Differential Diagnosis in Surgical Pathology: Expert Consult - Online and Print 2nd Edition

1107 Pages·2009·63.83 MB·English

by  Paolo Gattuso MD

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DIFFERENTIAL DIAGNOSIS IN SURGICAL PATHOLOGY ISBN: 978-1-4160-4580-9
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Library of Congress Cataloging-in-Publication Data
Differential diagnosis in surgical pathology. — 2nd ed. / [edited by] Paolo Gattuso … [et al.].
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-4160-4580-9
1. Pathology, Surgical. 2. Diagnosis, Differential. I. Gattuso, Paolo.
[DNLM: 1. Pathology, Surgical. 2. Diagnosis, Differential. WO 142 D5695 2009]
RD57.D535 2009
617′.075—dc22 2008048839

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Last digit is the print number: 9 8 7 6 5 4 3 2 1
To my wife Nancy and my children Vincent and Francesca.
Paolo Gattuso
To my son Vikram, for the nineteen years of life, love, and memories.
Vijaya B. Reddy
For my family, to whom I owe my appreciation of life and learning.
Odile David
To my parents for setting me on the right track, and to my wife Jodi
for her continuous support and encouragement.
Daniel J. Spitz
This book is dedicated to all of my former students, residents,
fellows, and physician associates who I have always learned more
from than I have been able to teach.
Meryl H. Haber
List of Contributors
Sylvia L. Asa, MD, PhD Byron E. Crawford, MD
Professor of Laboratory Medicine and Pathobiology Professor of Pathology
University of Toronto Faculty of Medicine Director of Anatomic Pathology
Pathologist-in-Chief Assistant Dean of Academic Affairs
Medical Director, Laboratory Medicine Program Tulane University School of Medicine
Senior Scientist, Ontario Cancer Institute New Orleans, Louisiana
Toronto, Ontario Bones and Joints
Canada
Adrenal Gland Magdalena Czader, MD, PhD
Assistant Professor
Director, Division of Hematopathology
Pincas Bitterman, MD Director, Clinical Flow Cytometry Laboratory
Professor of Pathology and Obstetrics and Gynecology Indiana University School of Medicine
Rush Medical College of Rush University Indianapolis, Indiana
Chicago, Illinois Spleen
Female Reproductive System
Michael J. Davis, MD
Instructor, Department of Ophthalmology
Jean E. Blair, MD
Rush Medical College of Rush University
Assistant Professor of Pathology
Chicago, Illinois
Northeastern Ohio Universities College of Medicine
Eye and Orbit
Rootstown, Ohio
Staff Pathologist
Adel K. El-Naggar, MD, PhD
AmeriPath Youngstown
Professor of Pathology and Head and Neck Surgery
Youngstown, Ohio
Program Director, Head and Neck Pathology Fellowship
Gastrointestinal System
University of Texas M.D. Anderson Cancer Center
Houston, Texas
Elizabeth J. Cochran, MD Head and Neck
Associate Professor of Pathology and Neurological Sciences
Rush Medical College of Rush University Mark F. Evans, PhD
Attending Physician Research Assistant Professor, Department of Pathology
Rush University Medical Center University of Vermont College of Medicine
Chicago, Illinois Burlington, Vermont
Central Nervous System Special Diagnostic Techniques in Surgical Pathology
Sandra E. Fischer, MD
Kumarasen Cooper, MBChB, FRCPath, DPhil Assistant Professor
Professor of Pathology University of Toronto Faculty of Medicine
University of Vermont College of Medicine Staff Pathologist
Director of Anatomic Pathology and Vice-Chair of Pathology University Health Network
Fletcher Allen Health Care Toronto, Ontario
Burlington, Vermont Canada
Special Diagnostic Techniques in Surgical Pathology Adrenal Gland
vii
viii Differential Diagnosis in Surgical Pathology
Richard J. Grostern, MD Cristina Magi-Galluzzi, MD, PhD
Assistant Professor of Ophthalmology and Pathology Assistant Professor
Rush Medical College of Rush University Cleveland Clinic Lerner College of Medicine of Case Western
Chicago, Illinois Reserve University
Eye and Orbit Director of Genitourinary Pathology
Cleveland Clinic Foundation
Mehmet Guler, MD, PhD Cleveland, Ohio
GI/Liver Fellow, Department of Pathology Ureter, Urinary Bladder, and Kidney
Johns Hopkins Medical Institutions
Baltimore, Maryland Maria J. Merino, MD
Pancreas Chief, Translational Surgical Pathology
National Institutes of Health
Ralph H. Hruban, MD National Cancer Institute
Professor of Pathology and Oncology Bethesda, Maryland
Johns Hopkins University School of Medicine Breast
Attending Pathologist
The Johns Hopkins Hospital
Cesar A. Moran, MD
Baltimore, Maryland
Professor of Pathology and Deputy Chairman of Anatomic
Pancreas
Pathology
University of Texas M.D. Anderson Cancer Center
Aliya N. Husain, MD
Houston, Texas
Professor of Pathology
Thymus and Mediastinum
University of Chicago Pritzker School of Medicine
Chicago, Illinois
Lung and Pleura Attilio Orazi, MD
Professor of Pathology and Laboratory Medicine
Alexandra N. Kalof, MD Weill Cornell Medical College of Cornell University
Assistant Professor of Pathology Attending Pathologist
University of Vermont College of Medicine Director, Division of Hematopathology
Attending Physician, Department of Pathology New York-Presbyterian Hospital
Fletcher Allen Health Care New York, New York
Burlington, Vermont Spleen
Special Diagnostic Techniques in Surgical Pathology
Robert E. Petras, MD
Robin D. LeGallo, MD Associate Clinical Professor of Pathology
Assistant Professor of Pathology Northeastern Ohio Universities Colleges of Medicine
University of Virginia Medical Center Rootstown, Ohio
Charlottesville, Virginia AmeriPath Gastrointestinal Institute
Soft Tissue Oakwood Village, Ohio
Gastrointestinal System
Jerome M. Loew, MD
Associate Professor of Pathology
Michael R. Pins, MD
Rush Medical College of Rush University
Professor of Clinical Pathology
Assistant Attending
University of Illinois at Chicago College of Medicine
Rush University Medical Center
Medical Director, Anatomic Pathology
Chicago, Illinois
Advocate Lutheran General Hospital
Lymph Nodes
Park Ridge, Illinois
Male Genitourinary System
Alexander Craig MacKinnon, Jr., MD, PhD
Fellow, Molecular Genetic Pathology and Cardiovascular
Jose A. Plaza, MD
Pathology
Assistant Professor of Pathology
University of Chicago Medical Center
Medical College of Wisconsin
Chicago, Illinois
Milwaukee, Wisconsin
Lung and Pleura
Thymus and Mediastinum
William R. Macon, MD
Professor of Laboratory Medicine and Pathology Martha M. Quezado, MD
Mayo College of Medicine Staff Pathologist
Consultant in Pathology, Department of Laboratory Medicine Laboratory of Pathology
and Pathology National Cancer Institute
Mayo Clinic Foundation National Institutes of Health
Rochester, Minnesota Bethesda, Maryland
Lymph Nodes Breast
List of Contributors ix
Vijaya B. Reddy, MD Carmela D. Tan, MD
Professor and Associate Chair of Pathology Staff, Section of Cardiovascular Pathology
Rush Medical College of Rush University Department of Anatomic Pathology
Senior Attending Cleveland Clinic Foundation
Rush University Medical Center Cleveland, Ohio
Chicago, Illinois Heart, Pericardium, and Blood Vessels
Skin and Adnexal Structures
Mark R. Wick, MD
Professor of Pathology
University of Virginia School of Medicine
E Rene Rodriguez, MD
Associate Director of Virginia Health System
Adjunct and Professor
Charlottesville, Virginia
Johns Hopkins University School of Medicine
Soft Tissue
Baltimore, Maryland
Staff, Department of Anatomic Pathology
Michelle D. Williams, MD
Cleveland Clinic Foundation
Assistant Professor of Pathology
Cleveland, Ohio
University of Texas M.D. Anderson Cancer Center
Heart, Pericardium, and Blood Vessels
Houston, Texas
Head and Neck
Matthew M. Yeh, MD, PhD
Saul Suster, MD
Associate Professor of Pathology
Chairman and Professor, Department of Pathology and
University of Washington School of Medicine
Laboratory Medicine
Staff Pathologist
Medical College of Wisconsin
Gastrointestinal and Hepatic Pathology
Milwaukee, Wisconsin
University of Washington Medical Center
Thymus and Mediastinum
Seattle, Washington
Hepatobiliary System
Paul E. Swanson, MD Ming Zhou, MD, PhD
Professor of Pathology Assistant Professor
University of Washington School of Medicine Cleveland Clinic Lerner College of Medicine of Case Western
Director of Anatomic Pathology Reserve University
Director of Immunocytochemistry Staff Pathologist
University of Washington Medical Center Cleveland Clinic Foundation
Seattle, Washington Cleveland, Ohio
Hepatobiliary System Ureter, Urinary Bladder, and Kidney
Preface
It has been nearly seven years since the publication of from additional acknowledged expert pathologists.
the first edition of this textbook. Who knew then that Another significant change from the first edition is the
Differential Diagnosis in Surgical Pathology would become inclusion of almost all color images in this edition.
a textbook widely used by residents and fellows in The editors, aware of the success of the book,
pathology departments in the United States, as well as became even more aware of some of its deficiencies or
around the world, and by innumerable practicing inadequacies. Every attempt to rectify any shortcomings
pathologists. As a result of this widespread acceptance the has been made in this edition. The use of algorithms, a
authors began the process of updating and revising the prominent feature of the first edition, has been dropped.
text and illustrations while making certain to continue Instead, each chapter outline follows a logical algorithmic
the successful features of the first edition, especially the approach to arriving at a correct diagnosis. The reason for
organization by systems; the use of an outline format for this change relates to the uneven quality of several of the
text; and integration of the photomicrographic images original algorithms and the fact that not all were useful in
with corresponding subject matter. This process took over reaching an accurate diagnosis, mostly because of the
three years. complexity of the diagnostic problem.
Writing a new textbook is an immense undertaking; The first edition’s concept of brevity of each topic, not
writing a second edition is, perhaps, an even greater encyclopedic coverage, and outline text format
undertaking. In this cost-containment environment an accompanied by integrated illustrative examples of the
important consideration was to keep the book’s price pathology and limited references is maintained. It is hoped
affordable for its audience, primarily by not increasing the that this textbook will find its way into the hands of
number of pages (over 1000) while updating the content. residents and practicing pathologists because of its concise
This was achieved with cautious and careful editing. It format, excellent representative illustrations, and
was also of primary importance to fill obvious gaps and immediate usefulness.
revise subject matter where needed with contributions Meryl H. Haber
xi
Acknowledgments
The second edition of this textbook has greatly benefited publisher, Elsevier, and William R. Schmitt, Executive
from the expertise and experience of its many contributors Editor, for his support and encouragement in the
throughout the United States of America and Canada. production of a second edition. A special thanks to Katie
We thank them all wholeheartedly for placing their DeFrancesco, Development Editor at Elsevier, for her
confidence in this book and sharing their knowledge so patience and competence in keeping the book on course
freely. over the last three years, and to Amy Norwitz, Senior
The editors gratefully acknowledge the work of authors Project Manager at Elsevier, who oversaw with great skill
who have contributed to this book in its previous edition. and tenacity the excruciating details that go into the final
We thank Irma Parker, Mira Davis, and Rachel Martin stages of the publication process.
for their secretarial assistance. We are thankful to our Vijaya B. Reddy, MD
xiii
Alexandra N. Kalof, Mark F. Evans, and Kumarasen Cooper
1
Special Diagnostic
Techniques in
Surgical Pathology
Light Microscopy Flow Cytometry
Tissue Processing Overview 2 Introduction 20
Fixation 2 Technical Overview 21
Pearls 3
Histologic Stains 3
Cytogenetic Analysis
Fluorescence Microscopy
Molecular Pathology Methods
Introduction 24
Electron Microscopy
Nucleic Acid Extraction
Technical Overview 8 Methods 24
Ultrastructure of a Cell 8 Tissue Microdissection
Methods 25
Amplification Methods 25
Immunohistochemistry
Gel Electrophoresis Methods 32
Introduction 10 Hybridization Methods 32
Technical Overview 10 Nucleic Acid Sequencing 37
Ground Rules for Quality Application Protein Analytical Methods 37
of Immunohistochemistry in Emerging Methodologies 37
Surgical Pathology 11
A Practical Tabular Approach to
Using Immunohistochemistry
for Common Diagnostic
Problems 12
Pearls 12
1
2 Differential Diagnosis in Surgical Pathology
A buffer prevents acidity that would promote
Light Microscopy
autolysis and cause precipitation of formol-
heme pigment in the tissues
Tissue Processing Overview
Tissue is fixed by cross-linkages formed in
● Fixation the proteins, particularly between lysine
— Preserves tissues in situ as close to the lifelike state residues
as possible This cross-linkage does not harm the structure
— Ideally, fixation will be carried out as soon as of proteins greatly, preserving antigenicity,
possible after removal of the tissues, and the and is therefore good for immunoperoxidase
fixative will kill the tissue quickly, thus preventing techniques
autolysis ◆ Glutaraldehyde
● Dehydration The standard solution is a 2% buffered
— Fixed tissue is too fragile to be sectioned and must glutaraldehyde and must be cold, buffered,
be embedded first in a nonaqueous supporting and not more than 3 months old
medium (e.g., paraffin) Fixes tissue quickly and therefore is ideal for
— The tissue must first be dehydrated through a EM
series of ethanol solutions Causes deformation of α-helix structure
● Clearing in proteins and therefore is not good for
— Ethanol is not miscible with paraffin, so nonpolar immunoperoxidase staining
solvents (e.g., xylene, toluene) are used as Penetrates poorly but gives best overall
clearing agents; this also makes the tissue more cytoplasmic and nuclear detail
translucent Tissue must be as fresh as possible
● Embedding and preferably sectioned within the
— Paraffin is the usual embedding medium; however, glutaraldehyde at a thickness of no more
tissues are sometimes embedded in a plastic resin, than 1 mm to enhance fixation
allowing for thinner sections (required for electron — Mercurials
microscopy [EM]) ◆ B-5 and Zenker
— This embedding process is important because the Contain mercuric chloride and must be
tissues must be aligned, or oriented, properly in the disposed of carefully
block of paraffin Penetrate poorly and cause tissue hardness
● Sectioning but are fast and give excellent nuclear
— Embedded in paraffin, which is similar in density to detail
tissue, tissue can be sectioned at anywhere from 3 Best application is for fixation of hematopoietic
to 10 µm (routine sections are usually cut at 6 to and reticuloendothelial tissues
8 µm) — Alcohols
● Staining ◆ Methyl alcohol (methanol) and ethyl alcohol
— Allows for differentiation of the nuclear and (ethanol)
cytoplasmic components of cells as well as the Protein denaturants
intercellular structure of the tissue Not used routinely for tissue because they
● Cover-slipping dehydrate, resulting in tissues’ becoming
— The stained section on the slide is covered brittle and hard
with a thin piece of plastic or glass to protect Good for cytologic smears because they act
the tissue from being scratched, to provide quickly and give good nuclear detail
better optical quality for viewing under the — Oxidizing agents
microscope, and to preserve the tissue section ◆ Permanganate fixatives (potassium
for years permanganate), dichromate fixatives
(potassium dichromate), and osmium tetroxide
cross-link proteins
Fixation
◆ Cause extensive denaturation
● There are five major groups of fixatives, classified ◆ Some of these have specialized applications but
according to mechanism of action are used infrequently
— Aldehydes — Picrates
◆ Formalin ◆ Bouin solution has an unknown mechanism of
Aqueous solution of formaldehyde gas that action
penetrates tissue well but relatively slowly; ◆ It does almost as well as mercurials with
the standard solution is 10% neutral buffered nuclear detail but does not cause as much
formalin hardness