mmmaaa t t t iii ooo nnn ooo f f f nnn eee www bbb lll ooo ooo d d d vvveee sss sss eee lll sss ((( aaa nnn ggg iii ooo ggg eee nnn eee

d d d eee p p p ooo sss iii t t t iii ooo nnn ooo f f f eee x x x t t t r r r aaa ccc eee lll lll uuu lll aaa r r r mmm aaa t t t r r r iii x x x ((( sss ccc aaa r r r f f f ooo r r r mmm aaa t t t iii ooo nnn ))) mmm aaa t t t uuu r r r aaa t t t iii ooo nnnhhh eee aaa lll iii nnn ggg ((( r r r eee mmm ooo d d d eee lll iii nnn ggg )))

Q2: Identify the granulation tissue. Name its componentsF F F iii bbb r r r ooo uuu sss t t t iii sss sss uuu eee , , , vvvaaa sss ccc uuu lll aaa r r r t t t iii sss sss uuu eee , , , ooo eee d d d eee mmmaaa , , , mmmaaa ccc r r r ooo p p p hhh aaa ggg eee sss , , , lll y y y mmm p p p hhh ooo ccc y y yt

p p p ooo lll y y ymmmooo r r r p p p hhh sss , , , p p p lll aaa sss mmmaaa ccc eee lll lll sss , , , f f f iii bbb r r r ooo bbb lll aaa sss t t t sss

Q3: Name another site where a similar situation may ariseC C C ooo r r r ooo nnn aaa r r r y y y aaa r r r t t t eee r r r y y y , , , ccc eee r r r eee bbb r r r aaa lll aaa r r r t t t eee r r r y y y , , , vvveee nnn ooo uuu sss t t t hhh r r r ooo mmm bbb ooo sss iii sss

A coronary thrombosis is seen microscopically occluding the remaining smalllumen of this coronary artery. Such an acute coronary thrombosis is often theantecedent to acute myocardial infarction.
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Chapter 4 : Thrombosis & Other Circulatory


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Slide 6S Lung - Pulmonary oedema (H&E x 10)This slide shows many of the alveolar spaces filled with pink fluid-like material. Thealveolar septae are congested. Some bronchioles are visible and the medium-sizedand large blood vessels are also congested.

Case 2: This is a section of lung of a patient who died of acute left ventricularfailure

Q1: Examine this slide A A A sss eee ccc t t t iii ooo nnn ooo f f f lll uuu nnn ggg ooo f f f aaa p p p aaa t t t iii eee nnn t t t wwwhhh ooo d d d iii eee d d d ooo f f f aaa ccc uuu t t t eee lll eee f f f t t t vvveee nnn t t t r r r iii ccc uuu lll aaa r r r f f f aaa iii lll uuu r r r eee

Q2: Explain the mechanism involved in the formation of pulmonaryoedema

L L L eee f f f t t t vvveee nnn t t t r r r iii ccc uuu lll aaa r r r f f f aaa iii lll uuu r r r eee p p p r r r eee sss sss uuu r r r eee t t t ooo lll eee f f f t t t aaa t t t r r r iii uuu mmm p p p uuu lll mmm ooo nnn aaa r r r y y y vvveee nnn ooo uuu sss p p p r r r eee sss sss uuu r r r eee p p p r r r eee sss sss uuu r r r eee iii nnn lll uuu nnn ggg mmm iii ccc r r r ooo vvvaaa sss ccc uuu lll aaa t t t uuu r r r eee p p p uuu lll mmmooo nnn aaa r r r y y y ccc aaa p p p iii lll lll aaa r r r y y y hhh y y yd d d r r r ooo sss t t t aaa t t t iii ccc p p p r r r eee sss sss uuu r r r eee t t t r r r aaa nnn sss uuu d d d aaa t t t iii ooo nnn ooo f f f f f f lll uuu iii d d d iii nnn t t t ooo p p p uuu lll mmm ooo nnn aaa r r r y y y iii nnn t t t eee r r r sss t t t iii t t t iii uuu mmm &&& aaa lll vvveee ooo lll iii

Q3: List the main symptoms seen in this patient before death D D D iii f f f f f f iii ccc uuu lll t t t y y y bbb r r r eee aaa t t t hhh iii nnn ggg , , , ccc ooo uuu ggg hhh iii nnn ggg uuu p p p bbb lll ooo ooo d d d , , , eee x x x ccc eee sss sss iii vvveee sss wwweee aaa t t t iii nnn ggg , , , aaa nnn x x x iii eee t t t y y y , , , p p p aaa lll eee sss k k k iii nnn

Heart is opened showing a mural thrombus on the wall of the left ventricle

A thrombus emerging from within the Superior Vena Cava (SVC) as itenters the right atrium


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Chapter 5 : Neoplasm


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cell of origin. Benign neoplasms mimic the cell of origin very well, but malignantneoplasms less so.

Slide 26B Colon Adenocarcinoma (H&E x 4)This slide shows large intestine with an abrupt transitional zone from nomal tomalignant mucosa. The malignant mucosa consists of back papilloglandularstructures that are lined by tall columnar pleomorphic cells with frecuent mitosis andfocal stratification. These malignant glands also infiltrate the submucosa and part ofthe muscle and extend into the serosa.

Case 2: A 66 year old Malay man complained of passing fresh blood with stools forseveral weeks. A section through the resected bowel is shown

Q1: Identify the normal tissue ciliated columnar epithelium with goblet cells lining the crypts

Q2: Identify and describe the microscopic features of the neoplastic changesseenSame with previous

Q3: What type of epithelium does this neoplasm arise from?Ciliated columnar to columnar

The infiltrating glands of this colonic adenocarcinoma demonstrate lessdifferentiation than the adenomatous polyp, although they still resemble glands. Ingeneral, less differentiation of a neoplasm means a greater likelihood of malignant

behavior. This is the basis for grading. The higher the grade, the more aggressive themalignant neoplasm. Benign neoplasms are not graded.


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Slide 7D - Lymph node - Squamous cell carcinomaThis slide shows a lymph node in which only few cortical lymphoid follicles are seen.The rest of the node is replaced by malignant tumour which consists ofinterconnecting sheets and island of large cells with abundant pink cytoplasm andoval vesicular nuclei with one or more nucleoli. There is abundant keratin pearlformation within these islands (indicating that this is a well differentiated squamouscell carcinoma). In fact, in some areas there are mainly keratin pearls seen with very

few tumour cells. Some areas of tumour show spindle cells.

Case 3: Six months after major oral surgery, Janaki presented to follow-up clinicwith enlarged cervical lymph nodes. This a section through an excisedlymph node

Q1: Identify the normal lymphoid tissuePrimary & secondary follicles

Q2: Identify and describe the neoplastic tissueSame with previous + well differentiated (keratin pearl &intercellular bridge)

Q3: Explain the pathogenesis of Janakis illness

Sireh genetic / DNA changes activation of proto-oncogenes excessive expression of cellular oncogenesexcessive clonal proliferation abnormal growth neoplasia

blood vessels / lymphatics spread metastasis

Microscopically, metastatic adenocarcinoma is seen in a lymph node here. It iscommon for carcinomas to metastasize to lymph nodes. The first nodes involved arethose receiving lymphatic drainage from the site of the primary neoplasm.

Squamous cellcarcinoma

infiltrating thelymph node


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Slide 2D Uterus Leiomyoma (H&E x 4)

Case 4: This is a section taken from one of the nodules present in the uterus of MrsWong

Q1: Identify and describe the microscopic features of the neoplasm seen inthis section

Myometrium cells do not vary greatly in size and shape and closely resemble normal smooth muscle cells.

Q2: What is the tissue of origin of the neoplasm?Smooth muscle

Q3: Describe the macroscopic (gross) appearance of this neoplasm Nodules are benign & well-circumscribed firm white masses

Mrs Wong, a 49 year old teacher, presented with menorrahgia for two months.She was married for many years but did not have any children

This is the hysterectomy specimen showing multiple leiomyomas in theuterus

Ovary Benign Cystic Teratoma Jenny, a 20 year old clerk, presented with acute & severe left-sided abdominal pain. A laparotomy was performed.


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Chapter 6 : Cardiovascular System


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Slide 2A Heart - Acute pericarditis, organizing (H&E x 4)The slide shows cardiac muscle with pericardium on one side. The pericardial regionis infiltrated by neutrophils, lymphocytes, eosinophils and plasma cells. External tothis is a zone of granulation tissue consisting of capillaries of varying sizes,fibroblast laying down collagen and a sprinkling of inflammatory cells.

Case 1: A 28 year old woman complained of severe central chest pain following a bout if viral upper respiratory tract infection. On auscultation she was found

to have a pericardial rub. If the pericardium were sampled, this is the tissueyou would see

Q1: Name the components of this tissue

Infiltration of neutrophils, lymphocytes, eosinophilsand plasma cellsGranulation tissues with varying sizes of capillaries,

fibroblast

Q2: Name the pathological process seen and the cells involvedOrganization & remodeling

Neutrophils, lymphocytes, eosinophils, plasma cells, fibroblasts

A 55 year old woman collapsed & died at home. She had a known history ofchronic rheumatic heart disease

An autopsy was done. Examination of the heart revealed fibrosis of the mitralvalve, & fusion of mitral valve, & fusion of chordae tendineae. Multiple,friable vegetations are present on the deformed valve


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Slide 2C - Heart Recent infarct (H&E x 10)

Slide 2B - Heart Healed myocardial infarct (H&E x 10)This slide shows mainly myocardial tissue with many areas of fibrosis. In some focismall groups of necrotic muscle bundles are seen in which nuclei are absent. Some ofthe viable cardiac muscle fibres show varying degrees of nuclear enlargement.

Case 2: Mr Balan, a 70 year old shopkeeper was brought in dead to A&E afterexperiencing severe chest pain. Autopsy was done & examination of theheart revealed thrombosis of the left descending coronary artery. Sectionsthrough the left ventricle are shown here

Q1: Explain the pathogenesis of this condition Atherosclerosis turbulent flow thrombosis ischem

infarction

Q2: Identify the pathological changes seen in slides 2C & 2B & correlatethem with clinical events


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Aorta Atherosclerosis Examination of aorta revealed extensive atherosclerotic changes which include

calcification & ulceration of atherosclerotic plaques in the case of MrBalan

A section through the left ventricle shows a recent infarct in the anteriorwall of the left ventricle. The colour of recently infarcted area is dark due tohaemorrhage. This infarct caused the death of the patient

In another area of the anterior wall of the left ventricle is a whitish are offibrosis . This corresponds to an area of previous infarction which hashealed


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Chapter 7 : Respiratory System


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Slide 6A Lung Bronchopneumonia (H&E x 10)The slide shows lung tissue. The alveolar septae are all congested and patchy areasof consolidation are seen around some of the bronchi. The lumina of these bronchiare filled with inflammatory cells and the walls of the bronchi are inflamed. Thealveoli around these inflamed bronchi show filling up of their air spaces withinflammatory cells (mainly polymorphs). Erythrocytes are also seen within thealveolar spaces. In between these patchy areas of concolidation, normal alveoli areseen. (Compare this slide with slide 6C-lobar pneumonia where you will see that allthe alveoli are filled with inflammatory exudates.)

Case 1: A 28 year old man, who was a known drug abuser with HIV was founddead in an alley. Post mortem was done. The lungs were congested &heavier than normal. The cut surface showed whitish areas of consolidationaround bronchioles with collections of pus.

Q1: Identify the structure if lung i.e. bronchioles (respiratory epithelium,muscular walls/cartilage), alveolar spaces, alveolar walls etc.

Q2: Identify the pathological process seen & the cells involved.Pathological process:

Bronchopneumonia implies a patchy distribution ofinflammation that generally involved > 1 lobe

This pattern result from initial inflammation of bronchi &bronchiole into adjacent alveoli (mainly neutrophils)

Well developed lesions are slightly elevated & grey-yellowcolour

Confluence if the foci of inflammatory consolidation mayoccur appearance of lobar consolidation

Cells involved: Acute inflammatory cells

The cut surface of this lungdemonstrates the typical appearance

of a bronchopneumonia with areas oftan-yellow consolidation. Remaininglung is dark red because of marked

pulmonary congestion.Bronchopneumonia (lobular

pneumonia) is characterized by patchy areas of pulmonaryconsolidation. These areas becomealmost confluent in the left lowerlobe on the bottom left of the

photograph. The areas ofconsolidation are firmer than thesurrounding lung.

This radiograph demonstrates patchyinfiltrates consistent with

bronchopneumonia from a bacterialinfection. Typical organisms includeStreptococcus pneumoniae, Staphylococcusaureus, Pseudomonas aeruginosa,Hemophilus influenzae, Klebsiella

pneumoniae, among others.

S S S mmm ooo ooo t t t hhh mmmuuu sss ccc lll eee

PPP sss eee uuu d d d ooo sss t t t r r r aaa t t t iii f f f iii eee d d d ccc iii lll iii aaa t t t eee d d d ccc ooo lll uuu mmm nnn aaa r r r

bbb r r r ooo nnn ccc hhh iii eee p p p iii t t t hhh eee lll iii uuu mmm

B B B r r r ooo nnn ccc hhh iii ooo lll eee

C C C aaa r r r bbb ooo nnn p p p aaa r r r t t t iii ccc lll eee

A A A lll vvveee ooo lll aaa r r r sss p p p aaa ccc eee


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Here is another example of a bronchopneumonia. The lighter areasthat appear to be raised on cut surfacefrom the surrounding lung are theareas of consolidation of the lung.

At higher magnification, the pattern of patchy distribution of a bronchopneumoniais seen. The consolidated areas here veryclosely match the pattern of lung lobules(hence the term "lobular" pneumonia).A

bronchopneumonia is classically a "hospitalacquired" pneumonia seen in personsalready ill from another disease process.Typical bacterial organisms include:Staphylococcus aureus, Klebsiella, E. coli,Pseudomonas.

This is a lobar pneumonia in whichconsolidation of the entire left upperlobe has occurred. This pattern ismuch less common than the

bronchopneumonia pattern. In part,this is due to the fact that most lobar

pneumonias are due to Streptococcus

pneumoniae (pneumococcus) and fordecades, these have responded wellto penicillin therapy so thatadvanced, severe cases are not seenas frequently. However,

pneumoccoci, like most other bacteria, are developing moreresistance to antibiotics. Severe

pneumococcal pneumonia stilloccurs, even in young to middle aged

persons (not just the very young andthe very old) and has a mortality rateof 20%!

A closer view of the lobar pneumoniademonstrates the distinct difference betweenthe upper lobe and the consolidated lowerlobe. Radiographically, areas ofconsolidation appear as infiltrates.


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Slide 6N - Lung Squamous cell carcinoma (H&E x 10)This slide shows lung tissue which is congested. One large bronchiole is filled withnecrotic material and exudates. Adjacent to this bronchiole is a focus of malignancyconsisting of sheets and islands of tumour cells that show abundant pink cytoplasm,

pleomorphism, vesicular nuclei and prominent mitotic activity. Some of the cellsshow excessively pink cytoplasm (evidence of individual cell keratinization).However, no keratin pearls are seen indicating that is not well differentiatedsquamous cell carcinoma. Some of u may have slides which u can also see foci oftumor necrosis.

Case 2: En Ahmad, a 75 year old retired army personnel was admitted for chroniccough & more recently coughing out blood. He gives a history of heavysmoking for past 50 years. Chest X-ray showed a large mass in the righthilar region. Tumour debulking surgery was performed followed byradiation therapy. This is a section from the tumour.

Q1: Identify the tumour tissue & described the histologySheets of squamous cell-like pleomorphic nuclei, eosinophiliccytoplasm, loss of nuclei polarity, nuclear hyperchromatic, mitotic activity

Q2: Explain the pathogenesis of malignancy in this patient

Chronic smoking damage of respiratory epithelium(columnar) atypical metaplasia (goblet cells hyperplasiabasal cell hyperplasia) squamous dysplasia carcinoma isitu invasive squamous cell carcinoma (hilar, cervicallymph node)

One month later, the patient succumbed to his illness. At post mortem, a large, solid, pale tumour was present in the hilar region of right lung. The tumour was seen toarise from the branch of the right main bronchus & infiltrate into thesurrounding lung parenchyma.

PPP sss eee uuu d d d ooo ccc aaa p p p sss uuu lll eee ccc ooo mmm p p p r r r eee sss sss eee d d d aaa lll ooo nnn ggg

p p p aaa r r r eee nnn ccc hhh y y y mmm aaa


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Slide 6Q Lung Adenocarcinoma (H&E x 10)This slide shows lung tissue with a fairly well-circumscribed tumour nodule in thecentre. This tumour consists of well formed papillo-glandular structures arranged

back to back. These glands are lined by tall columnar ce lls with basal, vesicular ovalnuclei that show mild pleomorphism and overlapping.

Case 3: Mr Chan, a 50 year old retired teacher, was found to have multiple opacitiesin the lung on chest X-ray at his follow-up visit. He died soon after this.

Eight months ago he was diagnosed with carcinoma of the caecum &ascending colon with involvement of the mesenteric lymph nodes. This is asection of the lung at post mortem.

Q1: Described the morphology of the tumourPapillary structure , center fibrovascular look, surroundedby cells (tall columnar stratified cells with basal nuclei),glands x uniform (varying size & shape), pleomorphic nuclei,high nuclear:cytoplasmic ratio, closely packed, basementmembrane is intact, well circumscribed

Q2: Explain the events that have taken place in the natural history of thedisease

1 cancer in mucosa membrane if caecum submucosaserosa lymph node portal circulation liver embof tumour cell in vein metastases to lung

This is the cut-surface of the right lung at post mortem. Multiple pale, nodular areasof tumour are scattered throughout the lung parenchyma . Histopathologicalexamination of the nodules showed adenocarcinoma.


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A nest of metastatic infiltrating ductal carcinoma from breast is seen in a dilatedlymphatic channel in the lung. Carcinomas often metastasize via lymphatics.Prostatic adenocarcinoma is famous for metastasizing to the lungs in a"lymphangitic" pattern in which streaks of tumor appear between lung lobules and

beneath the pleura in lymphatic spaces.

A focus of metastatic carcinoma from breast is seen on the pleural surface of the lung.Such pleural metastases may lead to pleural effusions, including hemorrhagiceffusions, and pleural fluid cytology can often reveal the malignant cells.

This chest radiograph demonstrates a nodular pattern resulting from multiplemetastases to the lung from a colonic adenocarcinoma. This is the same patient as the

previous radiograph, but at a later point in the course. (The plate and screws in thecervical spine repaired a pathologic fracture from metastasis).


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Chapter 8 : Gastrointestinal & Hepatobiliary


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Slide 23B Stomach - Adenocarcinoma (Intestinal variety) (H&E x 5)This slide shows stomach in which a tumour is seen arising from the mucosa. Thistumour consists of well differentiated glands of varying sizes arranged back to backwith a tubulo-papillary architecture. The glands are lined by tall columnar cells thatshow foci of stratification, pleomorphic vesicular nuclei and increased mitosis. Thetransition form normal to normal mucosa is very abrupt and dramatic and theuniformly pale staining normal mucosa contrasts very sharply with the deep stainingabnormal malignant mucosa. The malignant glands are also infiltrating the

submucosa and muscle coat and occasional lymphatics show tumour emboli. Thistumour is an example of the intestinal variety of gastric carcinoma which presumablyarises from areas of intestinal metaplasia that has occurred in the stomach.

Case 1: Encik Badri, a 52 year old businessman, complained of vague abdominaldiscomfort & noticed recent weight loss. Gastroscopic examination revealedan ulcerative lesion in the antral region. Gastrectomy was performed.

Q1: Identify the various areas as labeled above in the histological sectionprovided.

Q2: Name other possible modes of presentation of this condition A A A nnn ooo r r r eee x x x iii aaa , , , d d d y y y sss p p p lll aaa sss iii aaa , , , eee aaa r r r lll y y y sss aaa t t t iii eee t t t y y y , , , aaa nnn eee mmmiii aaa , , , hhh aaa eee mmm aaa t t t eee mmmeee sss iii sss , , , lll eee f f f t t t sss uuu p p p r r r aaa ccc lll aaa vvviii ccc uuu lll aaa r r r lll y y y mmm p p p hhh nnn ooo d d d eee eee nnn lll aaa r r r ggg eee mmmeee nnn t t t , , , aaa bbb d d d ooo mmmiii nnn aaa lll p p p aaa iii nnn

Q3: List the possible complication that may arise in this caseiii ... M M M eee t t t aaa sss t t t aaa sss iii sss ::: T T T r r r aaa nnn sss ccc ooo eee lll ooo mmmiii ccc ::: ooo vvvaaa r r r y y y &&& r r r eee ccc t t t ooo vvveee sss iii ccc aaa lll p p p ooo uuu ccc hhh

L L L y y y mmm p p p hhh aaa t t t iii ccc ::: t t t hhh ooo r r r aaa ccc iii ccc d d d uuu ccc t t t lll eee f f f t t t sss uuu p p p r r r aaa ccc lll aaa vvviii ccc uuu lll aaa r r r nnn ooo d d d eee sss ((( V V V iii r r r ccc hhh ooo www sss nnn ooo d d d eee )))

H H H aaa eee mmmaaa t t t ooo ggg eee nnn ooo uuu sss ::: lll iii vvveee r r r &&& lll uuu nnn ggg sss iii iii ... L L L ooo ccc aaa lll eee f f f f f f eee ccc t t t sss ::: L L L ooo ccc aaa lll iii nnn vvvaaa sss iii ooo nnn p p p aaa nnn ccc r r r eee aaa sss ooo bbb sss t t t r r r uuu ccc t t t iii ooo nnn &&& hhh aaa eee mmm ooo r r r r r r hhh aaa ggg

Fungating Early satiety X much discomfort Mass in stomach

Ulcerative Pain Weight loss Peritonitis

Diffused infiltrative

Continue Stomach Adenocarcinoma

The gastrectomy specimen shows a large ulcerative growth in the greater curvaturemeasuring 6.5cm x 4cm. the floor of the ulcer is irregular. The edges are raised &everted

GGG ooo b b b lll eee ttt ccc eee lll lll sss

D D D y y y sss p p p lll aaa sss iii aaa aaa r r r eee aaa

S S S t t t r r r aaa t t t iii f f f iii ccc aaa t t t iii ooo nnn ooo f f f eee p p p iii t t t hhh eee lll iii uuu mmm

222 nnn eee ooo p p p lll aaa sss t t t iii ccc ggg lll aaa nnn d d d sss f f f uuu sss eee

t t t ooo ggg eee t t t hhh eee r r r

N N N uuu ccc lll eee uuu sss lll aaa r r r ggg eee r r r nnn uuu ccc lll eee aaa r r r ::: ccc yyy ttt ooo p p p lll aaa sss mmm iii ccc

r r r aaa ttt iii ooo


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Colon Adenocarcinoma

A 66 year old man complained of passing fresh blood with stools for several weeks.Colonoscopy showed a fungating tumour obstructing the sigmoid colon.

The resected colon shows a large fungating mass measuring 4cm in diameter. The

tumour extends circumferentially & almost completely obstructs the lumen


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Liver cirrhosis

Mr. X, a 62 year old retired naval officer, died as a result of massive haematemesisdue to ruptured esophageal varices. Postmortem revealed a c irrhotic liver.

Q1: Describe the morphological changes seen in the liverQ2: List the aetiological factors that contribute to cirrhosis

Liver Metastatic carcinoma

Postmortem of a patient who died as a result of terminal illness associated withcarcinoma of the breast showed these findings in the liver

Note the multiple pale tumour deposits in the subcapsular region of the liver

Colon Familial polyposis coli

This is part of the colectomy specimen of a patient diagnosed with familial polyposiscoli. Note multiple adenomatous polyps arising on the entire mucosal surface.

Q1: What is the basis for this condition?Q2: What is the risk of carcinoma in this condition?


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Stomach Chronic Peptic Ulcer

The gastrectomy specimen shows a solitary punched-out ulcer measuring 1cm x1cm in the antral region.

The ulcer has perforated through the wall of the stomach. The edges of the ulcer areflat & flush with the mucosal surface. Note the gastric folds that radiate from theulcer


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Chapter 9 : Lymphoreticular system


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Slide 7E - Lymph node - Hodgkins lymphoma (H&E x 40)This slide shows a lymph node in which the nodal architecture is mostly lost withonly occasional lymphoid follicles seen in cortex. The rest of the node is replaced bya mixed population of cells consisting of lymphocytes eosinophils, plasma cells andReed-Sternberg cells which shows 2 or more nuclei. The nuclei are vesicular and

pale staining with prominent nucleoli and a perinucleolar halo. In the well stainedsections the nucleoli appear eosinophilic (pink staining). Note that the Reed-Sternberg giant cells are smaller than Langhans giant cells. Also seen aremononuclear variants of Reed-Sternberg cells which show similar nuclear features.

Case 2: Damien, a 22 year old engineering graduate was found to have severalnodular swellings on both sides of his neck during a pre-employmentmedical examination. On further questioning, he gave a history of feelingunwell & experiencing a loss of appetite for the past month

Examination revealed several firm, rubbery enlarged lymph nodes in theright & left cervical region. The nodes were discrete not matted together.There were no discharging sinuses seen. He was febrile, 38.5 C

Damien was admitted to hospital where several investigations including alymph node biopsy was done

Q1: What are the possible causes of lymph node enlargement in a youngadult like Damien?

R R R eee aaa ccc t t t iii vvveee hhh y y y p p p eee r r r p p p lll aaa sss iii aaa , , , nnn eee ooo p p p lll aaa sss t t t iii ccc

Q2: Correlate & explain the symptoms & signs seen in DamienF F F eee vvveee r r r ccc y y y t t t ooo k k k iii nnn eee eee f f f f f f eee ccc t t t ooo f f f t t t uuu mmmooo uuu r r r

E E E nnn lll aaa r r r ggg eee d d d L L L N N N H H H ooo d d d ggg k k k iii nnn sss lll y y y mmm p p p hhh ooo mmmaaa ((( nnn ooo d d d uuu lll aaa r r r sss ccc lll eee r r r ooo sss iii nnn ggg )))

Q3: List the investigations that you think would be useful in Damiens case? H H H iii sss t t t ooo lll ooo ggg iii ccc aaa lll eee x x x aaa mmmiii nnn aaa t t t iii ooo nnn ooo f f f lll y y y mmm p p p hhh nnn ooo d d d eee bbb iii ooo p p p sss y y y --- lll ooo ccc aaa t t t eee ccc lll aaa sss sss iii ccc R R R eee eee d d d --- S S S t t t eee r r r nnn bbb eee r r r ggg ccc eee lll lll PPP hhh eee nnn ooo t t t y y y p p p iii ccc mmmaaa r r r k k k eee r r r sss --- E E E S S S R R R , , , p p p eee r r r iii p p p hhh eee r r r aaa lll bbb lll ooo ooo d d d ccc ooo uuu nnn t t t --- S S S t t t aaa ggg iii nnn ggg N N N ooo d d d uuu lll aaa r r r sss ccc lll eee r r r ooo sss iii nnn ggg H H H ooo d d d ggg k k k iii nnn sss lll y y y mmm p p p hhh ooo mmm aaa iii nnn vvvooo lll vvveee mmm eee d d d iii aaa sss t t t iii nnn uuu mmm

ccc hhh eee sss t t t x x x --- r r r aaa y y y

Q4: In the low power sections of 7A & 7E, compare & contrast thearchitectural morphology of the lymph nodes

N N N ooo d d d uuu lll aaa r r r sss ccc lll eee r r r ooo sss iii sss H H H ooo d d d ggg k k k iii nnn sss lll y y ymmm p p p hhh ooo mmmaaa iii sss ccc hhh aaa r r r aaa ccc t t t eee r r r iii z z zeee d d d bbb y y y bbb r r r ooo aaa d d d bbb aaa nnn d d d ssccc ooo lll lll aaa ggg eee nnn ccc iii r r r ccc uuu mmm sss ccc r r r iii bbb iii nnn ggg nnn ooo d d d uuu lll eee sss f f f iii bbb r r r ooo sss iii sss mmm aaa y y y bbb eee sss ccc aaa nnn t t t ooo r r r aaa bbb uuu nnn d d d aaa nnn t t t ... TTTccc eee lll lll uuu lll aaa r r r iii nnn f f f iii lll t t t r r r aaa t t t eee mmmaaa y y y sss hhh ooo www vvvaaa r r r y y y iii nnn ggg p p p r r r ooo p p p ooo r r r t t t iii ooo nnn sss ooo f f f lll y y ymmm p p p hhh ooo ccc y y ytteee ooo sss iii nnn ooo p p p hhh iii lll sss , , , hhh iii sss t t t iii ooo ccc y y y t t t eee sss , , , lll aaa ccc uuu nnn aaa r r r ccc eee lll lll sss ... C C C lll aaa sss sss iii ccc R R R eee eee d d d --- S S S t t t eee r r r nnn bbb eee r r r ggg ccc eee lll llliii nnn f f f r r r eee qqq uuu eee nnn t t t

Q5: Identify the cellular changes seen in this conditionT T T hhh eee r r r eee iii sss aaa vvvaaa r r r iii aaa nnn t t t ooo f f f R R R S S S ccc eee lll lll , , , t t t hhh eee lll aaa ccc uuu nnn aaa r r r ccc eee lll lll , , , wwwhhh iii ccc hhh iii sss lll aaa r r r ggg eee , , , hhh aaa sss aaa sss iii nnnhhh y y y p p p eee r r r lll ooo bbb aaa t t t eee d d d nnn uuu ccc lll eee uuu sss wwwiii t t t hhh mmmuuu lll t t t iii p p p lll eee sss mmm aaa lll lll nnn uuu ccc lll eee ooo lll iii &&& aaa nnn aaa bbb uuu nnn d d d aaa nnn t t t p p p aaasss t t t aaa iii nnn iii nnn ggg ccc y y y t t t ooo p p p lll aaa sss mmm


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Chapter 10 : Haemopoietic System


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3 Peripheral Blood Film Iron deficiency anemia (MGG x 400)

Case 1: A forty-five year multiparous woman was seen at the antenatal clinic.Routine full blood count showed the following results:

Haemoglobin 52g/L ((( 111 000 555 --- 111 333 555 ))) Red cell count 2.6 x 10 12/L ((( 333 ... 7 7 7 --- 555 ... 333 ))) MCV 64 fL ((( 7 7 7 000 --- 8 8 8 6 6 6 ))) MCH 20 pg ((( 222 333 --- 333 111 ))) MCHC 312 g/L ((( 333 000 000 --- 333 6 6 6 000 )))

Q1: Comment on the full blood count B B B eee lll ooo www t t t hhh aaa nnn nnn ooo r r r mmm aaa lll

Q2: Describe the peripheral blood findings A A A nnn iii sss ooo p p p ooo iii k k k iii lll ooo ccc y y y t t t ooo sss iii sss ((( vvvaaa r r r y y y iii nnn ggg sss iii z z zeee &&& sss hhh aaa p p p eee ))) , , , hhh y y y p p p ooo ccc hhh r r r ooo mmmiii ccc R R R B B B C C C , , , mmm iii ccc r r r ooo ccc y y y t t t iii ccc , , , p p p aaa lll eee

Q3: What are the differential diagnosis based on the full blood count &peripheral blood film?

D D D eee ccc r r r eee aaa sss eee d d d sss eee r r r uuu mmm f f f eee r r r r r r iii t t t iii nnn lll eee vvveee lll I I I nnn ccc r r r eee aaa sss eee d d d iii nnn p p p lll aaa sss mmmaaa t t t r r r aaa nnn sss f f f eee r r r r r r iii nnn lll eee vvveee lll ((( T T T I I I B B B C C C )))

Q4: Discuss the pathophysiology underlying this condition

H H H eee mmm eee f f f ooo r r r mmmaaa t t t iii ooo nnn aaa f f f f f f eee ccc t t t eee d d d , , , bbb lll ooo ooo d d d lll ooo sss sss d d d uuu r r r iii nnn ggg d d d eee lll iii vvveee r r r y y y , , , iii nnn ccc r r r eee aaa sss eee d d d eee mmm aaa p p p ooo ooo r r r d d d iii eee t t t , , , ccc hhh r r r ooo nnn iii ccc iii nnn f f f eee ccc t t t iii ooo nnn

8-2 Peripheral Blood Film Beta thalassaemia major (MGG x 400)

Case 2: Seven month old infant with distended abdomen & pallor was seen at theoutpatient clinic in Banting. A full blood count showed the following:

Haemoglobin 52g/L Red cell count 3.1 x 10 12/L MCV 48 fL MCH 17 pg MCHC 354 g/L

Q1: Describe the major abnormalities seen on the full blood count &peripheral blood film

A A A lll lll vvvaaa lll uuu eee sss bbb eee lll ooo www t t t hhh aaa nnn nnn ooo r r r mmm aaa lll eee x x x ccc eee p p p t t t M M M C C C H H H C C C N N N ooo r r r mmm ooo bbb lll aaa sss t t t , , , bbb aaa sss ooo p p p hhh iii lll iii ccc sss t t t iii p p p p p p lll iii nnn ggg , , , hhh y y y p p p ooo ccc hhh r r r ooo mmm iii ccc , , , mmmiii ccc r r r ooo ccc y y y t t t iii ccc , , , aaa nnn iii sss ooo ccc y y y t t t ooonnn uuu mmmeee r r r ooo uuu sss t t t aaa r r r ggg eee t t t ccc eee lll lll sss , , , p p p ooo iii k k k iii lll ooo ccc y y y t t t ooo sss iii sss

Q2: Discuss the genetic basis & the pathophysiology underlying thethalassaemia syndromes

L L L aaa ccc k k k ooo f f f --- ccc hhh aaa iii nnn sss y y y nnn t t t hhh eee sss iii sss d d d uuu eee t t t ooo sss iii nnn ggg lll eee p p p ooo iii nnn t t t mmmuuu t t t aaa t t t iii ooo nnn iii nnn --- ggg lll ooo bbb iii nnn ggg eee nnn eeeccc hhh r r r ooo mmmooo sss ooo mmmeee 111 bbb

L L L ooo www H H H bbb A A A , , , eee x x x ccc eee sss sss f f f r r r eee eee --- ccc hhh aaa iii nnn aaa ggg ggg r r r eee ggg aaa t t t eee sss , , , iii nnn eee f f f f f f eee ccc t t t iii vvveee eee r r r y y y t t t hhh r r r ooo p p p ooo iii eee sss iii sss


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Q3: What complications may arise from this condition?PPP ooo sss iii t t t iii vvveee iii r r r ooo nnn bbb aaa lll aaa nnn ccc eee --- iii r r r ooo nnn aaa bbb sss ooo r r r p p p t t t iii ooo nnn iii nnn GGG U U U T T T

--- bbb lll ooo ooo d d d t t t r r r aaa nnn sss f f f uuu sss iii ooo nnn H H H aaa iii r r r --- ooo nnn --- eee nnn d d d aaa p p p p p p eee aaa r r r aaa nnn ccc eee d d d uuu eee t t t ooo eee x x x t t t r r r aaa mmmeee d d d uuu lll lll aaa r r r y y y eee r r r y y y t t t hhh r r r ooo p p p ooo iii eee sss iii sss --- f f f aaa ccc iii aaa lll / / / sss k k k eee lll eee t t t aaa lll d d d eee f f f ooo r r r mmm iii t t t iii eee sss bbb eee ccc aaa uuu sss eee ooo f f f bbb ooo nnn eee mmm aaa r r r r r r ooo www eee x x x p p p aaa nnn sss iii ooo nnn S S S eee vvveee r r r eee aaa nnn eee mmmiii aaa , , , hhh eee mmm ooo lll y y y t t t iii ccc j j j aaa uuu nnn d d d iii ccc eee , , , sss p p p lll eee nnn ooo mmmeee ggg aaa lll y y y , , , ggg r r r ooo wwwt t t hhh r r r eee t t t aaa r r r d d d aaa t t t iii ooo nnn , , ,

H H H eee p p p aaa t t t ooo mmmeee ggg aaa lll y y y ((( eee x x x t t t r r r aaa mmmeee d d d uuu lll lll aaa r r r y y y hhh eee mmm ooo p p p ooo iii eee sss iii sss ))) S S S eee ccc ooo nnn d d d aaa r r r y y y hhh aaa eee mmmooo ccc hhh r r r ooo mmm aaa t t t ooo sss iii sss lll iii vvveee r r r , , , hhh eee aaa r r r t t t , , , p p p aaa nnn ccc r r r eee aaa sss ((( f f f iii bbb r r r ooo sss iii sss x x x iii nnn sss uuu lll iii nnn D D D M M M )))

9 Peripheral Blood Film Acute myeloid leukemia (MGG x 400)

Case 3: Thirty year old presented with low grade fever of 2 weeks duration.Physical examination showed Hepatosplenomegaly and pallor

Haemoglobin 95g/L WBC 23.4 x 10 9/L ((( 444 --- 111 111 x x x 111 000 9

99)))

Platelets 48 x 10 9/L ((( 111 555 000 --- 444 000 000 x x x 111 000 999

)))

Q1: Describe the major abnormalities seen on the peripheral blood film M M M y y yeee lll ooo bbb lll aaa sss t t t wwwiii t t t hhh p p p r r r ooo mmm iii nnn eee nnn t t t nnn uuu ccc lll eee ooo lll iii , , , f f f iii nnn eee aaa z z zuuu r r r ooo p p p hhh iii lll iii ccc ggg r r r aaa nnn uuu lll eee sss iii nnn ccc y y y t t t ooo p p p lll aaasd d d iii sss t t t iii nnn ccc t t t iii vvveee r r r eee d d d --- sss t t t aaa iii nnn eee d d d r r r ooo d d d --- lll iii k k k eee p p p r r r eee sss eee nnn t t t ((( A A A uuu eee r r r r r r ooo d d d sss )))

Q2: How do myeloblasts differ from lymphoblasts?111 ... L L L y y ymmm p p p hhh ooo bbb lll aaa sss t t t hhh aaa sss nnn ooo p p p r r r ooo mmmiii nnn eee nnn t t t nnn uuu ccc lll eee ooo lll iii 222 ... M M M y y y eee lll ooo bbb lll aaa sss t t t ccc ooo nnn t t t aaa iii nnn sss A A A uuu eee r r r r r r ooo d d d 333 ... S S S ooo mmmeee mmm aaa t t t uuu r r r eee iii nnn t t t ooo p p p r r r ooo mmm y y yeee lll ooo ccc y y y t t t eee sss ((( hhh aaa sss ccc ooo aaa r r r sss eee ggg r r r aaa nnn uuu lll eee sss )))

Q3: What complications may arise from this condition? B B B ooo nnn eee mmm aaa r r r r r r ooo www f f f aaa iii lll uuu r r r eee A A A nnn eee mmm iii aaa f f f aaa t t t iii ggg uuu eee , , , mmmaaa lll aaa iii sss eee , , , p p p aaa lll lll ooo r r r T T T hhh r r r ooo mmm bbb ooo ccc y y y t t t ooo p p p eee nnn iii aaa aaa bbb nnn ooo r r r mmmaaa lll bbb lll eee eee d d d iii nnn ggg

N N N eee uuu t t t r r r ooo p p p eee nnn iii aaa iii nnn f f f eee ccc t t t iii ooo nnn


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8-2 Peripheral Blood Film Chronic myeloid leukemia (MGG x 400)

Case 4: Forty year old was seen at the outpatient clinic with complaints ofabdominal fullness and lethargy

Haemoglobin 122 g/L WBC 67.9 x 10 9/L Platelets 257 x 10 9/L

Q1: What are the characteristic features seen on the peripheral blood film M M M aaa nnn y y y nnn eee uuu t t t r r r ooo p p p hhh iii lll sss , , , M M M y y yeee lll ooo ccc y y y t t t eee sss , , , M M M eee t t t aaa mmm y y y eee lll ooo ccc y y y t t t eee sss , , , bbb aaa sss ooo p p p hhh iii lll sss , , , sss ooo mmmeee t t t iii mmmeee eee ooo sss iii nnn ooo p p p hhh iii lll sss

Q2: What is the molecular basis for the development of this disease?PPP hhh iii lll aaa d d d eee lll p p p hhh iii aaa ccc hhh r r r ooo mmm ooo sss ooo mmm eee t t t (((999 , , , 222 222 ))) --- R R R eee ccc iii p p p r r r ooo ccc aaa lll t t t r r r aaa nnn sss lll ooo ccc aaa t t t iii ooo nnn bbb eee t t t wwweee eee nnn ccc hhh r r r ooo mmm ooo sss ooo mmm eee 999 &&& 222 222

Q3: What are the clinical features of the disease?S S S lll ooo www d d d eee vvveee lll ooo p p p iiinnn ggg aaa nnn eee mmmiii aaa , , , eee nnn lll aaa r r r ggg eee mmm eee nnn t t t ooo f f f ooo r r r ggg aaa nnn iii nnn f f f iii lll t t t r r r aaa t t t eee d d d , , , eee x x x t t t r r r eeesss p p p lll eee nnn ooo mmm eee ggg aaa lll y y y , , , t t t hhh r r r ooo mmmbbb ooo ccc y y y t t t ooo sss iii sss , , , hhh y y y p p p eee r r r ccc eee lll lll uuu lll aaa r r r bbb ooo nnn eee mmmaaa r r r r r r ooo www , , , sss p p p lll eeeiii nnn f f f aaa r r r ccc t t t iii ooo nnn , , , ggg ooo uuu t t t

Q4: What is the natural course of this disease?C C C M M M L L L aaa ccc ccc eee lll eee r r r aaa t t t eee d d d p p p hhh aaa sss eee aaa ccc uuu t t t eee lll eee uuu k k k eee mmmiii aaa

Myelocytes

Myelocyte

Promyeloblast

Basophile

Basophiles (coarsegranules covering cells)

Metamyelocytes


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Chapter 11 : Renal System


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Slide 11E Renal (H&E x 10)

Case 2: Mr. KHH, a 50-year old man, was a pedestrian who was brought in deadafter being involved in a hit & run accident. At autopsy, he was found tohave multiple injuries including lacerated heart, liver, spleen & intracranialhaemorrhage. His right kidney was also found to be shrunken & scarred.His relatives gave a history that Mr. KHH had several episodes of feverwith right loin pain in the past. However, they were unsure about he soughtany treatment for this.

Q1: Describe the histological features of the kidney.111 ... I I I nnn t t t eee sss t t t iii nnn aaa lll f f f iii bbb r r r ooo sss iii sss 222 ... I I I nnn f f f iii lll t t t r r r aaa t t t iii ooo nnn ooo f f f iii nnn f f f lll aaa mmm mmm aaa t t t ooo r r r y y y ccc eee lll lll sss ((( lll y y y mmm p p p hhh ooo ccc y y y t t t eee sss &&& p p p lll aaa sss mmmaaa ccc eee lll lll sss ))) 333 ... T T T hhh y y y r r r ooo iii d d d iii z z zaaa t t t iii ooo nnn ccc ooo lll lll ooo iii d d d ccc aaa sss t t t

Q2: What is the diagnosis?C C C hhh r r r ooo nnn iii ccc p p p y y y eee lll ooo nnn eee p p p hhh r r r iii t t t iii sss

Q3: Postulate a few possible underlying causes that could have resulted inthis

111 ... OOO bbb sss t t t r r r uuu ccc t t t iii ooo nnn ((( mmmaaa lll iii ggg nnn aaa nnn ccc y y y , , , sss t t t ooo nnn eee sss ))) ooo f f f uuu r r r iii nnn aaa r r r y y y t t t r r r aaa ccc t t t sss t t t aaa sss iii sss ooo f f f uuu r r r iii nnn eee bbb aaa ccc t t t eee r r r iii aaa mmmuuu lll t t t iii p p p lll iii ccc aaa t t t iii ooo nnn

222 ... V V V eee sss iii ccc ooo --- uuu r r r eee t t t eee r r r iii ccc r r r eee f f f lll uuu x x x 333 ... X X X aaa nnn t t t hhh ooo ggg r r r aaa nnn uuu lll ooo mmmaaa t t t ooo uuu sss C C C hhh r r r ooo nnn iii ccc PPP y y yeee lll ooo nnn eee p p p hhh r r r iii t t t iii sss

M M M iii mmmiii ccc r r r eee nnn aaa lll ccc eee lll lll ccc aaa r r r ccc iii nnn ooo mmm aaa ((( R R R C C C C C C ))) ccc lll iii nnn iii ccc aaa lll lll y y y hhh iii sss t t t ooo lll ooo ggg iii ccc aaa lll lll y y y

GGG r r r ooo sss sss y y y eee lll lll ooo www nnn ooo d d d uuu lll eee M M M iii ccc r r r ooo sss ccc ooo p p p iii ccc f f f ooo aaa mmm ccc eee lll lll sss bbb y y y mmmaaa ccc r r r ooo p p p hhh aaa ggg eee sss

Slide 11N Kidney (H&E x 5)

Case 1: Encik Ali complained of vague right loin pain for the past 6 months.Recently he noticed that he has some blood in his urine. He was noted to be

polycythaemic. A right renal mass was found which was excised.

Q1: Describe the microscopic features of this excised massC C C eee lll lll sss aaa p p p p p p eee aaa r r r aaa lll mmmooo sss t t t vvvaaa ccc uuu ooo lll aaa t t t eee d d d ooo r r r sss ooo lll iii d d d ... T T T hhh eee vvvaaa ccc uuu ooo lll aaa t t t eee d d d ((( lll iii p p p iii d d d lll aaa d d d eee nnn )))ccc lll eee aaa r r r ccc eee lll lll sss d d d eee mmm aaa r r r ccc aaa t t t eee d d d ooo nnn lll y y y bbb y y y t t t hhh eee iii r r r mmmeee mmmbbb r r r aaa nnn eee ... N N N uuu ccc lll eee iii iii sss sss mmm aaa lll lll &&& r r r ooo uuu nnn d d d

Q2: What is the diagnosis? R R R eee nnn aaa lll ccc eee lll lll C C C A A A ((( ccc lll eee aaa r r r ccc eee lll lll C C C A A A ))) *** ccc ooo mmmmmmooo nnn eee sss t t t C C C A A A iii nnn aaa d d d uuu lll t t t sss

Q3: Why was Encik Ali polycythaemic despite having haematuria? PPP aaa r r r aaa nnn eee ooo p p p lll aaa sss t t t iii ccc sss y y y nnn d d d r r r ooo mmm eee eee x x x hhh iii bbb iii t t t eee d d d bbb y y y t t t hhh iii sss C C C A A A ...


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Chapter 12 : Endocrine System


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Slide 29E Thyroid - Non-toxic nodular goiter (H&E x 10)The slide shows thyroid tissue composed of follicles of varying sizes lined byflattened to cuboidal cells. Most of the follicles contain colloid. Many of the folliclesare cystically dilated and some of them show recent haemorrhage within the lumina.Features of fibrosis and old haemorrhage such as haemosiderin pigment andcholesterol clefts are not seen in this section.

Case 1: Mrs. Wong, a 45 year old teacher, presented with a large swelling in thefront of the neck which had grown slowly over the past 10 years. Theswelling moved with swallowing. The patient was euthyroid.Thyroidectomy was performed. This is the histological section.

Q1: Identify the cellular changes in the section--- F F F ooo lll lll iii ccc lll eee sss ooo f f f vvvaaa r r r y y y iii nnn ggg sss iii z z z eee sss lll iii nnn eee d d d bbb y y y f f f lll aaa t t t t t t eee nnn eee d d d t t t ooo ccc uuu bbb ooo iii d d d aaa lll ccc eee lll lll sss --- M M M ooo sss t t t ooo f f f t t t hhh eee f f f ooo lll lll iii ccc lll eee sss ccc ooo nnn t t t aaa iii nnn ccc ooo lll lll ooo iii d d d ... M M M aaa nnn y y y ooo f f f t t t hhh eee f f f ooo lll lll iii ccc lll eee sss aaa r r r eee ccc y y y sss t t t iii ccc aaa lll lll y y y

d d d iii lll aaa t t t eee d d d aaa nnn d d d sss ooo mmmeee ooo f f f t t t hhh eee mmm sss hhh ooo www r r r eee ccc eee nnn t t t hhh aaa eee mmmooo r r r r r r hhh aaa ggg eee wwwiii t t t hhh iii nnn t t t hhh eee lll uuu mmmiii nnn aaa

Q2: Correlate the gross appearance of the specimen with the clinicalpresentation & the histological features.--- E E E nnn lll aaa r r r ggg eee d d d t t t hhh y y yr r r ooo iii d d d d d d uuu eee t t t ooo aaa ccc ccc uuu mmmuuu lll aaa t t t iii ooo nnn ooo f f f ccc ooo lll lll ooo iii d d d --- A A A t t t t t t aaa ccc hhh t t t ooo t t t r r r aaa ccc hhh eee aaa mmm ooo vvveee wwwiii t t t hhh sss wwwaaa lll lll ooo wwwiii nnn ggg --- C C C uuu t t t sss uuu r r r f f f aaa ccc eee aaa p p p p p p eee aaa r r r eee d d d ggg eee lll aaa t t t iiinnn ooo uuu sss &&& ggg lll iii sss t t t eee nnn iii nnn ggg d d d uuu eee t t t ooo ccc ooo lll lll ooo iii d d d ccc ooo nnn t t t eee nnn t t t

Q3: List the possible complication that may arise as a result of this goitre

--- C C C ooo sss mmmeee t t t iii ccc aaa lll lll y y y uuu nnn aaa ccc ccc eee p p p t t t aaa bbb lll eee --- A A A bbb nnn ooo r r r mmmaaa lll t t t hhh y y yr r r ooo iii d d d hhh ooo r r r mmm ooo nnn eee p p p r r r ooo d d d uuu ccc t t t iii ooo nnn ((( r r r aaa r r r eee ))) --- R R R iii sss k k k ooo f f f ccc aaa r r r ccc iii nnn ooo mmm aaa ((( sss mmm aaa lll lll ))) --- D D D iii f f f f f f iii ccc uuu lll t t t iii eee sss iii nnn sss wwwaaa lll lll ooo wwwiii nnn ggg , , , bbb r r r eee aaa t t t hhh iii nnn ggg --- C C C ooo mmm p p p r r r eee sss sss iii ooo nnn ooo f f f lll aaa r r r ggg eee vvveee sss sss eee lll sss iii nnn nnn eee ccc k k k &&& uuu p p p p p p eee r r r t t t iii sss sss uuu eee sss --- C C C ooo mmm p p p r r r eee sss sss r r r eee ccc uuu r r r r r r eee nnn t t t lll aaa r r r y y ynnn ggg eee aaa lll nnn eee r r r vvveee

Slide 29B Thyroid - Follicular adenoma (H&E x 40)This slide of thyroid shows part of a well encapsulated tumour consisting of thyroidfollicle that lying back to back. These follicles are small to medium sized, lined bycuboidal to columnar epithelium and some of them contain colloid. The capsule ismade of fairy thick fibrous tissue and there is no capsular infiltration by tumour cellsnor is there any vascular permeation. Outside the capsule is seen normal thyroidtissue consisting of colloid-filled follicle lined by flattened or cuboidal epithelium.

Case 2: Ms Malini, 1 35 year old cashier, presented with a solitary nodular swellingin the left side of the neck which her colleagues had noticed for the pastmonth. The swelling moved with swallowing. Thyroid scan showed a coldnodule. A diagnosis of follicular neoplasm was made on Fine NeedleAspiration Cytology (FNAC). Thyroidectomy was performed. This is arepresentative histological section.

Q1: What is the clinical significance of a solitary thyroid nodule?--- OOO nnn lll y y y


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38A Leiomyoma (H&E x 20)

Case 1: Mrs. Vijaya, 1 35 year old lady married for 8 years, presented to theinfertility clinic for primary infertility. She complained of irregular periodswhich were heavy at times. She was otherwise well. Ultrasound showed awell defined mass in the fundus of the uterus. The mass was intramural inlocation. Other investigations were normal. Hysterectomy was performed.This is a representative section of the lesion in the hysterectomy specimen.

Q1: Identify the cellular pattern as labeled above in the histological sectionprovided.W W W hhh ooo r r r lll eee d d d bbb uuu nnn d d d lll eee sss ooo f f f sss mmm ooo ooo t t t hhh mmmuuu sss ccc lll eee ccc eee lll lll sss

Q2: Name other possible modes of presentation of this conditionT T T ooo r r r sss iii ooo nnn , , , p p p eee d d d uuu nnn ccc uuu lll aaa t t t eee d d d

Q3: List the possible complications of this condition--- R R R aaa r r r eee lll y y y uuu nnn d d d eee r r r ggg ooo mmmaaa lll iii ggg nnn aaa nnn t t t ccc hhh aaa nnn ggg eee sss --- R R R eee d d d d d d eee ggg eee nnn eee r r r aaa t t t iii ooo nnn , , , ccc y y ysss t t t iii ccc d d d eee ggg eee nnn eee r r r aaa t t t iii ooo nnn , , , p p p ooo sss t t t --- p p p aaa r r r t t t uuu mmm hhh aaa eee mmmooo r r r r r r hhh aaa ggg eee --- F F F eee t t t aaa lll mmmaaa lll p p p r r r eee sss eee nnn t t t aaa t t t iii ooo nnn , , , sss p p p ooo nnn t t t aaa nnn eee ooo uuu sss aaa bbb ooo r r r t t t iii ooo nnn

38E Large Cell Keratinizing Squamous Cell Carcinoma (H&E x 10)

38E Large Cell Keratinizing Squamous Cell Carcinoma (H&E x 40)

Case 2: Mrs. Velu a 48 year old widow presented to the GP clinic for PAP smearafter listening a radio health talk show. She did not complain of any

Stroma beinginfiltrated


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15E Infiltrating Ductal Carcinoma (H&E x 10)

Case 4: Puan Hasnah a 48 year old housewife presented to the surgical clinic for amedical check as the skin around her right areola appeared reddish. Onexamination the surgeon noted a lump measuring 2cm x 2 cm. She wasimmediately sent for a mammogram which was reported as malignant. AnFNAC was done & reported as malignant.

Q1: Describe the histopathological changes seen in this slide.--- L L L y y y mmm p p p hhh aaa t t t iii ccc iii nnn vvvaaa sss iii ooo nnn --- V V V aaa sss ccc uuu lll aaa r r r p p p eee r r r mmmeee aaa t t t iii ooo nnn --- F F F iii bbb r r r ooo uuu sss sss t t t r r r ooo mmm aaa iii nnn f f f iii lll t t t r r r aaa t t t iii ooo nnn --- PPP lll eee ooo mmmooo r r r p p p hhh iii ccc mmmaaa lll iii ggg nnn aaa nnn t t t ccc eee lll lll sss wwwiii t t t hhh aaa bbb uuu nnn d d d aaa nnn t t t ccc y y y t t t ooo p p p lll aaa sss mmm --- V V V eee sss iii ccc uuu lll aaa r r r nnn uuu ccc lll eee iii wwwiii t t t hhh p p p r r r ooo mmmiii nnn eee nnn t t t nnn uuu ccc lll eee ooo lll iii --- F F F r r r eee qqq uuu eee nnn t t t mmm iii t t t ooo t t t iii ccc f f f iii ggg uuu r r r eee sss --- F F F ooo r r r mmm iii nnn ggg sss mmm aaa lll lll / / / lll aaa r r r ggg eee ccc lll uuu sss t t t eee r r r sss &&& ggg lll aaa nnn d d d uuu lll aaa r r r d d d uuu ccc t t t aaa lll sss t t t r r r uuu ccc t t t uuu r r r eee sss --- S S S ooo mmmeee ccc ooo mmm eee d d d ooo p p p aaa t t t t t t eee r r r nnn ((( lll aaa r r r ggg eee t t t uuu bbb uuu lll aaa r r r wwwiii t t t hhh ccc eee nnn t t t r r r aaa lll nnn eee ccc r r r ooo sss iii sss )))

Q2: List the macroscopic changes seen in carcinoma of the breast--- GGG r r r iii t t t t t t y y y , , , r r r ooo ccc k k k hhh aaa r r r d d d , , , ggg r r r aaa y y y iii sss hhh wwwhhh iii t t t eee iii nnn f f f iii lll t t t r r r aaa t t t iii vvveee mmmaaa sss sss --- Y Y Y eee lll lll ooo wwwiii sss hhh --- wwwhhh iii t t t eee ccc hhh aaa lll k k k sss t t t r r r eee aaa k k k sss aaa r r r eee ccc hhh aaa r r r aaa ccc t t t eee r r r iii sss t t t iii ccc --- E E E x x x t t t eee nnn sss iii vvveee f f f iii bbb r r r ooo sss iii sss , , , p p p r r r ooo d d d uuu ccc iii nnn ggg aaa hhh aaa r r r d d d ((( sss ccc iii r r r r r r hhh ooo uuu sss ))) t t t y y y p p p eee ooo f f f ccc aaa nnn ccc eee r r r

Q3: List the risk factors of breast cancer--- PPP r r r ooo lll ooo nnn ggg eee d d d eee sss t t t r r r ooo ggg eee nnn eee x x x p p p ooo sss uuu r r r eee --- N N N uuu lll lll iii p p p aaa r r r ooo uuu sss , , , eee aaa r r r lll y y y mmm eee nnn aaa r r r ccc hhh eee , , , lll aaa sss t t t mmmeee nnn ooo p p p aaa uuu sss eee , , , d d d eee lll aaa y y y eee d d d p p p r r r eee ggg nnn aaa nnn ccc y y y --- OOO r r r aaa lll ccc ooo nnn t t t r r r aaa ccc eee p p p t t t iii vvveee p p p iii lll lll sss --- A A A t t t y y y p p p iii ccc aaa lll lll ooo bbb uuu lll aaa r r r &&& d d d uuu ccc t t t aaa lll hhh y y y p p p eee r r r p p p lll aaa sss iii aaa --- F F F aaa mmmiii lll y y y hhh iii sss t t t ooo r r r y y y ((( 111 s

ss t t t d d d eee ggg r r r eee eee r r r eee lll aaa t t t iii vvveee sss ))) --- S S S eee x x x , , , r r r aaa ccc eee , , , aaa ggg eee , , , ooo bbb eee sss iii t t t y y y --- OOO ccc ccc uuu r r r r r r eee nnn ccc eee ooo f f f C C C A A A iii nnn ooo nnn eee bbb r r r eee aaa sss t t t


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Chapter 14 : CNS


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CP.CILS/PAT/Ph2Session12/13

Jabatan PatologiFakulti Perubatan Universiti Malaya

Phase II (MBBS) Session 2012/2013

CP.CILS 14: Central Nervous System

1. Nerve 32B:

Mrs Tan is a 56-year-old housewife who complained of progressive hearingloss and tinnitus in her right ear for 6 months. Contrast-enhanced CT scanshowed a 1cm tumour in the right cerebello-pontine angle. Microsurgerywas performed and the tumour was removed.

a) Describe the microscopic appearance of the tumour.b) What is your diagnosis?


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2. Meninges 34A:

Mrs Tina is a 76-year-old retired school teacher with recentcomplaints of seizures. Plain CT scan of the head showed a duraltumour over the temporal lobe compressing the brain, which wasexcised.

a) Describe the microscopic appearance of the tumour.b) What is the most likely diagnosis?


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3. Meninges 34B:

Adina, a 6-year-old girl, was admitted with history of fever andheadache. Cerebrospinal fluid examination showed manyneutrophils. She passed away before treatment was started. APostmortem examination of the brain was performed.

a) Describe the microscopic appearance.

b) What is the provisional diagnosis?c) What are the possible aetiological factors?


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4. Brain 35A:

Mr Boon was a 66-year-old businessman with a history ofhypertension and chronic smoking. While having dinner, he suddenlycomplained of headache and developed hemiparesis. He soon lostconsciousness and died a few days later. Postmortem brain tissuewas obtained for examination.

a) Describe the microscopic appearance of the biopsy tissue.b) What is your diagnosis?c) Explain the possible pathogenesis of this condition in this


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5. Brain 35D:

Mr Subra, an 86-year-old retired policeman, presented withheadache and problems with speech and memory for 3 months.Magnetic resonance imaging (MRI) revealed an enhancing cystic

lesion in the left temporal lobe. Partial resection of this left temporalmass was performed.


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Chapter 15 : Diseases of Bones and Jo


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Slide 37A Bone - Giant cell tumour (osteoclastoma) (H&E x10)This slide shows a tumour composed of mononucleated and multinucleated giantcells. The mononucleated cells show pale pink cytoplasm and oval vesicular nucleiwhich are fairly uniform in appearance. The multinucleated cells show nuclei that aresimilar in appearance to the nuclei of the mononucleated cells. A few mitotic figurescan be seen. There is no osteoid or bone formation by the tumour cells. There is nonormal bone seen in this section.

Case 1: A 32 year old woman, presented with a 2 month history of pain around thelower portion of her right knee. Examination showed signs of local swelling.Roentgenograms revealed a well-defined, eccentric and lytic radiolucentlesion in the proximal tibia involving the metaphysis and epiphysisextending to the subchondral bone end plate of the articular surface. Therewas a notable absence of sclerotic rimming & the presence, instead, ofmoth-eaten destruction (arrows) & trabeculation.Microscopic examination of the surgical resection specimen revealed alesion represented by the section shown.

Q1: Describe the characteristic features of this cellular lesion, identifyingthe neoplastic cells & state its alternative name

Q2: On the basis of the microscopic presence of giant cells, what otherpossible differentials may be considered?

Q3: What is the clinical course of the disease?

37B Bone Osteomyelitis (H&E x20)

Case 2: A 57 year old chronic diabetic male presented at the out patient clinic withcomplaints of a dull, throbbing pain over the left lower leg, of a weeksduration.Local examination showed a poorly healed ulcer over the anteromedialaspect of the distal third of the limb close to the ankle. There were alsoother trophic changes of the surrounding skin imparting a generallyunhealthy appearance. There was no apparent swelling.Roentgenograms revealed a lytic focus in the distal tibia surrounded by welldefined sclerotic margin.The examined biopsy specimen yielded microscopic sections such as thatshown above.

Q1: Describe the microscopic features seen


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Microscopic examination of the excisional specimen showed typicalfeatures

Q1: Discuss other salient radiographic features of this benign bone tumour

Q2: Describe the gross & microscopic features seen, including otherexpected details

Q3: What is the risk, if any, of malignant development?


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Histopathology slide description


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Slide 1A Aorta - AtherosclerosisThe aorta showing an artheromatous plaque which is bulging slightly into the luminalaspect of the vessel. The centre of plaque shows heamorrhage. The luminal aspect ofplaque shows a fibrous cap with cholesterol clefts and the deeper part shows foamcells (lipid laden macrophages) and smooth muscle cells.

Slide 1C - Coronory Artery - ThrombosisIn this section you see adipose tissue, cardiac muscle, 2 veins and 3 arteries. Thecross section of one of the arteries shows a recent thrombus almost filling the lumen.The thrombus is composed of erythrocytes and leucocytes. Platelets are not clearlyvisible as they are incorporated into thrombus the part of the thrombus adjacent tothe endothelium is compose of fibrin adherent to the endothelium. There is alsosome congestion and haemorrhage seen in intima.

Slide 2D Heart - Rheumatic carditisThe slide of the heart shows a picture of pancarditis. The endocardim is heavilyinflamed with numerous lymphocytes, scattered eosinophils, polymorphs and a fewplasma cells. The characteristic features are the necrosis surrounded by collections ofanitschkow cells(plump activated histiocytes)and Aschoff giant cells. The anitschkowcells have abundant , amhophilic cytoplasm and central round to oval nuclei in whichthe chromatin is dispersed in a wavy slender ribbon resembling acaterpillar(caterpillar cells). The Aschoff giant cells are multinucleated histiocyteswith similar nuclei as described in aniscthkow cells. A few aschoff giant cells andother inflammatory cells are also seen in the myocardium and pericardium.

Slide 2E Heart - Recent and healed infarctThe slide shows cardiac muscle. The recent and the old infarct are at opposite endsof section. The area of recent infarct shows foci of dropout of cardiac muscle fibres

and these areas are filled with inflammatory cells, mainly polymorphs. The cardiacmuscle around these areas of dropout shows absence of nuclei and musclestriations and stain very brightly eosinophilic.some of larger areas of cardiac muscle

dropout show, in addition to polymorphs, lymphocytes, granulationtissue(indicating that healing has commended). Around this area of granulationtissue many of the cardiac fibres show golden brown pigment(possibly lipofuchsin).What has been described so far constitutes the recent infarct. Proceed to the otherend of the section and you will see large areas of dropout of cardiac musclesoccupied by fibrous tissue(healed infarct). Some of the cardiac muscle round theseareas show large and deep staining nuclei.

Slide 2H - Heart - old myocardial infarctThe slide shows endocardium , myocardium and pericardium. The pericardiumconsists of fibrofatty tissue while the endocardium consist of fibrous tissue .themyocardial region shows variably sized areas of muscle fibre dropout occupied byfibrous tissue. Some of these smaller foci of fibrous tissue are seen in thesubendocardial myocardium(close to the endocardium). Some muscle fibres aroundthe fibrotic areas show very large nd deeply-staining nuclei.

Slide 2I Heart - Recent infarctThe slide show a section of the heart showing recent infarction. This is a very earlyinfarct showing subendocardial foci of congestion and haemorrhage in areas of


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cardiac muscle dropout. Hemorrhage and congestion are also seen in other areas ofmyocardium and in some of them you can also see inflammatory cells(mainlypolmorphs)Along with a few histiocytes. Cardiac muscle fibres around this congested area showabsence of nuclei and striations.

Slide 3A Nose - Nasal polypIn this slide you see polypoid fragments of tissue lined by pseudostratified ciliatedcolumnar epithelium. The underlying tissue shows oedema and inflammatory cellinfiltration consisting of eosinophils ,lymphocytes and plasma cells. There are manyblood vessels seen and also mucous glands, some cartilage and bone.

Slide 3C Nasopharynx - CarcinomaThe slide shows 3 fragments of tissue, one partly lined by squamous epithelium. Theunderlying tissue in the two large fragments is heavily inflamed with numerousplasma cells, lymphocytes and a few eosinophils. Sheets and islands of tumour cellsare seen infiltrating this tissue. These tumour cells are large with pale pinkcytoplasm and pale staining large nuclei and macro-nucleoli. Part of the two largefragments and the entire small fragment show deep pink areas in which no nuclei arestained(ischemic necrosis).

Slide 6C Lung - Lobar pneumoniaThe section shows lung tissue with congested alveoli all of which are filled withneutrophils and histiocytes with erythrocyte. The alveolar septae arewidened and congested bronchi or normal alveoli are seen.

Slide 6E Lung - Miliary tuberculosisThe slide shows lung tissue with pleural absence at one end. Some of the alveolishow pink proteinacous materials in the lumen(oedema fluid). A few bronchi arevisible. Tuberculous are seen consisting of central caseation and

circumscribed clusters of epitheliod cells, Langhans giant cells and lymphocytes.

Slide 6H Lung - Hyaline membrane ________seThis slide of lung shows congestion . Some of the respiratorybronchioles , alveolar ducts and alveoli are lined by thick pink hyalinemembrane(which is made up of fibrin and cell debris derived from necrotic alveolarlining cells).

Slide 6I Lung - BronchiectasisThe slide shows lung with several bronchi showing mucous gland and cartilage in thewall. The bronchi are .Beneath the bronchial epithelium, inflammatorycells(mainly monocytes)are seen. At one focus near one end of the section thebronchial lining is desquamated with necrotic material, erythrocytes an leucocytes inthe lumen and the wall of the bronchus is heavily inflamed and the lumina of some ofthem are filled with inflammatory cells. Some lung tissue is seen which shows foci ofoedema and consolidation.

Slide 6P Lung - Small cell carcinomaThis slide of lung shows tumor tissue, some normal lung tissue and a lymph node inwhich a lot of anthracotic (carbon) pigment is seen. The tumor is composed of smallhyperchromatic cell ( slightly larger tan lymphocytes) with scanty cytoplasm, round


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to oval nuclei and mild to moderate pleomorphism. Some cells are spindle-shaped orpolygonal. These cells are arranged in loose clusters that show neither glandular norsquamous differentiation and are incompletely divided by fibrous tissue septae whichcontain blood vessels. This is the classic oat cell pattern

Slide 7G - Lymph node - Non Hodgkins lymphomaThis slide shows a lymph node with complete loss of nodal architecture. The lymphnode is replaced by a more or less homogenous population of lymphoid cells thatshow scanty cytoplasm and vesicular nuclei, some of which are cleaved. One or morenucleoli can be seen and mitotic figures are numerous. Some small lymphocytes arescattered in between these cells.

Slide 7K - Lymph node - Metastatic adenocarcinomaThis slide shows a lymph node which partly replaced b tumour consisting of glands ofvarying sized that are lined by tall columnar cells with vesicular nuclei. In betweenthe glands, some amount of fibrous tissue is seen and part of the uninvolved node isalso seen which shows lymphoid follicles.

Slide 9A Skin - histoplasmosisthis slideThis slide of skin shows an area of ulceration with exhuberant granulation tissueconsisting of blood vessels, polymorphs and histiocytes which contain numerousyeast forms of histoplasma capsulatum. The yeast forms measure about 2-4 mm indiameter and in H+E stained sections appear as central dot like structuressurrounded by a clear halo which represents the capsule. In the PAS stained slide theyeast form and the capsule are well demonstrated in deep magenta colour. The

histiocytes containing yeast forms are also seen in the superficial dermis in theadjacent non-ulcerated part of skin.

Slide 9G skin - malignant melanomaThe slide shows skin with a small area of ulceration. The superficial part of this ulceris composed of inflam

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