HISTOPATH LABORATORY

4. Functional Derangements and Clinical Manifestations

− The end results of genetic,
biochemical, and structural changes in
Thing to do during the Investigation:
cells and tissues are functional
• Type of firearm abnormalities,
• Distance of gun to victim − Which leads to the clinical
• Entrance vs exit wounds manifestations (symptoms and signs)
• Track of projectile of disease, as well as its progress
(clinical course and outcome)
Gunshot Wounds

• Starting of a contact wound ADAPTATIONS

o Barrel touching the skin (murder)
• Stippling
o Powder burns on the skin when the gun is inches
to a few feet from the victim (homicide)
PATHOLOGY
− The study (logos) of disease (pathos). More specifically, it
is devoted to the study of the structural, biochemical, and
functional changes in cells, tissues, and organs that
underlie disease
− Divided into:
• General Pathology
o Reactions of cells and tissues to abnormal
stimuli and to inherited defects
• Systemic Pathology
o The alternations in specialized organs and
tissues that are responsible for disorders
• Are reversible functional and structural responses to more
severe physiologic stresses and some pathologic stimuli,
during which new but altered steady states are achieved,
allowing the cell to survive and continue function.
• Adaptive response may consist:
o Hypertrophy and Functional activity
▪ An increase in the size of cells
o Hyperplasia
▪ An increase in their number
o Atrophy
▪ A decrease in the size and metabolic
activity of cells
o Metaplasia
▪ A change in the phenotype of cells

Four (4) aspects of the disease process

1. Etiology (Cause)
− Certain abnormal symptoms or
diseases are “caused”
− If someone became ill it was the
patient’s fault (for having sinned) or the
effects of outside agents, such as bad
smells, cold, evil spirits, or gods. (The
Acadians, 2500 BC)
o Two major classes:
− Genetics
• Inherited mutations and
disease-associated gene
variants, or polymorphisms
− Acquired
• E.g., infectious, nutritional,
chemical, physical

2. Pathogenesis
− The mechanism(s) of disease
development
− The sequence of events in the
response of cells or tissues to the
etiologic agent, form the initial stimulus
to the ultimate expression of the
disease.
− The study of pathogenesis remains
one of the main domains of pathology

3. Morphologic and Structural Changes

− The structural alternations in cells or
tissues that are either characteristic of
a disease or diagnostic of an etiology
process
 TABLE 1-1 – Cellular Response to injury

Nature of Injurious Stimulus Cellular Response

ALTERED PHYSIOLOGICAL; SOME
CELLULAR ADAPTATIONS
NONLETHAL INJURIOUS STIMULI
• Increase demand, increase
stimulation (e.g., by growth
• Hyperplasia,
factors, hormones)
hypertrophy
• Decreased nutrients,
• Atrophy
decreased stimulation
• Metaplasia
• Chronic imitation (physical of
chemical)
Mechanisms of Hypertrophy:
REDUCED OXYGEN SUPPLY;
CHEMICAL INJURY; MICROBIAL CELL INJURY • Hypertrophy is the result of increased production of
INFECTION
cellular proteins.
• Acute reversible
• Hypertrophy can be induced by the linked actions of:
injury Cellular
o Mechanical sensors
swelling fatty
• Acute and transient ▪ That are triggered by increased work
change
• Progressive and severe load
• Irreversible injury
(including DNA damage) o Growth factors
→ cell death
Necrosis ▪ Including TGF-, insulin-like growth
Apoptosis factor-1 [IGF-1], fibroblast growth
METABOLIC ALTERATIONS, INRACELLULAR factor
GENETIC OR ACQUIRED, CHRONIC ACCUMULATIONS; o Vasoactive agents
INJURY CALCIFICATION ▪ Such as -adrenergic agonists,
CUMULATIVE SUBLETHAL INJURY endothelin-1, and angiotensin II
CELLULAR AGING
OVER LONG-LIFE SPAN

CELL DEATH HYPERPLASIA

• The end result of progressive cell injury
• One of the most crucial events in the evolution of disease
in any tissue or organ
• It results from diverse causes, including ischemia
(reduced blood flow), infection, and toxins.
• Cell death is also normal and essential process in
embryonies, the development of organs, and the
maintenance of hemostasis
• TWO PRIMARY PATHWAYS:
o Necrosis
▪ The more common type of cell death
▪ Involving severe cell swelling,
denaturation and coagulation of
proteins, breakdown of cellular
organelles, and cell rupture.
o Apoptosis
▪ Occurs when a cell dies by activation
of an internal “suicide” program,
involving an orchestrated disassembly
of cellular components; there is
minimal disruption of the surrounding
tissue and there is a minimal, if any,
inflammation.
• Autophagy
o An adaptive cellular response that triggered by
Nutrients derivatization that may also culminate
in cell death.
ADAPTIVE RESPONSES
HYPERTROPHY
• Hypertrophy refers to an increase in the size of cells,
resulting in an increase in the size of the organ
• The hypertrophied organ has no new cells, just larger
cells.
• Hypertrophy can be physiologic and pathologic and is
caused by increased functional demand or by stimulation
by hormones and growth factors.
• The most common stimulus for hypertrophy of muscle is
increase workload
• An increase in the number of cells n an organ or tissue,
usually resulting in increased mass of the organ or tissue
• Hyperplasia takes place if the cell population is capable of
dividing, and thus increasing the number of cells.
• Hyperplasia can be physiologic or pathologic
•
Physiologic of Hyperplasia:
• Hormonal hyperplasia
o Which increases the functional capacity of a
tissue when needed
• Compensatory hyperplasia
o Which increases tissue mass after damage or
partial resection
Pathologic Hyperplasia:
• Caused by excesses of hormones or growth factors acting
on target cells
Hyperplasia is distinct from cancer, but pathologic hyperplasia
constitutes a fertile soil in which cancerous proliferation may
eventually arise.
• Hyperplasia is a characteristic response to a certain viral
infection, such as papillomaviruses, which cause skin
warts and several mucosal lesions composed of masses
of hyperplastic epithelium.
Mechanisms of Hyperplasia:
• Hyperplasia is the result of growth factor-driven
proliferation of mature cells and, in some cases, by
increased output of new cells from tissue stem cells.
ATROPHY
• Reduced size of an organ or tissue resulting from a
decrease in cell size and number
• Atrophy can be physiologic or pathologic
Physiologic Atrophy: TABLE 1-2 -Features of Necrosis and Apoptosis

• Common during normal development. Features Necrosis Apoptosis

• Some embryonic structures, such as the notochord and Cell size Enlarged (swelling) Reduced
thyroglossal duct, undergo atrophy during fatal (shrinkage)
development. Nucleus Pyknosis → Fragmentation into
Karyorrhexis → nucleosome-size
Pathologic Atrophy: Karyolysis fragments
Plasma membrane Disrupted Intact; altered
• Depends on the underlying cause and can be local or structure,
generalized especially
• The most common causes: orientation of lipids
o Decreased workload (atrophy of disuse) Cellular contents Enzymatic Intact; may be
o Loss of innervation (denervation atrophy) digestion; may leak released in
o Diminished blood supply (senile atrophy) out of cell apoptotic bodies
o Inadequate nutrition – marasmus, cachexia Adjacent inflammation Frequent No
o Loss of endocrine stimulation Physiologic or Invariably often physiologic,
o Pressure Pathologic role pathologic means of
(culmination of eliminating
irreversible cell unwanted cells;
injury) may be pathologic
after some forms
of cell injury,
especially DNA
damage

REVERSIBLE INJURY

Mechanisms of Atrophy:

• Atrophy results from decreased protein synthesis and

increased protein degradation in cells.
• In many situations, atrophy is also accompanied by
increased autophagy, with resulting increases in the • Cellular swelling
number of autophagic vacuoles. o Cells are incapable of maintaining ionic and fluid
• Autophagy (“Self-eating”) homeostasis and is the result of failure of
o The process in which the starved cell eats its energy-dependent ion pumps in the plasma
own components in an attempt to find nutrients membrane
and survive. ▪ Pallor, increased turgor, and increase
in weight of the organ
• Fatty change
o Occurs in hypoxic injury and various forms of
METAPLASIA
toxic or metabolic injury.
• Metaplasia is a reversable change in which one ULTARASTRUCTURAL CHANGES
differentiated cell type (epithelial or mesenchymal) is
replaced by another cell type. 1.) Plasma membrane alternations
• The influences that predispose to metaplasia, if persistent, − Such as blebbing, blunting, and loss of
may initiate malignant transformation in metaplastic microvilli
epithelium. 2.) Mitochondrial changes
− Including swelling and the appearance
of small amorphous densities.
3.) Dilation of the ER
− With detachment of polysome;
intracytoplasmic myelin. (Figures may
be present)
4.) Nuclear alternations
− With disaggregation of granular and
fibrillar elements.
 NECROSIS

• Denaturation of intracellular proteins and enzymatic

digestion of the lethally injured cell
• MORPHOLOGY:
o Increased eosinophilia
o Myelin figures
o Nuclear changes

Coagulative necrosis

• The architecture of dead tissues is preserved for a span

of at least some days
Fat necrosis
• A localized area of coagulative necrosis is called an infarct
• Refers to focal areas of fat destruction, typically resulting
from release of activated pancreatic lipases into the
substance of the pancreas and the peritoneal cavity.

Liquefactive necrosis

• Characterized by digestion of the dead cells, resulting in

transformation of the tissue into a liquid viscous mass.
• The necrotic material is frequently creamy yellow because
of the presence of dead leukocytes and is called pus Fibrinoid necrosis

• Seen in immune reactions involving blood vessels. This

pattern of necrosis typically occurs when complexes of
antigens and antibodies are deposited in the walls of
arteries.

Gangrenous necrosis

• Usually applied to a limb, generally the lower leg, that has

lost its blood supply and has undergone necrosis (typically
coagulative necrosis) involving multiple tissue planes.
• Wet gangrene

Caseous necrosis

• Encountered most often in foci of tuberculous infection

• Necrotic area appears as a collection of fragmented or
lysed cells and amorphous granular debris enclosed
within a distinctive inflammatory border; this appearance
is characteristic of a focus of inflammation known as a
granuloma
 FREE RADICALS Glycogen

• Chemical species that have a single unpaired electron in
an outer orbit. Energy created by this unstable
configuration is released through reactions with adjacent
molecules, such as inorganic or organic chemicals –
proteins, lipids, carbohydrates, nucleic acids – many of
which are key components of cell membranes and nuclei
Pigments
Reactive oxygen species (ROS)
− A type of oxygen-derived free radical whose role in cell
injury is well established.
− When the production of ROS increases or the scavenging
systems are infective, the result is an excess of these free
radicals, leading to a condition called oxidative stress
CATEGORIES
• A normal cellular constituent
o Such as water, lipids, proteins, and
carbohydrates, that accumulates in excess.
• An abnormal substance
o Either exogenous, such as a mineral or products
of infectious agents, or endogenous, such s a
product of abnormal synthesis or metabolism.
Lipids
• Steatosis and fatty change describe abnormal
accumulations of triglycerides within parenchymal cells
• Excess accumulation of triglycerides within the liver may
result from excessive entry or defective metabolism and
export of lipids.
• Glycogen masses appear as clear vacuoles within the
cytoplasm
• Glycogen storage disease, or glycogenosis
• Exogenous Pigments
o Carbon (coal dust)
o Anthracosis
o Tattooing
• Endogenous
• Lipofuscin
o Is an insoluble pigment, also known as
lipochrome or wear and tear pigment
• Melanin
o Derived from the Greek (melas, black), is an
endogenous, non-hemoglobin derived, brown-
black pigment formed when the enzyme
tyrosinase catalyzes the oxidation of tyrosine to
dihydroxyphenylalanine in melanocytes.
• Hemosiderin
o Is a hemoglobin-derived, golden yellow-to-
brown, granular or crystalline pigment that
serves as one of the major storage forms of iron
o When there is a local or systemic excess of iron,
ferritin forms hemosiderin granules

TRIGGERED EFFECT

• Prolonged moderate
hypoxia, such as that
produced by propound
anemia, causes
intracellular deposits of fat,
which create grossly
apparent bands of
yellowed myocardium
alternating with bands of
darker, red-brown,
uninvolved myocardium

Cholesterol and Cholesterol Esters

• Atherosclerosis
• Xanthomas
• Cholesterols
• Niemann-Pick disease, type C
 FINE NEEDLE ASPIRATION
PALPABLE MASSES

Applications • Sites:
o Breast
• Cytogenetics for chromosomal studies o Thyroid
• Identification of benign neoplasms o Soft tissue
• Diagnosis and management of cancer o Lymph node
• Diagnosis of non-neoplastic/inflammatory conditions • Needle: 22-23
• Diagnosis of specific infections o Size of the syringe depends on depth of lesion
• Hormonal imbalance and potential fluid content
• To follow up progress or improvement in disease process
• Diagnosis of specific infections. A variety of bacterial, viral,
protozoal and fungal infections can be identified by SLIDE PREPARATION
cytological methods
• SOLID LESION: few drops from the tip of the needle
• BLOODY SPECIME: cells are diluted and hard to find on
Samples DS
• Prepare max 4 slide, 1-2 drops on each slide, use slide
− Exfoliated cells, Aspirated Cells and body fluids pull technique.
• Rinse the needle in a preservative solution (Saccomano
The sample can be collected by: fluid)

• Scrapping the lateral walls of vagina

• Fresh early morning sputum
• Bronchial washings BREAST
• Buccal smears
LYMPHATIC DRAINAGE
• Gastric lavage
• Fresh catheterized urine samples
• AXILLARY (mostly)
• Pericardial, pleural and peritoneal fluids
o Palpable
• CSF
• INTERNAL MAMMARY
• Etc. o Non-palpable
FNA is a safe procedure • SUPRACLAVICULAR
o ? Palpable
Potential risks that you need to be aware of:

• Bleeding
• Skin infection
• Injury to vital neck structures (arteries, veins, nerves or
wind pipe)

FNA result could be 1 to 4 possible outcomes:

1.) Benign nodule → Regular follow-up

2.) Cancerous nodule → Surgical removal
3.) Indeterminate result → Repeat FNA
4.) Inadequate sample → Repeat FNA

Alternative to doing an FNA?

− Follow-up by ultrasound to monitor the nodule

FINE NEEDLE ASPIRATION

• Superficial masses (breast, thyroid, peripheral lymph

nodes)
• With laparoscopy, CT, sonography guide:
o Lung
o Mediastinum
o Abdominal organs
o Retroperitoneal organs