Textbook Of Pathology Research Articles

Calcifying Epithelial Odontogenic Cyst Associated with Complex Odontome of Maxilla

The term calcifying odontogenic cyst was first introduced by Gorlin in 1962 (Eshghyar et al., Acta Med Iran 44(1):59-62, 2006). The lesion is unusual in that it has some features of a cyst but also has many characteristics of a solid neoplasm (Cysts and tumors of odontogenic origin: textbook of oral pathology, 2006). It is classified into two types-Type I-the cystic variant, Type II-solid tumor variant. This case report present Type I B-odontome producing intraosseous calcifying odontogenic cyst and Type I C-with ameloblastomatous proliferation in a 19years old male patient in the right maxillary quadrant. The lesion involved an unerupted permanent maxillary central incisor, which was displaced to the infraorbital ridge of right side and the radiograph revealed a calcified mass in the periapical region of right incisor that was later recognized histopathologically as complex composite odontoma. The lesion was removed surgically. This case report emphasizes on the presence of this Type I B and C lesion and the need to keep them in follow up.

Inflammation, Immunity, and Hypertension

Aprominent pathology textbook used in the United States includes an image illustrating the renal histopathology caused by malignant hypertension. The legend describes striking “onion skin” changes of a renal arteriole. Curiously, a sea of mononuclear inflammatory cells surrounding this arteriole is overlooked both in the legend and in the related text. Moreover, nothing regarding inflammation or immune reactions is discussed. This lack of attention to inflammatory cells is, however, not surprising. Although many experimental studies have implicated inflammation in hypertension, these have largely been performed in experimental animals; there is no proof that inflammation contributes to human hypertension. In fact, some anti-inflammatory or immune-suppressing drugs (eg, nonsteroidal anti-inflammatory drugs and cyclosporine) paradoxically cause hypertension in humans, likely via off-target effects. Often the term “inflammation” is used in the context of cardiovascular disease as a catchall referring to nonspecific phenomena, such as elevation of C-reactive protein or the presence of macrophages in a tissue. Most clinicians and investigators find this vague and difficult to understand. Even more puzzling is that many studies now implicate the adaptive immune response, and in particular, lymphocytes, in hypertension and vascular disease. Traditionally, bacterial, viral, or tumor antigens activate this arm of immune defense. As such, it has been hard to imagine how adaptive immunity could be involved in a disease such as hypertension. In this article, we will attempt to address some of these puzzling questions. We will briefly review components of the innate and adaptive immune response, discuss data from many groups, including our own, that suggest that common forms of hypertension are immune mediated, and provide a working hypothesis of how signals from the central nervous system trigger an immune response that causes hypertension. ### General Concepts Regarding Inflammation and Immunity #### Innate Immunity The first line of defense against pathogens is the innate immune response. Important components of this system include epithelial …

Fatal Bronchial Asthma With Bilateral Lung Collapse

Fatal bronchial asthma is classically characterized in pathology textbooks and journal articles as associated with lung hyperinflation at autopsy. The following is a report of a case of fatal bronchial asthma associated instead with bilateral lung collapse. This manifestation of asthma at autopsy has not been previously reported, to my knowledge. A 31-year-old man with a history of recurrent asthma was found in an unresponsive state in his automobile after a low-speed collision. Medical personnel during the resuscitation noted a decrease in breath sounds bilaterally and some wheezing. There was no escaping air with needle thoracostomies at the outset. Cardiac monitoring demonstrated pulseless electrical activity during most of the 30-minute resuscitation attempt. An autopsy disclosed collapsed lungs bilaterally. Microscopic examination of the lungs disclosed the characteristic histopathologic features of bronchial asthma.

Guido Majno, M.D., 1922–2010

Guido Majno, M.D., 1922–2010

Moderate Pericardial Effusion Early After Myocardial Infarction

Pericardial effusion (PE) associated with myocardial infarction (MI) is considered to be associated with anterior ST-segment elevation MI (STEMI), with large infarcts, and when heart failure is present. When PE is associated with cardiac tamponade, it is usually due to cardiac rupture, hemorrhagic pericarditis, or aortic dissection involving the right coronary artery. However, the majority of PE does not cause hemodynamic compromise, and a small to moderate PE may often be viewed as a benign reaction to the MI. In 1986, Galve et al1 demonstrated in a study of 138 consecutive patients with acute MI that 28% of patients had a PE. The study was meticulously performed with repeated echocardiographic evaluations, and there were no cases of cardiac tamponade. However, these data may no longer be valid because the treatment of acute MI has changed dramatically since 1986. In a large study in the modern era of reperfusion from 25 French hospitals including 908 patients with MI, a PE was detected in only 6.6% of the patients.2 Patients had an echocardiogram performed at admission and again at discharge, and 0.8% developed left ventricular free wall rupture (FWR). This incidence of FWR is similar to that of a larger registry that did not search meticulously for rupture.3 Article see p 1902 Acute FWR is one of the most common causes of mortality in acute MI. The diagnosis is most often made by the presence of sudden electromechanical dissociation followed by death if left untreated. Some patients survive for several hours, allowing time for diagnosis and intervention. Textbooks of pathology often describe rupture as a late event, but large systematic series have shown that rupture is most common on day 1.4 In this issue of …

Felix qui potuit rerum causas cognoscere

As undergraduates, in my medical school, we had a grey booklet that listed the courses that we had to attend and have signed up in order to fulfil the requirements for taking our final examinations. We all went elsewhere after completing the pre-clinical course and at clinical school I found that those of us who had migrated north, alone among our new colleagues, were required to show that we had performed 5 post mortem examinations under supervision. We quickly learnt that we had missed much in examining the patient while alive and began to understand the importance of this final audit on the medical care of patients. Later, as a houseman I learnt how to approach the difficult task of requesting bereaved relatives to permit an autopsy with sensitivity, and subsequently taught this to generations of my own house physicians. Throughout my career, I continued to learn from the autopsy and subsequent discussions of the histopathology with colleagues in pathology, a learning process now seriously curtailed by the weak response of the medical profession to the Alder Hey scandal. Virgil’s line, happy he who was able to understand the causes of things, found an echo in the first great pathology textbook, published in the 80th year of Morgagni’s life, De Sedibus et Causis Morborum , on the sites and causes of diseases of 1761. The doctors of the Enlightenment were already beginning to find an answer to Voltaire’s contemporary comment that they gave drugs, about which they knew little, to cure diseases, about which they knew less, to patients about whom they knew nothing. Morgagni, professor in Padua, was to live another 10 years and influenced all future generations of doctors who looked to morbid anatomy to elucidate the causes of their patients’ symptoms. Perhaps the best known of these …

PR12 ATYPICAL FIBROXANTHOMA AND MALIGNANT FIBROHISTIOCYTOMA – A TEN‐YEAR REVIEW

Purpose: To review the clinical and histological differences between atypical fibroxanthoma (AFX) and malignant fibrohistiocytoma (MFH).Methodology: Cases of MFH and AFX were identified and histologically reviewed from our non‐melanoma skin cancer (NMSC) database 1996–2007 for the Central Region of New Zealand. Medline search and recent pathology textbooks were reviewed to determine current opinion and evidence for the diagnostic differentiation between AFX and MFH.Results: Of the 54,002 cases of NMSC, 103(0.2%) were histologically reported as AFX and 14(0.03%) MFH, with a mean age of 77 (range 51–93) and 74 (28–88) years respectively. The mean size of AFX was 16.3 (5–70) mm occurring on the head & neck (n = 97), limb (n = 3), trunk (n = 2). 15 (14.7%) lesions were incomplete excised. 12 (11.7%) cases developed local recurrence and 1 metastasis. The mean size of MFH was 20.9 (range 7–50) mm occurring on the head & neck (n = 10), trunk (n = 2), groin (n = 1) and limb (n = 1). 3 (21.4%) lesions were incompletely excised. 2(14.3%) patients developed local recurrence and 2 metastases. Local recurrence occurred in 12 (11.7%) cases of AFX and 2 (14.3%) cases of MFH. The literature states clinical and histological differences between AFX and MFH, but no immunohistochemical (IHC) stain reliably differentiates between them.Conclusion: Differentiating AFX from MFH based on histology and IHC is difficult and our cases did not conform to the typical presentation indicated in the literature. AFX and MFH are likely to belong to a spectrum of soft tissue sarcomas with variable aggressiveness.

Association of seedling myomas with myometrial hyperplasia

It is paradoxical that such a presumably quiescent tissue as myometrium, so sheltered from carcinogen exposure, has more neoplasms than any other internal tissue and that, in contrast to cervix and endometrium, pathology textbooks recognize no precursor. Although myometrial dysplasia has been described, it is rare. Myometrial hyperplasia (MMH) is a common structural variation characterized by irregular zones of increased myometrial cellularity, with increased nucleus-cell ratios; but to date, there has been only anecdotal evidence that it may give rise to myomas. We studied the relationship of seedling myomas to MMH in 50 consecutive hysterectomies and found that most seedling myomas (44/63, 70%) arose in MMH--35 in inframucosal MMH, 3 in subserosal MMH, and 6 from intramural MMH. Some seedling myomas were incompletely circumscribed, seeming to arise not only in but also from MMH. We suggest that even seedlings in normal myometrium may arise not from normal myometrial smooth muscle cells but rather from myometaplasia in intramural stromal emboli, with hyperplastic and then neoplastic transformation. These findings may explain the high frequency and multiplicity of uterine leiomyomas. Frequent mucosal injury with stromal repair reactions may release growth factors that promote the high frequency and multiplicity of uterine leiomyomas.

Integration of breeding and technology into diversification strategies for disease control in modern agriculture

While diversity for resistance has been recognised for more than 60 years as a key factor in disease management, and diversification strategies such as cultivar mixtures and multilines are described and advocated in almost every plant pathology textbook, the general view in modern agriculture is that diversity would be too difficult and expensive to implement. In addition, difficulties in marketing the produce are emphasised. The question thus arises if and how such strategies can be designed to find a place in modern agriculture. Considering the general ecological benefits of diversification and the possible economical benefits for growers and society, several possible approaches to the solution of actual and perceived problems in modern agriculture are discussed. An important route towards achieving diversity would be to integrate it into the breeding process. Selection criteria would include inducibility of resistance and competitive ability, in order to produce diversified varieties able to adapt both to unpredictable environmental conditions (especially climatic) and to changing pest and pathogen populations through co-evolution. Evolutionary breeding methods such as composite crosses and modern landraces and some of the legal problems associated with these approaches are discussed. Technical solutions are integral to the future use of diversification strategies and range from more or less simple adjustments to machinery for planting and harvesting to devices designed for separation of the harvested products.

Application of immunohistochemistry in clinical practice: a review

Immunohistochemistry (IHC) has radically altered the practice of diagnostic histopathology. It is increasingly being applied for more accurate and precise diagnosis, theranostics and prognostics in the management of tumours. Unfortunately clinicians and pathologists in resource-constrained settings may not be exposed to its clinical utility. To provide a review of the principles and utility of IHC in diagnosis as relevant to histopathological diagnosis in clinical practice. A retrospective PubMed search was used to find most recent studies and reviews published on immunohistochemistry. Popular anatomical pathology textbooks and online resources were also searched. The searches for articles were limited to the MeSH terms "humans" and "English language". Emphasis was placed on recent review and original articles that are dealing directly with respective technical aspects and immunohistochemical stains of interest. Both authors searched and reviewed related articles separately. The extracted information was compared so as to include the most updated information available. Immunihistochemistry has become an essential component of histopathology. Clinicians need to be conversant with developments in IHC in order to liaise appropriately with pathologists for the benefit of their patients. There is a need for urgent establishment of IHC practice within resource-constrained countries in order to meet current diagnostic standards in tumour pathology.

Recent Fungal Diseases of Crop Plants: Is Lateral Gene Transfer a Common Theme?

A cursory glance at old textbooks of plant pathology reveals that the diseases which are the current scourge of agriculture in many parts of the world are a different set from those that were prominent 50 or 100 years ago. Why have these new diseases arisen? The traditional explanations subscribe to the "nature abhors a vacuum" principle-that control of one disease creates the condition for the emergence of a replacement-but does little to explain why the new pathogen succeeds. The emergence of a new disease requires a series of conditions and steps, including the enhanced fecundity of the new pathogen, enhanced survival from season to season, and spread around the world. Recently, evidence was obtained that wheat tan spot emerged through a lateral gene transfer event some time prior to 1941. Although there have been sporadic and persistent reports of lateral gene transfer between and into fungal plant pathogens, most examples have been dismissed through incomplete evidence. The completion of whole genome sequences of an increasing number of fungal pathogens no longer allows such proposed cases of lateral gene transfer to be dismissed so easily. How frequent are lateral gene transfers involving fungal plant pathogens, and can this process explain the emergence of many of the new diseases of the recent past? Many of the apparently new diseases are dependant on the expression of host-specific toxins. These are enigmatic molecules whose action requires the presence of plant genes with products that specifically encode sensitivity to the toxin and susceptibility to the disease. It is also notable that many new diseases belong to the fungal taxon dothideomycetes. This review explores the coincidence of new diseases, interspecific gene transfer, host-specific toxins, and the dothideomycete class.

Forensic Neuropathology and Associated Neurology

Forensic Neuropathology and Associated Neurology

Cloacogenic bladder

Also called persistent cloaca..The dilated sac like structure in the center of the abdomen. There has been failure in early fetal life of the urorectal septum to divide the rectum from the urogenital inus. Entering the cloaca are the colon, the right ureter and the left ureter (there was left renal agenesis), 2300 m.l fluid was collected from cloaca. The cloaca served as rectum and bladder. The infant had no anus. The only outlet was a thin narrow urethra. PERSISTENT CLOACA. Etiology- Unknown. Pathogenesis- The abnormality results from failure of the urorectal septum to separate the primitive urogenital sinus from the hindgut. General Gross Description - The diagnosis rests on the gross demonstration of a common structure serving as bladder and rectum. General microscopic Description- not applicable. Clinical correlation - Associate anomalies may include imperforate anus, abscence of genital and urinary orifices,renal agenesis. derivatives of forgut, midgut is not well develop, absence of the prostate and seminal vesicles. Epitilial lined muscular viscus that can distended and hold up to 2300 ml of urine without a change in intra luminal pressure. Trigone, genital and urinary orifices are absent. Rt kidney is normal,left kidney is hypoplastic. Entering the cloaca are the colon,the right and left ureter. References Text book of fetal and perinatal pathology, Lengman’s medical Embryology 6th edit.

A brief review of the “vulgaris” lesions of the skin

Medical students and the trainees in dermatology and pathology have a curiosity about the names, such as, acne vulgaris or verruca vulgaris. The word “vulgaris” sounds like vulgar, commonly meaning crudely indecent, coarse, or obscene. However, the word “vulgar” is derived from the Latin word “vulgaris”, meaning “of or belonging to the common people”. In medical terminology, the word “vulgaris” means common or ordinary. A search through the indexes in Dermatology and Pathology text books revealed seven dermatologic conditions with “vulgaris” in their names. These included very common diseases, such as, acne vulgaris and verruca vulgaris as well as now rarely diagnosed disease, such as, lupus vulgaris. We are briefly reviewing the seven “vulgaris” diseases of the skin.

Practical Pathology of Gunshot Wounds

Gunshot wounds are the most common cause of homicidal death in the United States. Analysis and interpretation of fatal gunshot wounds is an important and common practice among forensic pathologists. Additionally, for pathology residents, it is an integral aspect of their training during their rotations at medical examiner or coroner offices. The correct interpretation of gunshot wounds by forensic pathologists not only provides valuable information that can assist law enforcement in their investigation but also is essential for the final determination of manner of death. Discussion of the practical, basic, and essential skills required to interpret gunshot wounds include distinguishing a classic entrance wound from an exit wound; recognizing atypical entrance and exit wounds; utilizing the features of soot and stippling patterns to differentiate among contact, close, and distant range gunshot wounds; understanding of the trauma produced by gunshot wounds; and understanding the importance of recovering and documenting/handling any projectiles recovered at autopsy. This article reviews numerous standard forensic pathology textbooks and the pertinent literature to formulate practical guidelines to assist the pathologist in the performance of forensic autopsies and the investigation of gunshot wound fatalities. Pathologists who perform investigations and autopsies to determine the cause and manner of death in gunshot wound cases must be aware of the implications, requirements, and pitfalls in interpretation of the injuries so that the examination fulfills its expectations to the community and the justice system.

SQUAMOUS DYSPLASIA AND CARCINOMA IN SITU OF THE ESOPHAGUS IN JAPAN

In this paper, the authors review recent topics of interest in relation to squamous dysplasia and squamous cell carcinoma in situ in Japan, and also the differences in diagnostic criteria for squamous cell carcinoma in situ between Japanese and Western pathologists. Photomicrographs of high‐grade squamous dysplasia in Western textbooks of surgical pathology are judged in Japan to be squamous cell carcinoma in situ. Squamous cell carcinoma in situ can be histologically subdivided by the appearance of the basement membrane into the simple replacement type, showing a linear pattern, and the bulky outgrowth type, showing a wavy pattern. Squamous cell carcinoma in situ may also be classified into a total layer type, in which the entire epithelium is replaced by tumor cells, and a basal layer type in which the basal half is replaced by tumor cells. It is frequently observed that minute squamous cell carcinomas of the basal layer type, but not the total layer type, show signs of early stromal invasion into the lamina propria mucosae. These histologic findings strongly indicate that the basal layer type is not low‐grade dysplasia but squamous cell carcinoma in situ.

Nodular hyperplasia of Bartholin’s gland

There has been very little mention of benign solid lesions of the Bartholin's gland (BG) in pathology and gynaecology textbooks, and very few cases have been reported in the literature. Among these lesions, the distinction between nodular hyperplasia (NH) and adenoma has not been well defined. We report ten cases of NH of the BG, describe their clinicopathological, immunohistochemical and ultrastructural findings, and review the literature. We examined retrospectively all lesions involving BGs from our surgical pathology records from 1990 to 2004 with emphasis on NH. To separate NH from adenoma, we applied the criteria proposed by Koenig and Tavassoli. Special stains (PAS with and without prior digestion, Mayer's mucicarmine and Alcian blue with and without hyaluronidase) and immunohistochemistry (CAM5.2, AE1/AE3, HMWK, monoclonal CEA, EMA, ER, PR, ALA, SMA, Ki-67, p53 and polyclonal CEA) were performed on NHs. Two cases were examined ultrastructurally. Using specific criteria, ten cases (age range 23-45 years; mean 36.1) of NH were identified, two of which were diagnosed previously as adenoma, but re-classified as NH. Clinically, these lesions were described either as Bartholin's duct cysts (BDCs) or vulvar lumps. Grossly, NHs were solid, tan and unencapsulated, measuring 12.5-45.0 mm in maximum dimension (mean 23.8). Histologically, the NHs were composed of a proliferation of mucus-secreting acini with preservation of the normal duct-to-acinar relationship. Chronic inflammation and squamous metaplasia were present. Eight lesions focally involved the surgical margins. Intracytoplasmic and intra-luminal secretions were positive for PAS with and without digestion, Alcian blue with and without hyaluronidase and mucicarmine. All lesions showed positive staining for CAM5.2, AE1/AE3, HMWK, EMA, and polyclonal CEA. There was negative staining for Ki-67, ER, PR, ALA, p53 and monoclonal CEA. Periacinar myoepithelial cells stained for SMA. Ultrastructurally, the findings included abundant intracytoplasmic secretory granules, granulofibrillar bodies, prominent Golgi and ribosomes. Myoepithelial cells were identified. There was no tumour recurrence or malignant transformation in eight patients with clinical follow-up. NH of the BG is a rare lesion with benign behaviour. It is a distinct entity and can be separated histologically from an adenoma.

Reply

Important medical discoveries frequently begin as simple observations. Examples include small reports of troglitazone-associated hepatotoxicity and pulmonary hypertension resulting from treatment with Fen-Phen, both ultimately leading to drug withdrawal. In 2004, we published a series of 5 patients with acute nephrocalcinosis following oral sodium phosphate (OSP) bowel cleansing (Hum Pathol 2004;35:675–684). We subsequently evaluated all renal biopsies processed at Columbia University Medical Center between 2000 and 2004 and found at least 16 additional cases of what we now more appropriately refer to as “acute phosphate nephropathy” (APhN) (J Am Soc Nephrol 2005;16:3389–3396). Dr. Koretz incorrectly states that Dr. Markowitz is a nephrologist. In fact, this study originates from a renal pathology laboratory, and 3 of the 4 authors are anatomic pathologists. Until recently, APhN was virtually unrecognized. Nephrology and renal pathology textbooks devote chapters to the entity of nephrocalcinosis. Based on the experience of one of the largest renal pathology referral centers in the United States, up to two thirds of nephrocalcinosis cases are caused by something that is not even mentioned in these chapters—the use of OSP bowel purgatives. Patients with APhN are typically older and present with acute renal failure, minimal proteinuria, bland urine sediment, and negative serologies. Based on this presentation, they may or may not be referred to a nephrologist. If they are referred, they are unlikely to undergo renal biopsy. Thus, the 21 cases in the numerator likely represents only a fraction of the cases of APhN occurring at the hospitals that send their renal biopsies to our laboratory, and it is a number that represents the experience of only a single center. Considering these facts, the most appropriate quote from the NY Times article is the one where Dr. Markowitz describes the results as “alarming.” Dr. Koretz quotes the NY Times article by saying that “Dr. Markowitz … does not think the risk is worth it and wants to make sure that every patient understands that the risk exists.” This is a direct quote from the article, not a direct quote from Dr. Markowitz. When choosing a bowel purgative for colonoscopy, the gastroenterologist should not adhere rigidly to a single preferred choice for use in all patients. The gastroenterologist should be aware that OSP is not meant for use in patients with kidney disease or certain electrolyte disorders, and that APhN is a potential complication. Risk factors that predispose to APhN include inadequate hydration, increased patient age, hypertension, concurrent use of ACE inhibitors, ARBs, diuretics, and NSAIDs, and possibly female gender. Until the denominator is known, it seems prudent to inform patients of the potential risk and advise them that safer alternatives exist. In the end, we agree with Dr. Koretz that: (1) we do not know the true incidence of APhN; (2) large prospective trials are needed; and (3) it is premature to establish public policy regarding this issue. Nonetheless, the finding of 21 cases on renal biopsy from a single center makes for quite a devilish numerator. The devil is in the denominatorGastroenterologyVol. 130Issue 7PreviewMarkowitz GS, Stokes MB, Radharkrishnan J, D’Agati VD (Departments of Pathology and Medicine, Division of Nephrology, Columbia College of Physicians and Surgeons, New York, New York). Acute phosphate nephropathy following oral sodium phosphate bowel purgative: an underrecognized cause of chronic renal failure. J Am Soc Nephrol 2005;16:3389–3396. Full-Text PDF

Smooth muscle pattern is more reliable than the presence or absence of an internal elastic lamina in distinguishing an artery from a vein

Major pathology textbooks suggest that the shape of the vessel and the presence or absence of an internal elastic lamina are the best means to distinguish an artery from a vein. Because the shape of the vessel is highly dependent upon the plane of section, the internal elastic lamina is often cited as a more reliable criterion. After evaluating a patient with superficial thrombophlebitis, in whom these conventional criteria had led to a misdiagnosis of polyarteritis nodosa, we sought to determine whether the pattern of smooth muscle in the media is a more sensitive discriminator between an artery and a vein. Anatomically identified arteries and veins were harvested from extremity amputation specimens and stored autopsy organ specimens and reviewed by two dermatopathologists who were blinded to the gross pathologist's impression. The biopsies were assessed for the smooth muscle pattern and the presence or absence of an internal elastic lamina. Forty-seven of the 50 cases (94%) were concordant with the pathologist's gross impression using only the smooth muscle pattern to differentiate an artery from a vein. On the basis of the presence or absence of an internal elastic lamina, 41 of 50 cases (82%) were concordant with the prosector's designation of the vessel. Vessels were harvested from a variety of sites, with lower extremity vessels predominating. There may be some regional variability not addressed in this study. In this study, the pattern of muscle fibers within the vascular media discriminated between arteries and veins better than assessment of the presence or absence of an internal elastic lamina. Although no single criterion is 100% reliable, assessment of both these criteria may minimize the risk of misinterpreting vessels in the deep dermis and subcutis.

Rib Torque Does Not Assist Resting Tidal Expiration or Most Conversational Speech Expiration

This research note discusses a common misconception in speech science and speech-language pathology textbooks that rib torque (i.e., rotational stress) assists resting tidal expiration and conversational speech production. The nature of this misconception is considered. An alternate conceptualization is offered that is consistent with knowledge from respiratory biomechanics.