EYE AND OCULAR

ADNEXA
Chapter 45
AGUINALDO, KRISTA P.
SPUP SOM – JUNIOR
INTERN
I. EYELIDS
I. DEVELOPMENTAL
ANOMALIES
DERMOID
CYST
Typically involves the
upper eyelid along the
lateral brow margin,
representing forward
extension of a mass that is
primarily intraorbital.
(Fig. 45.1).
I. DEVELOPMENTAL
ANOMALIES
DERMOID
CYST
Lined by well-
differentiated epidermal
and dermal tissues
containing all of the usual
skin appendages. The
lumen is filled with
keratinous debris, sebum,
and hairs.
(Fig. 45.2).
 II. INFLAMMATION
BLEPHAR
ITIS
Showing conjunctival
goblet cell loss and
squamous metaplasia.
(Fig. 45.3).
II. INFLAMMATION

CHALAZION
Lipogranuloma that develops in and
about a meibomian gland as a
consequence of the effects of
obstruction. It begins as a deep-seated
process, not infrequently it erupts
through the conjunctival surface of
the eyelid and can be associated with
an overlying pyogenic granuloma.
(Fig. 45.4).
II. INFLAMMATION

CHALAZION
The typical chalazion reveals
multiple foci of granulomatous
inflammation. In the center of
many of the granulomas are small
globules of fat, which in paraffin
sections present as empty, round
to ovoid spaces.
(Fig. 45.5).
IV. CYST
SUDORIFERO
US CYSTS
Also called hidrocystoma
Cysts arising from blocked
sweat glands are common
in the periocular region.
They are filled with a
watery fluid and can be
multilocular. (Fig. 45.6).
V. TUMOR AND TUMORLIKE
LESIONS
(ADNEXAL TUMORS)
SEBACEOUS
ADENOMAS AND
CARCINOMAS
They may arise from the cutaneous sebaceous glands,
the glands of Zeis, or the meibomian glands. They can
clinically mimic a range of conditions and are not
infrequently misdiagnosed as squamous cell or basal
cell carcinomas. Vacuolar adipophilin expression is
useful in distinguishing sebaceous from basal or
squamous cell carcinoma. Pagetoid involvement of the
overlying skin can also occur, resulting in a clinical
picture of chronic blepharoconjunctivitis, sometimes
with no clear mass lesion present. (Fig. 45.7).
V. TUMOR AND TUMORLIKE
LESIONS
(ADNEXAL TUMORS)
SEBACEOUS
ADENOMAS AND
CARCINOMAS
The most common presentation of sebaceous
carcinoma in the eyelid is as round highly
cellular nests of poorly differentiated tumor
cells in the dermis, sometimes with central
necrosis in a comedocarcinoma pattern.
(Fig. 45.8).
V. TUMOR AND TUMORLIKE
LESIONS
(ADNEXAL TUMORS)
ENDOCRINE MUCIN-
PRODUCING SWEAT GLAND
CARCINOMA (EMPSGC)
Additional valuable clues to the diagnosis
can be found in the pattern of tumor
dissemination, as intraepithelial spread
through the conjunctiva is quite common.
(Fig. 45.9).
V. TUMOR AND TUMORLIKE
LESIONS
(ADNEXAL TUMORS)
ENDOCRINE MUCIN-
PRODUCING SWEAT GLAND
CARCINOMA (EMPSGC)
Composed of bland, round to oval cells with
variably solid, cystic, and papillary growth
patterns (Fig. 45.10).
V. TUMOR AND TUMORLIKE
LESIONS
(ADNEXAL TUMORS)
ENDOCRINE MUCIN-
PRODUCING SWEAT GLAND
CARCINOMA (EMPSGC)
These lesions are distinctive due to their
focal expression of EMA and neuroendocrine
markers such as synaptophysin and
chromogranin, in conjunction with mucin
production (Fig. 45.11).
VI. MELANOCYTIC TUMORS
MELANOCYTIC
NEVI
Most nevi are of the
junctional or compound
type, but all variants can
be encountered at this site,
including nevi associated
with the Meibomian gland
(Fig. 45.12).
 VII. MESENCHYMAL TUMORS
AND TUMORLIKE
CONDITIONS
ANGIOMAS
Small lesions confined to the eyelid
or extend deep into the orbit.
The so-called port-wine stain
(nevus flammeus) may be
associated with malformations in
other tissues. (Fig. 45.13). In the
Sturge–Weber syndrome, the facial
hemangioma may be associatedwith
choroidal hemangioma, glaucoma,
and meningeal hemangioma, all on
VIII. MESENCHYMAL TUMORS
AND TUMORLIKE
CONDITIONS
XANTHELASMAS
Slightly elevated yellow plaques
located on the medial aspect of the
upper and lower eyelids
(Fig. 45.14).
VIII. MESENCHYMAL TUMORS
AND TUMORLIKE
CONDITIONS
XANTHELASMAS
These lesions show large, pale-
staining, fat-laden histiocytes
throughout the subepithelial
tissues
(Fig. 45.15).
IX. METASTATIC TUMORS
Carcinomas from various sites can
metastasize to one or both eyelids,
sometimes as the first
manifestation of the disease. A
notorious diagnostic trap in this
area is the mammary lobular
carcinoma having striking
histiocytoid features and
simulating an inflammatory
process
(Fig. 45.16).
II. LACRIMAL
GLANDS
I. TUMORS AND TUMORLIKE
CONDITIONS
Many of the mixed tumors have a predominant
EPITHELIAL TUMORS
component of hyaline cells of presumed
myoepithelial nature. (Fig. 45.17).
I. TUMORS AND TUMORLIKE
CONDITIONS
LYMPHOID TUMORS
AND TUMORLIKE
CONDITIONS
Lymphomas of the lacrimal gland
are most often MALT or other
low-grade B-cell neoplasms;
however, more aggressive forms
such as mantle cell lymphoma and
diffuse large B-cell lymphoma can
present at this site as well.
(Fig. 45.18).
III. LACRIMAL
PASSAGES
I. TUMORS
PAPILLOMAS
The microscopic features of squamous
papillomas are similar to those at other
sites, with stratified squamous
epithelium and focal dyskeratosis.
Transitional cell papillomas are
composed of cells with features
intermediate between columnar and
squamous epithelium, including
stratified elements and goblet cells or
mucin but in general no surface keratin
or prominent intercellular bridges.
(Fig. 45.19).
IV. ORBIT
I. THYROID
OPHTHALMOPATHY
Common cause of orbital disease and of
exophthalmos.
The most striking gross alterations are observed in
the extraocular muscles, which may be massively
enlarged. Muscle fibers degenerate and become
hyalinized. A great increase in the interstitial
connective tissue, including both cellular elements
and ground substance/glycosaminoglycans, is
observed particularly in the muscles.
(Fig. 45.20).
II. INFLAMMATORY
PROCESSES
GRANULOMATOU
S DISEASES
Orbital cholesterol granulomas or
cholesteatomas generally involve the
superior orbit and frontal bone in which
an epithelial lining is identified.
(Fig. 45.21).
II. INFLAMMATORY
PROCESSES
ROSAI–DORFMAN
DISEASE
Sinus histiocytosis with massive
lymphadenopathy which can present in the orbit,
involving the lacrimal gland. The infiltrate is
composed of large histiocytes (some exhibiting
lymphocytophagocytosis/ emperipolesis),
lymphocytes, and plasma cells. Fibrosis can be
very prominent.
(Fig. 45.22).
II. INFLAMMATORY
PROCESSES
IGG4-RELATED
DISEASE
This can involve all orbital structures, including
lacrimal gland, extraocular muscle, and soft
tissue. Fibrosis and phlebitis can be absent in the
periocular tissues, and lymphoid follicles with
germinal centers are more frequently observed.
(Fig. 45.23).
II. INFLAMMATORY
PROCESSES
INFLAMMATORY
PSEUDOTUMORS
Idiopathic orbital inflammation with the pathologic features
including the following: (Fig. 45.24).
1. The formation of an indurated orbital mass often
surrounding the optic nerve and incorporating one or more
of the extraocular muscles.
2. A tissue reaction that includes exudation of fluid,
excessive production of ground substance, mobilization of
chronic inflammatory cells, vascular proliferation, and
hyperplasia of connective tissue.
3. The absence of demonstrable etiologic agents or of
otherwise diagnostic histopathologic alterations indicative
of specific disease.
III. PRIMARY TUMORS
MESENCHYMAL TUMORS AND
TUMORLIKE CONDITIONS
Hemangiopericytoma and solitary fibrous tumor
The former term has been used when the tumor is
diffusely hypercellular and vascularity is
prominent, while the latter has been generally
employed when it contains keloid-like collagen
and an alternation of hypercellular and
hypocellular areas.
(Fig. 45.25).
 III. PRIMARY TUMORS
MESENCHYMAL
TUMORS AND
TUMORLIKE
CONDITIONS
Alveolar soft-part sarcoma
Can present as a primary orbital tumor. The age of
occurrence, microscopic appearance, and evolution
are similar to those seen in the other location of
this tumor (Fig. 45.26).
III. PRIMARY TUMORS
MESENCHYMAL TUMORS AND
TUMORLIKE
Angiomas
CONDITIONS
These soft, blue, compressible tumors
are diffuse throughout the orbit and
often extend forward into the eyelids.
In the infant, the lesion is usually of
capillary type and in the adult of
cavernous type.
(Fig. 45.27).
III. PRIMARY TUMORS
GLIOMA OF OPTIC NERVE
Relatively rare, slow-growing tumors
that can arise within the intracranial or
orbital segments of the nerve. As they
increase in size, they tend to form a
bulbous enlargement of the nerve
(Fig. 45.28).
III. PRIMARY TUMORS
GLIOMA OF OPTIC NERVE
Microscopically, almost all optic gliomas are
pilocytic astrocytomas, similar to those occurring
in the cerebellum and elsewhere in the CNS. (Fig.
45.29). Rosenthal fibers and eosinophilic granular
bodies are generally present, and florid vascular
proliferation is sometimes noted. Microcystic
change is also often encountered. Considerable
cytologic variation exists in different portions of a
given tumor. Varying degrees of cellularity are
observed, but generally these neoplasms are
characterized by a low degree of anaplasia with
bland, round to oval cells showing bipolar hair-
like processes. There are sometime areas of
myxoid degeneration within the tumor.
III. PRIMARY TUMORS
MENINGIOMA
Secondary lesions that invade into the orbit from
the sphenoidal ridge (Fig. 45.30).
Occasionally, orbital meningiomas without clear
links to either the coverings of the optic nerve or
brain are identified.
III. PRIMARY TUMORS
MENINGIOMA
Those arising from the inner portion of the
sphenoidal ridge can cause severe compression of
the optic nerve within the optic canal, resulting in
papilledema or optic atrophy. CT and MRI scans
have facilitated the diagnosis and localization of
these tumors, with primary meningioma often
showing a “tram-track” extension along the nerve
(Fig. 45.31).
III. PRIMARY TUMORS
MENINGIOMA
Can be primary or secondary lesions that invade
into the orbit from the sphenoidal ridge.
Microscopically, most orbital meningiomas are of
the meningothelial type, although many subtypes
are encountered.
(Fig. 45.32).
IV. LYMPHOID TUMORS AND
TUMORLIKE CONDITIONS
Microscopically,
these lesions are
characterized by a
rather uniform and
monotonous but
widespread
proliferation of
small lymphocytes,
frequently
associated with
involvement of
orbital fat, blood
vessels, and nerves.
(Fig. 45.33).
(Fig. 45.34).
IV. LYMPHOID TUMORS AND
TUMORLIKE CONDITIONS
V. CONJUNCTIVA
I. DEVELOPMENTAL
ANOMALIES
DERMOID TUMORS
Firm, localized, elevated opaque masses
that typically occur at the limbus, often
encroaching on the cornea.
(Fig. 45.36).
I. DEVELOPMENTAL
ANOMALIES
DERMOID TUMORS
These are solid choristomatous masses, not
to be confused with dermoid cysts of the
orbit. Over the lesion, the surface
epithelium and the subepithelial connective
tissue present the histologic features
characteristic of epidermis and dermis,
respectively. A few hairs typically project
from the tumor. The bulk of the mass is
composed of thick bundles of collagen. In
some lesions, skin appendages are few, and
adipose tissue is present; these are known
as dermolipomas (Fig. 45.37). Additional
choristomatous elements including
glandular tissue can also sometimes be
II. DEGENERATION
PTERYGIUM
They extend over the cornea and are
therefore a clinically more significant
lesion than the pinguecula (Fig.
45.38).
II. DEGENERATION
PTERYGIUM
Microscopically, they represent
conjunctival epithelium with variable
goblet cell loss and a variably fibrotic
underlying stroma. (Fig. 45.39).
III. TUMORS AND TUMORLIKE
CONDITIONS
EPITHELIAL TUMORS
Papillomas
Microscopically, it reveals pronounced
acanthosis and varying degrees of
keratinization, koilocytosis, and
nonspecific inflammation. Goblet cells
are generally retained at least focally.
(Fig. 45.40).
They occasionally contain dysplastic
foci, although when inflammation is
prominent the possibility of reactive
atypia should be considered.
III. TUMORS AND TUMORLIKE
CONDITIONS
EPITHELIAL TUMORS
Conjunctival intraepithelial neoplasia (CIN)
Almost always arises on the ocular surface rather
than the eyelid and varies considerably in its
clinical appearance. They may present clinically
as an area of leukoplakia, as a papillomatous
growth, or as a complication of pterygium or
pinguecula. (Fig. 45.41).
III. TUMORS AND TUMORLIKE
CONDITIONS
EPITHELIAL TUMORS
Conjunctival intraepithelial neoplasia (CIN)
Microscopically, there is thickening of the epithelium
with loss of goblet cells, suprabasal mitoses,
disordered growth, and lack of appropriate superficial
maturation but only modest cellular enlargement and
nuclear atypia. The identification of sharp borders at
the edges of the lesion can be critical in
differentiating it from non-neoplastic reactive changes
in the epithelium. (Fig. 45.42).
Clinically leukoplakic lesions generally show more
squamous differentiation and superficial parakeratosis
but also have well-defined edges. Koilocytic change
is often lacking.
III. TUMORS AND TUMORLIKE
CONDITIONS
EPITHELIAL TUMORS
Invasive squamous cell carcinoma
Generally arises from intraepithelial
dysplasia and is relatively rare in
regions where early “precancerous” or
“in situ cancerous” lesions are
efficiently excised. (Fig. 45.43).
Metastatic spread is uncommon.
IV. MELANOCYTIC TUMORS AND
TUMORLIKE CONDITIONS
NEVI OF THE BULBAR
CONJUNCTIVA
Characteristically, they are discrete,
flat, or slightly elevated lesions located
on the globe in the interpalpebral zone,
but they vary greatly in size, shape,
and position. They also exhibit much
variation in degree of pigmentation,
with a significant number being
essentially amelanotic. (Fig. 45.44).
IV. MELANOCYTIC TUMORS AND
TUMORLIKE CONDITIONS
NEVI OF THE BULBAR
CONJUNCTIVA
Microscopically, they are generally of
the junctional, compound, or
subepithelial varieties, with the latter
corresponding to the intradermal nevus
of skin. Frequently, there are numerous
solid and cystic inclusions of
conjunctival epithelium intimately
incorporated into the subepithelial
component of these nevi. (Fig. 45.45).
 IV. MELANOCYTIC TUMORS AND
TUMORLIKE CONDITIONS
NEVI OF THE BULBAR
CONJUNCTIVA
Conjunctival nevi in children, which
are usually of junctional or compound
types, tend to show a confluent pattern
of lentiginous growth and a lack of
maturation that may lead to
overdiagnosis of melanoma.
They can also grow rapidly and show
increased cytologic atypia when
inflamed, and many regard the
inflamed juvenile conjunctival nevus as
a distinct entity (Fig. 45.46).
IV. MELANOCYTIC TUMORS AND
TUMORLIKE CONDITIONS
CONJUNCTIVAL MELANOSIS
Microscopically, PAM without atypia
consists of increased conjunctival
epithelial pigmentation with little or no
increase in melanocytes and an
absence of cytologic melanocytic
atypia.
In PAM with atypia, an increase in the
number of melanocytes is seen along
the basal layer, individually or in
clusters, associated with various
degrees of atypicality and sometimes
pagetoid spread (Fig. 45.47)
IV. MELANOCYTIC TUMORS AND
TUMORLIKE CONDITIONS
MALIGNANT MELANOMA
Rare lesion which may arise without an
apparent precursor lesion, or it may be
the sequela of a nevus or PAM. (Fig.
45.48).
IV. MELANOCYTIC TUMORS AND
TUMORLIKE CONDITIONS
MALIGNANT MELANOMA
The microscopic appearance is similar
to that of its cutaneous counterpart.
(Fig. 45.49).
V. INTRAOCULAR
TISSUES
I. MALIGNANT MELANOMA
(GENERAL AND CLINICAL
FEATURES)
Typically presents as an elevated mass
with varying degrees of pigmentation
but can also consist of multiple small
nodules (tapioca iris melanoma) or
generate a broad carpet of growth on
the surface. (Fig. 45.50).
I. MALIGNANT MELANOMA
(GENERAL AND
CLINICAL FEATURES)
Choroidal melanoma also may vary in
pigmentation but characteristically is
an irregular, slate-gray, solid,
subretinal tumor producing an
overlying retinal detachment and
decreased vision. They generally
appear as a discoid, globular, or
mushroom-shaped mass but can
sometimes spread diffusely or extend
out along scleral canals into the orbit.
(Fig. 45.51).
I. MALIGNANT MELANOMA
(GENERAL AND
CLINICAL FEATURES)
Diagnosis and staging can be
problematic in cases with clinically
unsuspected tumors when fragmented
specimens are removed by
evisceration.
(Fig. 45.52).
I. MALIGNANT MELANOMA
(MICROSCOPIC FEATURES)
Microscopically, uveal melanomas
have been traditionally divided into
three types: spindle A, spindle B, and
epithelioid, which may occur singly or
in combination.
Spindle A cells are slender, benign-
appearing cells that have relatively
small fusiform nuclei and no nucleoli.
(Fig. 45.53).
I. MALIGNANT MELANOMA
(MICROSCOPIC FEATURES)
Spindle B cells are larger and more
pleomorphic, merging on the one hand
with spindle A cells and on the other
with epithelioid cells. They typically
possess large ovoid nuclei containing
prominent nucleoli. (Fig. 45.54).
I. MALIGNANT MELANOMA
(MICROSCOPIC FEATURES)
Both spindle A and spindle B tumors
tend to be quite cohesive. Some of
these tumors have a distinctly
fascicular pattern of growth.
Epithelioid cells are still larger and
more irregular.
(Fig. 45.55).
I. MALIGNANT MELANOMA
(SPREAD AND METASTASES)
Lymphatic channels are not present in
the eye, thus uveal melanoma spread
hematogenously, primarily to the liver,
lung, and skin.
Extraocular extension through scleral
canals is rare (Fig. 45.56), but
extensive extrascleral growth generally
prompts orbital exenteration.
II. RETINOBLASTOMA AND
RELATED LESIONS
(GENERAL AND CLINICAL
FEATURES)
The most common intraocular
neoplasm of children.
Approximately 60% of the cases are
unilateral, and the other 40% are
bilateral. (Fig. 45.57).
II. RETINOBLASTOMA AND
RELATED LESIONS
(CLINICAL AND GROSS
FEATURES)
Characteristically present as a
leukocoria (white pupillary reflex) or
less often as a strabismus. (Fig. 45.58).
Rarely, extraocular extension with the
formation of an orbital mass is the
presenting manifestation.
They may be flat and diffuse or
elevated and may show multicentric
foci of origin, especially in the
hereditary type.
II. RETINOBLASTOMA AND
RELATED LESIONS
(CLINICAL AND GROSS
FEATURES)
They may protrude into the vitreous
(endophytic type), often with vitreous
seeding, or they may grow between the
retina and the pigment epithelium
(exophytic type). (Fig. 45.59).
II. RETINOBLASTOMA AND
RELATED LESIONS
(CLINICAL AND GROSS
FEATURES)
Since the tumors tend to outgrow their
blood supply, necrosis is often
extensive and many minute foci of
calcification are often present in these
areas of necrosis. (Fig. 45.60).
II. RETINOBLASTOMA AND
RELATED LESIONS
(MICROSCOPIC FEATURES)
Microscopically, RBs are composed of
dense masses of small round cells with
hyperchromatic nuclei and scanty
cytoplasm. Dystrophic calcification
and hematoxyphilic DNA deposits in
and around blood vessel walls are
often seen in necrotic areas. (Fig.
45.61).
Both neuroblastic Homer Wright
rosettes containing a central tangle of
processes and Flexner–Wintersteiner
rosettes with true lumens can be found,
with the latter most common in
II. RETINOBLASTOMA AND
RELATED LESIONS
(MICROSCOPIC FEATURES)
Tumors showing an extreme degree of
differentiation are designated as
retinocytomas and regarded as benign.
These lesions carry the same initiating
genetic changes as conventional RBs;
they present as small placoid,
noninvasive lesions composed entirely
of benign-appearing cells with
numerous fleurettes, lacking necrosis
or mitotic activity. (Fig. 45.62).
II. RETINOBLASTOMA AND
RELATED LESIONS
(MICROSCOPIC FEATURES)
It has also recently been recognized
that anaplastic changes similar to those
in other embryonal tumors of the brain
can be encountered in RB and are
associated with worse clinical
outcomes.
(Fig. 45.63).
II. RETINOBLASTOMA AND
RELATED LESIONS
(ELECTRON MICROSCOPIC,
IMMUNOHISTOCHEMICAL, AND
MOLECULAR GENETIC FEATURES)
Immunohistochemically, there is
reactivity for general neuronal proteins
such as synaptophysin, as well as
markers of retinal differentiation such
as retinal-binding protein, retinal S-
antigen, interphotoreceptor retinal-
binding protein, cone opsin, and rod
opsin. (Fig. 45.64).
II. RETINOBLASTOMA AND
RELATED LESIONS
(SPREAD AND METASTASES)
Has a tendency to invade the optic
nerve, from which it can extend to the
brain or be carried there by the
cerebrospinal fluid. (Fig. 45.65).
II. RETINOBLASTOMA AND
RELATED LESIONS
(SPREAD AND METASTASES)
Large exophytic tumors with
secondary glaucoma are at highest risk
for optic nerve invasion. (Fig. 45.66).

It can also invade the uveal tract, and

“massive” choroidal invasion of over 3
mm is associated with hematogenous
metastasis.
II. RETINOBLASTOMA AND
RELATED LESIONS
(SPREAD AND METASTASES)
Vitreous seeding is also associated
with chemoresistance and poor
outcomes.
Distant metastases can be limited to the
cranial vault or involve distant sites,
particularly the skeletal system. (Fig.
45.67).
II. RETINOBLASTOMA AND
RELATED LESIONS
(PROGNOSIS)
Massive invasion of the choroid by RB
cells, defined as 3 mm or greater in
extent, is an unfavourable prognostic
sign.
Tumor cells must extend through
Bruch’s membrane and into the
choroid, and sub-retinal pigment
epithelium spread does not qualify.
Scattered clumps of tumor cells carried
over the choroid during specimen
processing should also not be
diagnosed as true tumor invasion. (Fig.
45.68).
III. OTHER PRIMARY TUMORS
FUCHS ADENOMA
(benign ciliary epithelioma, Fuchs epithelioma)
Benign tumor of the ciliary body usually found
incidentally in a surgically enucleated eye or
on post mortem examination.
Microscopically, it is formed by interlacing
trabeculae of uniform, nonpigmented ciliary
epithelial cells surrounded by an amorphous,
hyaline, PAS-positive material. (Fig. 45.69).
III. OTHER PRIMARY TUMORS
MEDULLOEPITHELIOMA
Also known as diktyoma.
Rare tumor that histologically resembles the
embryonal retina or medullary epithelium of
the brain. Most cases arise from the ciliary
epithelium in children, but a few have been
found in the optic nerve or retina.
They are composed of tubules and bands of
poorly differentiated neuroectodermal cells
lining a PAS-positive basement membrane.
(Fig. 45.70).
III. OTHER PRIMARY TUMORS
ASTROCYTIC HAMARTOMAS
(generally as a component of von Hippel-
Lindau disease)
They are sometimes found in the retina and are
sometimes called “retinal angiomas” by
clinicians but feature the same neoplastic
stroma seen in the same entity in the brain.
(Fig. 45.71).
III. OTHER PRIMARY TUMORS
ASTROCYTIC HAMARTOMAS
Similar in appearance to subependymal giant
cell astrocytomas in the brain.
“Reactive” retinal astrocytic tumors can
occur following trauma or as an apparently
spontaneous finding. They are also sometimes
designated vasoproliferative tumors of retina
when the vascular component is prominent or
massive retinal gliosis when growth is
particularly diffuse.
The primary cells within the lesion are spindled
GFAP-positive glia. (Fig. 45.72).
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END