Duke DPT Histopathology - Neoplasia & Autoimmunity

Neoplastic and Autoimmune Disease

Robbins Basic Pathology:

Ch 4: pp. 99-100, 109-124, 135-138
Ch 5: pp. 161-173, 177-198, 207-209
see also Junqueira Ch. 14, pp. 226-235 for an overview of the immune response

Learning Resources

This lesion was found incidentally at autopsy of a 56-year-old man and had nothing whatever to do with his demise. The lesion was a large yellow nodule beneath the intact mucosa of the colon. Looking at the slide, you can see the mucosa (consisting of a simple columnar epithelium) along the top edge of the slide. Underneath the mucosa, the mass appears as a collection of cells, each containing a single, large vacuole surrounded by a thin rim of cytoplasm [example].

1. Identify the vacuolated cells (i.e. name the cell type, e.g. macrophages, lymphocytes, fibroblasts, etc.)

2.The lesion is certainly an "-oma" of some sort. Name the "-oma" and indicate whether it was benign or malignant.

Slide 36 [WebScope] [ImageScope]

This section is from a bulky neoplasm in the thigh of a 49-year-old woman.m from the thigh of a 49-year-old woman.

At low magnification, you can see part of a lightly staining nodular lesion that is bordered by more deeply pink-staining tissue.
Close inspection reveals a rather cellular neoplasm, lobules of which extend into adjacent, distorted skeletal muscle. Despite its light-staining quality, the neoplasm itself is extremely cellular and has a finely vascular background.
Some of the cells in this lesion a more or less similar to those in slide 34 above. Other cells are rather peculiar, with multiple cytoplasmic vacuoles that characteristically indent their darkly-staining nuclei. Still others are rather nondescript-appearing, less well differentiated cells that have a more or less spindled shape.

1. This lesion is also an "-oma." Name the lesion and indicate whether it is benign or malignant.

Slide 33 [WebScope] [ImageScope]

This slide contains a biopsy of the uterus from a 38-year-old woman who presented with irregular menstruation and intesne, episodic uterine cramping. Grossly, the myometrium was distorted by numerous circumscribed nodules ranging in size from 2 to 6 centimeters. As you inspect this slide at low magnification, you will note a roughly circular area in the center of the tissue section that stains more deeply than the surrounding myometrium. This area is not really encapsulated, but it looks different, and seems to be separated from the adjacent myometrium along at least part of its circumference.

Note that this circumscribed area is more densely cellular, with a higher concentration of nuclei and a bluer color.
Note the structure of the surrounding normal myometrium -- interlacing bundles of spindle-shaped cells that run in fascicles. Some of these fascicles are cut longitudinally, and others in cross-section.
You will see that the neoplasm is also composed of interlacing bundles of spindle shaped cells. While not actually encapsulated, the nodule is easily distinguished from its surroundings by its denser cellularity and darker color.
Compare the nuclei in the neoplasm with those in the normal myometrium and note that they are essentially identical (although more closely packed).

1. Identify the primary cell type making up the neoplasm.

2. The lesion is also an "-oma" of some sort. Name the "-oma" and indicate whether it is benign or malignant.

Slide 35 [WebScope] [ImageScope]

This slide contains a section of the uterus from a 32-year-old woman who also presented with irregular menstruation and intense, episodic uterine cramping. As part of her initial workup, a biopsy was taken from which it was determined that the best course of action was to perform a radical hysterectomy along with medical treatment. The tissue shown here is from the outer wall of the uterus that was removed (the outer, fibrous capsule can be noted along the margins of the section). The underlying myometrium consists entirely of abnormal tissue.

1. Identify the primary cell type making up the neoplasm.

2. The lesion is also an "-oma" of some sort. Name the "-oma" and indicate whether it is benign or malignant.

Slide 50 [WebScope] [ImageScope]

A 19-year-old student presented to the campus health service complaining of transient knee and hip joint pains of one week’s duration. He had become febrile 2 days prior to seeking medical attention. Physical examination revealed swollen knee joints and small painless subcutaneous swellings located in the scalp and over the elbows. One week later, a heart murmur thought to be due to mitral regurgitation was detected. Congestive heart failure soon developed and the patient succumbed despite aggressive medical treatment. Slide 50 is prepared from the autopsy material.

Note the fibrinopurulent inflammation of the epicardium [example].

Note the valvular endocardial fibrin deposits (excrescences) are present in the slide [example].

Note also the focal areas of inflammation and necrosis in the myocardium [example].

1. You've seen this particular case before. What is the diagnosis?

2. While the disease was triggered by a bacterial infection, much of the symptoms are actually due to an autoimmune reaction. What general class of hypersensitivity reaction is this?

Type I
Type II
Type III
Type IV

UMich Slide 178 [WebScope] [ImageScope]

History: A 35-year-old man was clearing a path in the woods. When he returned home, he noticed an intensely pruritic linear vesicular eruption on his extensor forearms. A skin biopsy was taken.

Histologic features: There is pronounced spongiosis (intercellular edema) within the epidermis resulting in intraepidermal vesicles. Exocytosis of lymphocytes (lymphocytic spongiosis) may be seen in the epidermis. There is a superficial perivascular lymphocytic infiltrate.

1. Based on the history, presentation, and histological findings, what do you think is the best diagnosis for this case?

2. What type (I, II, III, or IV) of hypersensitivity reaction is this?

Type I
Type II
Type III
Type IV

CASE NUMBER 26
[WebScope] [ImageScope]

Clinical History: This 48-year-old male with a history of Hepatitis B infection was admitted with a history of weight loss (approximately 20 pounds in the last 4 months) chills, fever, and pain in the right upper quadrant. He was diagnosed with cholecystitis and cholangitis (inflammtion of the gallbladder and bile duct) and the gallbladder was resected. Grossly, the walls of the gallbladder were thickened. The mucosa of the gallbladder was intact and numerous gallstones were present.

Microscopically, the gallbladder had an unexpected finding. The small arteries in the wall are involved in a necrotizing and inflammatory process which appears to be in all stages of development, resolution, and healing. The earliest change seen is an acute fibrinoid necrosis of the wall of the artery, which appears in the innermost third of the media, frequently involves the wall in an eccentric arrangement, and finally involves the entire thickness of the wall. Many of these arteries are markedly dilated with the formation of aneurysmal-like sacs. There is a marked exudation of inflammatory cells both within the wall of the artery and surrounding the artery. These cells are made up of eosinophils, neutrophils, macrophages and lymphocytes [example]. In some of the vessels, the process appears to be in a healing phase with the site of artery represented by fibrous scar surrounded by a chronic inflammatory exudate. Arterioles, capillaries, and veins are relatively spared.

1. In light of these findings, it is likley that he has more a widespread "arteritis" (inflammation of the arteries) that is probably affecting other organs as well. Research the various types of arteritis and provide your best opinion as to which diagnosis is appropriate in this case.

2. What type (I, II, III, or IV) of hypersensitivity reaction is this?

Type I
Type II
Type III
Type IV

UMich Slide 268 [WebScope] [ImageScope]

UMich Slide 68alt [WebScope] [ImageScope]

A 24-year-old man presented to the emergency room with dyspnea, cough, and wheezing. He had had numerous similar episodes, usually triggered or exacerbated by exposure to cold air, physical activity, and exposure to cats and birds. Physical examination revealed wheezing prominent in both phases of respiration which was relieved upon administration of inhaled albuterol. The samples shown are from another individual who had similar a similar bout of wheezing and lost consciousness while driving, resulting in a fatal motor vehicle crash. Note that significant inflammation is observed in the airways. Slide 268 is taken at the branching of the left and right main stem bronchi and shows extensive inflammatory changes in these large airways [example]. Slide 68alt was taken farther out in the lung tissue and shows obtruction and pathologic changes in the the bronchioles as well [example].

1. You've seen a case similar to this before. What is the diagnosis?

2. The symptoms of episodic wheezing and dyspnea upon exposure to certain environmental factors are due to an autoimmune reaction. What general class of hypersensitivity reaction is this?

Type I
Type II
Type III
Type IV

Click here to submit questions or comments about this site.

updated 11/14/16 - Velkey

Neoplastic and Autoimmune Disease
Robbins Basic Pathology:		Ch 4: pp. 99-100, 109-124, 135-138 Ch 5: pp. 161-173, 177-198, 207-209 see also Junqueira Ch. 14, pp. 226-235 for an overview of the immune response
Learning Resources
Slide 34 [WebScope] [ImageScope] This lesion was found incidentally at autopsy of a 56-year-old man and had nothing whatever to do with his demise. The lesion was a large yellow nodule beneath the intact mucosa of the colon. Looking at the slide, you can see the mucosa (consisting of a simple columnar epithelium) along the top edge of the slide. Underneath the mucosa, the mass appears as a collection of cells, each containing a single, large vacuole surrounded by a thin rim of cytoplasm [example]. 1. Identify the vacuolated cells (i.e. name the cell type, e.g. macrophages, lymphocytes, fibroblasts, etc.) 2.The lesion is certainly an "-oma" of some sort. Name the "-oma" and indicate whether it was benign or malignant. Slide 36 [WebScope] [ImageScope] This section is from a bulky neoplasm in the thigh of a 49-year-old woman.m from the thigh of a 49-year-old woman. At low magnification, you can see part of a lightly staining nodular lesion that is bordered by more deeply pink-staining tissue. Close inspection reveals a rather cellular neoplasm, lobules of which extend into adjacent, distorted skeletal muscle. Despite its light-staining quality, the neoplasm itself is extremely cellular and has a finely vascular background. Some of the cells in this lesion a more or less similar to those in slide 34 above. Other cells are rather peculiar, with multiple cytoplasmic vacuoles that characteristically indent their darkly-staining nuclei. Still others are rather nondescript-appearing, less well differentiated cells that have a more or less spindled shape. 1. This lesion is also an "-oma." Name the lesion and indicate whether it is benign or malignant. Slide 33 [WebScope] [ImageScope] This slide contains a biopsy of the uterus from a 38-year-old woman who presented with irregular menstruation and intesne, episodic uterine cramping. Grossly, the myometrium was distorted by numerous circumscribed nodules ranging in size from 2 to 6 centimeters. As you inspect this slide at low magnification, you will note a roughly circular area in the center of the tissue section that stains more deeply than the surrounding myometrium. This area is not really encapsulated, but it looks different, and seems to be separated from the adjacent myometrium along at least part of its circumference. Note that this circumscribed area is more densely cellular, with a higher concentration of nuclei and a bluer color. Note the structure of the surrounding normal myometrium -- interlacing bundles of spindle-shaped cells that run in fascicles. Some of these fascicles are cut longitudinally, and others in cross-section. You will see that the neoplasm is also composed of interlacing bundles of spindle shaped cells. While not actually encapsulated, the nodule is easily distinguished from its surroundings by its denser cellularity and darker color. Compare the nuclei in the neoplasm with those in the normal myometrium and note that they are essentially identical (although more closely packed). 1. Identify the primary cell type making up the neoplasm. 2. The lesion is also an "-oma" of some sort. Name the "-oma" and indicate whether it is benign or malignant. Slide 35 [WebScope] [ImageScope] This slide contains a section of the uterus from a 32-year-old woman who also presented with irregular menstruation and intense, episodic uterine cramping. As part of her initial workup, a biopsy was taken from which it was determined that the best course of action was to perform a radical hysterectomy along with medical treatment. The tissue shown here is from the outer wall of the uterus that was removed (the outer, fibrous capsule can be noted along the margins of the section). The underlying myometrium consists entirely of abnormal tissue. 1. Identify the primary cell type making up the neoplasm. 2. The lesion is also an "-oma" of some sort. Name the "-oma" and indicate whether it is benign or malignant. Slide 50 [WebScope] [ImageScope] A 19-year-old student presented to the campus health service complaining of transient knee and hip joint pains of one week’s duration. He had become febrile 2 days prior to seeking medical attention. Physical examination revealed swollen knee joints and small painless subcutaneous swellings located in the scalp and over the elbows. One week later, a heart murmur thought to be due to mitral regurgitation was detected. Congestive heart failure soon developed and the patient succumbed despite aggressive medical treatment. Slide 50 is prepared from the autopsy material. Note the fibrinopurulent inflammation of the epicardium [example]. Note the valvular endocardial fibrin deposits (excrescences) are present in the slide [example]. Note also the focal areas of inflammation and necrosis in the myocardium [example]. 1. You've seen this particular case before. What is the diagnosis? 2. While the disease was triggered by a bacterial infection, much of the symptoms are actually due to an autoimmune reaction. What general class of hypersensitivity reaction is this? Type I Type II Type III Type IV UMich Slide 178 [WebScope] [ImageScope] History: A 35-year-old man was clearing a path in the woods. When he returned home, he noticed an intensely pruritic linear vesicular eruption on his extensor forearms. A skin biopsy was taken. Histologic features: There is pronounced spongiosis (intercellular edema) within the epidermis resulting in intraepidermal vesicles. Exocytosis of lymphocytes (lymphocytic spongiosis) may be seen in the epidermis. There is a superficial perivascular lymphocytic infiltrate. 1. Based on the history, presentation, and histological findings, what do you think is the best diagnosis for this case? 2. What type (I, II, III, or IV) of hypersensitivity reaction is this? Type I Type II Type III Type IV CASE NUMBER 26 [WebScope] [ImageScope] Clinical History: This 48-year-old male with a history of Hepatitis B infection was admitted with a history of weight loss (approximately 20 pounds in the last 4 months) chills, fever, and pain in the right upper quadrant. He was diagnosed with cholecystitis and cholangitis (inflammtion of the gallbladder and bile duct) and the gallbladder was resected. Grossly, the walls of the gallbladder were thickened. The mucosa of the gallbladder was intact and numerous gallstones were present. Microscopically, the gallbladder had an unexpected finding. The small arteries in the wall are involved in a necrotizing and inflammatory process which appears to be in all stages of development, resolution, and healing. The earliest change seen is an acute fibrinoid necrosis of the wall of the artery, which appears in the innermost third of the media, frequently involves the wall in an eccentric arrangement, and finally involves the entire thickness of the wall. Many of these arteries are markedly dilated with the formation of aneurysmal-like sacs. There is a marked exudation of inflammatory cells both within the wall of the artery and surrounding the artery. These cells are made up of eosinophils, neutrophils, macrophages and lymphocytes [example]. In some of the vessels, the process appears to be in a healing phase with the site of artery represented by fibrous scar surrounded by a chronic inflammatory exudate. Arterioles, capillaries, and veins are relatively spared. 1. In light of these findings, it is likley that he has more a widespread "arteritis" (inflammation of the arteries) that is probably affecting other organs as well. Research the various types of arteritis and provide your best opinion as to which diagnosis is appropriate in this case. 2. What type (I, II, III, or IV) of hypersensitivity reaction is this? Type I Type II Type III Type IV UMich Slide 268 [WebScope] [ImageScope] UMich Slide 68alt [WebScope] [ImageScope] A 24-year-old man presented to the emergency room with dyspnea, cough, and wheezing. He had had numerous similar episodes, usually triggered or exacerbated by exposure to cold air, physical activity, and exposure to cats and birds. Physical examination revealed wheezing prominent in both phases of respiration which was relieved upon administration of inhaled albuterol. The samples shown are from another individual who had similar a similar bout of wheezing and lost consciousness while driving, resulting in a fatal motor vehicle crash. Note that significant inflammation is observed in the airways. Slide 268 is taken at the branching of the left and right main stem bronchi and shows extensive inflammatory changes in these large airways [example]. Slide 68alt was taken farther out in the lung tissue and shows obtruction and pathologic changes in the the bronchioles as well [example]. 1. You've seen a case similar to this before. What is the diagnosis? 2. The symptoms of episodic wheezing and dyspnea upon exposure to certain environmental factors are due to an autoimmune reaction. What general class of hypersensitivity reaction is this? Type I Type II Type III Type IV Click here to submit questions or comments about this site. Duke Univeristy \| Duke Medicine \| School of Medicine \| School of Nursing \| Doctor of Physical Therapy Program Copyright © 2004-2016 Duke University School of Medicine updated 11/14/16 - Velkey