200 KEY POINTS IN SPECIAL PATHOLOGY 4

YEAR MBBS

TH

BY
DR EJAZ WARIS, ASSOCIATE PROFESSOR
HISTOPATHOLOGY AMDC
1.Key processes in atherosclerosis are intimal thickening and
lipid accumulation.
2.Atherosclerotic plaque consists of 3 components: a)cells
,including SMCs,macrophages,and leukocytes,b)ECM and
c)Intracellular and extracellular lipid.These components are
arranged in central core and fibrous cap.
3.The two most important causes of aortic aneurysms are
atherosclerosis and cystic medial degeneration of the arterial
media.
4.ANCA are antineutrophil cytoplasmic antibodies seen in
patients with vasculitis.c-ANCA are seen in Wegeners
granulomatosis and p-ANCA seen in Microscopic polyangiitis and
Churg-Straus syndrome.
5.Vasculitis are divided into three types : large vessel including
giant cell and takayasus ( granulomas),medium vessel
including PAN(fibrinioid necrosis ) and Kawasakis disease and
small vessels including Wegeners,ChurgStrauss syndrome and
Microscopic polyarteritis.
6.Lobular capillary hemangioma ( Pyogenic granuloma ) is a
common oral benign tumor occurring as polypoidal form
attached to mucosa.
7.Vascular immunomarkers include: CD31,CD34 and vWF.
8.Kaposis sarcoma is the most common AIDS associated cancer
in US.The lesion is caused by KSHV and shows three
morphological stages : Pact,Plaque and nodule.(PPN).
9.In Myocardial infarction,coagulation necrosis starts in 4 to 12
hrs and collagen deposition starts in 10 to 14 days.

10.Myxoma is the most common primart tumor of heart in

adults and Rhabdomyoma is most commonest in children.
11.Aschoff bodies ,pathognominic of Rheumatic fever,are foci of
swollen eosinophilic collagen surrounded by lymphocytes
,occasional plasma cells and plump macrophages called
Anitschkow cells.
12.The thalassemia syndromes are a heterogenous group of
inherited disorders caused by genetic lesions leading to
decreased synthesis of either the alpha or beta globin chain of
HbA.
13.Causes of enlarged lymph node include : Reactive lymph
node enlargement,Infections commonest is Tuberculosis and
Malignancies which may be primary ( Lymphoma ) or
metastatic.
14.Papillary carcinoma is the commonest thyroid
malignancy,linked with history of childhood radiation.Diagnosis
rests on nuclear features ,the nuclei typically are optically clear
( empty)-Orphan Annie appearance,show intranuclear
inclusions and intranuclear grooves.
15.Scharff Bloom Richardson system grades the Breast
carcinoma.It includes : a ) tubule formation ,
b ) no of mitoses and c)atypia and pleomorphism.
16.Medullary Carcinoma is linked with amyloid deposition.
17.Meningiomas are divided into 3 categories:a) simple benign
type ( WHO grade 1),b)atypical show 4 to 19 mitoses / 10HPF
or show 3 of following 5 features:
hypercellularity,macronucleoli,necrosis,patternless sheet like
arrangement and small cell components with high N/C ratio.,c)
Malignant type more than 20 mitoses per 10 HPF or loss of
differentiating features.
18.Syncitial,transitional,fibroblastic,psamommatous and
secretory types fall into type 1,Clear cell and chordoid types of
meningiomas fall into atypical variety and Papillary and
Rhabdoid types fall into malignant variety.
19.Dukes stage C refers to involvement of lymph nodes in
carcinoma of the large bowel.

20.Rosenthal fibers,eosinophilic granular bodies and microcysts

are seen in low grade Pilocytic astrocytoma.
21.WHO grading of Astrocytoma include : Grade I: low grade ,
Grade II: Diffuse fibrillary,Grade III: Anaplastic ( mitoses and
endothelial proliferation) and Grade IV : Glioblastoma
Multiforme ( necrosis).
22.Leiomyomas are differentiated from leiomyosarcoma on
three basis ; atypia , necrosis and number of mitoses ( <
5/10HPF: Leiomyoma,5-9/10HPF : Borderiine STUM P and >
10/10HPF: Leiomyosarcoma).
23.Synovial Sarcoma shows dual line of differentiation ( both
epithelial like and spindly mesenchymal cells are seen ).
24.Reed Sternberg cell is the hall mark of Hodgkins
Lymphoma .Immunomarker is CD 15 and CD 30.The thought of
origin is post germinal center B-Cell.
25.Giant cell tumor of bone consists of Mononuclear stromal
cells ( the main neoplastic element ) and evenly placed
multinucleated giant cells.
26.Tophi are pathognomonic hallmark of gout,consisting of large
aggregates of urate crystals surrounded by an intense
inflammatory reaction of macrophages,lymphocytesand large
foreign body giant cells.
27.Indian file pattern of tumor cells with monomorphic
morphology is seen in Infiltrating lobular carcinoma of breast.
28.Rheumatoid nodules consist of central zone of fibrinioid
necrosis surrounded by a prominent rim of epithelioid
histiocytes and numerous lymphocytes and plasma cells.
29.Ewing Sarcoma (PNET) of bone consists of malignant round
to oval tumor cells with cytoplasm containing
glycogen.Immunomarker is CD99(MIC-2)
30.Osteosarcoma is confirmed by the presence of malignant
lace like osteoid surrounded by tumor cells.
31.The histologic hall mark of Pagets disease of bone is mosaic
pattern of lamellar bone.

32.Peripheral palisading is seen in nests of tumor cells in Basal

cell carcinoma ( Rodent ulcer).It is locally aggressive
tumor,which rarely metastasize.Immunomarker is BER-EP4.
33.Lupus nephritis is of 6 classes : Class 1: no change , class II:
34.Malignant Melanoma shows two patterns of growth : radial
and vertical.The nature and extent of the vertical growth phase
determine the biologic behavious of malignant melanoma.
35.Follicular carcinoma of thyroid is confirmed by capsular and
vascular invasion by tumor cells.
36.Laurens classification of gastric carcinoma include diffuse
(signet ring cells) and intestinal types.
37.Adenoma is the commonest tumor Pituitary gland.
38.Fibroadenoma is commonest benign tumor of breast in
young females.
39.Invasive ductal carcinoma of breast is the commonest
malignant tumor of breast.
40.Carcinoid tumors common sites include small intestine and
tip of appendix.The cells are monomorphic with abundant
granular cytoplasm.Immunomarkers include Chromogranin and
synaptophysins.
41.Chronic cholecystitis is the inflammation of gall bladder
revealing subepithelial fibrosis and chronic inflammation in the
lamina propria.
42.Hydatidiform mole is characterized by cystically dilated
avascular chorionic villi with trophoblastic proliferation.
43.Choriocarcinoma shows no chorionic villi.
44.Panacinar emphysema is linked with alpha 1 antitrypsin
deficiency.
45.Reid index is the ratio of thickness of the mucous gland layer
to the thickness of the wall between the epithelium and
cartilage.It is increased in Chronic bronchitis.
46.Bronchiectasis is a disease characterized by permanent
dilation of bronchi and bronchioles caused by destruction of the

muscle and elastic tissue resulting from or associated with

chronic necrotizing infections.
47.Asbestos is linked with Mesothelioma and Bronchogenic
Carcinoma.
48.Baretts esophagus is linked with esophageal
adenocarcinoma,characterized by goblet cells and villous
morphology.
49.Pleomorphic adenoma is the commonest benign tumor of
salivary gland.
50.Seminoma is the commonest malignant tumor of testis in
adults.It is the most radiosensitive.
51.Helicobacter pylori is linked with chronic gastritis,peptic ulcer
disease,gastric carcinoma and gastric MALT lymphoma.
52.Active inflammation is signified by the presence of
neutrophils within the glandular and surface epithelial layer.
53.Ulcerative colitis is characterized by pseudololyps,superficial
ulcers,cryptitis,crypt destruction,crypt distortion and crypt
abscess formation.
54.Crohns disease is characterized by strictures,transmural
inflammation,deep linear ulcers,sinuses and granulomas.
55.Cirrhosis of liver is characterized by nodules of variable sizes
composed of benign hepatocytes and separated by thin fibrous
tissue septae infiltrated by chronic inflammatory cell
infiltrate.Active cirrhosis means the presence of piecemeal
necrosis.
56.Knodell Score is done to evaluate the grade and stage of
hepatitis activity.it comprises of : portal inflammation,piecemeal
necrosis,intralobular inflammation and fibrosis.Total score is 24.
57.Metavir score is another criteria of grading and staging of
liver activity.It comprises of A for activity and F for fibrosis.
58.Gleason Score is done for the grading of Prostatic
adenocarcinomas.
59.Perineural invasion is depicted by prostatic and pancreatic
adenocarcinomas.

60.Furrhman Grading is done for Renal cell carcinoma.

61.All patterns of Hepatocellular carcinomas have a strong
propensity for invasion of vascular channels.
62.Crescents are seen in rapidly progressive
glomerulonephritis,diffuse thickening of the glomerular capillary
wall with silver spikes are seen in membranous
glomerulonephritis and focal thickening of glomerular basement
membrane with silver tram track appearance is seen in
membranoproliferative glomerulonephritis.
63.Diabetic glomerulosclerosis is characterized by capillary
basement membrane thickening,diffuse mesangial sclerosis
,kimmelstiel-wilson nodules (PAS positive),capsular drops and
fibrin caps
64.Chronic pyelonephritis is characterized on gross examination
by a corticomedullary scar and on microscopy by tubular
atrophy and dilation,thyroidization and chronic interstitial
inflammation.
65.Acute pyelonephritis is characterized by patchy interstitial
suppurative inflammation,intratubular aggregates of
neurtophils and tubular necrosis.Three complications include
three Ps: Papillary necrosis,pyonephrosis and perinephric
abscess.
66.Multiple Myeloma is characterized by bence jones
proteinuria,cast nephropathy,hypercalcemia,hyperuricemia and
light chain deposition disease.
67.Hyaline arteriosclerosis is benign hypertensive vascular
change showing thickening and hyalinization of the walls with
narrowed lumina of small vessels.Hyperplastic arteriosclerosis is
malignant vascular hypertensive change showing fibrosis with
onion skin type layering of wall.
68.Renal cell carcinoma is of 4 major types: clear cell the most
common type,papillary ,chromophobe and bellini duct
carcinoma.
69.Renal cell carcinoma has the tendency to metastasize widely
before giving rise to any local symptoms or signs.

70.WHO grades Transitional cell tumors into Urothelial

papilloma,urothelial neoplasm of low malignant potential,low
grade papillary urothelial carcinoma and high grade papillary
urothelial carcinoma.
71.PT1 is for lamina propria and PT2 is for muscle wall invasion
in Transitional cell tumors.
72.Seminomatous germ cell tumors are radiosensitive and
chemo responsive while non seminomatous tumors are vice
versa.
73.Yolk sac tumor shows Schiller Duval bodies,Granulosa cell
tumor shows Call exner bodies.
74.Immature or malignant teratomas show sheets of
undifferentiated cells,not seen in a benign teratoma.Teratomas
in males are malignant,unless proved otherwise.
75.Alpha fetoprotein is the tumor marker of HCC and CEA is the
tumor marker of carcinoma of the colon.
76.Human Papilloma Virus is the etiologic agent of Squamous
cell carcinoma of the cervix ,the most common cervical
carcinoma.( types 16,18,31,33).
77.Bethesda system divided into ASCUS- atypical suamous cells
of undetermined significance,LSIL-low grade squamous
intraepithelial lesion( Koilocytosis and mild dysplasia) and HSIL
High grade squamous intraepithelial lesion ( Moderate and
severe).
78.Dysgerminoma is the counterpart of seminoma in females.
79.Tubular carcinoma of breast carries the best prognosis.
80.ER PR postivie breast carcinomas carry better prognosis
and are responsive to antiestrogen drugs.HER-2/neu positive
tumors carry poor prognosis.
81.Squmaous cell carcinoma is characterized by sheets and
groups of pleomorphic malignant squamous epithelial cells with
hyperchromatic nuclei and pale cytoplasm.Individual cell
keratinization.intracellular bridges and keratin epithelial pearls
are seen.

82.Cytokeratin is the immunomarker for epithelial tumors and

Vimentin is the marker for mesenchymal tumors.Desmin is
positive in skeletal muscle tumors.Melan-A and HMB45 is
positive for Melanomas.LCA is the universal leukocyte marker.
83.CD19,CD20 AND CD79a is positive in B-cells and CD 2,3,4,5
in T cells.
84.Adenocarcinomas are characterized by back to back
glandular structures lined by pleomorphic malignant epithelial
cells with hyperchromatic nuclei and eosinophilic
cytoplasm.Glandular wall sharing is one of the hall mark sign of
adenocarcinomas.
85.Acute appendicitis is depicted by the presence of neutrophils
in the muscularis layer.
86.Small cell carcinoma of the lung shows maximum
paraneoplastic syndromes most common cushing like picture
and ADH like morphology.Hypercalcemia is shown by squamous
cell carcinoma of lung.
87.Hodgkins Lymphoma is divided into five types : one set
include Lymphocyte rich,lymphocyte depletion,nodular sclerosis
and mixed cellularity ( CD 15 +,CD 30 +).The separate set
includes nodular lymphocyte predominance ( CD45 +).
88.Burkitts lymphoma carries 100% mitotic index.
89.Benign prostatic hyperplasia includes two components :
Glandular and fibromuscular.DHT is the source of hyperplasia.
90.Endometriosis is the presence of normal endometrial
glands,stroma and hemosiderin laden macrophages outside
uterus.
91.Calretenin is the immunomarker for
mesothelioma.Epithelioid and sarcomatoid types are noted in a
mesothelioma.
92.Squamous cell carcinoma of lung is strongly associated with
smoking.
93.PTEN is the antioncogene altered in endometrial hyperplasia
and adenocarcinoma.Simple and atypical are two types of
endometrial hyperplasia.EIN is the new term assoiated with
endometrial hyperplasia.Endometrial carcinoma arises on two

backgrounds: hormone dependent with good prognosis and vice

versa with poor prognosis(clear and papillary types).
94.The primary feature of primary biliary cirrhosis is the non
suppurative inflammatory destruction of medium sized
intrahepatic bile ducts.90% patients are positive for
antimitochondrial antibodies.
95.Hashimotos thyroiditis shows lymphoid follicles with
germinal centers and hurthle cells.DeQuervains type shows
presence of granulomas.
96.Pheochromocytoma is composed of polygonal to spindle
shaped chromaffin cells clustered with the sustentecular cells
into small nests of alveoli ( Zell ballen appearance) by a rich
vascular network.

97.MEN TYPE 1 or Wermer syndrome shows abnormalities in 3

Ps : Parathyroid,pancreas and pituitary.MEN -2A or Sipple
syndrome shows pheochromocytoma,medullary carcinoma
thyroid and parathyroid hyperplasia.MEN2-B is same as 2A,with
the exception of parathyroid involvement.
98.Round blue cell tumors of childhood include tumors with blue
cell morphology with scanty cytoplasm,e.g
Lymphoma,Neuroblastoma,Medulloblastoma and
Retinoblastoma etc.
99.Chicken wire calcification is seen in chondroblastoma.
100.Antoni A cellular areas and Antoni B myxoid areas are seen
in Schwanommas.
Few Characteristics Exclusive to Lesions - Rapid revision:
101.Peripheral Palisading Basal cell carcinoma.
102.Pseudopalisading in tumor GBM.
103.Whorls like arrangement Meningioma.
104.Signet ring cells Poorly differentiated mucin secreting
adenocarcinoma.
105.Keratin pearls Squamous cell carcinoma.

106.Verocay bodies ( Antoni A and B ) Schwanomma.

107.Call exner bodies Granulosa cell tumor.
108 .Psamomma bodies Papillary carcinoma thyroid,Papillary
serous ovarian tumors,Meningioma.
109.Capsular / vascular invasion Follicular carcinoma thyroid.
110.Amyloid Medullary carcinoma thyroid.
111.Osteoid formation Osteosarcoma.
112.Chicken wire calcifications chondroblastoma.
113.Schiller Duval bodies Yolk sac tumor.
114.Indian file pattern Lobular carcinoma breast.
115.Piecemeal necrosis Chronic active hepatitis.
116.Mallory bodies Alcoholic cirrhosis.
117.Stellate cells Cardiac myxoma.
118.Oat cells Small cell carcinoma lung.
119.Hair in tumor Benign cystic teratoma ( dermoid cyst )
120.Reed Sternberg cells Hodgkins Lymphoma.

Typical descriptions / Key Points of Few common major Lesions :

121.Carcinoid tumor : nests,aggregates and packets of

monomorphic cells with round to oval nuclei and granular
cytoplasm.Chromogranin positive.
122.Adenocarcinoma : Back to back closely packed gland like
structures lined by pleomorphic malignant epithelial cells with
hyperchromatic nuclei and eosinophilic cytoplasm.Wall sharing
is noted.
123.Squamous cell carcinoma : sheets and clusters of
pleomorphic malignant squamous epithelial cells with
hyperchromatic nuclei and pale cytoplasm.Keratin epithelial

pearls,intercellular bridges and individual cell keratinization are

seen.
124.Hemangioma : Aggregates of closely arranged thin walled
vascular channels lined by benign endothelium and separated
by scanty fibrous stroma.
125.Angiosarcoma: Sheets of malignant oval to spindly cells
with hyperchromatic nuclei.Mitoses are noted.
126.Sarcoma : Sheets of malignant oval to spindly cells with
hyperchromatic nuclei .Abnormal mitoses and focal necrosis is
noted in high grade sarcomas.
127.Papillary carcinoma thyroid : Papillary structures with
fibrovascular cores lined by pleomorphic malignant epithelial
cells with Orphan Annie nuclei.Nuclear Grooves are
seen.Psamomma bodies are present.
128.Seminoma : Sheets and groups of seminoma cells with
hyperchromatic vesicular nuclei and water clear
cytoplasm.These tumor cells arranged in lobules separated by
fibrous tissue septae infiltrated by lymphocytes.
129.Yolk sac tumor : sheets and nests of pleomorphic malignant
oval to polygonal cells forming schiller duval bodies.Eosinophilic
secretions are noted.
130.Meningioma : whorls and bundles of oval to fusiform to
polygonal cells with regular nuclei.Psamomma bodies may also
be seen.
131.Non Hodgkins Lymphoma : Sheets of monotonous
population of atypical lymphoid cells with hyperchromatic nuclei
and scanty cytoplasm.Mitoses are noted.
132.Hodgkins Lymphoma : Heterogenous population of cells
including lymphocytes,plasma cells,macrophages and
eosinophils ( Characteristic feature).Reed Sternberg cells are
hall mark.
133.Basal cell carcinoma ( Rodent ulcer ) ; Nests and groups of
pleomorphic basaloid cells with hyperchromatic nuclei and
scanty cytoplasm.Peripheral palisading is noted at the periphery
of nests.Mitoses can be seen.

134.Malignant melanoma : Sheets of malignant oval to

polygonal cells with hyperchromatic nuclei and prominent pink
nucleoli.Pigment deposition is noted.
135.Ductal carcinoma breast : Ductal structures,sheets and
groups of pleomorphic malignant epithelial cells with
hyperchromatic nuclei and eosinophilic cytoplasm .
136.Liver cirrhosis : Nodules composed of benign hepatocytes
separated by thin fibrous tissue septae.
137.Teratoma : Cystic lesion lined by benign stratified
squamous epithelium and cyst wall showing hair
follicles,sebaceous glands.Other types of tissue like
nervous,thyroid tissue can be seen.
TYPICAL immunomarkers :
138. Cytokeratin Carcinomas.
139.Vimentin Sarcomas.
140.S-100 Melanoma , nEural marker.
141.Melan A.Malignant melanoma.
142.Desmin Muscle marker.
143.LCA Leukocyte common antigen Lymphomas.
144.Chromogranin Neuroendcrine marker ,carcinoid.
145.CD 15 & CD 30 Reed Sternberg cells / Hodgkins.
146.CD19,CD20,CD79a B cell Lymphoma Marker.
147.CD3,4,5 ,8 T cell Lymphoma Marker.
Famous GRADING / STAGING to be Learnt by heart:
148.Bloom Richardson grading : Breast carcinoma.
149.Gleasons Score : Carcinoma Prostate.
150.Dukes Staging : Carcinoma colon .
151.TNM Staging of Lung.
152.Fuhrmanns Grading : Renal cell carcinoma.

153.Knodell score : Chronic hepatitis / cirrhosis / liver activity.

154.FIGO grading / staging : Carcinoma endometrium and
cervix.
155.Meningioma : WHO grading.
156.WHO grading of Astrocytoma.
157.Laurens Classification : carcinoma stomach.
158.Hodgkins Lymphoma staging. ( Ann Arbor)
Important DIFFERENTIAL DIAGNOSIS in special pathology
159. Cold nodule thyroid : Benign hyperplastic colloid
nodule,follicular adenoma,Carcinoma thyroid, thyroid cyst /
nodule.
160.Enlarged cervical lymph node : Reactive lymph node
enlargement ,Tuberculous lymph node,Lymphoma , Metastatic
malignancy.
161.Lump Breast in 40 yrs old female : Carcinoma
breast,fibrocystic disease,fibroadenoma,non specific abscess.
162.Posterior fossa brain tumors : Medulloblastoma,pilocytic
astrocytoma,meningioma,schwanomma.
163.Ulcer Intestine : Tuberculosis,Typhoid,Inflammtory bowel
disease,Carcinoma,Perforation.
164.Brown black pigment in liver : Haemochromatosis,Bile
pigment in cholestasis,lipofuscin pigment in aging,fomalin
pigment,metastatic melanoma.
165.follicle like arrangement in thyroid : Follicular
adenoma,follicular carcinoma,follicular variant of papillary
carcinoma thyroid.
Some other Last Points in Special Pathology not to be missed:
167.Active gastritis or colitis means presence of polymorphs .
168.crypt abscess means presence of collections of neutrophils
in glands or crypts lumen.
169.Clinical outcome of a malignant tumor rests mainly on
staging/lymph node invasion / mets.

170.LFTs mean Serum billirubin,SGOT,SGPT,serum

albumin,LDH.
171.RFTs mean BUN and serum creatinine.
172.Thyroid function tests include TSH,T4,T3.
173.Cardiac Profile include : Troponin,Creatine Kinase ,LDH.
174.Lipid Profile include :
Cholesterol,HDL,LDL,VLDL,Triglycerides.
175.Special Liver stains include : PAS,PAS-D,Reticulin.
176.Methenamine silver and PAS stains are done for kidney
biopsies to see thickening of basement membrane of capillaries.
177.ZN stain is done to look for AFB ( Acid fast bacillus ) in
Tuberculosis.
178.Van gieson and masson trichrome stains are done to look
for collagen fibers / fibrosis.
179.Alcian blue is the stain used to look for mucin.
180.GMS stain is done for fungus. ( Gomori methenamine
silver )
181.Sudan black and Oil Red 0 are special stains for fat.
182.Perls Prussian blue stain is used to look for iron.
183.The most frequent causes of mild anemia with hypochromia
and microcytosis are iron deficiency anemia,the anemia of
chronic disease and b thallesemia minor.
184.The granulomas of sarcoidosis are characteristically non
caseating.
185.The hallmark of the megaloblastic anemia is the finding of
megaloblastic erythroid hyperplasia in the bone marrow.
186.Nodular melanoma has two pattern of growths,horizontal
and vertical.It tends to spread vertically more than horizontally.
187.The majority of salivary gland tumors occur in parotid and
most common tumor is Pleomorphic adenoma.

188.Adenoid cystic carcinoma is a common malignant salivary

gland tumor.
189.Biopsy is always preferable over FNAC.
190.Biopsies are of many types : Excision biopsy,Trucut
biopsy,Incisional biopsy.
191.Routine histopathological stain is Haematoxylin and Eosin.
192.Routine cytological stain is Giemsa and Papanicoalau( for
nucleus ).
193.Common Histo fixative is 10 % Formalin.
194.Common Cytology fixative is 95% ethyl alcohol.
195.Special stains / Immunostains are needed when diagnosis
cannt be made with a Routine stain.
196.Kaiserling solution is used to keep specimens fixed in
museums for long term.
197.When give Differential diagnosis of any lump always go in
this order : infections,benign tumors and than malignant
tumors.
198.FNAC common sites for superficial lumps lymph
nodes,salivary glands,thyroid and breast.
199.FNAC deep lumps common sites include Liver,lung and
abdominal lymph nodes.
200.FNAC of deep seated lumps need help of Ultrasound /CT.