Escolar Documentos
Profissional Documentos
Cultura Documentos
101 v2.0
v1.0 For the last 2 weeks we have endured long days and sleepless nights to bring you these notes. Apologies to
future dermatologist and orthopaedic surgeons, we didn’t get to starting musculo or skin, look out for them in
the second edition (may or may not be released next year, probably not).
The main inspiration to keep us going to get these done was that Raj really needed them.
v2.0 So its 3wks in now and I’ve got an update, guess next year came quicker than expected. I know the exam is
soon but it might help. All the systems are there now and thanks to Tash we now have skin notes. Thanks to
Ben for his help with notes on demyelination.
The main inspiration to get this done was that Raj said he’d do dentistry if he didn’t get into orthopaedics.
High output failure: heart is pumping normally, however tissue demands have greatly increased.
vs Low output failure: heart cannot keep pace with basic peripheral demands.
Acute heart failure: quick onset, usually systolic heart failure and hypotension but no oedema.
vs Chronic heart failure: long term, often normal BP but with oedema.
Angina Pectoris
Chest pain due to inadequate perfusion (reversible myocardial ischaemia). Felt as crushing/squeezing
substernal chest pain, can radiate to left and jaw.
Stable angina: is predictable, occurring during exacerbation or increase O2 demand. >75% due
to fixed atherosclerotic narrowing.
Unstable angina: is erratic, occurring at rest or with low exertion, getting progressively worse
(pre-infarct state). Caused by plaque disruption, thrombosis or vasospasms.
Variant (Prinzmetal) angina: occurs at rest due to vasospasm. Artery may be normal.
Slow development of atherosclerotic plaque build up allows time for compensation from collateral
circulation. Clinically significant plaques are predominantly in the first few cms of left anterior
descending, left circumflex or entire length of right coronary artery.
Morphology: early changes after vascular obstruction are reversible (angina). Irreversible changes after
20-40min of severe ischaemia → myocyte death (coagulative necrosis).
<12hrs, AMI is not grossly apparent, however Infarcts >3hrs can be seen with vital stains for
lactate dehydrogenase which leaks into blood during myocyte damage. Infarct seen as pale
zone.
12-24hrs, infarct is grossly identified by a reddish brown discolouration (stagnant, trapped
blood). Becomes yellow and soft thereafter.
10-14days, infarcts rimmed with highly vascularised granulation tissue.
Weeks, fibrous scar tissue formation (from border to centre).
Extent of MI: infarction begins in subendocardial zone then spreads outwards to include transmural
thickness of chamber. Extent of infarct depends on:
Size, site and degree of obstruction
Rapidity of onset and extent of collateral circulation that was allowed to develop.
Duration of occlusion, reaches full size within 3-6hrs, hence intervention can limit damage.
Associated arterial spasm.
Clinical: severe crushing substernal chest pain, can radiate to neck, jaw, epigastrium, left arm. Can be
asymptomatic (10-15%), usually due to diabetic neuropathies or in the elderly. Dyspnoea and features of
left sided heart failure are also common.
ECG can show pattern of injury.
o Changes in Q waves indicate transmural infarcts.
o ST segment abnormalities, T wave inversion indicate myocardial repolarisation problem.
o Arrhythmias can be detected, indicates conduction pathway damage.
Laboratory tests are important in confirming diagnosis and are based on measuring intracellular
macromolecules which leak out of damaged cells.
o Myoglobin, troponin T and I, creatine kinase (CK), lactate dehydrogenase (LDH) etc.
o Troponins and CK-MB have high specificity and sensitivity for myocardial damage.
Treatment: goal is to salvage maximal amount of ischaemic myocardium by reperfusing tissue quickly.
Can use thrombolysis (drugs), balloon angioplasty, coronary artery bypass graft.
Reperfusion injury can occur, mediated by oxygen free radicals from increased leukocyte
numbers. Can cause endothelial swelling or haemorrhage.
Complications: risk depends on infarct size, site and thickness of damaged heart wall. Sudden death
(15%), no complications (10-15%), complications (65-70%).
Contractile dysfunction: severe pump failure (cardiogenic shock) proportional to infarct size.
Arrhythmias: responsible for many sudden deaths due to conduction problems.
Myocardial rupture: due to CT lysis, can occur in ventricular wall (haemopericardium and
tamponade), IV septum (shunt formation) or papillary muscle (mitral valve regurgitation).
Pericarditis: fibrous or haemorrhagic. Typically spontaneously resolves.
Mural thrombus ± systemic thromboembolism, pulmonary embolism
Ventricular aneurysm
Progressive late LV congestive heart failure.
Pathophysiology: Hypertension results in pressure overload on LV, which adapts by depositing myofibrils
parallel to the long axes of cells. This results in concentric hypertrophy.
Wall thickening without change in chamber size, hence cavity diameter reduced size.
Hyperplasia cannot occur as myocytes are terminally differentiated.
Hypertrophy initially compensatory but if prolonged/excessive eventuates into myocyte contractile
failure. This is due to:
↑ O2 demand due to increased cell size, ↓ blood supply as capillaries don’t grow (ischaemia).
Change in gene expression leading to less functional protein and hence ↓ contractility.
Stenosis Incompetence
Failure of valve to open completely, obstructing
(Insufficiency/Regurgitation) Failure of valve to
forward flow. Creates a high pressure gradient
close completely, allowing reverse flow. Creates
across valve causing turbulent flow. backward volume overload.
Mitral Stenosis Mitral Regurgitation
-Cause: post inflammatory scarring (RHD). -Causes:
o Myxoid degeneration (floppy leaflet that
-Clinical: LA pressure increase → pulmonary
prolapses into LA due to abnormal ECM).
congestion and hypertension → RV
Mitral Valve Disease
-Causes: RHD, degenerative calcification (eg. -Causes: leaflet abnormalities (eg. RHD, IE), aortic
old age, congenitally deformed valve) diseases (eg. degenerative aortic dilation, syphilitic
aortitis, ankylosing spondylitis, rheumatoid
-Clinical: small pulse, LV hypertrophy, angina,
arthritis, Marfan syndrome).
syncope, LV failure or sudden death.
-Clinical: wide pulse pressure, collapsing pulse, LV
-Murmur: systolic, ejection murmur
hypertrophy, angina, LV failure
-Murmur: diastolic, opening snap, 3rd heart sound
Damage to right side valves (tricuspid and pulmonary) is rarer due to lower pressure.
Rarely isolated, often asymptomatic or symptoms dominated by left valve problems.
Can be caused by portal/pulmonary hypertension, oedema or fatigue.
Acute RHD is associated with inflammation of valves, myocardium and Aschoff Bodies
pericardium due to cross reacted auto-antibodies. Inflammatory lesions in heart
Endocarditis (valves): focal fibrinoid necrosis and fibrin thrombi consisting of fibrinoid change,
along lines of closure. lymphocytes, plasma cells and
Myocarditis: Aschoff body formation. May have LV dilatation macrophages. Diagnostic.
or failure due to mitral stenosis/incompetence. Can be found in any layer of heart,
or in all layers (pancarditis).
Pericarditis: fibrinous/serofibrinous exudates, resolves spontaneously.
Infective Endocarditis
Infection of valves and endocardium with formation of vegetations. Usually affects abnormal valves (eg.
previously damaged, congenitally malformed or artificial valves). Other risk factors include
neutropaenia, immunosuppression, IVDU and dental work/surgery.
Dilated Cardiomyopathy
Cardiac dilation and systolic dysfunction, usually with hypertrophy, in all four chambers. Characterised
by forward failure with reduced CO.
Clinical: most pursue a downhill course, majority die within 3yrs of symptom onset
due to heart failure or arrhythmia. Can affect any age, >55yrs worse prognosis.
Progressive CHF (dyspnoea, poor exertion capacity), end stage with ejection
fraction <25% (normal 60%).
Secondary mitral incompetence and arrhythmia due to LV dilatation.
Embolism from intracardiac emboli.
DCMP
Hypertrophic Cardiomyopathy
Characterised by LV hypertrophy of a non-dilated chamber (concentric), without obvious cause such as
hypertension or aortic stenosis.
Pathology: about 50% of cases due to autosomal dominant mutations in genes coding for myocyte
contractile apparatus (eg. B-myosin heavy chain). Marked hypertrophy results, but is asymmetrical (LV).
Abnormal diastolic filling due to increased thickness of ventricular wall.
Some patients have further dynamic obstruction to LV outflow. This is due to anterior leaflet of
mitral valve being displaced by hypertrophy, narrowing the subaortic area.
Hypertrophy is accompanied with fibroblast proliferation causing interstitial fibrosis.
Complications: atrial fibrillation with mural thrombus formation, IE of mitral valve, CHF, arrhythmias,
and sudden death
Restrictive Cardiomyopathy
Characterised by a primary decrease in ventricular compliance, with Endomyocardial Fibrosis:
an excessively rigid LV wall and impaired diastolic filling. dense fibrosis of endocardium and
subendocardium from apex to AV
valves. Seen in young people in Africa.
Pathology: can be idiopathic or associated with; hypertrophic CMP,
systemic diseases that affect the myocardium (eg. radiation fibrosis, Loeffler Endomyocarditis:
amyloidosis, sarcoidosis) and constrictive pericarditis. endomyocardial fibrosis associated with
Similar pathology to endomyocardial fibrosis, Loeffler eosinophilia from any cause.
Myocarditis
Inflammation of myocardium with neutrophilic infiltration causing injury (not response to injury).
Secondary to infections (eg. viral, bacterial) or immune reactions (eg. post viral, SLE). Coxsackie
A and B most common causes.
Can be asymptomatic or cause serious heart disease (eg. CHF, CMP, sudden death).
Can affect previously well fit persons.
Pericardial conditions include inflammatory diseases and effusions. Isolated disease is unusual,
pericardial lesions are usually associated with heart, surrounding structure or systemic disease.
Pathology: may be infectious, non-infectious or immune related. Inflammatory exudates may serous,
fibrous, haemorrhagic, suppurative or caseous.
Infectious Pericarditis: virus is most common infectious cause (eg. coxsackie, echovirus,
mumps). Bacteria and fungi may be involved. Myocarditis may also be present, especially with
viral disease.
Non-Infectious Pericarditis: more commonly secondary to AMI, uraemia, irradiation, neoplasia,
myxoedema or trauma.
Hypersensitivity/Autoimmune Pericarditis: rheumatic fever, collagen vascular disease (eg. SLE),
drug induced or post cardiac injury.
Clinical: may be acute (<6wks), subacute (<6mnths) or chronic
Pericardial Effusions
(>6mnths).
Effusions <500mL do not interferes
Roughened pericardial surface can be heard as greatly with heart function.
‘pleural rub’.
Rapid accumulation of fluid, often due
Effusion present as globular appearance on x-ray.
to catastrophic haemorrhage (eg. AMI,
Healed/chronic cases may result in adhesive ruptured aneurysm, trauma) can cause
pericarditis, adhesive mediastinopericarditis or cardiac tamponade and restrictive HF.
constrictive pericarditis.
Transplantation
Usually only an option for dilated CMP and severe IHD in younger patients. Overall prognosis of 80% 1yr
survival, 60% 5yr survival depending on two main issues:
Graft coronary arteriosclerosis (GCA) is a late stenosing intimal disease of coronary arteries. Very
common and leads to silent IHD/MI, HF or sudden cardiac death.
Obstructive lesions include valvular stenosis and aortic coarctaion (constricting or narrowing). Clinical
severity of lesion depends on the degree of stenosis and the openness of the ductus arteriosus.
Shock
A state of circulatory failure characterised by inadequate tissue perfusion due to a lack of CO/BP. Low
blood perfusion to tissues can result in ischaemia and necrosis.
Arrhythmias
Abnormal electrical activity within the heart resulting in either an altered impulse generation or
conduction (ie. altered beating rhythm).
Are a result of other heart diseases that affect the conductive tissue (eg. MI, CHF).
Either bradyarrhythmias (slow rhythm) or tachyarrhythmias (fast rhythm).
Can be intermittent (alternate), transient (come and go) or permanent/persistent.
VASCULAR
PATHOLOGY
ARTERIOSCLEROSIS
Arteriosclerosis
Arterial wall thickening and loss of elasticity, 3 different patterns which may coexist.
Arteriolosclerosis: thickening and luminal narrowing of small arteries/arterioles associated with
hypertension and diabetes. Has 2 variants; hyaline and hyperplastic.
Monckeberg medial calcific sclerosis: uncommon calcific deposits in media of muscular arteries,
while intima and adventitia may appear normal. Usually not clinically significant as arteries are
not narrowed. Typically in limbs or uterus of people >50yrs.
Atherosclerosis: an intimal based lesion organised into a fibrous cap and a lipid core
(atherosclerotic plaques). Obstruct blood flow and weaken underlying media which may
rupture. Most frequent and clinically important.
Prevention: can be primary (risk factor identification and modification to delay atheroma formation) or
secondary (prevent AMI, stroke etc using drugs).
Risk factors: high dietary salt (Na) intake, stress, obesity, smoking, inactivity and some genetic
susceptibility (multifactorial eg. genes coding regulation mechanisms).
Complications: atheroma acceleration (MI, strokes) most deadly. Increased risk of LVH, CHF, aortic
dissection and renal failure.
Renin-Angiotensin System
Regulation of Hypertension Renin is a major regulator of blood pressure,
Blood pressure is regulated by a combination of CO and secreted by kidneys in response to
peripheral resistance (BP α CO x SVR). This is done via neuronal decreased afferent arteriole pressure or
and hormonal mechanisms. glomerular Na filtration.
Cardiac output: blood volume (Na, mineralocorticoids, Converts angiotensinogen to angiotensin
ANP) and cardiac factors (HR, contractility). CO=HR x SV → ACE converts to angiotensin II
Peripheral resistance: neural, hormonal and local Angiotensin II causes vascular SMC
factors (autoregulation, pH, hypoxia). contraction and aldosterone secretion
→ increased Na (hence water)
resorption → increase blood volume/BP.
Vascular Pathology in Hypertension
Vascular changes during hypertension include: atherosclerosis acceleration, degenerative changes in
walls of larger arteries, and arteriosclerosis in small vessels (hyaline or hyperplastic).
Benign Hypertension (95%) persists slowly over years and is of moderate degree. Is usually idiopathic,
although can be due to renal disease.
Small arteries/arterioles undergo hyaline arteriosclerosis.
Consists of homogeneous eosinophilic hyaline thickening of
media → narrowing of lumen can cause ischaemia.
Small to medium arteries show intimal fibrosis and media SMC
hypertrophy.
Large muscular and elastic arteries have accelerated
Hyaline arteriosclerosis
atherosclerosis.
Complications: rupture, occlusion (by thrombus or pressure), embolism, mass effect on surrounding
structures.
Causes: majority of cases result from an altered balance between collagen degradation
and synthesis.
Mediated by local inflammatory cells and their proteolytic enzyme release.
Elevated matrix metalloproteases (MMPs), lowered tissue inhibitor of
metalloproteases (TIMP) → degrade ECM of arterial wall.
Familial predisposition, hereditary defects in structural components of vessel
wall (eg. Marfan's).
Complications:
Rupture into peritoneal cavity or extraperitoneal tissue, can be fatal. Risk of Ruptured
Aortic Aneurysm
rupture α size of aneurysm, >5cm serious.
Occlusion of a branch vessel (iliac, renal, mesenteric, vertebral arteries) → ischaemic damage.
Embolism from atheroma or mural thrombus.
Impingement on adjacent structure (eg. compression of ureter, erosion of vertebrae).
Syphilitic Aneurysm
Pathogenesis:
Late complication of syphilis, whereby T. pallidum affects the vasa vasorum in the Vasa Vasorum
aortic adventitia, causing ‘obliterative endarteritis’ (endothelium inflammation). Arterial network
supplying larger
Affected vessels show luminal narrowing and obliteration. Scarring of vessel wall
blood vessels.
with surrounding inflammation (lymphocytes and plasma cells).
Lumen narrowing of vasa vasorum causes ischaemic injury of aortic media → loss of elastic
fibres and muscle cells (destruction and weakening of media) → dilation (aneurysm).
Complications:
Contraction of fibrous scarring leads to wrinkling of aortic intima, resembles tree bark.
Associated atherosclerosis of aortic root can obstruct coronary ostia, can cause MI.
Weakening of aortic root dilates valvular annulus → valvular insufficiency → volume overload
(eccentric) hypertrophy of LV – “cor bovinum” (cow’s heart).
Most patients with syphilitic aneurysms die of heart failure induced by valvular incompetence.
Aortic Dissection
Blood dissects aortic wall and tracks along luminal planes of the media. Forms a blood-filled channel
within the aortic wall. Occur in mainly in men aged 40-60 with hypertension.
Morphology: histology commonly shows cystic medial degeneration (CMD) in the media.
cystic spaces filled with proteoglycan rich ECM separating elastic tissue and SMCs in the media
fragmentation and loss of elastic tissue.
Takayasu Arteritis involves granulomatous inflammation with transmural fibrous thickening of aorta.
Histology: indistinguishable from giant cell arteritis, distinction by age (<40yrs).
Clinical: symptoms depend on aortic branches involved. Possible ocular disturbances,
neurological deficits (carotids), pulmonary/systemic hypertension (lung/renal), AMI (coronary).
Weak peripheral pulse due to luminal narrowing.
Kawasaki Disease arteritis of medium sized vessels associated with anti-endothelial/SMC antibodies.
Histology: PAN-like morphology.
Clinical: febrile illness of infancy and childhood. ‘Mucocutaneous lymph node syndrome’ as it
presents with inflammation (conjunctival, oral, skin), rash and lymph node enlargement.
Complications: arteritis of coronary arteries can cause aneurysms that rupture or thrombose
causing AMI. Leading cause of acquired heart disease in children.
Small Vessel Vasculitis (arterioles, capillaries, venules)
Microscopic Polyangiitis (hypersensitivity vasculitis) is a necrotising (fibrinoid) vasculitis.
Pathology: antibody response to drugs, microorganisms etc. Results in immune complex
deposition or triggering secondary immune responses (neutrophil). p-ANCAs present in 80%.
May accompany Henoch-Schonlein purpura, essential cryoglobulinaemia, CT disorders.
Histology: fibrinoid necrosis, acute inflammatory cell infiltrate, RBC extravasation, nuclear dust
(leukocytoclastic vasculitis). All lesions are of the same age in any given patient.
Clinical: symptoms depend on vascular bed involved eg. purpura (skin), haematuria (kidneys),
pain, haematemesis and melena (GIT), pain and weakness (muscle), haemoptysis (lungs).
Most patients recover from removal of offending agent.
Churg-Strauss Syndrome granulomatous necrosis of respiratory tract with eosinophils in lesions and
peripheral blood. Related to Wegener Granulomatosis but distinguished by strong association with
allergic rhinitis, asthma, eosinophil involvement and p-ANCA.
Infectious Vasculitis
Important to distinguish between immunologic and infectious mechanisms because immunosuppressive
therapy will help the former but exacerbate the latter.
Mainly due to bacteria or fungi (aspergillus and mucor species).
Can weaken arterial walls (mycotic aneurysms) or induce thrombosis and infarction.
Indirect vasculitis can occur from drugs used to treat infection eg. penicillin.
HAEMATOLOGIC
PATHOLOGY
RED CELL DISORDERS
Anaemias are a group of disorders characterized by a decrease in the number of circulating
erythrocytes. Classified by erythrocyte morphology and pathogenesis.
Pathogenesis: anaemias may result from (i) blood loss, (ii) haemolysis, or (iii) decreased
production of RBCs.
Reticulocyte count is a measure of newly synthesised RBCs; compensatory increase after blood
loss/haemolysis, low count in hypoproliferative anaemia.
Morphology: RBCs may be normal in size but different shape (normocytic), large (macrocytic) or
small (microcytic). Measured in terms of mean cell volume. Hb may be normal (normochromic)
or decreased (hypochromic).
Signs and symptoms: palpitations, systolic cardiac murmurs, high output heart failure, pallor,
hypotension (decreased volume), tachycardia, fatigue, dizziness, syncope and angina.
Haemolytic Anaemia
Group of disorders characterised by premature RBC destruction, Hb breakdown and a compensatory
increase in erythropoiesis. Can be intra- or extravascular.
Intravascular causes elevated serum and urinary Hb, jaundice, urinary haemosiderin, and a
decrease in circulating haptoglobin (glycoprotein that binds free Hb, allowing removal by liver).
Extravascular haemolysis occurs in the organs of the reticuloendothelial system.
Hereditary Spherocytosis membrane defect leads to less deformable spherical RBCs which are
vulnerable to splenic sequestration and destruction.
Pathology: autosomal dominant (25% are recessive) gene codes for defective spectrin molecules
in erythrocyte membrane. Treated by splenectomy.
Morphology: peripheral smear shows spherical RBCs lacking in central pallor and reticulocytosis.
RBCs also have increased osmotic fragility. Normocytic, normochromic.
Sickle Cell Disease sickle haemoglobin (HbS) mutation results in deformed RBC, causing increased splenic
destruction and microvascular obstruction.
Pathology: hereditary substitution (valine for glutamic acid) in β-chain of Hb, producing HbS
molecules. These aggregate and polymerise when deoxygenated, causing sickle shape.
Morphology: RBC assume abnormal, rigid, sickle shape Congestive Splenomegaly
(elongated and crescentic). Diagnosis on prep with reducing Occurs mostly in young children due to
agent (metabisulfate) of Hb electrophoresis. infarction in spleen from microvascular
Clinical: sickle cells are removed by splenic phagocytes obstruction. Causes scarring, shrinkage
producing a chronic normocytic anaemia. Widespread and loss of function (autosplenectomy).
microvascular obstruction due to sickle aggregates can Functional asplenia leaves patients
cause acute pain crisis and tissue infarction. vulnerable to infection, most die <30.
G6PD Deficiency results in oxidative stress on the RBC, leading to haemolysis.
Pathology: X-linked disorder coding for deficient G6PD (glucose-6-phosphate dehydrogenase).
G6PD is needed to generate NADPH which maintains glutathione in reduced state. RBCs
normally defend against oxidative injury via reduced glutathione.
Morphology: peripheral smear shows reticulotytosis and Heinz bodies, which are clumps of Hb
degradation products seen after staining RBCs with new methylene blue.
Immune Haemolytic Anaemia haemolysis due to anti-RBC antibodies, Warm antibody: functions at body
idiopathic or secondary to malignancy, infection or drug use. temperature, is usually IgG.
Pathology: antibodies bind and opsonise RBCs. Phagocytosis in Eg. malignancy (CLL), drugs (penicillin,
spleen or complement fixation with intravascular haemolysis. quinidine), SLE.
Warm and cold antibodies, each associated with different Cold antibody: functions below body
underlying diseases/infections. temperature, is usually IgM.
Diagnosis: Coombs test measures antibodies on RBCs (direct) Eg. Mycoplasma infection,
or antibody in serum (indirect). mononucleosis, B-cell malignancy.
Polycythaemia
Polycythaemia is an increase in the concentration of circulating erythrocytes. May be relative or
absolute (primary and secondary).
Relative Polycythaemia is due to loss or sequestration of intravascular volume without loss of RBCs. Can
be caused by dehydration, vomiting, diarrhoea, burns, adrenal (aldosterone) insufficiency.
Laboratory Tests
Platelet counts: determined from anticoagulated blood using an electronic
particle counter.
Bleeding time: time taken for standard skin puncture to stop bleeding.
Assessment of in vivo clotting, normally mins.
Prothrombin time (PT): tests the extrinsic and common coagulation
pathways. Represents clotting time in the presence of tissue thromboplastin
(factor III), normally 12-15 sec. INR=[patient PT/normal PT]ISI.
Partial thromboplastin time (PTT): tests factors in the intrinsic and common
coagulation pathways, normally 25-35 sec.
Thrombin time (TT): measures factor I (fibrinogen).
Leukaemias
Chronic Myeloid Leukaemia (CML) arises from mutation in a pluripotent myeloid
CML
stem cell, resulting in overproduction and accumulation in blood. Present in
multiple myeloid lineages.
Pathology: acquired genetic translocation (9;22), producing a BCR-ABL
fusion gene that codes for a tyrosine kinase protein.
o This protein activates transduction pathways to uncontrolled cell
growth, whereas the original ABL gene switches itself off.
o Effects granulocyte precursors most, retain capacity for terminal
differentiation resulting in elevated granulocytes in blood.
Clinical: chronic phase (slow with non specific symptoms), accelerated phase (symptoms
become severe) and blastic phase (>30% myeloblasts in blood or marrow).
Diagnosis: bone marrow biopsy with FISH probes to identify BCR-ABL gene. Quantitative PCR.
Treatment: chemotherapy, drugs (imantinib mesylate), bone marrow transplant.
AML with pallor of
Acute Myeloid Leukaemia (AML) neoplasm comprised of immature myeloid cells. renal substance.
Pathology: diverse genetic lesions express abnormal transcription factors
that block myeloid cell differentiation. This results in replacement of normal
marrow elements by leukaemic blasts.
o Abnormal cytogenetics found in 60-80% of AMLs.
o Most common is the t(15;17) translocation in Acute Promyelocytic
Leukaemia (APML) resulting in abnormal vitamin A receptors (Tx
with vit A analogue).
Clinical: makes up 90% of adult and 15% of childhood acute leukaemias. Present with pallor,
purpura and petechiae.
Diagnosis: chromosome testing most definitive.
Chronic Lymphocytic Leukaemia (CLL) formation of neoplastic B-cells that suppress normal B-cell function.
Pathology: >95% involve B-cell linage, DNA changes associated with apoptosis (90% have
increased bcl-2 levels).
o Auto antibody production by normal B-cells indicates
breakdown in immune regulation.
o Cell surface characteristics include CD19+ (pan-B marker) (pancreas)
and CD5+ (pan-T marker). CLL of Coeliac LNs,
Clinical: most common leukaemia in adults, may be asymptomatic early. Non-specific symptoms
with lymphadenopathy and hepatosplenomegaly occur. Progressive rise in WCC, low blood
counts in advanced disease (may be aggressive late).
Acute Lymphoblastic Leukaemia (ALL) aggressive tumours composed of immature lymphocytes (blasts).
Pathology: malignant change, usually in pre-B-lymphoblast causes block in differentiation.
o Leads to accumulation of immature lymphoblasts in bone marrow, which suppresses
normal haematopoietic stem cells.
o Mutation is often an oncogene translocation to an active DNA transcription site.
Clinical: 80% of childhood leukaemias. Is a rapid growing disease involving blood, marrow,
spleen and other sites (CSF, testes, lymph nodes).
Lymphomas
Non-Hodgkin Lymphomas most often involve malignant B-cells (>85%). Malignancy develops at a point
in normal development– specific markers present on cell at specific points. Change usually due to
oncogene translocation during DNA transcription.
Non-Hodgkins
Small lymphocytic lymphoma (4%) is similar to CLL, only with no or limited Lymphadenopathy
peripheral blood involvement.
Follicular lymphomas (40%) are lymph node tumours with a nodular appearance.
95% of cases have a t(14;18) translocation leading to increased bcl-2 expression
(anti-apoptotic).
Burkitt’s lymphoma is associated with t(8;14) translocation and EBV infection. Need
for intensive therapy, including CNS prophylaxis.
MALT lymphoma is usually a localised, indolent disease. >95% of GIT cases
associated with H. pylori infection, eradication often allows remission.
Multiple myeloma is malignant growth of mature B-lymphoid cells (plasma cells) which are
normally secretory. Can cause anaemia, infections, bone pains or fractures, and abnormal
monoclonal antibody production (paraprotein).
Hodgkin Lymphomas are neoplasms that arise in a single lymph node and spread in an anatomical
stepwise fashion.
Characterised by malignant Reed-Sternberg (RS) cells which are derived from B-cells. These are
greatly outnumbered by reactive lymphocytes, macrophages and stromal cells.
Associated with distinctive clinical features, including systemic features eg. fever.
Predictable spread allows for localised treatment if detected early, unlike NHLs.
RESPIRATORY
PATHOLOGY
ATELECTASIS
Atelectasis (collapse) is loss of lung volume caused by inadequate expansion of air spaces.
Results in pathological shunting of deoxygenated blood from arteries to veins (↓ VA/Q ratio).
Is classed by underlying mechanism and distribution of collapse.
Resorption Atelectasis when obstruction prevents air from reaching distal airways.
Air present gets absorbed, leading to collapse.
Can be entire lung, lobe or segment depending on obstruction.
Most commonly due to mucopurulent (mucous) plug. This can be
postoperative complication or due to obstructive lung disease.
Compression Atelectasis when fluid, blood or air accumulates in pleural cavity and
mechanically collapses adjacent lung. Can be due to:
Pleural effusion from congestive heart failure. Pneumothorax (air).
Elevated diaphragm causes basal atelectasis, commonly in bedridden or
ascites patients.
Contraction atelectasis when local/generalised fibrotic changes in lung or pleura
hamper expansion and increase elastic recoil during expiration (interstitial disease).
Highly compromised lung function.
Non-reversible (others can be treated).
Microatelectasis loss of surfactant, lung cannot expand equally resulting in collapse.
Emphysema
Abnormal permanent distension of airspaces in acinus (distal to terminal bronchioles) with destruction
of alveolar septae. Obstruction results due to loss of elastic recoil.
NB: several conditions have enlargement of acini with no destruction eg. compensatory over-
inflation of lung after pneumonectomy. Not considered emphysema.
Pathogenesis: emphysema results from the destructive effects of high protease activity in subjects with
low antiprotease activity (protease-antiprotease imbalance).
↑Proteases: ↓Antiprotease:
1. Neutrophils (protease source) are normally 1. Tobacco smoke contains abundant ROS
sequestered capillary periphery. which deplete antioxidant mechanisms in the
2. Smoking induces accumulation of neutrophils lung (oxidant-antioxidant imbalance).
and macrophages in alveoli via nicotine 2. This elicits direct tissue damage but also
(chemoattractant) and ROS (induce IL-8, LT-B4, TNF). inactivates antiproteases, causing a ‘functional
3. Accumulated neutrophils/macrophages are α1-antitrypsin deficiency’ → further protease
activated and release variety of protease granules tissue damage.
(eg. elastin). Results in tissue breakdown.
Classification: defined by morphological changes, unlike chronic bronchitis (clinical).
1. Centriacinar Emphysema involves only the respiratory bronchioles, distal alveoli are spared.
More common in upper lobes, particularly apical segments.
Distal alveoli may become involved in severe form making differentiation difficult.
Common consequence of cigarette smoking, without α1-antitrypsin deficiency.
3. Distal Acinar Emphysema involves the distal part of the acinus, sparing the respiratory bronchioles.
More prominent adjacent to pleura, septae and the lobular edge.
More severe in upper lung, esp. following previous injury (adjacent to fibrosis or atelectasis).
Characteristic enlarged subplueral, cystic air spaces (0.5-2cm) called bullae. Can rupture and
cause pneumothorax (common cause in young people). Not exclusive to distal emphysema.
4. Irregular Emphysema involves non uniform parts of the acinus, often with scarring.
Often results from healed inflammatory disease (scarring).
Usually asymptomatic, may be most common form.
Clinical: rarely occurs in pure form, usually as part of COPD with chronic bronchitis.
Signs and symptoms of predominantly emphysema:
Older patient (>50 yrs), severe dyspnoea and less sputum.
Weight loss, barrel-chest (hyperinflation), purse-lip breathing, prolonged expiratory time (FEV1).
‘Pink puffers’ as hyperventilation may maintain blood oxygenation till late in the disease.
↑ Air spaces causes hyper-resonant percussion and low density on X-ray.
Complications may include:
Respiratory failure with acidosis and coma.
Right sided heart failure (cor pulmonale). This is due to obliteration of alveolar septal
capillaries/vessels resulting in increased resistance (↑ pulmonary BP).
Pneumothorax, leading to compression atelectasis.
Chronic Bronchitis
A clinical diagnosis of persistent productive cough for at least 3 months in 2 consecutive years.
Pathogenesis: characterised by chronic irritation causing hypersecretion of mucous (~75mL
sputum/day). Usually due to cigarette smoke, but also SO2, NO2, resulting in:
Damage to conducting airways with mucous gland hypertrophy in trachea/bronchi.
Inflammation (CD8+ Tcells, macrophages and neutrophils) with scarring and fibrosis.
Actual airway obstruction occurs in more peripheral airways as a result of:
Bronchiolitis (small airways disease) induced by Goblet cell metaplasia with mucous plugging of
bronchiolar lumen.
Coexistent emphysema or bronchospasm (asthmatic bronchitis).
Clinical: affects 10-20% of urban population, even higher in cigarette smokers. Many have COPD.
Signs and symptoms of predominantly chronic bronchitis:
Younger patient (40-45yrs), milder dyspnoea and plentiful sputum.
Barrel-chested, hypercapnia, hypoxia (respiratory failure).
‘Blue bloaters’ as compensation is rarer resulting in cyanosis in skin and lips.
Complications may include:
Bronchiolitis Obliterans
Cor pulmonale (right heart failure due to pulmonary hypertension). Mucous plugs are
Infections don’t usually initiate bronchitis but perpetuate it. Can result permanently fibrosed
in acute infective episodes, causing pneumonia or respiratory failure. which results in complete
Eventual malignant change in epithelium due to squamous metaplasia. obliteration of the
May lead to Bronchiolitis obliterans bronchiolar lumen.
Asthma
Intermittent, reversible airway obstruction due to enhanced reactivity to a variety of stimuli.
Classification: may be extrinsic or intrinsic.
Extrinsic Asthmas (70%) are due to IgE and TH2 mediated immune responses.
Atopic (allergic) asthma involves type I (IgE) immune reactions to certain antigens (allergens).
Runs in families, begins in childhood, associated with hay fever and eczema.
Occupational asthma also involves type I (IgE) immune reactions; to fumes, organic/chemical
dust etc. associated with the workplace.
Allergic bronchiopulmonary aspergillosis is due to aspergillus in airways causing type I and III
reaction.
Intrinsic Asthmas (30%) are triggered by non-immune, usually idiosyncratic, stimuli.
Non-atopic asthmas are thought to be caused by viral respiratory tract infections, some chronic
bronchitis, air pollution, exercise or stress → mechanism unknown.
Pharmacological asthma eg. aspirin may cause asthma due to excessive leukotriene production
via inhibition of the cyclooxygenase pathway.
Pathogenesis: atopic asthma is caused by IgE mediated immune response to environmental stimuli.
1. Person sensitised to common allergen (eg. dust, pollen, animal hair) via TH2 activation.
IL-4, activates IgE production by B cells → specific IgE sensitised mast cells.
TH2 IL-5, eosinophil recruitment (priming or sensitisation).
IL-13, increased mucous production.
2. Re-exposure results in IgE-mast cell release of mediators (immediate phase, minutes).
o Induce bronchospasm, ↑ vascular permeability, mucous production.
o Mediator effect can be direct or via neuronal reflexes.
3. Mast cell release recruits additional mediator-releasing cells from blood (late phase, hours).
o Eosinophils, neutrophils, basophils and TH2 cells are recruited.
o Release LT-C4/D4/E4, PG-D2, PAF, TNF etc. resulting in further inflammation.
o Eosinophilic major basic protein A can cause epithelial cell damage and
bronchoconstriction.
Bronchiectasis Bronchiectasis
Abnormal, permanent dilation of the bronchi and bronchioles due to destruction of their (with emphysema)
Pathology: alveolar membrane damage (epithelial and Neonatal Resp. Distress Syndrome
endothelial) allows fluid, protein, cellular debris to enter alveoli Occurs in premature infants with surfactant
→ neutrophils and macrophages damage alveoli further by deficiency due to inadequate lecithin
generating ROS and digestive enzymes as part of the synthesis by immature type II pneumocytes.
inflammatory process. Alveoli collapse with resulting hypoxia →
endothelial/epithelial damage → oedema and
Histology: alveolar oedema, epithelial necrosis, accumulation of fibrin exudation → hyaline membrane
neutrophils, presence of hyaline cartilage in ducts. formation.
Clinical: 90% develop ARDS within 72hrs of injury, mortality 60- Increased risks; <2.5kg, <36wks, maternal
100%. Fibrosis of lung is common in survivors. diabetes, caesarean section.
Fibrosing Diseases
Disorders with diffuse chronic involvement of pulmonary CT, principally in the alveolar wall.
Hallmark of these diseases is reduced compliance → lower capacity and dyspnoea.
Diagnosed clinically or histologically, many have unknown cause.
Pathology: all disorders thought to begin with alveolitis. Interactions of inflammatory cells result in
parenchymal injury and progressive fibrosis.
1. Lung injury from inhaled agents, dust, blood borne toxins, unknown antigens etc.
2. Activation of macrophages which recruit neutrophils (via IL-8, LT-B4).
3. Macrophages/neutrophils release oxidants and proteases which damage type I pneumocytes.
4. Macrophage and type II pneumocyte cytokines lead to fibroblast proliferation → fibrosis.
Idiopathic Pulmonary Fibrosis (IPF) is an interstitial Other Diffuse Fibrosing Diseases
pneumonitis of unknown aetiology which leads to May have similarities with IPF, but can be
interstitial fibrosis (process above). Also called cytogenic distinguished histologically and/or clinically.
fibrosing alveolitis (CFA). Non-specific interstitial pneumonia (NIP) diagnosis
Histology: patchy interstitial fibrosis with cystic of elimination, similar to IPF but without
spaces forming honeycomb lung. heterogeneity (existence of early and late lesions).
This pattern is known as usual interstitial Cryptogenic organising pneumonia (COP)
pneumonitis (UIP). unknown aetiology, polypoid plugs of CT in alveoli
and bronchioles.
Clinical: presents with non-productive cough,
Acute-, desquamative-, lymphocytic- interstitial
progressive dyspnoea and inspiratory crackle.
pneumonitis (AIP, DIP, LIP).
Cyanosis, cor pulmonale and peripheral oedema in
Pulmonary involvement in CT disorder eg.
later stages (median survival <5yrs). rheumatoid arthritis, SLE, collagen diseases.
Pneumoconiosis is pulmonary fibrosis due to inhaled particulates, most commonly mineral dust.
Also involve macrophages activating inflammatory response leading to fibrotic change
(above).
Can all cause extensive fibrosis with increasing pulmonary dysfunction, pulmonary
hypertension and cor pulmonale (PMF).
Smoking increases risk/severity of disease and cancer in all exposure, esp. asbestos. Anthro
Classified according to causative particulate (may be organic or non-organic). -Silicosis
Granulomatous Diseases
Sarcoidosis multisystem (disseminated) granulomatous disease that can cause restrictive disease in the lung.
Characterised by non-caseating granulomas in many tissues and organs.
Pathology: idiopathic, likely to be disorder of immune regulation. Antigens, including infectious agents,
with T cell involvement are hypothesised. Diagnosis of elimination.
Clinical: lung is involved in 90% of patients → granulomas replaced by diffuse interstitial fibrosis
(honeycomb lung) in 5-15%. Additional lymphadenopathy, eye involvement and skin lesions.
Hypersensitivity Pneumonitis is an immune mediated lung disease that primarily affects alveoli (ie. allergic
alveolitis). Restrictive, not obstructive like bronchitic asthma, since in alveoli.
Pathology: caused by exposure to organic dusts and other antigens. Chronic reaction of type IV
hypersensitivity.
Clinical: two types, (i) Farmers lung, caused by actinomycetes growing on hay, and (ii) Byssinosis,
caused by cotton, linen or hemp exposure.
PULMONARY VASCULAR DISEASE
Pulmonary Oedema
Pulmonary oedema/congestion is the build up fluid and blood in lung tissue. Oedema refers to fluid build up
while congestion refers more specifically to blood.
Pathology: initial transudate (↓protein) escapes into the alveolar space → hypoxia increases capillary
permeability → exudate (↑protein) then leaks.
Histology: lungs become heavy with frothy fluid from cut surface. Pink staining alveoli due to protein
leak (exudate).
Causes: may be passive or active.
o Passive causes are due to altered hydrostatic pressure/high blood pressure. Includes LHF
(backward failure resulting in ↑ pulmonary BP), renal failure (salt/water overload,
hypoproteinaemia) or lymphatic blockage.
o Active causes are due to direct microvascular damage. Includes infections, inhaled gas or
particulates, drugs, shock or ARDS.
Pulmonary Embolism
Venous emboli travel via IVC into right heart, then impact in pulmonary arterial tree. Massive Pulmonary
95% arise from the deep veins of the legs eg. femoral, popliteal. Embolism
Can be thrombus (mostly), fat, air, amniotic fluid, tumour, foreign body.
Cause pathological shunting (↓ VA/Q ratio) and increase RV pressure.
Morphology: vascular alterations involve the whole arterial tree. Plexiform Lesions
Main elastic arteries: atheroma development.
Different morphology in primary and shunting
Medium muscular arteries: thickening of muscular wall, hypertensions called plexiform lesions.
smaller lumen.
Vessel wall is thinned and network of
Smaller arteries/arterioles: medial hypertrophy, capillary like channels replaces part of arterial
thickening of elastic membrane, intimal fibrosis. wall. Fibrinoid necrosis of walls occurs
NB: all increase resistance and progressing hypertension. resulting in irreversible hypertension.
Clinical: can develop at any age usually due to underlying pulmonary or cardiac disease.
Symptoms include fatigue, dyspnoea, syncope (esp. during exercise), and cyanosis.
Can result in respiratory failure, RHF (cor pulmonale), pneumonia, embolism and even death.
PULMONARY INFECTIONS
Community Acquired Pneumonia
Mostly acute bacterial pneumonias that can present as one of two patterns (lobar or bronchopneumonia).
Lobar pneumonia: airspaces in a lobe are homogenously filled with exudate consolidation. S. pneumoniae
causes 90% of adult cases. Typically evolve through 4 stages that can be altered or halted by antibiotic
treatment.
1. Congestion: vascular congestion with proteinaceous fluid, neutrophils and
bacteria in alveoli, affected lobes are heavy, red, boggy (24hrs).
2. Red hepatisation: RBCs/ fibrin in alveoli give lobe liver like consistency (solid,
airless) (2-4days).
3. Grey hepatisation: lung is dry, grey and firm. Due to red cell lysis, while
fibrosuppurative exudate persists in alveoli (4-8days).
4. Resolution: exudates within alveoli are enzymatically digested. Debris is
reabsorbed, ingested by macrophages, or coughed up (begins after 8days).
Lobar Pneumonia
NB: consolidation = exudate
Bronchopneumonia: foci of inflammatory consolidation in patches throughout one or more lobes.
combining into a firm dense mass.
Most frequently bilateral, affecting basal areas.
Intervening areas between isolated consolidation foci are normal.
Initial infection centred on bronchi and surrounding alveoli, well developed lesion (3-4cms)
→ can coalesce in severe cases, producing the appearance of lobar consolidation.
Usually secondary infection accompanying other illness (eg. cancer, heart failure, stroke).
More common at extremes of age.
Lobar vs Bronchopneumonia
The distinction between lobar and
bronchopneumonia is blurry because (i) many
organisms present with either of the two
patterns, and (ii) confluent
bronchopneumonia is hard to distinguish
from lobar pneumonia.
Hence, pneumonias are best classified by
either the specific aetiological agent or by the
clinical setting in which the infection occurs.
Clinical: abrupt onset with fever, chills, productive chest pain, productive mucopurulent cough, haemoptysis
(occasionally).
Lobar: severe fever and rigors, cough with rusty sputum, dyspnoea, possible pleurisy.
Bronchopneumonia: septicaemic, high temperature, crackles at affected areas.
Pathogens: S. pneumoniae most common cause, usually via aspiration of pharyngeal flora (oropharyngeal
commensal in 20% of adults).
Affects young healthy adults, hence usually 10.
More frequent in those with chronic diseases, immune defects or
decreased splenic function.
Gram +ve, lancet shaped diplococci on sputum gram stain. Blood
cultures more specific, as may be commensal flora in sputum sample. S. Pneumoniae [sputum sample]
Pathogens: Mycoplasma pneumoniae (most common), viruses (influenza A/B, RSV, adenovirus, rhinovirus, rubeola,
varicella) and Chlamydia spp (pneumoniae, psittaci). Pathogen not known in third of cases.
Clinical: acute, nonspecific febrile illness characterised by fever, headache, malaise, cough with minimal sputum.
Course can vary from a severe URTI that goes undiagnosed as pneumonia, or may present as fulminant,
life threatening infection in the immunocompromised.
“Walking pneumonia” since lungs with extensive infection may look normal under X-ray.
Septal alveolocapillary block may cause respiratory distress out of proportion to clinical findings.
NB: chronic pneumonia can be suppurative (actinomycetes, nocardiosis), fungal (aspergillus, crytpococcus) or
granulomatous (tuberculosis, other mycobacteria, histoplasma). Not necessarily community acquired either.
Non-Infectious Pneumonia
Aspiration pneumonia occurs following aspiration of gastric contents, fluid or food.
Resultant chemical pneumonia (irritant effects) followed by infection.
Overall similar picture to bronchopneumonia
If severe can lead to necrosis, abscess formation and even death.
Often in debilitated patients with abnormal gag and swallowing reflexes (eg. comatose).
Morphology: four main histological types that begin as small mucosal lesions. As they develop may undergo
cavitation (necrosis), haemorrhage or dissemination.
Adenocarcinomas (35%) arise from submucosal glands or Atypical Adenomatous Hyperplasia
epithelium, often preceded by ‘atypical adenomatous Precursor lesion with well demarcated foci of
hyperplasia’. Usually peripheral tumours (bronchioles/alveoli). epithelial proliferation, demonstrating cytologic
Most cases are smokers, but is commonest type in non- change (pleomorphism).
smokers (also women, <45 groups). Broncioalveolar Carcinomas
Grow slowly, form smaller masses, but metastasise Subtype of adenocarcinomas, only grow along
widely at an earlier stage. pre-existing structures and preserve the alveolar
Tumours form well circumscribed, grey-white masses architecture.
that rarely cavitate. Mucinous and non-mucinous types.
Can project out into alveolar spaces in
Histologically classified as acinar, papillary or solid.
papillary formations.
o Acinar; well differentiated gland forming
Well differentiated, tall, columnar-cuboidal
structures, produce mucin.
cells.
o Papillary/solid; poorly differentiated, no mucin.
Squamous Cell Carcinomas (30%) malignant tumour of squamous epithelium, often preceded by squamous
metaplasia/dysplasia. Typically central in major bronchi.
Closely related to cigarette smoking (>90%), hence more common in men than women.
Aggressive local spread to hilar lymph nodes but disseminate outside thorax later than other types.
Due to lymphatic > blood spread.
Large lesions are prone to necrosis and cavitation.
Histologically, often well differentiated squamous cells with keratin pearls and intercellular bridges.
May be poorly differentiated with minimal features.
Small Cell Carcinomas (25%) neuroendocrine tumours, most often forming centrally located masses.
Rapid growth and early metastasis via lymphatics/blood. Usually metastasised at diagnosis.
Can narrow bronchi by extraluminal tumour bulk (expansion within lung parenchyma).
Ectopic hormone production common resulting in paraneoplastic syndromes.
Histologically, fusiform to round cells approx 2x size of lymphocytes (classic ‘oat cell carcinoma’
presentation).
Large Cell Carcinomas (10%) form peripheral, undifferentiated lesions that can become quite large and active.
Central or peripheral, poor prognosis.
Lack cytologic features of small cell, glandular or squamous differentiation.
Probably represent squamous cell or adenocarcinomas that are so undifferentiated that they can no
longer be recognised by light microscopy.
Adenocarcinoma Squamous Cell Carcinoma Small Cell Carcinoma Large Cell Carcinoma
Clinical: staging is by size of the tumour, number of affected nodes, and distant metastases (TNM). Lung
cancers are silent, insidious lesions that commonly spread before producing symptoms.
Early stages: can have chronic cough, sputum or haemoptysis before spread due to intrabronchial
lesions.
Later stages: of disease can include a wide range of presentations:
a) Nonspecific symptoms only; weight loss, anorexia,
Intrathoracic Dissemination
fatigue, weakness, nausea.
Intrathoracic spread can cause:
b) Intrathoracic spread; invasion/compression of
o Apical neoplasms that invade the brachial
nerves can cause related symptoms, can also
(ulnar nerve pain) or cervical (Horner’s
obstruct blood vessels or oesophagus. syndrome) sympathetic plexuses. Known as
c) Extrathoracic spread; to lymph nodes (mediastinal, ‘Pancoast syndrome’.
clavicular, scalene, Virchow’s nodes), liver, brain, o Phrenic nerve → diaphragmatic damage.
adrenal and bone metastases (most common). o Recurrent laryngeal nerve → hoarseness.
d) Paraneoplastic syndromes; systemic syndromes o Obstruction in SVC → dilation of head/neck
due to ectopic substance (hormone, cytokine) veins, facial swelling, cyanosis.
production. Occurs in 3-10% of lung carcinomas. o Oesophageal obstruction → dysphagia.
Paraneoplastic Syndromes
Ectopic hormone production can cause:
o Hypercalcaemia; PTH secretion (most common in squamous cell carcinomas).
o Cushing syndrome; ACTH production leading to ↑ cortisol from adrenals.
o Syndrome of inappropriate ADH (SIADH) secretion, resulting in fluid overload.
o Neuromuscular syndromes; myasthenia, peripheral neuropathy, poliomyelitis.
o Haematologic/vascular syndromes; anaemia, coagulopathy, DIC, non infectious endocarditis, embolism
(most common with adenocarcinomas).
o Dermatologic signs; dermatomyositis, hyperpigmentation, acanthosis nigricans.
o Skeletal /CT syndromes; hypertrophic pulmonary osteoarthropathy.
NB: apart from hypercalcaemia and haematologic syndromes, most are more common with SCLCs
Treatment: practically split into SCLC/NSCLC for treatment distinctions. 5 year survival around 15%.
Small Cell Lung Cancers (SMLC) have all metastasised by the time of diagnosis, hence not curable by
surgery, and best treated with chemotherapy ± radiotherapy.
o Median survival with treatment is 1 year.
Non-Small Cell Lung Cancers (NSCLC) respond poorly to chemotherapy, better treated with surgery
(lobectomy or pneumonectomy) if detected before spread. Better prognosis than SCLCs.
o At diagnosis, 75% have metastasised, inoperable.
o Includes squamous cell carcinoma, adenocarcinoma, and large cell carcinoma.
Carcinoids arise from neuroendocrine (Kulchitsky) cells that line bronchial mucosa. Contain dense
neurosecretory granules but rarely release hormonally active peptides.
Slow growing malignant tumours that rarely
metastasis (<10%). Typical Carcinoid; small rounded cells with
diffuse chromatin granules, absent/rare mitoses,
Either obstructs lumen or penetrates bronchiolar
little pleomorphism. 80% 10yr survival.
wall, can be central or peripheral.
Atypical Carcinoid; higher mitotic rate, increased
Histologically, can be typical or atypical.
pleomorphism, necrosis. 50% 5 yr survival.
Affects genders similarly, often <40 yrs.
Malignant Mesotheliomas rare cancer of mesothelial cells usually arising in parietal or visceral pleura.
Cause: related to asbestos exposure (not smoking) with long latent period (25-40yrs). Asbestos not
removed/metabolised → generates ROS → DNA damage → oncogenic mutations.
Morphology: diffuse lesion, invasion of thoracic structures. Lung is encased by thick layer of grey-pink
tumour. Epithelial, sarcomatoid and biphasic histological types.
Clinical: chest pain, dyspnoea, pleural effusion. Prognosis is poor (12-14mnths).
Secondary Lung Cancers result from blood-borne metastasis of tumours from other sites. Most often from
breast, colon, stomach, pancreas, kidney (in relative order).
Clinical Syndromes
Jaundice (Icterus) is excess bilirubin accumulation in the skin and sclerae, producing a yellow discolouration of
these tissues. Bilirubin is the end product of haem degradation and is in excess when >2mg/dl
(hyperbilirubinaemia).
Unconjugated bilirubin has not yet been made soluble by liver. Jaundice Hereditary
Usually due to excessive haemolysis (haemolytic jaundice). Can be Syndromes
due to ↓hepatic uptake or impaired conjugation. Not excreted in Dubin-Johnson Syndrome -
kidneys, stool still contains pigment (no obstruction). impaired transport of anions.
Conjugated bilirubin is soluble due to conjugation with glucoronic Gilber Syndrome- relatively
acid. Usually due to impaired bile flow (obstructive jaundice). Can be common mild conjucgation
due to hepatocellular damage. Dark urine (soluble so excreted in disorder.
kidneys), stool is pale as no pigments can reach intestine.
Hepatitis
Inflammation of the liver which can be acute (lasts less than 6 months) or chronic (lasts more than 6 months).
It can be caused by infectious agents, toxins (eg: alcohol), or autoimmune reactions.
Acute Viral Hepatitis is viral induced inflammation of the liver which usually lasts 4-6 weeks.
Pathogens: associated with infection by Hepatitis Viruses A-E.
o HAV: a self limiting hepatitis. Fecal-oral transmission.
o HBV: can cause acute or chronic hepatitis. Associated with hepatocellular carcinoma (200x
increased risk). Parental or sexual transmission.
o HCV: most progress to chronic hepatitis, and is associated with hepatocellular carcinoma.
Transmission via blood.
o HDV: in associated with HBV. Parental and sexual transmission.
o HEV: a self limiting hepatitis. Fecal-oral transmission.
Morphology: enlarged liver with tense capsule. Microscopically involves coagulative necrosis of liver
cells with increased eosinophilia.
Clinical: symptoms include U/A pain, hepatomegaly, jaundice, malaise, anorexia, fever, nausea.
o Blood test: elevated serum bilirubin (if icteric), elevated transaminases (ASL/ATL) and alkaline
phosphatate. Serology tests for specific viruses/antibodies.
Chronic Hepatitis is chronic inflammation of the liver associated with hepatocyte destruction, cirrhosis and
liver failure. It is more likely to occur in the very young, very old, males, immunocompromised, and dialysis
patients.
Pathology: characterised by portal infiltrate, necrosis and fibrosis.
o Excessive portal lymphocytic infiltrate that spreads to adjacent parenchyma.
o Piecemeal necrosis: a condensation, fragmentation and phagocytosis of hepatocytes.
o Bridging necrosis: destruction of adjacent hepatocyte lobules.
o Progressive fibrosis → cirrhosis.
Causes: HBV, HCV, HDV, drug toxicity, alcohol and autoimmune reactions.
Fulminant Hepatitis involves massive hepatic necrosis, progressive hepatic dysfunction and acute liver failure
(mortality 25-90%).
Cause: hepatitis viruses (A-E), carbon tetrachloride, chloroform, other drugs.
Morphology: progressive shrinkage of the liver as parenchyma is destroyed. Histologically get
coagulation necrosis followed by liquefactive necrosis → macronodular cirrhosis (if patient survives).
Alcoholic Hepatitis is inflammation of the liver resulting from prolonged alcohol abuse, characterised by
swelling of hepatocytes.
Followed by necrosis and polymorphonuclear inflammation, formation of alcoholic hyaline (Mallory
bodies) in swollen hepatocytes, cholestasis, and the beginning of fibrosis.
Alcoholic Cirrhosis fibrous tissue replaces fatty swelling, Drug Induced Liver Damage
resulting in nodule formation. Different drugs can damage liver cells through
different mechanisms:
Early stages of disease: enlarged liver with
1) Hepatotoxins (carbon tetrachloride,
micronodular formation.
methotrexIschaemic Atrophy: due to
Later stages: small, macronodular liver with a atherosclerosis of pancreatic arteries, usually
‘hobnail’ appearance on its surface. asymptomatic.
2) Obstruction of pancreatic duct: affects
only exocrine pancreas, which becomes small,
Haemodynamic and Vascular Abnormalities fibrous and nodular.
ate, anabolic steroids).
Portal Hypertension is increased resistance to portal blood flow that may
Hypersensitivity (drugs can act as haptens).
develop form pre-, intra- or post- hepatic causes. Most dominant cause is
Metabolic response to drugs (paracetamol,
cirrhosis (intrahepatic). May manifest as ascites (fluid/lymph in peritoneal
phenothiazines, methyldopa, halothane).
cavity), splenomegaly, oesophageal varices and/or hepatic encephalopathy.
Passive Congestion and Central Necrosis are associated with right heart
failure, characterised by congestion of central veins and centrilobular hepatic
sinusoids (‘nutmeg liver’). Clinically manifests as milf hepatomegaly, a
pulsatile liver tender to palpation. Atrophy and necrosis are secondary to
hypoxia and hypoperfusion.
Liver Infarcts are rare due to double blood supply to the liver. Interuption of
the main hepatic artery can be compensated by retrograde accessory vessels
and the portal venous system.
Hepatic-Biliary Tract Disorders
Cholestasis is inability of bile to flow from the liver to the duodenum. Results in retention of bilirubin, bile
acids and cholesterol. Hence get pale stools, dark urine, itching, increased serum lipids.
Intrahepatic causes: hepatocellular cholestasis seen in viral hepatitis, cirrhosis, drug toxicity.
Extrahepatic causes: gallstones, cholangitis, cancer of bile ducts and head of the pancreas.
Cholangitis is inflammation of the bile ducts. Usually associated with biliary duct obstruction (gall stones,
carcinoma), which leads to infection with enteric organisms → purulent exudation within the bile ducts, bile
stasis. Clinically manifests as jaundice, fever and upper right quadrant pain (“Charcot Triad”).
Hepatic Tumours
Benign Tumours: may be asymptomatic (incidental finding on imaging), a
palpable mass, cause liver dysfunction due to mass effect, or occasionally
haemorrhage or rupture.
Include nodular hyperplasia, hepatocellular adenoma,
haemangioma, bile duct adenomas and cysts.
Haemangioma Hepato- Adenoma
Malignant Tumours: most commonly secondary metastases, but primary tumours do occur.
Metastatic Tumours are much more common than primary neoplasms, most
commonly arising from the breast, lung and colon. Characterised by multiple,
well circumscribed nodules in a markedly enlarged liver.
Hepatocellular Carcinoma cancer of hepatocytes, causing 90% of primary
liver neoplasms. Associated with cirrhosis, HBV infection, anabolic steroids,
and aflatoxin B (fungal toxin).
o Causes liver enlargement (unifocal, multifocal, or infiltrative).
Multiple
o Often bile strained and invades vessels. Metastases generally first Metastatic Tumours
occurs in the lungs.
o Alpha-feto protein present in 50-90% of patient’s serum.
o Death due to GI bleed or hepatic failure.
BILIARY PATHOLOGY
Cholelithiasis (Gall Stones)
Gall stones can result from (i) supersaturation of bile pigment or cholesterol, and/or (ii) decreased amounts of
phospholipid or bile salts, in the gall bladder.
Clinical: most stones remain in the gall bladder and are asymptomatic. Obstruction of:
The gall bladder or cystic duct → biliary colic, acute cholecystitis, and mucocele formation.
Common bile duct → obstructive jaundice, ascending cholangitis.
Ampulla of Vater (→ pancreatitis) or distal small bowel (→ gallstone ileus).
Cholecystitis
Acute Calculous Cholecystitis is inflammation of the gall bladder, caused by obstruction of the gallbladder
neck/cystic duct by gallstones. Calculus obstruction is followed by secondary bacterial infection in 75% of
cases, and by chemical irritation.
Morphology: enlarged, erythematous and tense gall bladder. Thickened wall Acute Calculous
with oedema and fibrosis. Microscopically, has acute inflammatory infiltrate Cholecystitis
with mucosal ulceration, erosion and necrosis/haemorrhage.
Clinical: typically acute onset upper right quadrant pain, fever, tenderness and
leukocytosis. Most resolve with medical management.
Complications: secondary bacterial infection. Can progress to empyema (lumen
filled with pus), gangrenous necrosis, or rupture. These cases require
cholecystectomy.
Acute Non-Calculous Cholecystitis cholecystitis without gallstones. It is associated with congenital anomalies,
diabetes, infections, polyarteritis nordosa, burns, trauma and surgery.
Chronic Cholecystitis is chronic inflammation of the gallbladder of unknown aetiology. It is probably due to
chemical injury from supersaturated bile, and not due to irritation by stones.
Gallbladder wall is thickened by fibrosis.
Rokitansky-Aschoff’ sinuses; penetrations of the mucosa through the muscularis, with chronic
inflammation.
Gallbladder Tumours
Benign Tumours: Papillomas, Adenenomas and Adenomyomas.
Cholangiocarcinoma adenocarcinoma of the bile ducts, either extra or intra hepatic. Tumours are
usually small, with papillary, fungating, nodular, or infiltrative lesions.
o Often presents with obstructive jaundice, upper right quadrant pain and sometimes symptoms
of pancreatitis due to obstruction of the pancreatic duct.
o Half metastasise via ducts/lymph/blood to lungs, bones, adrenals and brain.
o Associated with primary sclerosing cholangitis, liver fluke infection.
PANCREATIC PATHOLOGY [Note: disorders of endocrine pancreas
discussed in Endocrine Pathology]
Acute Pancreatitis
Diffuse necrosis of the pancreas caused by the release of activated pancreatic enzymes. It is associated with
alcoholism and biliary tract disease.
Morphology: grey (parenchyma destruction), yellow/white (fat necrosis) and red (haemorrhage) areas.
Proteolysis of parenchyma → necrosis of acini with
surrounding inflammatory infiltrate.
Necrosis of fat by lipases → FA combine with calcium
to form insoluble white salts.
Destruction of blood vessels → haemorrhage with
Acute Pancreatitis
microvascular leakage (oedema).
Chronic Pancreatitis
This condition involves remitting and relapsing episodes of mild pancreatitis, causing progressive pancreatic
damage.
Pathology: is unclear, possibly, excess protein secretion by the pancreas leads to ductal obstruction.
Chronic Calcifying Pancreatitis (associated with alcoholism): hardened organ with multiple
calcifications. Involves acinar atrophy, fibrous and inflammation in a lobar distribution. Occasional
squamous metaplasia of ductal epithelium.
Chronic Obstructive Pancreatitis (associated with gallstones): lesions more common in the head of the
pancreas, with no lobular distribution.
Clinical: usually asymptomatic until late in its course, prognosis very poor.
If resectable, <5% 5yr survival, death usually within 6 months of symptoms.
Jaundice in half with carcinomas of head of pancreas. Painless jaundice with a palpable gall bladder is
suggestive of pancreatic cancer.
(Draft)
ORAL CAVITY PATHOLOGY
Non-Neoplastic Disorders
Various problems include:
• Infections – HSV, candida
• Inflammation – glossitis, xerostoma, aphthous ulcers
• Leukoplakia
• Odontogenic cysts and tumours
• Calculi in salivary ducts
Mouth Tumours
Squamous cell carcinoma (SCC) is the most common malignant tumour of the oral cavity involving the tongue,
floor of mouth, palate and buccal mucosa (lower lip is the most common site). Lesions can be papillary or
ulcerative. Peak incidence is 40-70. Predisposing factors include:
1. Physical and chemical irritants: chewing and smoking tobacco products, alcohol abuse, chewing betel
nuts, UV radiation, poor oral hygiene.
2. Iron deficiency in the form of Plummer-Vinson syndrome with angular stomatitis.
3. Infection with certain strains of Human Papilloma Virus.
The precursor lesion has dysplasia which progresses to Squamous Cell Carcinoma In-Situ, and then to invasive
SCC. Precursor lesions present as white or red thickenings/plaques called leukoplakia with atypia (although
leukoplakia can also be simple hyperplasia without atypia. Invasive carcinoma has variable differentiation, with
poorly differentiated tumours being more infiltrative and metastasize to regional lymph nodes.
Treatment: complete excision of tumour ± removal of regional lymph nodes ± radiation therapy,
Pleomorphic adenoma (most common) is a benign neoplasm composed of glandular and stromal elements.
• Arises in superficial love of parotid as a slow growing painless smooth mass
• More commonly in the middle aged and women
• Diagnosis made by Fine Needle Aspiration cytology
• Treatment is by surgery which is usually curative as long as an adequate clear margin is obtained.
“Shelling out” the tumour usually leaves behind small extentions of tumour which will recur.
• Complications due to cranial nerve VII (facial nerve) involvement (bell’s palsy).
• Occasionally undergo malignant transformation, usually to a carcinoma.
Mucoepidermoid, Adenoid cystic and Acinic Cell Carcinoma are malignant epithelial tumours, associated with
rapid growth and acute onset of pain due to nerve involvement. Local invasion, particular along nerves.
Metastasize to regional lymph nodes and beyond. They show characteristic cytological and histological
features enabling diagnosis. Prognosis depends on the grade and stage of the tumour and adequacy of
excision.
OESOPHAGEAL PATHOLOGY
Various problems include:
• Congenital - tracheo-oesophageal fistula, achalasia
• Infection – HSV, candida
• Varices secondary to liver cirrhosis
Oesophagitis
Reflux Oesophagitis (Gastro-oesophageal reflux disease or GORD)
A condition associated with chronic symptoms or mucosal damage produced by abnormal reflux of gastric
content into the esophagus. This can be due to a defective gastroesophageal sphincter, transient
gastroesophageal sphincter relaxation, impaired removal of gastric reflux, pr a hiatus hernia. This can result in
persistent reflux (mild, moderate or severe) causing:
• Inflammation
• Hyperplasia of the squamous epithelial lining and
• Erosion/ulceration of the epithelium
Barrett’s Oesophagus
Barrett's oesophagus is generally defined as intestinal metaplasia (the replacement of one adult cell type by
another adult or mature cell) of the squamous epithelium lining the oesophagus. This process is reversible, and
represents adaptive substitution of squamous epithelial cells that are sensitive to stress (ie: acid reflux) by
secretory columnar epithelium with Goblet cells that are more stress resistant. In some patients, Barrett's
oesophagus progresses through low and high grade dysplasia to adenocarcinoma.
Dysplasia: A premalignant state involving disordered cell characteristics or abnormal cell growth. This usually
occurs in epithelium and is characterised by cytological (pleomorphism, enlarged hyperchromatic nuclei, abnormal
mitotic activity) and/or architectural changes (loss of nuclear polarity, nuclear stratification, gland crowding and
cribiform arrangements).
Regular surveillance by endoscopy and biopsy is recommended for patients with Barrett's oesophagus. Patients
with low grade dysplasia are followed by short interval surveillance and treated with acid suppressing agents. The
finding of high grade dysplasia is an indication for oesophagectomy.
.
Corrosive Oesophagitis
Caused by ingestion of acid or alkaline material. This leads to mucosal injury of the mouth, pharynx,
oesophagus and stomach. Severity is dose dependent and in severe forms leads to full thickness mucosal
necrosis, ulceration and even perforation. It heals by fibrous stricture formation.
Infectious Oesophagitis
Rare in immunocompetent individuals, but is more common in the immunocompromised (eg: AIDS and
transplant patients). Common infectious agents include:
1. Candida species – colonise the squamous epithelium, giving rise to white plaques and hyperkeratosis
with an inflammatory infiltrate.
2. Herpes Simplex Virus – infects squamous epithelial cells resulting in blisters and superficial ulcers.
Infected cells are typically multinucleated with intranuclear viral inclusions which have a glassy
basophilic appearance.
3. Cytomegalovirus (CMV-. Infects both endothelial and squamous epithelial cells. Infected cells appear
enlarged with prominent intranuclear inclusions, with or without basophilic intracytoplasmic
inclusions.
Oesophageal Tumours
• Commonly occurs after the age of 50, male incidence 3x greater.
• Clinical features include dysphagia, retrosternal pain, anorexia, weight loss, melena, systemic
symptoms of metastases.
• Locations: 50% middle third of esophagus, 30% lower and 20% upper.
• Prognosis generally poor , with the average 5 year survival being less than 10% due to late diagnosis.
• Common sites of metastases include the liver and lungs.
Oesophageal adenocarcinoma
Usually arises in the distal oesophagus is often reflux induced.
• Acid reflux causes intestinal metaplasia (Barrett’s oesophagus)
• Further genetic alteration of the metaplastic mucosa may lead to low-grade dysplasia, high-grade
dysplasia and in-situ and invasive carcinoma
The life time risk of developing adenocarcinoma from Barrett's oesophagus is approximately 10%.
STOMACH PATHOLOGY
Various problems include:
• Menetriers disease
• Pernicious anaemia/ atrophic gastritis
• Pyloric stenosis (congenital)
Gastritis
Acute Gastritis (acute gastric ulceration, erosive gastritis). These lesions are complications of NSAIDs or severe
physiological stress (eg. severe trauma/head injury, burns, shock, sepsis).
Pathogenesis: poorly understood, but is associated with decreased prostaglandins, acid hypersecretion (vagal
nerve stimulation), impaired oxygenation secondary to vasoconstriction and systemic acidosis.
Morphology:
Macroscopic: Multiple, small (<1cm), round, superficial defects with a blood stained base. Adjacent
mucosa is normal with no thickening or scarring.
Microscopic: Superficial erosion of surface epithelium which may extend deeper to become full
thickness mucosal ulceration.
Gastric Tumours
Gastric Adenocarcinoma (>90%)
Most common primary malignancy in the stomach (90-95%). 50% arise in the antrum and pylorus, 25% in the
gastric cardia. Metastases is frequently present at the time of diagnoses (symptoms develop late). Very high
incidence in Japan, Chile, China and Russia, with relatively lower incidence include Australia, New Zealand, US,
UK, and Canada.
Predisposing factors:
• Helicobacter infection causing chronic gastritis, gland atrophy and intestinal metaplasia. This may
evolve to dysplasia and carcinoma.
• Autoimmune gastritis, which often is associated with gland atrophy and intestinal metaplasia, can
progress to gastric carcinoma.
• Diet (eg: preservatives, salted and smoked foods)
• Genetic alterations and susceptibility.
Types of gastric carcinoma
• Diffuse type (Signet Ring Cell Type)- not associated with chronic gastritis. Composed of gastric type
mucous cells that doesn’t form glands but permeates the mucosa as signet cells. Diffuse infiltration of
the gastric wall causes the stomach to have a gross leather bottle appearance, also known as “linitis
plastic”. Female predominance at a younger age.
• Intestinal type- associated with chronic gastritis caused by H.pylori infection, with gastric atrophy and
intestinal metaplasia. Composed of malignant cells forming glands. Male predominance, usually >50.
Clinical:
Spread; penetration of serosa lymph nodes (Virchow’s node), and in females spread to ovaries
(Krukenberg tumours).
Prognosis; depends on the depth of invasion. Early gastric cancer has better prognosis and those
advanced (invasion beyond submucosa) have poor prognosis with five year survival rate less than 15%.
Gastric Lymphoma
Lymphoma accounts for less than 5% of gastric tumours. Nearly all gastric lymphomas arise
from B-cells. The most common type of gastric lymphoma is MALT (Mucosa Associated Lymphoid Tissue)
lymphoma.
• Majority are associated with chronic Helicobacter gastritis (NB: some MALT lymphomas regress
after H.pylori eradication).
• Characterised by atypical lymphoid cell infiltration of the mucosa.
• If not treated, progression to a higher-grade diffuse large B-cell lymphoma is possible.
Coeliac Disease
Coeliac disease (Gluten-sensitive enteropathy)- an autoimmune disorder occurring in genetically predisposed
people. It is characterised by an immune reaction to gliaden, a gluten protein found in wheat (including oats,
barley and rye). This leads to flattening of the small bowel lining (villous atrophy), interfering with nutrient
absorption.
Pathogenesis: Upon exposure to gliaden, the enzyme transglutaminase within enterocytes modifies the
protein, causing a T lymphocytes to cross react with the epithelial cells. It is familial with a strong association
with HLA-DQ2 or HLA DQ8. Found predominantly in Caucasians and has a prevalence of 1:100 – 1:200
Morphology:
Macroscopic: mucosa has a scalloped or flattened appearance as the villi are shortened or absent.
Microscopic: loss of normal villous architecture, intra-epithelial T lymphocytes, inflammation within
lamina propria, regenerative changes in the crypts.
Diagnosis: Detection in the blood of raised levels of antibodies to gliadin, endomysium or tissue
transglutaminase is useful in establishing the diagnosis.
Clinical: symptoms of diarrhoea, loss of weight, anaemia, fatigue, flatulence, and possibly associated with
extra-intestinal features.
Treatment involves gluten-free diet.
Complications of long term risk of lymphoma
Morphology:
Macroscopic: yellow, nodular, 1-2cm diameter causing mucosal elevation. Mucosa is usually intact
until the tumour enlarges, causing ulceration. The tumour infiltrates outward into the serosa where
the accompanying fibrosis may cause kinking and obstruction.
Microscopically: nest, cords and rosettes of small round cells with a uniform and characteristic
appearance.
Clinical effects: These tumours can secrete a variety of substances which have clinical effects.
Carcinoid syndrome where over secretion of serotonin causes diarrhoea, episodic flushing,
brochospasm, cyanosis, telangiectasia and skin lesions.
Endocardial fibrosis and damage to the tricuspid and pulmonary valves are more serious long term
effects that do not regress with removal of the tumour.
Primary Lymphoma
Lymphoma occurs in the small bowel in two clinical settings (both involve abdominal pain and diarrhoea:
1. Western-type intestinal lymphoma: affects children <10 and adults >40. Most common in the ileum
and can manifest as multiple plaques, diffuse thickenings or as a tumour mass. It can present as
obstruction, intussusception or perforation as well as occult bleeding. The sub-type of lymphoma is
variable although in the setting of coeliac disease it is usually a T cell lymphoma. It is thought that the
persistent activation to T lymphocytes is a predisposing factor although a decrease in the inflammatory
response, does not remove the risk of lymphoma. The prognosis is poor.
2. Mediterranean Lymphoma- occurs in young men of low socio-economic status in poor countries,
possibly due to an environmental factor. Arise from B lymphocytes and is associated with α-heavy
chain disease under the label immunoproliferative small intestinal disease (IPSID). It predominantly
involves the duodenum and proximal jejunum affecting a long segment. Diffuse inflammatory infiltrate
within the mucosa can result in malabsorption.
APPENDIX PATHOLOGY
Appendicitis
Inflammation of the appendix usually associated with obstruction of the lumen by a faecolith (firm rounded
aggregate of faeces). This predisposes to bacterial overgrowth and infiltration into the wall. On-going secretion
of mucus into the blocked lumen causes increased luminal pressure and compromises venous outflow
resulting in ischaemia and possibly causing infarction (gangrene perforation and peritonitis). Acute
appendicitis usually occurs in children and young adults but can occur at any age.
Signs and symptoms include pain (first periumbilical, followed by right iliac fossa), nausea and vomiting,
abdominal tenderness and guarding, mild fever. Note: these signs and symptoms are non specific and seen in
a range of other pathologies (eg: mesenteric lymphadenitis, systemic viral infection, acute salpingitis, ectopic
pregnancy, Meckel’s diverticulum).
Colitis
Colitis (“Inflammation of the colon”) comprises of many different types/causes of inflammation- infectious,
tuberculosis, pseudomembranous, ischaemic, idiopathic inflammatory bowel disease, Crohn’s disease,
Ulcerative colitis, microscopic, collagenous/lymphocytic, obstructive, graft vs host disease, and allergic colitis.
Symptoms and signs can be acute or chronic, persistent or intermittent. They include: abdominal pain,
diarrhoea, haemorrhage (overt leading to per rectum bleeding, or occult leading to anaemia), fever,
dehydration, malabsorption, perforation info the peritoneal cavity and sepsis.
Investigations
Stool culture
Radiology: Plain abdominal X ray, barium enema, angiography
Colonoscopy/sigmoidoscopy
Biopsy (random vs targeted)
Surgical resection
Pseudomembranous Colitis
Caused by the exotoxins of Clostridium Difficile (a normal gut commensal). Overgrowth is associated with
antibiotic therapy (clindamycin/lincomycin). It is characterised by the formation of an adherent inflammatory
exudate overlying the site of mucosal damage. Can present as acute abdominal pain with diarrhoea, and
diagnosis involves detection of Clostridium Difficile cytotoxin in stool.
Morphology:
Macroscopic: Fibrino-purulent necrotic debris and mucus form a plaque-like exudate attached to the
mucosa
Microscopic: Surface epithelium is shed with a layer of mucous and acute inflammation over the
surface. Neutrophils and capillary thrombi in lamina propria, crypts distended by mucopurulent
material, and a layer of mucous and acute inflammation over the surface.
Differential diagnosis: Inflammatory bowel disease.
Treatment: Antibiotics (vancomycin) and occasionally surgery (sometimes due to misdiagnosis).
Macroscopic Macroscopic
♦ Mucosal cobblestone appearance ♦ Blood and mucus in lumen
♦ Deep fissuring linear ulceration- fistula formation ♦ Hyperaemia, granularity, friability
♦ Transmural inflammation ♦ Broad based ulceration (not linear) with pseudopolyps
♦ Intestinal wall thickened - oedema, inflammation, of regenerating mucosa
fibrosis, muscle hypertrophy ♦ Muscularis propria and serosa normal
♦ Stricturing
Microscopic
Microscopic • Continuous and relatively uniform
• Variable between fragments and sites • Mucosa and submucosa
• Transmural changes • Lymphoplasmacytic inflammation in the lamina
• Mucosal inflammation propria
• mainly chronic, some acute • Ulceration (flask shaped) confined to the
• Ulceration – classically “rose thorn” mucosa/submucosa with granulation tissue
• Non-caseating granulomas (40-60% of cases) • No granulomas
• Architectural distortion - cycles of destruction and • Mucosal acute inflammation with cyptitis and crypt
regeneration, paneth cell metaplasia abcesses
• Retention of mucus production • Goblet cell depletion
• Submucosal fibrosis • Pseudopolyps of granulation tissue
• Hypertrophy of the muscularis • Architectural damage - regeneration, fibrosis, gland
• Serosal thickening due to fibrosis, creeping fat disarray/atrophy, paneth cell metaplasia
Complications
Complications
• Toxic megacolon with perforation
• Toxic megacolon – perforation – peritonitis/abcess
• Stricture with obstruction
• Strictures rarely
• Fistula - bowel, bladder vagina, peritoneal cavity,
• Loss of blood or fluid and electrolytes – anaemia,
perianal skin
malnutrition
• Iliitis - malabsorption, protein losing enteropathy,
• Carcinoma (20-30x risk in pancolitis for 10+ years)
pernicious anaemia (vitamin B12), steatorrhoea (bile
salts) Treatment
• Carcinoma colon • Supportive therapy
• Immunosuppression –
Treatment
local/systemic
♦ Supportive therapy
• Surgery – total colectomy
♦ Immunosuppression – local/systemic
• Surveillance for malignancy
♦ Surgery – total colectomy, reconnection depends on
the presence of perianal disease
♦ Surveillance for malignancy
Large Intestine Tumours
Investigations:
- Clinical examination, faecal occult blood test (FOBT)
- Imaging (plain films, barium studies)
- Endoscopy, Colonoscopy
- Pathology: cytology, fine needle aspiration, brushings, fluids, biopsy, resection.
Polyps (Adenomas)
Polyps are abnormal epithelial growths projecting from the mucosa (smooth, discrete and round
elevations). Two main types of polyps are:
1) Hyperplastic polyps (90%)- non-neoplastic lesions, occurring mostly in the rectosigmoid colon.
2) Adenomatous polyps- true neoplasms, which are precursor lesions for adenocarcinoma. There is
a higher incidence of cancer in higher grade, larger polyps, and those containing a greater
proportion of villous growth:
a. Tubular adenomas (pedunculated)- 75%. Familial Adenomatous Polyposis
Can be sporadic of familial. Male to A genetically inherited (autosomal dominant)
female ratio of 2:1. Average age is 60. condition associated with a mutation in the APC
Mostly occur in the left colon. gene on chromosome 5. This predisposes to
multiple (hundreds) of colonic adenomas starting in
b. Villous adenomas (usually sessile)-
the rectosigmoid area, and eventually covering the
largest, least common polyp. 33% are
entire colon. This occurs during adolescence and
cancerous. Characteristic “cauliflower- early adulthood. Benign polyps undergo malignant
like” growth (1-10cm diameter). transformation usually in the 30s and 40s.
c. Tubulovillous adenomas Treatment is by total colectomy.
Morphology: The mucosal lining of adenomatous polyps show increasing architectural complexity and
cytologic atypia (ie: low and high grade dysplasia).
Adenocarcinoma
This malignancy accounts for 98% of all colon cancers. There is a high incidence in urban, Western
societies. It is the 3rd most common tumour in men and women. Most colorectal adenocarcinomas
appear to arise from villous adenomas, but are also associated with ulcerative colitis, Crohn’s disease,
and familial polyposis.
Risk factors include: age, prior colorectal carcinoma, familial/genetic predisposition and diet (low dietary
fibre, high fat and red meat).
Morphology:
Macroscopic: tumours can be polypoid (protruding into the lumen), ulcerating (eroding into
surrounding structures) or infiltrative (spread within colonic wall). 75% occur in the rectum
or sigmoid colon.
Microscopic: variable differentiation. Usually irregular glandular structures lined by atypical
columnar epithelium.
Spread:
Direct invasion is usually into the mesentery and if the surface is breached, can involve adjacent
structures (small bowel, female genital tract, bladder)
Lymphovascular invasion is common with metastasis to mesenteric lymph nodes followed by
the liver, lungs and bones.
Clinical features:
May be clinically silent and rarely presents as an abdominal mass
Rectal bleeding
Change in bowel habits (constipation/diarrhoea)
Obstruction - more common with left sided tumours; lumen is smaller and faeces more solid
Perforation with peritonitis
Fistula formation (eg: rectovaginal)
Systemic symptoms related to malignancy – anorexia, malaise, weight loss, weakness.
Screening: Faecal Occult Blood Testing (FOBT) and subsequent colonoscopy/biopsy with patients that
test positive. This allows for early detection of precursor adenomas or early stage adenocarcinomas,
possibly improving the overall outcome.
Treatment:
Surgical excision.
Chemotherapy and radiotherapy: have a role to play, either before surgery to down size the
tumour or after surgery to decrease the likelihood of or palliate any recurrence.
ANAL PATHOLOGY
Various problems include:
Haemorrhoids
Fissure/ fistula (Crohn’s disease)
Rapidly Progressing Glomerulonephritis (RPGN) is a clinical entity with rapid loss of renal function and
features of nephritic syndrome. Regardless of cause, distinctive histologically due to crescents.
RPGN is associated with severe glomerular injury and necrosis of the GBM. Results in
proliferation of parietal epithelium (crescents).
Usually immune mediated eg. anti-GBM antibody disease, immune complex deposition.
Renal Failure
Inability of the kidneys to function, including blood filtration and urine concentration. Morphologically,
usually involves obliteration of glomeruli and significant interstitial necrosis.
Acute Renal Failure, urine flow falls within 24hrs to less than 400mL/day (oliguria). Can result from all
acute glomerular, tubular, interstitial or vascular injury. Most common glomerular disease is RPGN.
Chronic Renal Failure, characterised by prolonged symptoms of uraemia, is the end result of all chronic
renal disease. Chronic glomerulonephritis is an important cause of endstage renal disease, probably
represents the endstage of a variety of entities (eg. FSGS, MGN, IgA nephropathy).
DISEASES OF TUBULES & INTERSTITIUM
Tubulointerstitial nephritis includes a group of inflammatory diseases of the kidneys that involve the
tubules and interstitium. May be bacterial (pyelonephritis) or nonbacterial (interstitial nephritis).
Acute Pyelonephritis
Suppurative inflammation of the kidney and renal pelvis, caused by bacterial infection. A manifestation
of UTIs; lower (cystitis, prostatitis, urethritis) and/or upper (pyelonephritis) UTI.
Pathogens: main causative organisms are the gram –ve rods with E. coli most common by far. Proteus,
Klebsiella, Enterobacter, Pseudomonas species are other causes, associated with recurrent infection.
Pathogenesis: bacteria can reach the kidney via the blood or from the lower urinary tract.
1. Bloodstream (haematogenous): involves bacterial seeding of
kidneys during septicaemia or infective endocarditis. Less common,
typically involves S. aureus or E. coli.
2. Ascending infection from lower urinary tract: most common and
important route.
a. Adhesion of bacteria to mucosal surfaces → colonisation of
distal urethra.
b. Organisms gain access to bladder via urethral
instrumentation (eg. catheter ) or direct colonisation (women
more common due to shorter urethra, closer to rectum and
trauma during sex).
c. Outflow obstruction or bladder dysfunction (diabetes
↑susceptibility) → urinary stasis → bacteria multiply.
d. Vesicoureteral reflux (VUR); reflux of urine up the ureter due
to defective vesicoureteral orifice (normally only allows
unidirectional flow).
e. Urine propelled up to renal pelvis and farther into renal
parenchyma through open ducts at the tip of the papillae
(intrarenal reflux).
Acute Pyogenic
Morphology:
Pyelonephritis
Macroscopic: kidneys have discrete yellowish and raised abscesses on their
surfaces. Often hyperaemic, usually unilateral.
Microscopic: suppurative necrosis or abscess formation within the renal
parenchyma. Large masses of intratubular neutrophils.
Clinical: typical sudden onset pain at costovertebral angle. Chills, fever, malaise.
Pyuria and bacteriuria, urethral irritation causes dysuria, frequency, urgency.
Disease tends to be benign and self limiting even without antibiotic treatment.
Predisposed by: obstruction, instrumentation, pre-existing lesion or VUR, females, pregnancy,
older males (prostatitis), immunosuppression.
Diagnosis: finding leukocytes by urinalysis and urine culture.
Chronic Pyelonephritis
A clinical entity whereby interstitial inflammation leads to grossly visible scarring and deformity of renal
parenchyma and the pelvicalyceal system. Associated with urinary obstruction or reflux.
Non-Infectious Nephritis
Drug Induced Interstitial Nephritis is reaction to a drug, characterised with interstitial inflammation,
often with abundant eosinophils and oedema.
Pathology: drugs act as haptens that, during secretion by tubules, covalently bind to cytoplasmic
or extracellular components of tubular cells and become immunogenic.
o most frequently occurs with synthetic penicillins (methicillins, ampicillin), rifampicins,
diuretics (thiazides), NSAIDs.
Clinical: disease begins ~15days after exposure to drug and is characterised by fever,
oesinophilia, rash and renal abnormalities. Associated haematuria and leukocyturia.
o Can cause drug induced renal failure (withdrawal of offending agent → recovery).
Analgesic Nephropathy is the result of consumption of large quantities of certain analgesics (NSAIDs,
paracetamol), which results in the development of chronic interstitial nephritis. Often associated with
renal papillary necrosis.
Pathology: not clear, varies. Paracetamol injures cells by covalent binding and oxidative damage.
Aspirin inhibits prostaglandin synthesis (vasodilator), predisposing to ischaemia.
o ‘triple whammy’; ACE-I (↓glomerular filtration) + NSAIDs (↓blood to glomeruli) +
diuretics → net effect is loss of haemostatic control in glomeruli.
Clinical: common clinical features of renal failure, hypertension and anaemia. Cessation of
analgesic intake may stabilise or improve renal function.
o Although renal disease can occur in healthy individuals, pre-existing renal disease seems
to be a necessary precursor to analgesic induced renal failure.
o ↑ Incidence of transitional cell carcinoma in those that survive renal failure.
Acute Tubular Necrosis
Acute tubular necrosis (ATN) is characterised by damaged tubular epithelial cells and acute
suppression of renal function. It is the most common cause of acute renal failure.
Morphology: characterised by necrosis of segments of the tubules (typically the proximal tubules),
proteinaceous casts in distal tubules, and interstitial oedema.
Benign Nephrosclerosis is progressive, chronic renal damage associated with benign hypertension.
Pathology: slow progressing hypertension, resulting in gradual organ damage, usually over
years. Mostly idiopathic.
o Frequency and severity of lesions are increased with age, hypertension and diabetes.
Morphology: characterised by hyaline arteriosclerosis and narrowing of vascular lumens with
resultant cortical atrophy.
Clinical: rarely causes severe damage in the kidney, mild degree of proteinuria.
o Some functional impairment, such as loss of concentrating ability or diminished GFR.
TTP HUS
Caused by defects in von Willebrand caused by endothelial injury by an E. coli toxin
factor (vWF) leading to excessive → activation and intravascular thrombosis.
thrombosis with platelet production (see This disease is one the main causes of acute
cardio notes). Multiple thrombi renal failure in children.
throughout vasculature, including 25% of children eventually develop renal
kidney, result. insufficiency due to 20 scarring.
Clinical: small cysts start to develop during adolescence, asymptomatic until around age 40yr.
Most common presenting complaint is flank pain or a heavy dragging sensation.
Typically leads to intermittent haematuria, hypertension and urinary infection.
Complications: saccular aneurysms in Circle of Willis (10-30%), end stage renal failure (50yrs),
death usually results from uraemia or hypertensive complications.
Autosomal Recessive (Childhood) Polycystic Kidney Disease
Rare developmental defect of the kidney that is autosomal recessive.
Pathology: caused by mutations in the PKHD1 gene coding for a membrane
receptor protein called fibrocystin.
Morphology: many small cysts in the cortex and medulla giving the kidney a
spongelike appearance. Cysts originate from the collective tubules, nearly
always accompanied by cysts in the liver.
Clinical: serious manifestations usually present at birth. Infants can due
quickly from hepatic and renal failure. Survivors develop liver cirrhosis.
Child ARPKD
Pathology: the most important cause is increased urine concentration of various constituents, so that it
exceeds their solubility in urine (supersaturation). May also occur from the lack of substances that
normally inhibit mineral precipitation.
Calcium Stones (Oxalate/Phosphate/Mixed) (75%) mostly caused
Causes of Calcium Stones
by hypercalciuria but can be due to other metabolic abnormality,
Hypercalcuria (60%); ↑ gut absorption,
or even idiopathic. Favoured by ↑pH. ↓ renal reabsorption, hypercalcaemia
Struvite (Magnesium Ammonium Phosphate) (15%) occur in (↑PTH, vit D etc).
persons with persistently alkaline urine due to UTIs. Urea splitting
Hyperuricosuria (20%); ↑ uric acid in
bacteria (eg. P. Vulgaris, Staph) predisposes persons to stones.
urine, promoting Ca deposition.
Uric Acid Stones (6%) gout and diseases involving rapid cell
Hyperoxaluria (5%); hereditary ↑ in
turnover (eg. leukemia) lead to high uric acid levels in the urine
oxalate in urine.
and the possibility of the uric acid stones. Favoured by ↓pH.
Cystine stones (1-2%) genetic defect in the renal transport of No known metabolic problem (15%)
cystine (AA) forming yellow, soft stone. Favoured by ↓pH.
Morphology: unilateral in 80% of cases, commonly in the renal pelvis, calyces, and bladder.
Usually small (2-3mm), however progressive accretion of salts can lead to branching.
Staghorn calculi; development of branching structures which create a cast of the renal
pelvicalyceal system.
Staghorn Calculi
Clinical: stones can exist without producing symptoms or renal damage. Smaller stones may
pass into the ureter producing paroxysms of intense flank pain, radiating to the groin.
Complications; gross haematuria, bacterial infection.
Diagnosis; radiological, calcium stones are radiopaque.
Hydronephrosis
Dilation of the renal pelvis and calyces, with accompanying atrophy of the renal parenchyma. Caused by
obstruction to the outflow of urine.
TUMOURS
Renal Cell Carcinoma
Malignant neoplasms derived from renal tubular epithelium, hence located predominantly in the cortex.
Represent 80-85% of all primary tumours of the kidney, 2-3% of cancer deaths.
More common in 60-70yrs, men 2x risk.
Higher risks for smokers, hypertensive or obese patients, and those exposed to cadmium
Clinical: characteristic triad of painless haematuria, palpable abdominal mass, and dull flank pain but
may present in many fashions. Fever due to necrosis. Mortality rate of 40%.
Paraneoplastic syndromes result in polycythaemia (erythropoietin release), gynacomastia
(gonadotrophin release) and hypercalcemia (PTH release).
These tumours frequently invade the renal vein metastasise to bone, lungs and liver.
Secondary kidney tumours have metastasised from other sites. Most common primary sites are lung,
skin, contralateral kidney, GIT and gonadal tumours.
Benign Kidney Tumours present in 25-50% of patients with tuberous sclerosis. May include renal
papillary adenoma, renal fibroma/hamartoma or angiomyolipoma.
BLADDER PATHOLOGY
Cystitis
Cystitis is inflammation of the urinary bladder, usually due to bacterial infection. It is extremely
common, especially in females.
Bacterial Cystitis is most often caused by gram negative bacilli from the GIT, especially E. coli. It is often
associated with, and precedes, pyelonephritis.
Pathogens: mainly E. coli, also Proteus, Klebsiella, Enterobacter and Mycobacteria species.
Pathology: similar to acute pyelonephritis. Ascending infection after colonisation of distal
urethra is by coliform organisms most common (women more susceptible). Haematogenous
infection is less common.
Morphology: nonspecific acute/chronic inflammation, varies with cause. Typically; ulceration on
bladder mucosal surface, congested blood vessels, oedema, and neutrophilic infiltrate in
bladder wall. Histiocytes are seen in chronic form.
Clinical: can be acute or chronic, symptomatic or asymptomatic. Urinary symptoms include
frequency, dysuria, abdominal pain and haematuria.
Nonbacterial Cystitis can be due to fungi, viruses and protozoa (eg. Candida, Mycoplasma, adenovirus).
Cystitis cystica is a chronic cystitis glandularis (glandular metaplasia) with cyst formation.
Granulomatous forms can be cause by TB or intravesical BCG, following instrumentation.
Iatrogenic (radiation or chemotherapy)
Others: Malakoplakia, Schistosomal, Eosinophilic (protozoa), Interstitial Cystitis (idiopathic)
Bladder Neoplasms
More than 90% of bladder neoplasms arise from transitional epithelium. Most are malignant, frequently
multifocal, and may involve other urothelial lined surfaces (eg. ureter, renal pelvis).
Congenital Lesions
Hypospadias The urethral opening develops on the underside of the penis, most commonly on the
inferior aspect of the glans.
o Due to failure of fusion of urethral folds over the urogenital sinus.
o Commonest congenital abnormality of male urethra (1 in 250 births).
Epispadias Urethra opens onto dorsum of penis, usually at base of the shaft, near pubis.
o Results in urinary incontinence and infections.
o Is much less common.
Non-Infections Inflammations
Balanoposthitis Inflammation of inner surface of prepuce (posthitis) usually accompanied by
(balanitis) inflammation of adjacent surface of glans penis (balanitis).
o Often associated with a tight prepuce (phimosis).
o Due to secondary infection of smegma by pyogenic bacteria.
NB: smegma is cheesy substance (exfoliatd epithelial cells, skin oils and moisture) that
can accumulate under male foreskin (prepuce) or vulva in females.
Phimosis Prepuce unable to be retracted, tightening up.
o Commonest medical indication for male circumcision.
Paraphimosis Tight prepuce retracted behind glans.
o Obstructs venous return → oedema
Balantis Involves thickened white plaques and fissures on glans and prepuce.
Xerotica o Non retractile prepuce or discharge.
Obliterans o Treated with circumcision.
(BXO) o Histology similar to lichen sclerosus of vulval skin.
o Usually 30-50yrs
Infections
Genital Herpes Is caused by HSV types 1 and 2, most genital tract lesions due to type 2 as STI.
o Itching followed by appearance of closely grouped vesicles surrounded by
erythema.
o Becomes latent for life and reactivates intermittently.
Genital warts Condyloma acuminatum lesion is caused by HPV.
o Commonest urogenital lesion.
o Infection with HPV types 6 and 11 (unlike warts
types 1, 2 and 4 in other parts of body)
o Histology: epidermis shows papillomatous
hyperplasia. Cytoplasmic vacuolation and
kiolocytes (keratinocyte squamous cell with
irregular and enlarged nuclei). Cytoplasmic
clearing at the periphery. Condyloma Acuminatum
NB: condyloma acuminatum is wart like growth with stalk base (planum is flat).
Found around anus, vulva, glans penis.
Syphilis Is caused by T. pallidum, with three distinct stages.
o Primary stage: chancre on penis, a painless ulcerated nodule with firm raised
boarders. Endarteritis with lymphocytes and associated lymphadenitis.
o Secondary stage: condyloma lata, generalised lymphadenitis.
o Tertiary stage: gumma (destructive granulomatous lesions), often in testis.
NB: second/tertiary stages not commonly seen due to antibiotic treatments when
detected.
Tumours of the Penis
Intraepidermal Carcinoma is full thickness dysplasia of epidermis with no stromal invasion.
Carcinoma in situ with strong association with HPV infection.
A sharply delineated red patch with moist keratotic patch (“erythroplasia of Queyrat” on glans).
Significant risk of progression to invasive SCC.
TESTICULAR PATHOLOGY
Non-Neoplastic Testicular Lesions
Congenital Abnormalities
Cryptorchidism When one or both testes fail to descend into scrotum.
o Instead, may be found in inguinal canal, upper scrotum or abdomen.
o Increased risk of germ cell tumours (4-10x).
o Risk of torsion and infarction.
NB: orchidopexy is to retrieve undescended testes into scrotum.
Anorchidism Absecnce of both testes.
Polyorchidism More than 2 testes (extremely rare).
Acquired Abnormalities
Testicular Torsion Occurs when the spermatic cord is twisted, cutting off blood supply to testes. This
may result in testicular infarction, in the form of coagulative necrosis.
o Orchialgia (testicular pain) is common.
o Outline of seminiferous tubules consists of
inflammatory cells.
o Predisposed by congenital factors (eg. abscence of
scrotal ligament, shortened peritoneal ligaments,
cryptorchidism, atrophy of testes).
o Needs treatment within 6-8hrs of onset to prevent
loss of testes.
Hydrocele Accumulation of serious fluid within tunica vaginalis of testis (can occur in any
body cavity).
o Smooth, pear shaped swelling (commonest
intrascrotal swelling). Tense testicles but usually
fluctuant (swelling changes).
o Transilluminable upon exposure to light and testis
not palpable due to transparent surrounding fluid.
o Can be acute inflammatory hydrocele (accumulates
rapidly, often painful) or chronic hydrocele (involves
gradual stretching of tunica, dragging sensation).
Congenital hydrocele appears first few weeks of life.
o Due to patent processus vaginalis, an embryonic outpouching of
peritoneum (forms tunica vaginalis) that doesn’t close → peritoneal fluid
drains under gravity causing hydrocele.
Secondary hydrocele may be associated with underlying lesion of testis or
epididymis.
o This can be caused by inflammation (eg. mumps, gonococcal infection)or
neoplasms.
Varicocele Abnormal dilation and tortion of pampiniform plexus veins (combine to form
gonadal veins) in spermatic cord.
o Due to insufficiency of venous valves.
o 90% left sided (gonadal vein drains into renal vein first on left, not
straight to IVC like on right), 10% bilateral.
o Associated with infertility due to ↑ temperature during blood stasis.
Orchidoepididymitis Inflammation of the testes and epididymitis, often due to infection.
o Viral orchidoepididymitis; mumps, coxsackie B. Bilateral involvement
results in infertility.
o Bacterial orchidoepididymitis; most commonly due to C. trachomatis, N.
gonorrhoea (young) or E. coli from UTI (older). Other species can cause
infection via haematolymphatic spread.
o Granulomatous, fungal, syphilitic orchidoepididymitis.
Seminomas
Large cell tumours that arise from IGCNs, with classic and spermatocytic types.
Classic Characteristic classic triad of large tumour cells (with
Seminomas cytoplasmic clearing), fibrous tissue and lymphocytes
o The most common germ cell tumours (50% of all cases).
o May present with painless mass, 15% normal on
examination.
o 30% have metastasised at presentation, but rarely have
symptoms from these metastases.
o Serum AFP (alpha fetoprotein) normal, 10-20% have
↑ β-HCG (human chorionic gonadotropin).
Spermatocytic Occur only in testes (2% of germ cell tumours).
Seminomas o Consist of small, intermediate and large cells.
o Patients in their 50s and present with a mass.
o Very rarely metastasise.
o Usually cured with orchidectomy.
Non-Seminomatous Germ Cell Tumours (NSGCT)
Group of tumours which may arise from IGCN or seminomas.
Embryonal Ill-defined invasive masses with foci of haemorrhage and
Carcinoma necrosis.
o Second most common germ cell tumour (20% of cases)
and present in the majority of mixed GCT.
o Mostly 20-30yr men with testicular mass, very rare in
children and older men.
o >2/3 have metastasis, but only 10% symptomatic.
o Serum AFP normal, 60% have ↑ β-HCG.
Yolk Sac Tumour ‘Endodermal sinus tumour’ with multitude of histological patterns.
o Children: most common testicular cancer in children where
it occurs in pure form. Is usually diagnosed before
24months age.
o Adults: pure form rare, but found in 50% of mixed GCT.
o Usually presents with a mass, ↑ Serum AFP
o In children orchidectomy alone is curative in 90%.
Teratoma Tumour of all three embryonic layers (endo-, ecto-, meso- derms).
o Adults and children present with a testicular mass.
o Children: 2nd most common GCT in children, occurs in pure form, diagnosed
around 20months. Metastases don’t occur in children.
o Adults: component of mixed GCT, is identified in >50% of mixed tumours,
however still treated like a pure NSGCT. Metastasis occurs in adults.
Choriocarcinoma Very unusual pure form (<1% of germ cell tumours) which is bright red tumour
(highly vascular) and contains trophoblastic cells with nuclear atypia.
o Found in 15% of mixed GCT.
o Many patients present with symptoms related to metastases to lungs or
brain. ↑ serum β-HCG
o Does not develop in children.
o Poorer prognosis but tumour is chemosensitive.
Mixed Germ Cell Tumours (Mixed GCT)
Lesions composed of two or more germ cell tumour types. Comprises 33% of all GCT. Often consists of
seminoma and non-seminomatous components.
NB: Non-germ cell tumours are uncommon but include sex-cord stromal tumours (sertoli or leydig cell),
mixed tumours, haematopoietic tumours and secondary (metastasised) tumours.
Morphology: most common in the central and transitional zones (ie. inner part) of the prostate.
Macroscopic: firm rubbery enlargement up to 200g (normal 2g).
Benign Prostatic Hypertension
o Begins in periurethral glands, compresses them.
o Multinodular proliferation surrounded by compressed
prostatic tissue (psuedocapsule).
o Nodules vary in appearance according to composition
(often cystic).
Microscopic: hyperplasia may be glandular, muscular, fibrous or
mixed.
o Cystic dilation often prominent, containing secretions ±
corpora amylacea (calcified amyloid material in ducts).
o Often secondary inflammation, infarction (25%) or
squamous metaplasia.
o Glands have double epithelial lining; in carcinoma it’s single.
Clinical: prostatism which involves poor urinary stream, dribbling, frequency, nocturia etc.
Rectal examination shows enlarged, nodular, soft, boggy gland.
Late manifestations relate to urethral obstruction with urinary retention and infection.
Very common, esp >50 (80% at 80 yrs). Common in Australia, USA, Europe but not in Asian
countries.
Tumours of the Prostate
Nearly all prostatic neoplasms are adenocarcinomas. Others are very rare, including transition cell
carcinomas, squamous cell carcinomas, sarcomas and lymphomas.
Mostly >50yrs (average 75, 10-80% by 80 depending on definition).
Incidence and death rate increasing (aging population, better diagnosis). Over 1000 new
cases/yr in WA. 2nd highest cause of cancer death in men.
Common in developed countries, low in Asia.
Pathology:
Prostatic Adenocarcinoma
Sporadic Adenocarcinoma (95-97%) begin as carcinoma in situ (usually
high grade ± invasion).
o Predisposed to by premalignant conditions eg. atypical
hyperplasia, duct-acinar dysplasia, prostatic intraepithelial
neoplasia.
o Other risk factors include; age, race, endogenous hormones
and environmental factors.
Hereditary Adenocarcinoma (3-5%), autosomal dominant inheritance.
Usually early onset <50yrs and multifocal.
Clinical: great variation between clinical significance depending on how adenocarcinoma is defined.
Symptoms: often asymptomatic early, initial symptoms like hyperplasia (prostatism). Back pain
and anaemia due to bone metastases in later stages.
Complications: renal complications if urinary obstruction occurs, metastatic complications.
Prognosis: depends on size (volume), grade (Gleason, score), TNM staging. New prognostic
factors include; PSA and genetic alterations.
Treatment: nil, surgery, radiation, hormonal (oestrogens, anti-GnRH).
Histology: viral cytopathic effect of HPV is characteristically the formation of koilocytes (cells with
nuclear atypia and cytoplastic clearing).
Carcinoma Precursors: cervical interstitial neoplasia (CIN) is a carcinoma precursor lesion. Not all cases
of CIN progress, some stay latent or even regress. Risk of cancer depends on type of CIN lesion.
Low Grade Squamous Intraepithelial Lesion (LSIL) characterised by productive HPV infection.
They involve CIN 1 and HPV cytopathic effect.
NB: CIN 1 and HPV effect is mostly self limiting. Persistent infection can cause low grade
lesions to progress to high grade precursor lesions (HSIL)
High Grade Squamous Intraepithelial Lesion (HSIL) involve CIN 2 and 3 (true precursor lesions).
All cervical carcinomas derive from high grade precursor lesions in the surface epithelium.
Morphology: early cervical cancer is only visible by colposcopy, later grossly visible.
Early: focal induration, ulceration and elevated granular area which bleeds readily on touch.
Advanced: lesions can be endophytic (ulcerated/nodular) or exophytic (polypoid/papillary).
Clinical: presentation depends on stage, may be asymptomatic until cancer is in advanced stages.
Signs: abnormal papsmear, abnormal bleeding (ie. Instrumental or post sex).
Symptoms: pain (pelvic, back, leg), haematuria, weight loss (metastases).
Behaviour: can invade, form fistulas or metastasise.
o Direct local invasion to LN (iliac, obturator),ureteric obstruction.
o Formation of vesico-vaginal and recto-vaginal fistulas (leakage of waste into vagina).
o Metastases to other organs occurs relatively late (eg. lung).
Staging: FIGO staging depends mainly on spread.
Treatment: depends on stage, includes surgery (hysterectomy, LN), radiation, chemotherapy.
UTERINE PATHOLOGY
Non-Carcinoma Uterine Lesions
These inflammatory and benign lesions can involve the endometrium (glands and stroma) or the
myometrium (muscle). Most patients with abnormal uterine bleeding have benign conditions.
Bleeds can be abnormal cyclic (heavy, painful or irregular periods), intermenstrual, post menopausal
(most significant) or infertility related.
Abnormalities of Cyclical Development the endometrium doesn’t always follow a uniform cyclical
progression with oestrogen and progesterone stimulation.
There can be disordered proliferative changes, irregular maturation, inadequate/delayed
progestogenic effect (luteal phase) or irregular/delayed shedding.
Correlation with cycle dates and hormonal assessments are required.
Endometritis acute or chronic inflammation of the endometrium characterised by the presence of
plasma cells in the stroma. Variable microbiology, and is usually due to ascending infection.
Actinomyces is associated with intrauterine contraceptive devices (IUCD).
Endometritis may lead to pelvic inflammatory disease (PID).
Endometrial Polyps these are common benign neoplasms with glandular and stromal
components. Are commonly attached to the uterus by an elongated stalk
(pedunculated) or flat (sessile).
Often asymptomatic, but may cause irregular bleeding, bleeding between
periods and after menopause.
Cause not known, but grow in response to oestrogen and during Tamoxifen
treatment.
Neoplastic tumours may arise from these polyps. Endometrial Polyps
Endometrial Carcinoma
Refers to several malignancies arising from the endometrium. It is the most common gynecological
malignancy in regions with cervical cancer screening.
Pathology: classified as type 1 and type 2 endometrial carcinomas. Familial risk is important with
association with PTEN, MMR and p53 (type 2) gene mutations. History of Lynch syndrome or colorectal
cancer also increases risk.
Type 1 Endometrial Carcinomas (80-85%) are associated with unopposed oestrogen exposure and/or
endometrial hyperplasia precursor lesions.
Precursor hyperplasia is classified as simple/complex and typical/atypical.
Atypical hyperplasia (endometrial intraepithelial neoplasia, EIN) has the highest
cancer risk.
Endometrioid subtypes looks similar to normal endometrium.
Hyperoestrogenic states include obesity, anovulation, hormonal therapy,
oestrogen secreting tumours and relative progesterone deficiency.
Often occur in younger women (pre or perimenopausal).
Usually low grade/early stage, generally good prognosis. Endometrial Carcinoma
Type 2 Endometrial Carcinomas (10-15%) are not associated with raised oestrogen and involve
serous or clear cell types.
Precursor lesions include EIC and serous carcinoma in-situ,
Similar molecular pathology as invasive serious carcinoma (ovarian carcinoma).
Usually occur in older patients (with post menopausal atrophic uteri)
Often high grade with extrauterine spread, generally poor prognosis.
Endometrial Cancer Staging
Clinical: usually in post menopausal women (although it can occur at
Stage 1: confined to uterus
any age). Often confined to the uterus at diagnosis, with
(subdivided according to depth of
Treatment: hysterectomy ± bilateral salpingo-oophorectomy
myometrial invasion).
(removal of ovaries and fallopian tubes). Lymph node
Stage 2: extension to cervix.
dissection ± omental sampling in high risk cases.
Stage 3: Invasion of serosa, adnexae
→ postoperative radiotherapy/chemotherapy.
or positive peritoneal cytology.
Prognosis: depends on staging, however overall good
Stage 4: bladder/bowel invasion or
prognosis, 80-90% 5 yr survival.
distant metastases.
Mesenchymal Tumours
Refers to several malignancies arising from the stromal components, which are usually benign.
Endometrial Stromal Tumours are relatively rare, with most being low grade malignancies. Often
progestogen responsive.
Endometrial Stromal Sarcomas
OVARIAN PATHOLOGY
Non-Neoplastic Ovarian Lesions
Cystic and Inflammatory Lesions are relatively common.
Cysts are common, identified on ultrasound.
Polycystic Ovarian Syndrome is a clinic-pathological syndrome of obesity, androgenism, insulin
resistance, anovulation, infertility.
Inflammatory Lesions are uncommon, secondary to abdomino-pelvic sepsis, PID, autoimmune.
1. Surface Epithelial Tumours: (70%) derived from mesothelium covering ovaries which is constantly
scarred during ovulation. Further divided into three categories each with various histological subtypes.
Overall, serous subtype tumours are the most common, others include mucinous, endometrioid etc.
Benign Tumours (serous/cyst adenomas) are characterised by a single layer of columnar epithelium
that lines the cyst or cysts. Can have accompanying stromal component.
Borderline Tumours (borderline serous tumours) mainly include serous or mucinous types.
Epithelial proliferation and atypia but no destructive tissue invasion.
Generally excellent prognosis.
Serous types: 30-40% have extraovarian ‘implants’, late recurrence/progression may occur.
Malignant Tumours (serous/cyst adenocarcinoma) most ovarian malignancies are of epithelial type,
hence ‘malignant surface tumours’ is used synonymously with ‘ovarian cancer’. Ovarian carcinomas
are usually high grade, with a poor prognosis at later stages (most are detected late).
Pathology: the progression is debated, and precursor lesions
generally aren’t identified or accessible for sampling. There is a
proposed ‘dual model’ describing the pathogenesis of ovarian cancer;
types 1 and 2, each associated with different mutations.
o Type 1: mainly low grade carcinomas arising in precursor
lesions (endometriosis, benign or borderline tumours).
o Type 2: high grade carcinomas probably arising from ovarian Serous Cystadenocarcinoma
surface epithelium or fallopian tubes.
Cause: not known, but risk factors include multiple ovulation, environmental and hereditary
factors. Hereditary ovarian cancer (10-15% cases) mainly associated with BRCA 1 (usually high
grade serous carcinoma) and less commonly BRCA 2/Lynch Syndrome.
Clinical: patients present as they would with most ovarian tumours,
Ovarian Cancer Staging
except in later stages when metastases occur.
Stage 1: confined to ovaries.
o Spread: mainly intraabdominal, paraaortic nodes, distant
(liver, lung etc). Stage 2: spread to pelvis.
o Diagnosis: clinical, radiology (ultrasound, CT), serology Stage 3: spread to
(serum CA125) or surgical. extrapelvic peritoneum,
lymph nodes or bowel wall.
o Prognosis: depends mostly on stage, also grade, subtype,
and response to therapy. Stage 4: distant metastases.
o Screening: not yet established but could involve clinical NB: most are detected in
examination, serum CA125 and ultrasound. advanced stages.
2. Germ Cell Tumours: (20%) often occur in children and young adults, usually benign
with mixed differentiation.
Mature Cystic Teratoma are most common, benign dermoid cysts
(recognisable dermis).
Malignant tumours are rare, with various types (see male genital notes).
Often radio/chemosensitive with good prognosis. Tumour markers (AFP,
HCG). Benign Cystic Teratoma
3. Sex Cord Stromal Tumours: (5-10%) relatively uncommon stromal tumours that are mostly benign.
Thecoma-fibroma consist of solid grey fibrous cells to yellow (lipid laden) thecal cells.
Granulosa-thecal cell tumours consist of granulosa and thecal cells with cystic spaces.
o 3-5% of ovarian malignancies, usually post menopausal. Often with oestrogenic
release (can lead to endometrial/breast cancer).
o Late metastases common.
Sertoli-Leydig cell tumours (androblastomas) result in androgen
production and virilism.
Many are low grade (granulosa and sertoli tumours) and may present
with effects of hormone secretion. Androblastoma
NB: although germ cell/stromal cell tumours make up around 30% of tumours, they are only
responsible for <10% of malignant tumours as most are benign.
Metastatic Tumours: (5%) can be difficult to distinguish from a primary ovarian carcinoma histologically.
Primary sites include colorectal, appendix, stomach, pancreas, endometrium, breast etc.
Krukenberg Tumour a secondary ovarian malignancy with primary site from the GIT (gastric
origin most common). Metastatic carcinoma, usually bilateral with mucin producing signet ring
cells. Prominent reactive stromal proliferation.
Tumours of Fallopian Tube are uncommon, malignancies rarer, but incidence depends on definition.
Some ovarian and peritoneal carcinomas may arise in the fallopian tube (and perhaps previous
ovarian primaries are instead secondary to fallopian carcinoma).
Increased risk with BRCA 1 patients.
Usually serous carcinomas, may spread even when in-situ.
Tumours of the Peritoneum most are metastatic (GI, biliary, cervical, uterus etc), primary malignancies
include mesotheliomas and carcinomas.
Most primary carcinomas are high grade serous carcinomas (similar appearance, behaviour and
treatment similar to ovarian serous carcinoma).
Diagnosis of exclusion, increased risk in BRCA 1 mutation
BREAST PATHOLOGY
Fibrocystic Changes
A range of changes that occur in breast tissue, due exaggeration and distortion of the normal cyclic
(menstrual) hormonal changes that affect the breast.
Tend to arise during the reproductive period but may persist after menopause.
Can produce ‘lumps’ and are classified as non-proliferative or proliferative lesions.
Epithelial Hyperplasia proliferative lesions within the ductules, terminal ducts and lobules. Can be typical
or atypical (similar to ductal carcinoma in-situ).
Lumen filled with heterogenous cells of different morphologies, with irregular slit-like
fenestrations, esp at periphery.
Atypical hyperplasia is associated with 5x risk of carcinoma (10x with family history).
Sclerosing Adenosis lesion with proliferation of ductule and acini cells, aggregation of proliferating
ductules (adenosis), and marked intralobular fibrosis (sclerosing).
Can be clinically and morphologically similar to invasive ductal carcinoma.
Hard, rubbery consistency similar to cancer, associated with 1.5-2x risk of carcinoma.
Acute Mastitis develops when bacteria gains access to the breast tissue through ducts.
Can occur when there is; thickening of secretions, fissures in the nipples (nursing), or various
forms of dermatitis involving the nipple.
Usually Staphylococcus, can induce abscess formations which heal with scarring (hardened areas
within breast).
Rarely due to Streptococcus, which causes a spread out infection of entire breast, with pain,
swelling and tenderness.
Mammary Duct Ectasia (periductal or plasma cell mastitis) is a non-bacterial chronic inflammation of the
breast. Associated with thickening of breast secretions in the main excretory ducts.
Ductal dilation with rupture leads to inflammatory changes in the
surrounding breast tissue.
Characterised by lymphocytic/plasma cell infiltration and granulomas in
periductal stroma.
Uncommon, generally occurring in 40s and 50s.
Lesions cause hardening on the breast and retraction of the skin and
nipple, mimicking changes caused by carcinomas. Mammary Duct Ectasia
Traumatic Fat Necrosis is an uncommon and innocuous lesion producing a mass, often associated with
preceding trauma to the breast.
Lesions are small (<2cm), tender and sharply localised. Have central focus of necrotic fat cells
surrounded by neutrophils and lipid filled macrophages.
Focus replaced by scar tissue or debris encysted in scar capsule. Calcification may then develop.
Benign Tumours
Fibroadenoma most common neoplasm of female breast, composed of fibrous and glandular tissue.
Usually occurs in young females.
Lesions are discrete, firm, freely moving nodules (1-10cm).
Usually solitary, but can be multiple/bilateral.
Development of these lesions is associated with an increase in oestrogen.
Phyllodes Tumor much less common, thought to arise from periductal stroma and not from pre-existing
fibroadenomas.
Lesions may be small, but many grow very large, distending the breast.
Usually benign, localised and cured by excision.
Malignant lesions usually remain localised, except the most malignant (15%) do metastasise.
Pathogenesis: not known but genetic, hormonal and environmental influences have importance.
Genetic Influences
Familial: 5-10% of breast cancers are related to specific
BRCA1 and BRCA2 Genes
inherited mutations. Majority are with the BRCA1 and
Majority of inherited breast cancers are
BRCA2 genes, less commonly involve p53, PTEN and ATM
attributed to BRCA1 and BRCA2 genes
genes. (highly penetrant, austosomal dominant).
o Increased risk with history of breast cancer in 10 BRCA1 and BRCA2 genes are thought
relative, esp if multifocal or premenopausal. to function in DNA repair, acting as
o Familial cancer tend to occur at younger age and tumour suppressing genes.
are more severe/bilateral. Cancer arises when both alleles are
Sporadic: 90-95% have no known cause, probably multiple inactive/defective, one mutant
genes interacting with environmental factors contributing BRCA allele is inherited, and the
to breast cancer genesis. second allele is inactivated by
o Overexpression of HER2 proto-oncogene is found in somatic mutation.
30% of invasive breast carcinomas. Is a member of BRCA1 and BRCA2 mutations are rare
the ‘epidermal growth factor receptor’ family, and in sporadic breast cancer.
its overexpression is associated with poor prognosis Most patients with these mutations
(stimulates cell growth, not a cause). develop breast cancer by 70yr.
Hormonal Influences
Hormonal imbalance plays a significant role. Oestrogen stimulates growth factor production by
epithelial cells. If epithelial cells are neoplastic, this production can be exaggerated, leading to an
autocrine mechanism of tumour development.
Increased exposure to oestrogen peaks during the menstrual cycle.
o Long duration of reproductive life (menarche to menopause), late age of pregnancy, and
nulliparity (no previous pregnancy).
Prolonged exposure to exogenous postmenopausal oestrogens (ie. HRT)
Environmental Influences
Age: rare under 30, however risk increases with age and plateaus after menopause.
Geography: risk much greater in Western countries, due to environmental factors such as diet,
reproductive patterns, and nursing habits.
Previous Breast Lesions: in order of risk; proliferative lesions, atypical proliferative lesions,
ductal/lobular carcinoma in situ.
Ionising Radiation: to the chest increases risk depending on dose and duration. Only women
irradiated before 30, during breast development, seem to be affected.
Lifestyle Factors: obesity, alcohol, high fat diet; are all less well established factors.
Morphology: Breast cancers are classified into those that have not yet penetrated the limiting basement
membrane (non-invasive) and those that have (invasive).
Non-Invasive Carcinomas
Two types of breast cancers both of which arise from the terminal duct lobular unit.
Ductal Carcinoma In-Situ (DCIS) is a neoplastic epithelial
Paget’s Disease of the Nipple
proliferation, precursor to invasive ductal carcinoma. Is
Caused by the extension of DCIS up to
typically found on mammographic examination as
the lactiferous ducts and adjacent to
calcifications or a mass. the skin of the nipple. Presents as a
o Classified by growing pattern (solid, cremedo, unilateral crusting exudate over the
cribiform, papillary, micropapillary) nipple and the areolar skin. An
o Graded as low (monotonous nuclei) or high underlying invasive carcinoma may be
(pleomorphic) grade. present, and prognosis is based on the
o Risk and rate of DCIS progression is thought to be underlying carcinoma.
proportional to grade (ie. low grade DCIS → slower
progressing, low grade IDC).
o Prognosis is very good (>97% survival with
mastectomy ± radiation therapy, Tamoxifen).
o When invasive cancer develops, it is usually in the
Paget’s Disease
same breast and of ductal histology.
Lobular Carcinoma In-Situ (LCIS) is an expansion of the lobules by discohesive, bland neoplastic
cells. This lesion is frequently an incidental finding and doesn’t form masses or calcification.
o Approximately 1/3 of women with LCIS will develop invasive carcinoma.
o When invasive carcinomas develop, it occurs in either breast with the same frequency,
and may be lobular or ductal carcinoma.
Male Breast
Gynocomastia enlarged male breast which may occur in response to oestrogen excess.
Associated with liver cirrhosis (inability of liver to metabolise oestrogen), oestrogen secreting
tumours, oestrogen Therapy, and anabolic steroids
Physiologic gynocomastia often occurs in puberty and old age.
Male Breast Carcinoma is uncommon, 120x less likely than females, mostly in the elderly.
Associated with BRCA2 mutations, Klinefelter syndrome, excess oestrogen, obesity, and
testicular abnormalities.
SKIN
PATHOLOGY
Microscopic Terms
Hyperkeratosis Thickening of the stratum corneum, often associated with a qualitative
abnormality of the keratin.
Parakeratosis Modes of keratinization characterized by the retention of the nuclei in the
stratum corneum. On mucous membranes, parakeratosis is normal.
Hypergranulosis Hyperplasia of the stratum granulosum, often due to intense rubbing.
Acanthosis Diffuse epidermal hyperplasia.
Papillomatosis Surface elevation caused by hyperplasia and enlargement of contiguous dermal
papillae.
Dyskeratosis Abnormal keratinization occurring prematurely within individual cells or groups of
cells below the stratum granulosum.
Acantholysis Loss of intercellular connections resulting in loss of cohesion between
keratinocytes.
Spongiosis Intercellular edema of the epidermis.
Hydropic swelling Intracellular edema of keratinocytes, often seen in viral infections.
(ballooning)
Exocytosis Infiltration of the epidermis by inflammatory or circulating blood cells.
Erosion Discontinuity of the skin exhibiting incomplete loss of the epidermis.
Ulceration Discontinuity of the skin exhibiting complete loss of the epidermis and often of
portions of the dermis and even subcutaneous fat.
Vacuolization Formation of vacuoles within or adjacent to cells; often refers to basal cell-
basement membrane zone area.
Lentiginous Referring to a linear pattern of melanocyte proliferation within the epidermal
basal cell layer. Lentiginous melanocytic hyperplasia can occur as a reactive
change or as part of a neoplasm of melanocytes.
REMOVE ONES NOT USED.
INFLAMMATORY DERMATOSES
Lichenoid
Dermatoses Reaction Histology
Lichen planus and variants Characterised by epidermal basal layer Lichen planus
Lichenoid drug reactions damage Hyperkeratosis
Lichenoid keratosis Basal vacuolar change or cell death Epidermal hyperplasia: saw tooth pattern
Erythema multiforme, FDE Accompanying inflammatory infiltrate Wedge shape hypergranulosis
GvHD o Lymphocytes Band like lichenoid inflammatory infiltrate
Lupis erythematosus o Histiocytes Basal vacuolar change with Civatte bodies
Dermatomyositis o Eosinophils May have subepidermal clefting: Max Joseph space
Pityriasis lichenoides Lupis
Basal vacuolar change or dyskeratosis
Superficial and deep dermal perivascular lymphocytic infiltrate
Follicular plugging
Usually epidermal atrophy, but can be hyperplastic
Dermal mucinosis
Basement membrane thickening
May have very dense lymphocytic infiltrate: tumid lupis
IF: Positive lupis band
Psoriasiform
Psoriasis Regular epidermal hyperplasia with Psoriasis
Lichen simplex chronicus elongation of the rete ridges Regular epidermal hyperplasia (acanthosis – thickening)
Pityriasis rubra pilaris Increase mitotic activity Elongated club-shaped rete ridges
Parapsoriasis Accompanying inflammatory infiltrate Parakeratosis (scale)
Mycosis fungoides (T cell o Lymphocytes Mild spongiosis
lymphoma) o Histiocytes Superficial dermal perivascular lymphocytic infiltrate
Secondary to infections o Polymorphs Thinning suprapapillary plates
etc Neutrophilic infiltration; in stratum corneum, in epidermis forming
spongioform pustules, in transit in epidermis
In perivascular areas in superficial dermis
Spongiotic
Atopic dermatitis (eczema) Intraepidermal and intercellular oedema dermatitis
Allergic contact dermatitis ‘eczematous reaction’ Intracellular oedema within epidermis (spongiosis)
Insect bite reaction Associated inflammatory infiltrate Lymphocytic exocytosis
Seborrhoeic dermatitis Intra-epidermal collections of langerhans cells
Stasis dermatitis Superficial perivascular lymphocytic infiltrate with some eosinophils
Pityriasis rosea
Drug reactions
Vesiculobullous
Pemphigus foliaceus Intracorneal and subcorneal Pemphigus vulgaris
Spongiotic vesicular disease Intraepidermal Intraepidermal vesicle- acantholysis in the supra basal layer
Pemphigus vulgaris Suprabasilar Superficial dermal lymphocytic and eosinophilic infiltrate with
Bullous pemphigoid Subepidermal extension into the superficial epidermis
Epidermolysis bullosa o subclassified according to the Intracellular IgG and C3 on IF
Erythema multiforme inflammatory infiltrate Several clinico-pathological variants
Dermatitis herpetiformis Miscellaneous Bullous pemphigoid
Subcorneal pustular dermatosis Sub-epidermal 100esicle containing mainly eosinophils
Porphyria cutanea tarda (PCT) Superficial dermal perivascular and interstitial lymphocytic and dense
eosinophilic infiltrate
Autoimmune antibodies directed against hemidesmosomes – linear IgG
and C3 localised to the roof of the vesicle
Superficial dermal oedema especially in pre-bullous lesions
Dermatitis herpetiformis
Sub-epidermal vesicle
Papillary dermal micro-abscesses containing neutrophils, nuclear dusts
and fibrin
Histologically indistinguishable from linear IgA disease
IF: granular pattern IgA and C3 at the dermo-epidermal junction in DH,
linear pattern in linear IgA disease
Granulomatous
Granulomas annulare Chronic dermal inflammation with Granuloma annulare
Necrobiosis lipoidica histiocytes or epithelioid histiocytes Dermal necrobiotic granulomatous reaction
Sarcoidosis o Sarcoidal, TB granulomas Well circumscribed foci of necrobiosis surrounded by palisade of
TB, leprosy, syphilis o Necrobiotic granulomas epithelioid histiocytes and multinucleated histiocytes and patchy
Fungal infections o Suppurative granulomas lymphocytic infiltrate
Foreign bodies etc o Foreign body granulomas Sarcoidosis
Tight and naked granulomatous inflammatory infiltrate
Usually no necrosis
Various inclusion bodies (non specific); Asteroid bodies, Schaumann
bodies, Calcium oxalate crystals, Hamazake-Wesenberg bodies.
Vasculopathic
Senile purpura Non-inflammatory purpuras Leukoclastic vasculitis
Disseminated intravascular Vascular occlusive diseases AKA hypersensitivity vasculitis
coagulation Uticarias Affects small vessels in the superficial dermis
Uticaria Vasculitidies Fibrinoid necrosis
Vasculitidies (leukoclastic, Neutrophilic dermatoses Swollen endothelium
lymphocytic) others Perivascular lymphocytic infiltrate, nuclear dust and RBC extravasation
Sweet’s syndrome Hereditary angioedema
Hypersensitivity Decreased of dysfunctional esterase inhibitor leads to increased kinin
Henoch Scholein purpura formation
SKIN TUMOURS
Benign Tumours
Epidermal origin Seborrhoeic keratosis
Wart
Squamous papilloma
Melanocytic Lentigines
Naevi; junctional, compound, dermal
Skin adnexal Syringoma
Trichoepithelioma
Sebaceoma
Soft tissue Dermatofibroma Neurofibromatosis:
Hemangioma NF1 (classic) 1:4000 Chr 17
Neural tumours NF 2 (central acoustic) 1:50 000 Chr 22
Lipomas Systemic involvement: hypertensive headaches (pheochromocytomas)
pathological #, (bone cysts), mental retardation, astrocytomas, short stature,
precocious puberty (early menses, clitoral hypertrophy), iris hamartoma (NF1)
Skin: Café-au-lait macules, neurofibromas, plexiform neurofibromas
Malignant Tumours
Basal cell Most common skin tumour Sun exposure (UV-B) Multifocal superficial
carcinoma 70% all skin malignancies Radiation, X-ray exposure Nodular
BCC:SCC = 5:1 Thermal burns Infiltrating
Sun exposed skin of fair individuals Pre-existing organoid naevi, epidermal naevi Morphoeic
80% head and neck BCC naevus syndrome Mixed
Male, older patient Xeroderma pigmentosum Other
Most slow growing (some Arsenic poisoning (Tumour cells can resemble epidermal
aggressive) Stasis dermatitis of the legs basal layer)
Metastasis rare PUVA therapy for psoriasis
Transplant, AIDS and immunosuppressed
Squamous cell Second most common skin Sun exposure (UV-B) Similar to SCC from other sites
carcinoma malignancy Chronic ulceration Malignant squamous cells with dermal
Sun exposed areas of fair skinned Trauma, Burns, Frostbite invasion
individuals Fistula tracts, pilonidal sinus Dyskeratosis, acantholysis
Most arise in the head and neck, Hidradenitis suppurativa Spindle cell, verrucous, adenosquamous
dorsum of hands, vermillion Marjolin’s ulcer variants
border Dystrophic epidermolysis bullosa
Lichen sclerosus etc
Malignant Malignant melanoma of Increased sun sensitivity (pale skin, blond/red hair, Lentigo maligna melanoma (5-15%)
melanoma melanocytes freckles, poor tan Superficial spreading melanoma (50-70%)
Qld highest rate in world History of painful or blistering sunburns during Nodular melanoma (15-35%)
55.8/100000 childhood or adolescence (2 or more before 20) Acral lentigonous melanoma (5-10%)
Lifetime risk 1/87 Intermittent intense sun exposure Desmoplastic, neutropaenic melanoma
4.6% male mortality Dysplastic naevi Unclassified histo types
Others- genetics, PVC, xeroderma pigmentosum
Histological classification of melanoma has no effect on the prognosis of the tumour
Melanoma prognosis depends on the clinical staging, melanoma thickness, level of invasion and a few other histological classifications
Staging
Metastasis in any form (local, satellite nodule, metastasis in a scar, regional lymph node metastasis, distal visceral metastasis) confers a poor prognosis,
as it indicates that melanoma cells have entered the systemic circulation and can survive the body’s defence mechanism
Metastasis is only lethal if it affects a vital organ
Microscopic description: minimum essential elements
CORRECT diagnosis of MM Spitz naevus (benign)
Nevoid melanoma
Melanoma arising in naevus
Dysplastic naevus
Atypical melanocytic lesions
Melanocytic tumour of unknown biologic potential, minimal
deviation melanoma, malignant blue naevus, mucosal melanoma etc
Maximum tumour Measures tumour volume SIZE mm 5 year survival %
thickness according to the Vertical measure from the granular layer of the epidermis to the < 0.76 98
method of Breslow, deepest part of melanoma 0.76-1.49 96
measured to the nearest One dimensional estimate of the tumour bulk or tumour volume 1.5-2.99 86
0.1mm Most accurate yet imprecise guide to the behaviour of some 3.0-3.99 79
melanomas (thin melanomas that metastasise 4< 58
Clark level of invasion anatomical compartment LEVEL Level of invasion
Provides useful prognostic information in melanoma arising in very I Intraepidermal in situ
thick or very thin skin and in thin melanomas II Invasion of papillary dermis
III Invasion/expansion of papillary dermis
IV Invasion of reticular dermis
V Invasion of subcutaneous layer
Completeness of excision Entire tumour must be thoroughly sampled
Margins examined for the presence of invasive melanoma, in situ
melanoma and other atypical melanocytic lesions
Microscopic measurement
of margins of excision
ENDOCRINE
PATHOLOGY
PITUITARY GLAND PATHOLOGY
Overview
Pituitary abnormalities result in mechanical and functional problems.
Mechanical: raised ICP, bony erosion (sella turcica) and local pressure on anatomical relations
(3rd ventricle, hypothalamus, optic chiasm or CN III-VI).
Functional: hypo or hyperpituitary secretion with associated clinical syndromes.
Hormone Hypersecretion Hyposecretion
GH Gigantism, Acromegaly Dwarfism
PRL Amenorrhoea, impotence
ACTH Cushing’s disease Hypoadrenalism
FSH/LH Usually silent, rare testes enlargement Hypogonadism
or menstrual irregularities
TSH Very rare – causes hyperthyroidism Hypothyroidism
Plurihormonal GH + PRL with other combos – probably Panhypopituitarism (Simmond’s disease
common eg. Sheehans syndrome)
ADH Inappropriate ADH secretion Diabetes insipidus
Pathological Hyperplasia (primary or secondary to Surgery, tumour destruction of >75% of
Lesion ectopic promoters of secretion), gland, ischaemia (eg. Sheehans
Neoplasia syndrome), inflammation, hypothalamic
lesions etc.
Anterior Hyperpituitarism
Pituitary Adenomas
Most common cause of hyperpituitarism is an isolated adenoma in the anterior
lobe (3% are associated with MEN-1). Found in 20% of population post-mortem,
represent about 15% of all intracranial neoplasms, most non-functioning and
benign. Mutation of the GNAS1 gene, which results in continual activation of Gs-
protein is a common cause. Pituitary Adenoma
They are classified on basis of cell type, function and size:
Cell type: based on immunohistochemical stains of hormone(s) produced by neoplastic cells.
Function: can be clinically functional (clinical symptoms due to hormone excess), silent
(hormone production demonstrated without clinical manifestations) or hormone negative (no
hormone specific differentiation demonstrated, rare).
Size: microadenoma (<1cm) or macroadenoma (>1cm). Note that silent/hormone negative
adenomas tend to be larger when diagnosed as they usually come to clinical attention at a later
stage (eg. after mechanical symptoms).
Most functional pituitary adenomas consist of one cell type and produce one hormone, although there
are exceptions. Clinical symptoms vary according to type of cells involved:
Type of Adenoma Clinical Manifestations
Prolactinoma -Most common hyperfunctioning pituitary adenoma resulting in
amenorrhea, galactorrhea, loss of libido and infertility.
-Often composed of chromophobe cells (lack of granules/staining).
-Stalk effect; condition can be caused by compression of stalk which
prevents dopamine from inhibiting prolactin release
GH-producing -Somatotroph adenomas are second most common, often plurihormonal
Adenoma with prolactin.
-Gigantism occurs when excess secretion occurs before epiphyses close
resulting in hepatic secretion of ILGF-I and hence increased body size with
disproportionate long arms and legs.
-Acromegaly occurs when such secretions occur after epiphyses close
resulting in acromegalic facies, goitre, hyperstosis (thoracic vertebrae),
cardiomegaly (with hypertension), barrel chest, insulin resistance, male
sexual dysfunction, large hands and feet, arthritis, peripheral neuropathy
and thickened skin (increased glands).
Corticotroph -Excess ACTH results in Cushing’s disease (hypercortisolism) which can
Adenoma occur from other sources (see below).
Thyrotroph Adenoma -Rare cause of hyperthyroidism (see below)
Gonadotroph -Difficult to recognise due to lack of clinical syndrome.
Adenoma -Usually detected later when mass (eg. impaired vision, headaches) or
hypopituitary effects (pressure invasion) occur.
Non-functioning and -Usually detected later when mass (eg. impaired vision, headaches) or
Hormone negative hypopituitary effects (pressure invasion) occur.
Other Causes
Hyperpituitarism can occur from non-neoplastic causes, although less common:
Pituitary hyperplasia can be primary, or secondary to changes in peripheral target organs.
Carcinomas are exceedingly rare. Often extend beyond sella turcica with distant metastases.
Hypothalamic disorders can result in increased stimulation and hyperplasia of pituitary cells.
Ectopic secretion of hormones by extra-pituitary tumours is rare.
Anterior Hypopituitarism
Hypofunction of adenohypophysis is usually caused by acquired conditions (rarely congenital):
Non-functioning pituitary adenomas are usually detected at
Sheehan Syndrome
a later stage after they enlarge causing mass effects. Postpartum panhypopituitarism
Enlargement can cause pressure atrophy of adjacent cells. (Simmond’s disease) results from
Ischaemic necrosis of anterior pituitary is important cause, haemorrhage caused by increased
however >75% loss of parenchyma must be lost before pituitary size without increased
clinical consequences develop. This can occur in Sheehan blood flow during pregnancy.
syndrome or less commonly in DIC, elevated ICP, sickle cell Sheehan’s results in decreased
anaemia or traumatic injury. MSH, TSH, prolactin, ACTH and
FSH/LH.
Removal of the pituitary by surgery or radiation.
Disorders that interfere with delivery of stimulating hormones from hypothalamus eg.
hypothalamic tumours. Less frequent, usually accompanied by posterior pituitary dysfunction.
Other pathological lesions eg. traumatic, inflammatory (TB, syphilis, fungi etc.), vascular,
infiltrative (amyloid etc.).
Clinical Manifestations: changes (often subtle) are due to the hypermetabolic state and overactive
sympathetic nervous system, induced by excessive thyroid hormone:
Constitutional: warm sweaty skin, flushed, heat intolerance, weight loss
Cardiac: palpitations, tachycardia, high output cardiac failure
Neuromuscular: nervousness, agitation/irritability, tremor, muscle weakness/wasting
Ocular: wide staring glaze, lid lag, exophthalmos (proptosis) in Grave’s disease
Goitre: associated with hyperfunctioning goitre
Causes: reduction in thyroid function can arise from a primary or secondary cause.
Primary: intrinsic abnormality of the thyroid, congenital (eg. aplasia/hypoplasia,
metabolism defects) or acquired (eg. surgery, radiation, iodine deficiency,
goitrogens, thyroiditis).
Secondary: hypothalamic or pituitary disease (uncommon)
Clinical Manifestations: can manifest itself as cretinism or myxoedema depending on when it develops
in the patient.
Although all cases of hypothyroidism have low T4, TSH is increased in primary cases while
decreased in those due to secondary disease.
Pathological features also depend on cause; the gland may be atrophic or enlarged (goitre).
Cretinism Myxoedema
Hypothyroidism that manifests in Hypothyroidism that develops in older children and
infancy or early childhood resulting adults (more common in females).
from lack of T3/T4 during development.
Low T3/T4 causes subtle changes; slowing of
Cretinism results in; impaired physical/mental activity, lethargy, weakness, cold
mental/physical development, dry intolerance, slow speech, constipation and
rough skin and face abnormalities (puffy hypercholesterolaemia. Mucopolysaccharide rich
eyes, large tongue, broad nose). oedema also causes subcutaneous thickening,
broadened/course facial features and a hoarse voice.
Goitre
Persistent enlargement of the thyroid that can occur in eu-, hypo- and hyperthyroid
states. Goitre is the most common manifestation of thyroid disease.
Simple colloid goitre; diffuse hyperplasia of follicular cells (to 150gm) →
irregular colloid accumulation → simple goitre.
Nodular colloid goitre; simple colloid goitre → recurrent episodes of
hyperplasia and involution → more irregular enlargement of thyroid → cut
surface with nodules of irregular size separated by fibrous tissue.
Benign
Note: haemorrhage, cysts, scarring and calcification in nodular goitre. Multinodular Goitre
Causes: often endemic iodine deficiency, goitrogens (cabbage, turnips, CaCl2, cyanates, iodides etc.),
metabolic defect or Grave’s disease (see above).
Clinical Manifestations: dominant symptoms caused by mass effects (eg. airway obstruction, dysphagia,
vessel compression, cosmetic problems).
If goitre is insufficiently compensating for iodine deficiency hypothyroidism will result.
Other goitres are hyperfunctioning (toxic) resulting in hyperthyroidism.
Thyroiditis
Thyroiditis encompasses a diverse group of disorders characterised by some form of thyroid
inflammation.
Hashimoto’s Disease
Chronic lymphocytic (Hashimoto) thyroiditis is most Non Specific Forms
common cause in populations with sufficient iodine. It Infective thyroiditis: invasion results in
occurs at any age, being more common in females. acute illness with severe thyroid pain.
Pathology: HLA-DR5 and HLA-DR3 associations (define Palpation thyroiditis: caused by vigorous
Tcell antigen recognition). Deficient suppressor Tcells clinical palpation of gland resulting in follicular
permit development of variety of auto-antibodies. disruption associated with chronic inflammation
Overall effect is depletion of thyroid epithelial cells and (however no abnormalities).
mononuclear cell replacement (Hurthle cells). Rare
atrophy and fibrosis. Specific Forms
Clinically: usually hypothyroidism, however may be Hashimoto disease:
hyper (transient) or euthyroidism. Associated painless autoimmune disease, most common
enlargement. Slight increase risk of lymphoma, cause in populations with sufficient
carcinoma. iodine.
De Quervain’s disease: self
de Quervain’s Disease limiting disease, probably secondary
Subacute granulomatous (de Quervain) thyroiditis is a Hashimotos Disease
to viral infection.
self limited disease, commonly affecting middle aged
Reidel’s struma: rare idiopathic (likely
women.
autoimmune) disease with extensive fibroses
Probably secondary to a viral infection, also has HLA- involving the thyroid and neck structures. Thyroid
B35 associations. Granulomatous inflammation causes becomes hard and fixed.
painful enlargement, fever, malaise ± transient
hyperthyroidism.
Thyroid Neoplasms
Thyroid gland gives rise to a variety of neoplasms that present mostly as solitary thyroid nodules.
Only 1% of all thyroid nodules are neoplastic, most of which are epithelial.
Different types of neoplasms have very different natural histories.
Diagnosis involves imaging, cytology, excision and histological assessment.
Thyroid Adenomas are the most common benign neoplasm. They are derived from the follicular
epithelium with differing patterns.
Most are non-functional, functional adenomas usually result from mutations activating the TSH
receptor (causes follicular growth and hyperthyroidism).
Adenoma cells are histologically demarcated from parenchymal cells by a well-defined, intact
capsule. Distinguished from follicular carcinoma by lack of capsular/vascular invasion.
Thyroid Carcinoma
Papillary Carcinoma (80%) most common thyroid carcinoma often occurring in
young females. Increasing incidence associated with radiation and alterations in RET
proto oncogene.
Often multifocal (may be hidden) and metastasise to regional lymphatics,
however prognosis is very good (0.2% mortality).
Diagnosis based on nuclear features (ground glass nuclei, pseudo
inclusions), even in absence of papillae. Psammoma calcified bodies are also
characteristic.
Follicular Carcinoma (15%) second most common form, usually affecting older females.
Fairly uniform follicular epithelial pattern with two types:
o Microinvasive where there is minimal capsular ± vascular invasion (better prognosis)
o Widely invasive where extensive and obvious invasion of parenchyma occurs
Diagnosis by evidence of capsular/vascular invasion (micro or widely invasive) and elimination of
papillary carcinoma nuclear features.
Can metastasise via blood vessels rather than lymphatics to bones, liver, lungs etc.
Medullary Carcinoma (5%) cancer of neuroendocrine (nonepithelial) origin, derived from parafollicular
cells (C cells). May be preceded by C cell hyperplasia.
Most secrete calcitonin and have amyloid stroma.
Cytologically variable, may also be solitary or multifocal.
Behaviour also variable, metastasise via blood or lymphatics (65% 10yr survival).
25% are familial cases associated with MEN syndromes 2A/B or other inherited disorders
(screening of families essential). Other 75% are sporadic cases.
Anaplastic Carcinoma rare, highly aggressive neoplasm that is associated with previous thyroid disease.
Thought to arise from dedifferentiation of already differentiated/damaged cells.
Usually bulky, locally invasive and widely metastatic (very poor prognosis).
Spindle, giant and small cell histological variants.
PARATHYROID GLAND PATHOLOGY
Hyperparathyroidism
Causes: excess PTH secretion can be primary, secondary or tertiary and is classified accordingly.
Primary – parathyroid adenoma (commonest, up to 90%), primary hyperplasia, parathyroid
carcinoma rare.
Parathyroid Adenomas Parathyroid Hyperplasia Parathyroid
Typically solitary (if multinodular, Primary hyperplasia typically involves Carcinomas
hyperplasia suspected). Most in all glands. Very rare with variable
inferior glands (may be ectopic sizes. Diagnosis is
Pathology: mainly chief cells with
and hard to locate). difficult as it requires
nodular pattern (polyclonal origin).
Pathology: usually chief cell type Hyperplastic chief cells completely evidence of invasion ±
with monoclonal origin. Most are replace fatty tissue normally preset in metastasis. Normally
sporadic, 25% of these have adult parathyroid. May be familial slowly progressive.
similar Ch11 mutation to familial (associated with familial Ch11 gene
forms. Rarely associated MEN 1. loss and MEN 1).
Secondary – hyperplasia usually due to renal disease; less commonly vit D deficiency, intestinal
malabsorption, calcitonin producing tumour or pseudo-hypoparathyroidism.
Tertiary – ectopic secretion of PTH like substance by non-parathyroid tumour eg. lung SCC,
renal, ovarian cancers.
Clinical Manifestations: most clinical problems relate to hypercalcaemia caused by increased PTH. Can
be summarised as “painful bones, renal stones, abdominal groans and psychic moans”.
Metastatic calcification; kidneys, blood vessels, lungs, GIT, skin, conjunctiva (worse if phosphate
retention).
Bone lesions; osteoporosis, fractures, osteitis fibrosa cyctica (triad of osteoclast Ca resorption,
peritrabecular fibrosis and cystic brown tumours)
Renal lesions; calculi, nephrocalcinosis, renal failure
GIT lesions; nausea, vomiting, peptic ulcers, pancreatitis, cholelithiasis
Others; hypertension, muscle atrophy, weakness, headaches, depression, seizures
Hypoparathyroidism
Causes: hypoparathyroidism is much less common with varying causes.
Surgical removal, often advertently during thyroidectomy
Autoimmune disorder, commonly polyglandular
Congenital absence (polyglandular) and familial syndromes are less common.
Diabetes Mellitus
Diabetes mellitus is a group of metabolic disorders sharing the common underlying feature of
hyperglycaemia. They result from defects in insulin secretion and/or action, causing abnormalities in
carbohydrate, fat and protein metabolism:
Normal glucose metabolism dysregulated (homeostasis disruption)
Inability to transport glucose into cells
Diminished protein synthesis
Breakdown of fat to produce energy can result in ketone body formation and acidosis.
Classification
Although all forms share hyperglycaemia, the underlying causes vary widely. The vast majority of cases
fall into two primary broad classes:
Type 1 (insulin dependent) Type 2 (non-insulin dependent)
Description -Autoimmune disease characterised by -Combination of peripheral resistance to
the progressive destruction of islet β-cells insulin and inadequate pancreatic
in pancreas response (β-cell dysfunction)
-Leads to “absolute insulin deficiency” -Leads to “relative insulin deficiency”
Clinical -Accounts for 10% of cases -Accounts for 80-90% of cases
-Early onset (<20yr) -Late onset (>30yr)
-Normal weight -Obese (part of metabolic syndrome)
Biochemical -Insulin levels low -Insulin can be normal (high early)
-Antibodies to islet cells -No islet auto-antibodies
-Ketoacidosis common -Ketoacidosis rare
-Association with HLA-DR3/4 -Polygenic inheritance
Pathology -Non specific T-cell/cytokine insulates -Variety of genetic defects and obesity
often with auto-antibodies against β- contribute to insulin resistance.
cells. -β-cell dysfunction means inability to
-Later atrophy, fibrosis and β-cell adapt to peripheral resistance.
depletion/degranulation. -Islet amyloidosis and degeneration at
later stages.
A variety of monogenic and secondary causes make up the remaining causes of diabetes:
Diseases of the pancreas; haemochromatosis, pancreatitis, neoplasms
Endocrine diseases; Cushing’s, Acromegaly, hyperthyroidism, phaeochromocytoma
Others; genetic defects, infections, carcinoid syndrome, drug-induced, gestational
Clinical Manifestations Diagnosis
The clinical manifestations of diabetes include; If a patient is suspected of diabetes from such
Polyuria; glycosuria induces osmotic clinical signs then a diagnosis is confirmed
dieresis based on blood glucose tests:
Polydipsia; renal water loss combined with Random blood glucose conc. >11mmol/L,
hyperosmolarity with classical signs/symptoms
Polyphagia; increased protein and fat Fasting glucose conc. >7mmol/L, on more
metabolism than one occasion
Weight loss (without appetite loss), OGTT with glucose conc. >11mmol/L, 2hrs
Fatiguability after carbohydrate load on more than one
Clinical signs of diabetes related occasion
complications (see below).
Complications
The long term complications of diabetes are similar regardless of aetiology. Complications arise due to
(1) formation of advanced glycosylation end products (AGEs), (2) activation of protein kinase C (PKC) and
(3) accumulation of intracellular sorbitol (polyol that causes osmotic injury):
Biochemical disturbances; severe complications
Diabetes Associated Diseases
resulting in ketoacidosis and death, seen less with
The disease processes mentioned on the left
adequate control. lead to various common diabetic complications
Accelerated atherosclerosis; hyaline atherosclerosis in various organs:
narrows vascular lumen. Leads to coronary, Heart; ischaemic heart disease is leading
cerebral, renal and peripheral vascular disease. cause of death due to diabetes
Diabetic microangiopathy; increased permeability Eyes; haemorrhages, microaneurysms,
of small vessels and protein deposition in basement diabetic retinopathy, cataracts, glaucoma.
membrane. Especially leads to retinal, peripheral Diabetic nephropathy; renal failure due to
nerve and glomerular disease. glomerular and vascular lesions.
Peripheral neuropathy; sensory, motor and
Predisposition to infection; especially bacterial and
ANS dysfunction, mostly in extremities.
fungal infections of skin, mucosa and urinary tract.
Gangrene; peripheral due to vascular
Related to impaired leukocyte function and
insufficiency.
diminished blood supply.
ADRENAL CORTEX PATHOLOGY
The most important cortical lesions are growth disorders which may result in abnormal function.
Adrenocortical hyperplasia; can be diffuse or nodular, often with minimal enlargement. Can be
congenital (enzyme deficiency triggers hyperplastic compensation), idiopathic or secondary to
ACTH excess.
Adrenocortical adenoma; usually small solitary, yellow nodule. Lipid laden pleomorphic cells
make diagnosis difficult. Many are non-functional.
Adrenocortical carcinoma; usually large, unencapsulated, highly anaplastic and malignant.
Smaller ones difficult to distinguish from adenoma. Lymphatic or blood metastasis to lungs etc.
Less common; aplasia, hypoplasia, diff number of glands, atrophy.
Symptoms; weakness, fatigue, central obesity, moon facies, skin striae, hypervolaemia, cardiac
hypertrophy and hypertension, osteoporosis, diabetes mellitus, psychic disorders/emotional
disturbance, menstrual problems (amenorrhoea), purpura and skin ulcers (poor healing).
Hyperaldosteronism
Conditions that cause excess mineralocorticoid levels. These cause Na retention and K excretion with
resultant hypokalaemia and hypertension.
Primary aldosterone-secreting adenoma (Conn Syndrome)
Secondary to excess renin release (eg. decreased renal perfusion, hypovolaemia, pregnancy)
Other causes; bilateral hyperplasia, carcinoma, rare familial entities
Symptoms are usually ill defined; headache, polydipsia, polyuria, nocturia, muscle weakness, discomfort,
tetany, paralysis, paraesthesiae, visual disturbance.
Adrenogenital Syndromes
Conditions that cause excess release of androgens from adrenal cortex. This can occur as a pure
syndrome or as a component of Cushing disease. The adrenal causes of androgen excess include:
Adrenocortical neoplasms, usually carcinomas
Congenital adrenal hyperplasia (CAH), a group of congenital disorders that result in enzyme
defects which affect steroid biosynthesis (mainly cortisol).
Note: With reduced cortisol, compensatory increase in ACTH release results in secondary
hyperplasia of adrenal cortex (bilateral).
Symptoms; are most commonly associated with virilism (excess androgen causing signs of masculinity in
females).
MEN SYNDROMES
Multiple endocrine neoplasia (MEN) syndromes are a rare group of inherited diseases resulting in
proliferative lesions in multiple endocrine glands.
Multiple tumours occur at a younger age, either synchronously or metachronously.
Autosomal dominant, family follow up important.
Effected Organs Genetic Abnormality
MEN-1 -Parathyroid (95%), primary hyperplasia -Loss of tumour suppressor
-Pancreas (40%), endocrine neoplasms (usually gene at Ch11q13.
metastatic) or less commonly gastrinomas -Unknown mechanism of
-Pituitary (30%), mostly prolactin or GH secreting action.
MEN-2a -Thyroid, medullary carcinoma in virtually all cases -Inheritance of RET proto-
-Adrenal medulla (50%), phaeochromocytomas oncogene on Ch10q11.
-Parathyroid (30%), primary hyperplasia -Multiple tyrosine kinase
MEN-2b -Thyroid and adrenal medulla disease similar as 2a mutations.
-No parathyroid involvement
-Extraendocrine manifestations.
MUSCULO-
SKELETAL
PATHOLOGY
Fracture Healing and Repair
The ideal situation for fracture healing relies upon; minimal necrosis and abscess (sequestrum), wound
immobilisation (precise anatomical reduction), good vascular supply, lack of infection, and minimal
physical stress. The sequence of events which follows bone fracture includes the following:
STAGE I Haematoma and fibrin clot formation encases ends of bone.
STAGE II Traumatic inflammation, usually forms soft callus. Mediator release eg. PDGF, TGF-b, ILs.
STAGE III Demolition phase - macrophages remove debris.
STAGE IV Granulation tissue formation (derived from periosteum/endosteum). pH low (acid tide).
STAGE V Woven bone ± cartilage formation, at this stage pH high (alkaline tide). Union occurs when
repaired bone spans the fracture site, which may be achieved by any of the processes below.
a) Where immobilisation is adequate mesenchymal cells are able to differentiate to form
woven bone. Calcification follows. The mass of tissue uniting the bone ends is known as a
hard "callus".
b) With increasing motions at the fracture site cartilage forms instead. If movement limited
normal callus will form. However, if persistent and excessive motion occurs, a cleft will
form causing non-union of the fracture. Termed a pseudoarthrosis.
c) If there is an excessive gap between the fracture fragments the fracture site is spanned by
dense fibrous connective tissue. Healing can occur from here.
STAGE VI If a callus forms it is invaded by capillaries and bone cells. Non-viable woven bone or cartilage
is removed by osteoclasts. Osteoblasts begin to lay down osteoid, which calcifies to form
lamellar bone, arranged in flat plates or Haversian systems.
STAGE VII Remodelling: continued osteoblastic and osteoclastic activity results in an eventual return to
normal.
Pathogens/Route: S. aureus is most common in adults and children >3yrs, but other pathogens do occur.
1. Haematogenous osteomyelitis acute infection occurs more commonly in children, typically in
metaphyseal regions with high vascular flow eg. in the femur, tibia, humerus and radius.
Neonatal osteomyelitis often also involves adjacent joint, usually following haematogenous
infection by S. aureus, group B strep or E. coli.
In adults haematogenous spread probably occurs through periosteal vessels, hence most
often seen in the cortex of long bones or in flat bones, eg vertebra.
IV drug users develop pseudomonas osteomyelitis, often involving the spine or pelvis.
2. Direct osteomyelitis results from direct introduction of pathogens into skeleton from outside
body. Most commonly affects bones which are prone to injury and have the least soft tissue
covering eg. phalanges, tibia and forearm bones.
Infections are often polymicrobial, and most often due to compact/comminuted fractures,
puncture wounds etc.
Iatrogenic infection may occur as a result of surgical procedures (joint replacement etc.).
Diabetics at increased risk due to neuropathic foot ulcerations and altered immune function.
Pathology: trauma is a predisposing factor as it is associated with stasis and/or thrombosis, thus
providing a nidus for infection.
1. In acute pyogenic osteomyelitis organisms lodge in Haversian canals or marrow
spaces and elicit an acute inflammatory response.
2. Oedema from inflammatory reaction raises intracompartmental pressure →
compromises blood supply to osteocytes resulting in eventual necrosis of bone.
3. Infection walled off by granulation tissue then dense fibrous tissue → trapped,
necrotic bone (sequestrum).
4. In local infection Brodie’s abscesses form, otherwise exudate passes through the
periosteum. Can lift the cortex in children, or rupture, forming a draining sinus.
5. New reactive bone (involucrum) forms around abscess in attempt to isolate the Osteomyelitis
infection. of Femur
Morphology: suppurative exudate in bone marrow, neutrophil polymorphs, RBC’s, fibrin and debris.
Osteoclast activity at necrotic margins. Can have granulation tissue or abscess depending on stage.
Outcome: determined by the anatomic location, the host response (resistance), the number and relative
virulence of the pathogens, and the effectiveness of therapy.
Ideal outcome; with resolution and repair, the sequestrum is resolved, the organisms are dealt
with by the immune response and the defect fills with granulation tissue.
Ultimately undergoes intramembranous ossification and healing.
Clinical: local pain and fever, especially in children. May be difficult to distinguish from a neoplasm.
X-rays often normal for first 14days, inflammation and reactive bone seen with time.
Intense uptake isotope scans can be used, but MRI imaging will often reveal
infection/abnormality the earliest.
Conclusive diagnosis either by blood cultures (may be -ve) or from the lesion itself.
Pott’s Disease
Kyphotic deformity of thoracic spine during tuberculous
osteomyelitis.
Destruction of anterior vertebral end plates → spreads to IV discs
→ involves adjoining vertebral bodies.
Large, cold abscesses filled with necrotic gaseous material may
form in the soft tissues eg. the paravertebral/psoas musculature.
Can also cause spinal cord compression, meningitis and/or
ankylosis (fixation). Pott’s Disease
Joint Infection
Acute septic arthritis is the invasion of the joints by pathogenic microorganisms which trigger an
immune response and degradation of the cartilage. Infection of joint may occur by:
Haematogenous dissemination to synovium.
Extension from adjacent focus of osteomyelitis or soft tissue infection.
Direct implantation of organisms via trauma or operative intervention.
Pathology: presence of pathogens incites an acute inflammatory reaction within the joint capsule and
synovium, with swelling and effusion.
Inflammatory response causes degradation of the cartilage, esp articular cartilage.
Cellulitis and suppurative exudates may extend beyond the joint capsule → complete joint
disruption into soft tissues with sinus formation.
Morphology: hallmarks evident within the synovial tissues where there is dense, mixed inflammatory
cell infiltrate. Patchy fibrinous exudate at synovial surface which may be eroded in some areas. Synovial
blood vessels are congested and prominent.
Clinical: clinical course determined by the pathogens involved, host response and therapy. Early
recognition, diagnosis and treatment is critical due to rapid cartilage damage.
Often present with a swollen, red, warm and painful joint. Associated fever and ↑WCC.
Purulent material may be recovered on joint aspiration.
Diagnosis by aspiration and synovial fluid examined for the crystals and microorganisms.
Treatment by surgical incision, drainage, immobilisation and antibiotic therapy
Tuberculous arthritis most often involves large joints, as a result of haematogenous colonisation within
the synovium. Cases chronic granulomatous inflammation throughout the joint cavity.
Destroys the articular cartilage and also infiltrates and destroys subchondral bone.
Joint destruction is often followed by the formation of fibrous scars, ie. fibrous ankylosis.
Early manifestations of chronic swelling and effusion, with few acute signs of inflammation.
With progression there is loss of range of motion of the joint, which may be accompanied by the
formation of draining sinuses.
DEGENERATIVE JOINT DISEASE
Clinical arthritis is the consequence of loss of the joint’s normal function, which depends on many joint
structures (ligaments, tendons, muscles) as well as articular cartilage and surrounding bone. Joints must
be able to move freely, stay stable during use and distribute force during stress.
Pathology: acute or chronic injuries that result in – articular surface alterations, loss of
supporting structure integrity, or alteration in the mechanical properties of tissues – can cause
arthritis. Relatively common changes include:
o Cartilage clefting, repair and metaplasia, ± necrosis.
o Synovial hyperplasia/hypertrophy, haemosiderin ± loose bodies.
o Bone necrosis, reactive sclerosis, microfractures and osteophytes.
o Synovial fluid changes in colour and content (cell count, proteins, pathogens etc).
Clinical: common signs and symptoms include:
o Symptoms; pain, stiffness, deformity, loss of function, systemic illness.
o Signs; heat, redness, swelling, loss of movement, deformity, tenderness, crepitus
Can be classified as; non-inflammatory ‘osteoarthritic’, inflammatory ‘rheumatic’, infectious (see
above) or metabolic ‘crystal’ arthritis.
Non-Inflammatory Arthirits
Osteoarthritis is a non-inflammatory functional joint disorder, characterised by altered joint anatomy
and loss of articular cartilage.
Pathology: many cases are idiopathic, other causes
Osteoarthritis Process
include trauma, metabolic conditions, infection, 1. ↑ chondrocyte activity due to various stimuli (eg.
avascular necrosis, other forms of arthritis, congenital trauma)
alterations etc. 2. Abnormal quantity and quality of proteoglycan
Result in damaged cartilage and alteration in and collagen production.
shape of the articular surfaces. 3. Joint may maintain normal function for years but
Articular cartilage exhibits fibrillation and clefting. eventually, the arrangement and size of collagen
Variable loss and thinning can expose underlying fibres are altered.
4. Proteoglycans begin to break down faster than
bone (eburnation).
they can be synthesized resulting in degenerative
Subchondral bone reveals sclerosis, cystic change,
cartilage (pieces can fragment into joint).
fractures, exostoses and osteophytes.
Clinical: typical presentation of pain (esp with use/activity), stiffness and reduced
mobility in joint. No inflammatory or systemic signs.
Affects all societies and races, is more common in women, and increases with age.
Individual risk factors for arthritis include genetic influences, hormonal factors,
obesity, trauma and occupation.
Patterns of clinical presentation include disease limited to a large single joint
(sometimes bilateral), a generalised process (involving joints of fingers/hands,
knees and hips), and Charcot joints.
Osteoarthritis
Rheumatoid Arthritis
Rheumatoid arthritis is a chronic systemic disorder of unknown aetiology, which effects females more
often than males. The peak age of onset is in the fourth to sixth decade.
Pathology: although the cause is unclear, 70% to 80% of affected individuals test
positive for histocompatibility antigen DW4 and there are some familial cases.
It is clear that there is a immunological reaction and increased formation of
degradative enzymes within the joint.
Rheumatoid factors (RF) are immunoglobulins that complex with IgG.
Approximately 70% of patients are RF +ve.
Synovium from
Morphology: joint destruction with little reparative activity. The synovium joint with RA
demonstrates chronic inflammation, hypertrophy and hyperplasia, frequently with
fibrinous exudates at the surface.
Clinical: has great clinical heterogeneity but does have characteristic symptoms.
General malaise, with pain and stiffness in the joints (most marked in the
morning).
Usually effects several joints in a symmetric pattern, especially those of the
hands and lower limb. These joints are hot, swollen and tender.
Complications of joint instability, including subluxation, dislocation and Rheumatoid
ankylosis. nodule from elbow
Extra-Articular RA Manifestations Spondylarphropathies (RA Variants)
There are numerous extra-articular manifestations of Group of conditions in which RF is usually –ve but involve
Rheumatoid Arthritis (Rheumatoid Disease). inflammation in the spine and peripheral joints.
Subcutaneous rheumatoid nodules occur in Anklyosing Spondylitis; low back pain and stiffness due
approximately one third of cases, usually on support to synovial inflammatory changes. Eventual fusion.
structures of the joint. Psoriatic Arthritis; psoriasis usually precedes the onset
Weakness/skeletal muscle atrophy is common. of arthritis but may follow or accompany it.
Limited forms of vasculitis can occur and manifest as Enteropathic Arthritis/Spondylitis; patients with chronic
cutaneous vasculitis, peripheral neuropathies, ischaemic colitis, can develop peripheral arthritis/spondylitis.
leg ulcers etc. Rarely serious. Reactive Arthritis; infection of GIT, followed weeks later
Pleuritis, pleural effusion most common in lung. by a sterile synovitis. Reiter’s syndrome is an example.
Ocular disease includes episcleritis and scleritis All these diseases exhibit: enthesopathy, synovitis,
Cardiac and neurological disease are uncommon may dactylitis, sacroileitis, spondylitis, extra-articular
occur as a result of vascular compromise. inflammation (eg. GIT), family history, antigen HLA - B27.
Metabolic/Crystal Arthropathies
Gout is characterised by episodic acute attacks of inflammatory arthritis, and chronic deposition of urate
crystals around affected joints. May occur sporadically or as a hereditary condition.
Morphology: crystals can be seen in microscopic examination of synovial fluid under polarised light.
It reveals an inflammatory exudate and the presence of negatively birefringent needle shaped
crystals in gout.
Crystal deposits form lobulated collections. These collections are ringed by characteristic
deposits of histiocytes and multinucleate giant cells.
Osteoporosis
Osteoporosis is any degree of skeletal fragility associated with an increased risk of fracture. The bone
has normal composition and structure but is of reduced skeletal mass. There is an inadequate amount of
mineralisation (proportional loss of matrix and mineral).
Pathology: generally an age related disorder where there is an imbalance between resorption and new
bone formation (continual process). This imbalance may become manifest at different ages and in
different sites of the skeleton. Various factors influence this incline towards resorption.
Peak bone mass achieved in skeleton and the rate of bone loss thereafter.
Calcium metabolism and hormone status, especially oestrogens, with the disease occurring
earlier and more rapid in menopausal women.
Physical activity which has been shown to increase bone mass.
Classification: is based on the cause osteoporosis, which can be primary Osteoporosis with crush
(involutional) or secondary. fracture and kyphosis
Clinical: asymptomatic in itself, but presents with complications, namely pain, microfractures and
deformity (eg. height loss). Fractures are a high risk, esp in hip, vertebrae and radius.
Diagnosis: serum is normal, X-ray can indicate density loss but is inaccurate. Densinometry to
show decreased bone density, histological bone thinning and fracture history are more accurate.
Prevention: maximise peak bone growth and avoid/modify risk factors, esp in menopausal.
Osteomalacia/Rickets
Osteomalacia and Rickets are characterized by defective mineralisation of the organic matrix. The lack of
mineralisation affects both the quality and quantity of bone formed. Deformities of weight-bearing
bones and pathological fractures may result.
Pathology: normal skeletal mineralisation depends upon the presence of sufficient calcium and
phosphate at the mineralisation sites, normal cellular function, and absence of inhibitory/deleterious
metabolic factors. Any factor which interferes with these requirements may be associated with the
development of these diseases.
Often vitamin D related; vit D deficiency, disturbance in metabolism (sunlight), increased
resistance (phosphate wasting, enzymatic deficiency, end organ insensitivity, renal acidosis).
Other dietary deficiencies; calcium, phosphate.
GIT disorders; gastric or hepatobiliary disease,
malabsorption syndromes etc.
Drug associated; phenytoin, aluminium, heavy metals etc.
Tumour associated; oncogenic ostemalacia.
Chronic renal failure, hepatic disease. ↑ Osteoid (non-mineralised bone), due to Ca deficiency.
Osteomalacia occurs in adults, resulting in osteopenia (reduced overall skeletal mass). May clinically be
asymptomatic or have various features underlying the disorder.
Soft bone (deformity), fragile (fractures), bone pain/tenderness (back, hips, generalised),
proximal muscle weakness (hypocalcaemia).
Multiple bilateral and symmetric lucencies may be seen on X-rays, altered calcium, phosphorus
and vit D in serum tests.
Rickets is when the growing skeleton is involved, including both bone and the cartilage matrix of the
growth plates. Results in inadequate endochondral ossification, and a variety of distinctive skeletal
abnormalities may develop.
Reduced bone length, prone to deformities/fractures, deranged bone growth and development,
weakness and hypotonia.
Microscopically, excessive osteoid, islands of cartilage, fibrosis and widened diameter.
Hyperparathyroidism
Hyperparathyroidism is a surplus of PTH released from chief cells of the parathyroid gland.
Pathology: excess PTH has various effects on bone, also resulting in hypercalcaemia.
Increased bone resorption (↑ osteoclastic activity) resulting in mobilisation of Ca2+/PO42-.
Cysts (macro or micro) or rarer brown tumours (large localised areas of resorption).
Marrow fibrosis, resulting in ‘osteitis fibrosa cystica’.
Classification: occurs in two major forms, primary and secondary.
Primary hyperparathyroidism uncontrolled production of parathyroid hormone from neoplastic or
hyperplastic parathyroid tissue. In most cases (>95%) is caused by sporadic parathyroid adenoma or
hyperplasia, rarely carcinoma or familial MEN syndromes.
Patients may be asymptomatic (biochemical abnormality
detected incidentally) NB: many other causes of
Present with signs and symptoms related to hypercalcaemia hypercalcaemia eg. vit D
intoxication, familial condition,
(abdominal cramps, constipation, muscle fatigue, peptic
sarcoidosis. Doesn’t have to be
ulceration, renal calculi, cardiac valve calcification etc.).
hyperparathyroidism.
Have bone related disease (only 10%).
Secondary hyperparathyroidism results from chronic parathyroid
Tertiary Hyperparathyroidism
stimulation by low serum calcium (occasionally associated with other
Represents autonomous and
disease processes). The clinical features are usually dominated by those
continuing PTH secretion in the
of chronic renal failure, vit D deficiency and malabsorption. In general,
absence of low serum calcium.
the osseous pathology is less severe than that seen in primary
hyperparathyroidism.
Morphology: remodelling is disordered and purposeless resulting in thickened bone with mosaic
patterns of cement lines.
Clinical: relatively common in late adult life with greatly variable presentation
depending upon site, extent of disease and presence of complications.
Signs: often asymptomatic or patients present with pain, increasing bone
size, deformity or fracture.
Diagnosis: raised alkaline phosphatase as a result of osteoblastic activity
or radiological changes (bone deformity, thickening, coarseness).
Complications: stress, fracture, high output heart failure, sarcoma. Paget’s disease in clavaria
Renal Osteodystrophy
Refers to a range of skeletal abnormalities seen in association with chronic renal disease and
haemodialysis. Associated with phosphate retention, hypocalcaemia, decreased vit D and sometimes a
metabolic acidosis. The clinical and pathological manifestations of renal osteodystrophy are variable.
Hypocalcaemia may trigger secondary hyperparathyroidism
Acidosis promotes osteoporosis/osteopenia.
Various manifestations eg. osteomalacia, osteosclerosis and OFC can occur in combination.
MUSCULOSKELETAL NEOPLASMS
Bone Neoplasms
Neoplasms and tumour-like conditions of the musculoskeletal system are a remarkably diverse group of
entities, which can be divided into the following groups.
1. Primary neoplasms, which can involve any cell normally present in the bone or soft tissue.
2. Secondary or metastatic bone neoplasms.
3. Primary neoplasms of haemopoietic marrow (myeloma, lymphoma, etc.).
4. Psuedoneoplastic lesions (pseudotumours) are processes which may mimic neoplasia.
Chondrosarcoma Malignant tumour of cartilage, 20% of bone tumours. Tumour osteoid is not directly
from sarcomatous stroma. Develop in any bone preformed in cartilage eg. pelvis,
femur, ribs, sternum, craniofacial. Most common in 30-60yrs.
Secondary Bone Neoplasms
Metastatic Metastasis to bone is the most common bone malignancy, and location for
Disease metastases with virtually every malignancy being able to invade bone.
Spread: metastatic deposits reach bone via vascular systems,
lymphatics are less likely. The most common sites of
involvement are bones of the axial skeleton though virtually
any bone can be affected. Most common sources include
breast, prostate, lungs, kidney, thyroid.
Morphology: metastasis may produce combinations of
osteoblastic and osteoclastic activity, and as such may be
lytic, blastic or mixed in appearance. Most are osteoclastic,
however prostatic and breast carcinomas become typically
blastic. Typically have destructive changes with moth eaten
appearances. Extension into soft tissue and periosteal
reaction can be present.
Clinical: presentation is with pain, swelling or tenderness.
Acute presentation may result from fracture, mass effect or
hypercalcaemia. Identification of the primary site of origin is
important, as it may influence therapeutic decisions.
Primary Marrow Neoplasms
Multiple Malignant plasma cell proliferation with osteolytic lesions. Is most common primary
Myeloma malignant neoplasm of bone. Most often located in vertebral bodies, ribs, pelvis and
skull. The neoplastic cells are characterized by production of a single homogenous
immunoglobulin product .
Morphology: spectrum of differentiation may be seen.
Clinical: can cause hypercalcaemia, anaemia, renal failure, amyloidosis.
Radiology reveals lytic, punched out, little areas of periosteal reaction and
destruction. Bone scans are typically negative.
Lymphomas, Discussed with the haematological system.
leukaemias.
Diagnosis: management decisions in rest upon tissue diagnosis from biopsy. Must obtain sufficient sample (for
accurate diagnosis and classification), but consider possible procedure complications. Without careful planning,
biopsies may lead to adverse effects (20%) on treatment and outcome as a result of misdiagnosis or procedural
complications.
The radiological assessment of neoplasms of bone also plays an invaluable role. Plain X-rays reflect growth
patterns outlined above, while more sophisticated imaging (CT, MRI, PET) enhances the diagnostic work-up.
Staging: musculoskeletal and soft tissue neoplasms use the Enneking system (not haematopoietic or metastatic
neoplasms).
Grade of biological aggressiveness: G0 (benign), G1 (low grade malignant), G2 (high grade malignant).
Site: T0 (confined by capsule), T1 (extracapsular, intracompartmental), T2 (extracompartmental)
Metastases: M0 (local), M1 (metastasised).
Soft Tissue Neoplasms
Soft tissues are those which are non- epithelial, reticuloendothelial, CNS and skeletal. They are of
mesodermal and neuroectodermal origin, including fibrous CT, smooth muscle, skeletal muscle, fat,
peripheral nerves and blood/lymphatic vessels.
Soft tissue tumours are complex and highly heterogenous. They may be classified as benign,
borderline, malignant or pseudoneoplastic (appear as tumours, but are not).
The vast majority of tumours have unknown patho-aetiology. Associated with radiation,
carcinogens, trauma and inherited/familial disorders.
Growth pattern is affected by its proliferative, matrix forming and destructive characteristics,
also influenced by response in surrounding tissues.
Generally non-specific symptoms. Depends on anatomical location, rate of growth, size attained
and secondary changes (eg. necrosis, haemorrhage). Local effects (pain, swelling) reflect mass
effect and impingement on surroundings.
Incidence of 3 per 1000, with most being benign (100:1). Could be many more as many benign
neoplasms are not biopsied.
Classified by pattern of soft tissue differentiation and cell origin type. This histogenesis is
disputed/uncertain in some tumours. Can present in any cell population of soft tissue.
Vascular Neoplasms Benign: haemangioma Rhabdomyosarcoma
Intermediate: haemangioendothelioma of forearm
Malignant: angiosarcoma
Adipose Tissue Benign: lipoma
Neoplasms Malignant: liposarcoma
Smooth Muscle Benign: leiomyoma
Tumours Malignant: leiomyosarcoma Fibrosarcoma
Skeletal Muscle Benign: rhabdomyoma of thigh
Tumours Malignant: rhabdomyosarcoma
Mesenchyme (CT) Benign: fibroma
Tumours Malignant: fibrosarcoma
Myxoid Liposarcoma commonest Synovial Sarcoma 5-10% of all soft tissue sarcomas,
liposarcoma subtype, is low grade. usually in young males.
Grow close to joints, tendons, bursae but rarely involve
Liposarcomas are often in thigh and synovial membrane.
retroperitoneum. Usually deep seated large Most around knee and ankle, presenting with enlarging
lesions with variable appearances (eg. mass and pain. Seldom systemic. Often long duration of
fatty, myxoid). Non specific presentation. symptoms (years) before developing metastases.
Proximal (Generalised) Acute: symmetric difficulty using large Eg. Guillain Barre (motor unit),
Myopathies muscles of the hip and shoulder. Myasthenia Gravis (NM junction)
Chronic: lifelong slowly progressing Eg. congenital myopathies,
disorders. muscular dystrophies
Distal Predominant Symmetrical distal weakness of Eg. Charcot-Marie Tooth
Myopathies hand/foot, no sensory involvement.
Channelopathies Episodic weakness, due to defective Cl, Eg. potassium imbalances (Na,
(Episodic Weakness) Na, Ca etc channels (↓ AP, contractility). Ca), congenital myotonias (Cl)
Exercise-Induced Rare painful weakness with cramping and Eg. metabolic myopathies of
Myopathies myoglobinuria. glycogen, lipid etc.
Muscular Dystrophy
A group of inherited muscle disorders resulting in weakness and dysfunction of the muscles. Two main
diseases are Duchenne’s and Becker’s, both lacking the major contractile protein dystrophin.
Duchenne Muscular Dystrophy is the more severe of the Clinical Signs of Duchenne’s
two disorders as there is an absence of dystrophin Kids have a very characteristic way of
completely. Has early onset, manifesting when child getting from lying to standing
starts walking and relentlessly progresses till death (Gower’s maneuver with lordosis).
(usually around 20yr). Waddling decompensation of gait as
Becker’s Muscular Dystrophy is a milder form since muscle function deteriorates.
dystrophin is made, but it is in altered quality and/or Large calves due to fatty
quantity. Has later onset, often in late childhood/early replacement (pseudohypertrophy).
adolescence, and slower, progression. more clinical Abnormal posture due to progressive
weakness → wheelchair bound.
variability and overlap makes it harder to prognosticate.
Genetics: X-linked mutations (mostly deletions in Ch Xp21) hence manifests mostly in males.
Females are usually just carriers, however they can express phenotype depending on how much
of the X-chromosome is inactivated.
Very large gene so there’s lots of room for abnormalities (hence the variation in Becker’s).
2/3 are familial, other 1/3 are sporadic new mutations.
Pathology: dystrophin is at periphery muscle cells and is responsible for transducing the contractile
force of intracellular sarcomere to extracellular CT matrix → shortens muscle causing contraction.
In dystrophin deficiency there is sarcolemma instability and the work of the
sarcomere is not manifest in muscle movement.
Membrane is then ‘ripped apart’ when contraction occurs and there is a
degeneration of muscle fibres (inflammatory response) → chronic
necrotizing myopathy.
Results in CK release (↑ serum CK), fibrous regeneration/repair and
hypertrophy of the remaining fibres.
Eventually there is a failure of regeneration and existing fibres atrophy →
Duchenne’s
replaced by connective tissue and fat.
NB: dystrophin isoforms may play a role in the CNS causing abnormalities and mild mental retardation.
Can also affect myocardium and this with respiratory failure is usually the cause of death.
Myositis
Inflammatory conditions of skeletal muscle. Below are three non-infectious causes.
Dermatomyositis is an acute inflammatory proximal myopathy that affects children and adults.
Characteristic muscle pain doing simple things; rising from chair, walking up stairs, brushing hair.
Pathology: B-cell mediated autoimmune disease resulting in complement mediated injury.
Strong association with cancer especially Ovarian.
Clinical: classic skin alterations; rash around eyes (helitrope discoloration) and knuckle pads.
Dystrophic calcification can be seen on x-ray. CHO-lowering drugs can cause a similar disease.
Treatment: RNA synthetase anti-Jo-1 is a common target.
Polymyositis is a sub-acute proximal myopathy that affects adults. Steadily progressing with difficulty
performing proximal muscular activities.
Pathology: T-cell mediated (CD8+) autoimmune disease. Chronic necrotizing myositosis
(elevated CK normal BVs). Inflamed endomysium → myofibril necrosis → phagocytosis.
Clinical: pure myopathy, no skin manifestations.
Treatment: RNA synthetase anti-Jo-1 is a common target.
Inclusion Body Myositis is a non-responsive, relentlessly progressive disease that affects older aldults.
Pathology: more sporadic than familial. Idiopathic histiocyte destruction of myofibrils. See
characteristic rimmed vacuoles in sarcolemma.
Clinical: begins with distal muscular involvement and asymmetric weakness, eventually fatal.
Treatment: RNA synthetase anti-Jo-1 is a common target.
NERVOUS SYSTEM
PATHOLOGY
MASS LESIONS OF THE CNS
Cerebral Oedema
Accumulation of excess fluid within the brain parenchyma (intra/extracellular but not ventricular).
Vasogenic oedema occurs when integrity of the blood-brain barrier is disrupted. Increased
vascular permeability allows fluid to shift into cellular spaces of the brain. May be localised
(adjacent to inflammation or tumour) or generalised.
Cytotoxic oedema is secondary to neuronal, glial or endothelial membrane injury. This can be
due to ischaemic or toxic insult.
Interstitial oedema occurs during obstructive hydrocephalus where increased pressure causes
rupture of CSF-brain barrier. This permits CSF to penetrate brain and spread into extracellular
spaces of white matter.
Hydrocephalus
Causes: accumulation of excessive CSF within the ventricular system. Result of some form of imbalance
between CSF formation (choroid plexus) and resorption (arachnoid granulations).
Most cases occur due to impaired flow or resorption of CSF.
Rare cases are due to increased production.
Communicating Hydrocephalus Non-Communicating Hydrocephalus
Results from impaired resorption of CSF or during Results from obstruction of CSF pathways within
obstruction of CSF pathways in subarachnoid ventricular system. Ventricular system behind
CH
space (not ventricular system). This is a general point of obstruction becomes dilated.
condition where all the ventricular system is
Can be caused by congenital malformations,
enlarged.
tumours, inflammation or haemorrhage.
Can be caused by inflammation (meningitis),
Commonly in intraventricular foramen (Monro)
subarachnoid haemorrhage or tumour (meningeal
NCH and cerebral aqueduct (Sylvius).
carcinomatosis).
Clinical Manifestations: dilation of ventricular system, interstitial oedema and reduction in white matter
volume is common to all forms.
Adults experience raised ICP with associated headache, vomiting, papilloedema and raised SBP.
Infants experience enlargement of head as cranial sutures are not yet fused.
Cerebral Herniation
Cerebral herniation occurs when ICP causes displacement of soft tissue of the brain through available
openings. An increase in volume in intracranial contents (eg. pathological mass, oedema) results in
increased ICP due to the limited capacity of blood, cerebral tissue and CSF to compress.
Subfalcine herniation displacement of cingulate gyrus under the edge of the
falx. This can compress on branches of anterior cerebral artery.
Transtentorial herniation occurs when uncal notch on medial temporal lobe
displaces under the tentorium. This can compress the posterior cerebral
artery, CN III (fixed dilated pupil), midbrain and aqueduct (Sylvius).
Tonsillar herniation is displacement of cerebellar tonsils through foramen
magnum. Life threatening due to compression of vital centres in the medulla.
Transcalvarial herniation is external as it is due to a skull defect (surgical or
traumatic).
CEREBROVASCULAR DISEASE
Cerebrovascular disease is the third leading cause of death (after CVD and cancer). The term denotes
any abnormality of the brain caused by pathological process of the blood vessels. The three basic
processes are thrombosis, embolism and haemorrhage.
Hypoxic-Ischaemic Encephalopathy
Brain requires constant supply of oxygen and glucose (15% of CO, 20% of O2 consumption). It is hence
susceptible to hypoxic damage when blood/oxygen supply is disrupted.
Causes: CNS changes that result from alterations in normal perfusion (cerebral perfusion pressure =
systemic BP – ICP).
Global cerebral ischaemia occurs when there is generalised reduction of cerebral perfusion
resulting in widespread ischaemic/hypoxic injury.
o Hypoxaemic hypoxia; reduction in Po2 of blood eg. severe anaemia, CO poisoning, near
drowning, respiratory arrest, status epilepticus.
o Stagnant hypoxia; global reduction in blood flow eg. cardiac arrest, profound
hypotension, raised ICP, respirator brain (brain dead person kept on ventilation).
o Histotoxic hypoxia; cyanide/sulphide exposure, inhibiting mitochondrial enzymes.
Local cerebral ischaemia occurs when arterial occlusion leads to localised damage in the
distribution of the compromised vessel. Arterial thrombus or emboli most common.
Hypertensive Haemorrhage
Massive and small types have a predilection for certain locations (eg. 50%
in posterior putamen, 10% in thalamus).
Slit haemorrhages occur in small penetrating vessels, leaving a slitlike
cavity. Not common but may cause epilepsy.
Hypertensive Haemorrhage
Petechial haemorrhage occurs in acute hypertensive encephalopathy with
severe neuro symptoms.
Presentation: depends on site and volume, often progressing over hours or days.
Subarachnoid haemorrhage is most frequently
Common due toheadache,
symptoms; rupture vomiting,
of a berryhemiparesis,
aneurysm. hemisensory
Blood seepsloss,
intocoma.
the
subarachnoid space between the pia and arachnoid mater. 15-20% go unnoticed. Other causes include:
Rupture of other aneurysms (eg. fusiform, giant, infective).
Vascular malformation (eg. arteriovenous malformation, cerebral amyloid angiopathy), however
these are more likely to cause parenchymal haemorrhage.
Systemic factors (eg. bleeding diathesis)
Berry Aneurysm
Stroke
Stroke is a term for a disease with acute onset of a neurological deficit as the result of vascular lesion
(either loss of blood supply or haemorrhage). It is the clinical designation that applies to all the above
conditions.
Clinical: major cause of hospital admission and death (10% of all mortality). Of those that survive 50%
are severely disabled, 10% return to normal activity. Suddenness of onset indicates vascular cause:
Embolic: very sudden, maximal deficit immediate.
Thrombotic: similar but stepwise progression.
Haemorrhagic: usually progresses steadily over minutes or hours.
CNS TRAUMA
Traumatic Parenchymal Injuries
Contusions are caused by a blunt impact to the head causing rapid tissue
displacement and disruption of vascular channels.
Brain collides with skull at site of initial impact (coup injury) and on
opposite side (countercoup).
Injury caused by subsequent haemorrhage, tissue injury and
oedema (ie. bruising).
Concussion is reversible altered consciousness following head
trauma without contusion. Contusion with Haematoma
Epidural haematoma (extradural) is blood collecting between the ‘periostial layer of dura
mater’ and the ‘calvaria of the skull’.
Presentation: usually due to torn middle meningeal artery, often with cranial
fracture. Only 1% of all hospital admissions, mostly male.
Clinical: brief concussion followed by drowsiness and possible coma.
Treatment: if excessive compression of brain occurs, craniotomy may be required.
Outcome: 20-55% die usually due to herniation. Reduced to 10% with optimal
treatment.
Epidural Haematoma
Subdural haematoma (dural border) is extravasated blood that splits open and collects between the
‘meningeal layer of dura mater’ and ‘arachnoid mater’ (in potential space).
Presentation: usually due to rupture of bridging veins, often after a fall or assault. Causes 21% of
severe brain injuries. Elderly patients may have chronic form usually due to drugs (not trauma).
Clinical: generalised headache or confusion, as most haematomas develop within 48hrs.
Treatment: observation and craniotomy if required. Brain swelling may be uncontrollable.
Outcome: 50-90% die, depends on age, GCS, surgery time (within 4hrs).
TUMOURS OF THE CNS
Overview
Classification: is based on type of differentiated cell within the tumour (eg. astrocytic, meninges).
Primary neoplasms: can originate from any cell present in the CNS. Other primary neoplasms are
undifferentiated or are embryonic in character.
Secondary neoplasms: are metastatic neoplasms from other site of body.
Pseudoneoplastic lesions: are psuedotumours and other processes (eg. cysts, haematomas,
malformations) that may clinically and raiologically mimic neoplasia.
Causes: majority of cases have sporadic unknown cause. Contributing factors include age, sex, radiation,
immunodeficiency and genetic syndromes (eg. von Hippel Lindau).
Clinical Effects: depend on location, rate of growth, size and secondary changes.
Localised: loss of function, neuro deficits, inappropriate excitation, seizures.
Generalised: raised ICP and associated problems.
Astrocytomas (80-90%) is a group of tumours, each with different behaviour, histology and distribution.
Fibrillary (diffuse) astrocytomas are the most frequent adult brain tumour, esp 40-60yrs.
o Have broad clinical behaviour and inherent tendency to anaplastic change.
o Classified into three groups based on degree of differentiation; low grade diffuse
astrocytoma, anaplastic astrocytoma and glioblastoma.
Low Grade Diffuse Astrocytomas Glioblastomas
Well differentiated tumour with initial The least differentiated form which may evolve from
slowly progressing symptoms. Eventually astrocytoma (via anaplastic degeneration) or be present
anaplastic degeneration occurs leading to from start. Rapidly fatal.
clinical deterioration.
Macroscopic: white matter of hemispheres is variegated
Macroscopic: ill defined infiltrative tumour. (colourful), haemorrhage, necrosis, thrombosed vessels.
It is solid, firm and tough (± cystic). Circumscribed expansion of cerebral tissue.
Microscopic: variable cell morphology, Microscopic: anaplastic astrocytes, endothelial
usually fibrillary and increased nuclei. proliferation, mitotic activity.
Pilocytic astrocytomas are relatively benign tumours, often cystic. Typically occur in younger
population and located in cerebellum.
Other special astrocytomas include sub-ependymal and pleomorphic forms.
Oligodendrogliomas (10-15%) are most common in cerebral hemispheres, esp 40-60yrs. Patients may
have several years of neurological complaints (often including seizures), however has better prognosis
than astrocytomas.
Ependymomas (2-6%) are most common in the ependyma-lined ventricular system, esp <20yrs. Most
are infratentorial, children in the fourth ventricle, adults in the spinal cord.
Other Tumours
Neuronal tumours include cells resembling the neuron parenchyma.
Central neurocytoma are low grade neoplasms found within the ventricular system.
Gangliogliomas have a mixture of glial elements and mature appearing neurons.
Neuroepithelial tumours are a low grade and usually in childhood.
Meningiomas are predominantly benign tumours of adults (esp female 60yrs). Usually
attached to the dura and project into sudural space (arise from arachnoid cells).
Compresses parenchyma but usually not invasive (may invade bone, sinuses
or dura).
Slow growing, symptoms usually due to compression of underlying brain.
Meningioma
Shwannomas are benign tumours arising from Schwann cells with symptoms referable
to compression of involved nerve or adjacent structures (often acoustic loss, CN VIII).
Encapsulated and attached to, but does not replace, nerve. Firm, solid and
sometimes cystic.
Two patterns of growth; Antoni type A (spindle bipolar cells) and type B
(microcystic). Schawnnoma- bilateral CNVIII
CNS Lymphomas are most common in the immunocompromised, esp AIDS and EBV.
Primary lesions are uncommon except in Hodgkins. Majority are B-cell high
grade lymphomas.
Secondary involvement is a late complication of meningeal, nerve root or
epidural lymphoma.
Metastatic Melanoma
Pituitary neoplasms account for 10-15% of intracranial neoplasms (see endocrine notes).
Symptoms from mass effects or secretory abnormalities.
Metastatic tumours are secondary tumours that comprise of 20-25% of adult CNS tumours.
Metastases form sharply demarcated, multifocal masses usually at white/grey border.
Most common primary sites are; lung, breast, skin, kidneys, GIT.
INFECTIONS OF THE NERVOUS SYSTEM
Overview
Acute infections of the CNS require early recognition and prompt appropriate therapy. Can be classified
by site, pathogen, route of infection or clinical course.
Site: can affect brain all its coverings including leptomeninges (meningitis), parenchyma
(encephalitis, cerebritis/abscess), spinal cord (myelitis) and nerve roots (radiculitis).
Pathogens: bacteria (mostly suppuratives, sometimes granulomatous), viruses, fungi or
parasites/protozoa. Considered as pathogenic or opportunistic.
Route: haematogenous (commonest), direct implantation (traumatic/iatrogenic), local extension
of infection (sinuses, mastoid) or peripheral nerve conduit (eg. rabies).
Clinical: may all present with non-specific fever and headache until altered consciousness, focal
neurological signs and/or seizures develop.
Infections of Leptomeninges
Acute Pyogenic Meningitis is inflammation of the leptomeninges and CSF mostly due to bacteria.
Bacteria have poor access to CSF, but once gained proliferate rapidly in this excellent culture medium.
Common Pathogens: E. coli and S. agalactiae in neonates. H. influenza, S. pneumonia, N.
meningitidis in children and young adults.
Clinical Signs: febrile illness with evidence of headache, photophobia,
irritability, neck stiffness or altered consciousness.
Diagnosis: lumbar puncture reveals cloudy/purulent CSF, increased
pressure, raised protein, decreased glucose and raised neutrophils.
Culture positive for bacteria.
Complications: organisation of exudate by fibrosis can cause
hydrocephalus, spinal arachnoiditis or spinal cord infarction. Cranial
Acute Meningitis
nerve palsies and meningoencephalitis may also occur.
(with abscesses)
Aseptic Meningitis is clinical term for meningitis without recognisable organism. In most cases viral
pathogen is eventually found.
Common Pathogens: echovirus and coxsackie A/B (enteroviruses), HSV2
Clinical Signs: similar but less fulminant than pyogenic meningitis, usually self limiting.
Diagnosis: CSF reveals lymphocytosis, moderate protein elevation and normal glucose.
Chronic Meningitis is caused by mycobacteria and spirochetes, often with parenchymal components.
Tuberculous meningitis causes increased cellularity and protein in the CSF. May result in well
circumscribed parenchymal mass (tuberculoma) or spinal TB (Potts Disease).
Neurosyphilis is a tertiary stage of syphilis with major meningeal manifestation. Paretic
(progressive mental/physical function loss) and tabes dorsalis (dorsal root damage) forms.
Neuroborreliosis is nervous system involvement by B. burgdorferi.
Infections of Parenchymal
Brain Abscesses are focal suppuratives infections nearly always caused by bacteria.
Known as cerebritis if no abscess forms. Fungi and parasites are rarer causes.
Causes: direct implantation of organisms, local extension from adjacent foci
(mastoiditis or sinusitis), or haematogenous spread (primary site from heart,
lungs, bones etc.).
Pyogenic Abscesses
Morphology: discrete, non invasive, destructive parenchymal lesions.
o Macroscopic: central liquefactive necrosis surrounded by fibrous capsule.
o Microscopic: vascularisation, granulation tissue. Reactive gliosis outside fibrous capsule.
Clinical Signs: fever ± signs related to focal deficits and raised ICP.
Complications: rupture can cause ventriculitis, meningitis, venous sinus thrombosis.
Classification: old methods had overlap between the diverse range of ND diseases. Modern methods are
according to familial vs sporadic aetiology:
Familial ND result from genetic mutations and tend to have an early onset.
Sporadic ND is largely due to environmental factors and tends to have a late onset.
Many ND have both a common sporadic form and uncommon familial form.
NB: can also have pathological classification (subcortical or cortical), as is done below.
Pathology: it is thought that neuroinflammation and altered protein Dementia vs Neurodegeneration (ND)
dynamics play a large role in the disease processes. This may include
abnormal protein breakdown, folding or aggregation. These abnormalities ND is a disease process, dementia is a
can render proteins soluble (neurotoxic) or insoluble (filaments/deposits). clinical sign.
This leads to cellular dysfunction and neuronal death. Not all ND results in dementia eg.
motor ND may only result in
somatic deficit.
Clinical: dementia is the development of memory impairment and other
Not all dementias are due to ND
cognitive deficits during normal consciousness. It is a clinical sign that is
eg. some dementias are caused by
present in many ND diseases and is not a normal part of aging.
vascular disease.
Subcortical Degenerations
Motor Neuron Disease involves neurodegeneration of upper motor neurons (Betz cells) in the motor
cortex and/or lower motor neurons in the spinal cord, both resulting in weakness.
Clinical: depends on location, sensory systems and cognitive functions are usually unaffected, but
types with dementia do occur. Death within 5 years due to respiratory failure or aspiration.
UMN loss also results in hyperreflexia, hypertonicity, paresis and +ve Babinski sign.
LMN loss also results in hyporeflexia, hypotonicity, muscle wasting and fasciculations.
Pathology: most cases are sporadic. Specific forms of degeneration have familial cause eg. 10% of
amyotrophic lateral sclerosis (ALS) are due to a SOD-1 gene mutation.
Morphology: loss of associated motor neurons with shrunken ventral nerve roots. Inclusion bodies in
surviving motor neurons (bunina bodies). Neuronal swelling.
Parkinsonism results from degeneration of dopaminergic neurons of the substantia nigra. Is distinct
from other such conditions by the presence of Lewy bodies. Parkinsonism – substantia
Clinical: classic symptoms of cogwheel rigidity, bradykinesia, resting tremor and nigra pallor.
postural instability. Dementia occurs 40% of the time. Most common ND
movement disorder.
Pathology: most cases are idiopathic and sporadic. Some autosomal forms exist.
Morphology: diagnostic feature is presence of Lewy bodies, an inclusion of α-
synuclein in surviving neurons. Grossly, there is pallor of the substantia nigra.
Progressive Supranuclear Palsy (PSP) is characterised clinically by axial rigidity (akinesia), supranuclear
gaze palsy and mild dementia.
Clinical: death within 6-7yrs due to aspiration pneumonia.
Pathology: unknown, there is accumulation of tau (protein that stabilises microtubule) within
neurons and glial cells.
Morpholgy: atrophy of midbrain and pallor of substantia nigra. Microscopically there is; inclusions of
tau aggregate, neuronal loss and gliosis.
Cortical Degenerations
Alzheimer’s Disease is the commonest cause of dementia (50-75%) characterised by memory and higher
intellectual impairment.
Clinical: progressive dementia with eventual end stage cachexia, death by bronchopneumonia. 4% in
>75yrs, 40% for >90.
Pathology: neurodegeneration of cortical/subcortical neurons due to the build up of various proteins.
Amyloid precursor protein (APP) is a transmembrane glycoprotein which when abnormally
cleaved forms Aβ amyloid. This aggregates extracellularly and forms plaques.
Small Aβ aggregates can alter neurotransmission and can be toxic. Large aggregates lead to
neuronal death and elicit an inflammatory response.
Alzheimer’s – cortical atrophy
Surviving neurons develop filaments of hyperphosphorylated
tau inclusions. These neurofibrillary tangles (NFT’s) can
cause neuritic plaques.
Morphology: macroscopically shows variable cortical atrophy and
widening of cerebral sulci. Diagnosed by the microscopic presence of
extracellular amyloid plaques and intracellular NFT’s.
Lewy Bodies Dementias are the second most common type of dementias (10-25%). Hallmark of cortical
lewy bodies in deep grey matter.
Clinical: fluctuating cognitive decline can cause recurrent visual hallucinations and spontaneous
motor features of Parkinsonism. These often coexist with Alzheimer’s features.
Pathology: most cases idiopathic and sporadic.
Morphology: mild-moderate fronto-temporal atrophy, pallor of substantia nigra and locus coeruleus.
Morphology: characteristic central vessel surrounded by a zone of demyelination at the periphery. This
zone is filled with lymphocytes and macrophages (microglia).
Plaques vary in size and shape and can occur anywhere in the white matter, often at angles of
ventricles, white-grey junction and surface of brain stem/spinal cord (forms grey depressions).
Active early plaques are pink (inflamed), inactive old plaques are grey (sclerosed).
Clinical: signs are highly protean (variable) and depend on site and extent of plaques.
Cerebellar/brainstem: wide based gait, autonomic dysfunction (eg. BP).
Spinal cord: weakness, sensory loss, bowel and bladder dysfunction.
Optic nerve: sudden unilateral blindness which is self limiting lasting 2-3 wks.
NB: ephaptic neurotransmission causes neuralgia and muscle spasms.
Diagnosis: can be asymptomatic so need to use investigations. Best test is MRI as it reveals ‘silent’
plaques. CSF sample (electrophoresis) and evoked response tests (visual/auditory/somatosensory) can
be used to support diagnosis.
Multiple Sclerosis
CNS disease with intermittent and seemingly random neurological symptoms, can occur at any age.
Manifests as well demarcated area of demyelination which
causes multifocal white matter plaques. There is axonal
preservation, except late in disease.
White matter is more affected than grey matter as it has a
predominance of myelinated axons.
In cases of severe demyelination lasting years, cavities form
when axons break down which can mimc infarcts. Demyelination due to MS
Abnormal Tcell response to several myelin proteins, thought to be precipitated by viral
infection. Other associations with bacteria, defective gliosis, diet, genetic, toxins.
Charcot (Classic) Type has three Acute Fulminant Type is a rare clinical presentation and
clinical patterns; tends to happen as a one off severe episode.
Relapsing-remitting with attacks Acute (Marburg Type) occurs in younger people, has
once every 2 years (commonest). a rapid course, large plaques Involves destruction of
Primary progressive with later myelin and some neuronal loss.
onset and spinal cord Neuromyelitis Optica (Devic’s Disease) occurs
involvement. especially in Asian populations.
Secondary progressive. Concentric Sclerosis (Balo’s Disease)
Trigeminal Neuralgia
Involves intense lanciating pain localized to small areas of the face, lasting secs (Tic doloreaux).
Due to localized demyelination of sensory fibres in the proximal CNS that arepart of trigeminal
root. Most commonly caused by compression of overlying artery or vein.
Results in attempts at remyelination and abnormal groupings → ephaptic neurotransmission
with unexpected pain from normal touch sensation.
APPENDIX
LABRATORY/CHEMICAL PATHOLOGY
Lab