Microscopy Tutorials

1
Microscopy Tutorials

• This covers the WebCT microscopy tutorials for
  Term 2 and Term 3 for pathology
• These are fairly heavy slides in some cases,
  with a decent amount of detail. Like the last
  powerpoints, this one is also set up to
  self-test yourself with the images so that
  should one of these nasty micro pictures come up
  in an exam MCQ...... Hopefully you recognise
  something p
• Best of luck!

2
Respiratory and CVS
3
Case 1 35yo female, atrial mass
4
Case 1 35yo female, atrial mass (cont)
Dispersed plump and stellate mesenchymal cells
Polypoidal fragments
Cardiac muscle showing degenerative changes with
fibrosis and inflammatory foci
Surface lining of endothelial cells invaginating
into underlying stroma
Areas of blood clot and fibrin
Left Atrial Mass - Atrial Myxoma
5
Case 2 58yo female Biopsies upper and middle
lobe right lung
Macroscopic view of 5 pieces of cream tissue
Extensive granulomatous inflammation comprising
epithelioid histiocytes and multinucleated giant
cells with surrounding chronic inflammation and
fibrosis
Florid non-caseating granulomatous inflammation
consistent with sarcoidosis
Bronchial wall tissue
6
Case 3 68yo female, pleural effusion, left upper
lobe mass, non-smoker
Forming acinar structures
Moderately cellular
Numerous malignant cells
Pleomorphic hyperchromatic nuclei, often
prominent single nucleoli and moderate amounts of
vacuolated cytoplasm
Immunohistochemistry shows cells positive for
ttf-1
PAS/D stain shows intracytoplasmic mucin on
malignant cells
Malignant adenocarcinoma (primary)
7
Case 4 Colonic cancer diagnosed 5-6 years ago
with a subsequent liver secondary resected.
Obstructed right middle bronchus
Necrotic material
infiltrating adenocarcinoma with a desmoplastic
stromal response
Adenocarcinoma composed of glands in back-to-back
arangement
Nuclear crowding, stratification and loss of
polarity
Immunohistochemistry shows the tumour cells to be
positive for CK20
Bronchial biopsy extensively necrotic
moderately differentiated adenocarcinoma
consistent with metastasis from a colonic primary.
8
Case 5 48yo female, left pleural mass Core
biopsy of mass
Core of tissue
Focal infiltration by a malignant tumour
Acini lined by pleomorphic cuboidal epithelium
Mucin within glandular structures can be
demonstrated with the D/PAS
Immunohistochemistry shows positive cytoplasmic
staining for EMA
Adenocarcinoma consistent with an origin from a
primary lung tumour
9
Case 6 Pneumothorax
Multinodular and stellate expansion of the
pulmonary interstitium
Polymorphous infiltrate composed of lymphocytes,
plasma cells, eosinophils and foamy macrophages
Interstitial lung disease
Histiocytic cells with enlarged oval nuclei
showing a vesicular chromatin pattern, very
occasional grooving and prominent nucleoli
Cells show positivity for CD1a
Multifocal nodular interstitial histiocytic
infiltration with features consistent with
Langerhans cell histiocytosis (Histiocytosis X)
10
Case 7 58 year old women no history Sputum
Sample (yummy)
Numerous highly atypical squamous cells that have
polygonal, spindled and bizarre cell shapes
Cellular
Benign squamous cells
Round to oval nuclei which are either
degenerate/pyknotic or have coarse granular
chromatin
Squamous Cell Carcinoma
11
Endocrine System
12
Case 1 71yo male, lump right thyroid lobe US
guided FNA of nodule
Highly cellular
Abundant epithelial cells arranged in sheets,
rounded aggregates
Occasional finger-like projections
Crowded, rounded or oval nuclei
Prominent intranuclear inclusions
Thick colloid
Papillary thyroid carcinoma
13
Case 1 Follow up
Papillary architecture of the tumour with central
branching fibrovascular cores lined by a layer of
neoplastic epithelium
multifocal papillary carcinoma
Invasion of normal thyroid
Metastatic papillary carcinoma was present within
one of the perithyroidal lymph nodes
14
Case 2 47yo male, hypertension resistant to
treatment, right adrenal mass on imaging, right
laparoscopic adrenalectomy
Expansion of the adrenal medulla by a tan tumour
Demarcated from the adrenal cortex but without a
definite capsule
Cells arranged in anastomosing trabeculae
Cells arranged in nested pattern
Tumour cells are polygonal with round to oval
nuclei, dispersed chromatin and moderate to
abundant granular eosinophilic cytoplasm
15
Case 2 (cont)
Immunohistochemistry shows the tumour cells to be
positive for neuroendocrine marker chromogranin
Negative for adrenocortical markers (calretenin
and melan A)
Pheochromocytoma
16
Case 3 57yo female - massive goitre present for
years (image), patient unaware, thought it was
obesity. Current airways symptoms especially when
supine
On examination
Small amount of thyroid epithelium
abundant thin colloid
flat and folded sheets of uniform follicular
epithelial cells
Benign multinodular goitre
17
Case 3 Follow up
18
Case 4 52yo female - diffusely enlarged thyroid
with multiple small nodules, previous FNA of
single thyroid nodule
Aggregates of Hurthle cells, some follicular
epithelium and numerous lymphoid cells in a
heavily bloodstained background
lymphocytes can be seen intimately mixed with a
follicular and Hurthle epithelium
Hurthle cells have round nuclei and abundant
granular cytoplasm
Thyroid gland is pale because of the inflammatory
infiltrate and increasing fibrosis
Autoimmune disease with antibodies against
thyroid epithelial cells causing their destruction
Hashimoto's thyroiditis
19
Case 5 58yo female - non functioning (negative
functional studies) right adrenal tumour
associated with episodic hypokalaemia and
hypertension
Tumour well circumscribed and encapsulated with
adjacent compressed adrenal gland
tumour cells are arranged in compact, closely
apposed nests and trabeculae
tumour demonstrates slitlike sinusoidal blood
vessels
mitotic count is up to 12/50 high power fields
Discreet areas of tumour necrosis and foci
suspicious of lymphovascular space invasion are
noted
Immunohistochemistry positive for inhibin
Adrenal cortical carcinoma
20
Case 5 (cont)
Macroscopic adrenal gland tumour
21
Case 6 31yo female - enlarging right side thyroid
nodule, 6/40 pregnant - FNA right thyroid nodule
follicular epithelium forming small clusters and
micro follicular aggregates
Thick colloid which is also present as free lying
globules
Follicular neoplasm - differentiation between a
follicular adenoma and carcinoma is not possible
on cytological criteria
follicular cells demonstrate round to oval nuclei
with an even chromatin pattern
22
Case 6 Follow up
23
Skin / Breast
24
Case 1 Right cheek skin lesion
centrally located pale indurated and ulcerated
zone
ulcerated basal cell carcinoma of nodular type
infiltrating to the level of the mid dermis
tumour comprises well circumscribed islands of
basaloid cells arising from the base of the
epidermis and infiltrating into the underlying
dermis
islands show peripheral palisading and the cells
have round to oval hyperchromatic nuclei and
scanty cytoplasm
Ulcerated nodular basal cell carcinoma
25
Case 2 84 yo man, excision of skin lesion right
lateral thigh
tumour comprises irregular interlocking
trabeculae and islands within an inflamed stroma
centrally located cream to white smooth nodule
well differentiated keratinising squamous cell
carcinoma infiltrating the level of deep dermis
islands show maturation of the cells on towards
the middle with central keratinisation and
keratin pearl formation
cells have large vesicular nuclei, prominent
nucleoli and abundant pink cytoplasm
Squamous cell carcinoma
26
Case 3 84 yo man, excision of skin lesion right
lateral thigh
proliferation of atypical melanocytes along the
dermo-epidermal junction extending down along
adnexal structures
occasional nesting
skin ellipse, border is irregular and the
pigmentation variable, margins clear
elongated hyperchromatic nuclei, granular
chromatin, small nucleoli and variable pale
cytoplasm
melanocytes are more epithelioid and display
vesicular moderately pleomorphic nuclei with
prominent nucleoli and moderate eosinophilic
cytoplasm containing abundant pigmen
Nodular melanoma arising in lentigo malignant
melanoma
27
Case 4 68 yo female with palpable lump in right
breast. A mammogram shows a stellate opacity
FNA aspiration
population of cells arranged in large cohesive
groups as well as singly, in a background of
blood
cells have large (when compared to a red blood
cell) pleomorphic nuclei and a moderate amount of
cytoplasm and there is considerable variation
between cells
Malignant Carcinoma of the Breast
28
Case 5 8mm mass 10 o'clock right breast US
guided core biopsy
tumour invades in cords and irregular tubular
structures through a fibrous stroma
cells are crowded and disorganised and show large
nuclei, granular chromatin, small nucleoli and
scanty cytoplasm
Lumpectomy performed to remove carcinoma with a
margin of uninvolved tissue
Immunohistochemistry for oestrogen receptors
shows strong and moderate nuclear positivity in
50 of cells
Invasive Ductal Carcinoma
29
Case 6 8mm mass 10 o'clock right breast US
guided core biopsy
Lumpectomy specimen comprising breast tissue
fibrofatty tissue within which lies a
circumscribed mass consisting of myxoid stroma
stroma is moderately cellular and there is
accentuation of the myxoid nature around the
ductal structures
ducts are lined by a double layer of cells
comprising an outer flattened layer and an inner
cuboidal to columnar layer showing mild
hyperplasia
Benign Fibroadenoma
30
CNS
31
Case 1 54yo female -- History of confusion
Brain Biopsy
Bifrontal and suprachiasmic tumour
Mitotic figures
smaller separate piece of necrotic tumour
Microvascular proliferation
Immunohistochemistry reveals strong staining for
glial fibrillary acid protein (GFAP)
Glioblastoma multiforme
32
Case 2 39yo female, incidental left frontal
convexity tumour
tumour is seen attached to a small amount of
dural tissue
composed of whorls of spindle cells surrounded by
fine fibrous tissue
Meningioma
Scattered psammoma bodies are present
33
Case 3 33yo male with acromegaly
Smears of tissue
Pituitary adenoma
cytoplasm is relatively abundant and either
markedly granular and eosinophilic or only
lightly staining
Immunohistochemical stains show widespread strong
positivity for growth hormone
34
Case 4 54yo male presenting with increasing
unsteadiness. Known history of non-small cell
lung carcinoma
CT shows cerebellar tumour
moderately differentiated adenocarcinoma
infiltrating and effacing the cerebellar
parenchyma
tumour is characterised by complex glands
malignant cells have hyperchromatic, mildly
pleomorphic nuclei often with prominent nucleoli
Immunohistochemistry reveals positive cytoplasmic
staining for cytokeratin7
negative staining for cytokeratin20
Cerebellar tumour -- metastatic moderately
differentiated adenocarcinoma
35
Liver
36
Case 1 Jaundiced
Several portal tracts show mild fibrous expansion
moderate proliferation of bile ductules with
native bile ducts intact
Cholestasis
parenchyma shows marked cholestasis with feathery
degeneration of hepatocytes and accumulation of
bile within hepatocytes and canaliculi
37
Case 2 63yo male - long history of alcohol abuse,
abnormal liver function tests (GGT 539, ALT 65),
stigmata of chronic liver disease
architectural distortion due to fibrous expansion
of the portal tracts with extension of fine
fibrous septa into the lobules
moderate chronic inflammation within the portal
tracts, which extends into the lobules as
piecemeal necrosis
numerous neutrophils, both at the edge of the
portal tracts, and within the lobular parenchyma,
often associated with degenerate or necrotic
hepatocytes
fatty change affecting 80 of hepatocytes
normal portal tract
Active chronic hepatitis resulting in incipient
cirrhosis consistent with HCV
38
Case 3 45yo man, asymptomatic, abnormal liver
function tests (LFTs) found during medical
examination for life insurance. Mild alcohol
intake, drug use in his early 20s.
piecemeal necrosis
Lymphoid aggregates are noted
moderate portal tract fibrosis with portal to
portal bridging, focally resulting in a nodular
parenchyma
Lobules contain occasional necro-inflammatory
foci with mild/moderate steatosis
Occasional apoptotic hepatocytes are noted
rat liver showing a classical lobular architecture
Active steatohepatitis with severe fibrosis
falling short of cirrhosis
39
Case 4 64 yo man - chronic liver disease
secondary to HCV infection resulting in
cirrhosis. A mass was detected in the liver on
screening ultrasound and confirmed with MRI
focal endothelial rimming
cohesive aggregates of cells
Normal
Increased nuclear to cytoplasmic ratio
Cells are crowded and disorganized
Hepatocellular carcinoma
40
Case 5 66yo male - abnormal liver function tests
(LFTs), increased ferritin, haemochromatosis
screen positive
The portal tracts show minor fibrosis and a mild
inflammatory infiltrate consisting of lymphocytes
and eosinophils
Bile ducts are present within portal tracts and
appear unremarkable. Increased iron pigment is
noted within the hepatocytes
Perl's special stain for iron (blue staining)
Haemachromatosis
41
Bone Tumours

• 6 cases

42
Case 1 71 year old woman presented with back
pain. Lytic lesion L3 vertebral body on CT scan
plasma cells are seen in HE sections
immunohistochemical reactions for CD138
lambda light chain restriction confirming
monoclonality
Multiple myeloma
43
Case 2 Known prostatic cancer, thoracic cord
compression (CT scan and MRI) Imaging showed
multiple bony metastases in cervical, thoracic
and lumbar spine, fracture T7/8 with epidural
tumour spread T5-T8. Also massive abdominal
lymphadenopathy. Note osteosclerotic lesions in
CT scan and encroachment on spinal cord in MRI.
Immunohistochemical reactions show reactivity
with PSA
Bone is infiltrated by deposits of tumour cells
in sheets and forming rare glands
Metastatic carcinoma of prostate.
44
Case 3 14 year old schoolboy who presented with a
3 month history of pain in the left thigh which
apparently related to an injury sustained while
trampolining. CT scans and MRI were performed
(Images 1, 2 and 3).
Sections show pleomorphic cells of spindled or
rounded contour as well as numerous giant cells.
The malignant cells show mitotic activity
including abnormal mitoses. The tumour is
associated with the deposition of osteoid matrix
Osteosarcoma left femur
45
Case 4 A 53 year old male who presented with a
fractured right tibia. Imaging revealed a lytic
lesion in the right distal femur
The tumour is composed of multinucleate giant
cells as well as sheets of mononuclear cells
arranged in a compact fashion with little
intervening collagen. Rare mitotic figures are
seen. Reactive bone formation is present at the
periphery.
Giant cell tumour of bone
46
Case 5 A 74 year old woman presented with a 2
month history of right groin pain, paratially
relieved by Dexamethasone. Image showed a lesion
in the upper shaft of right femur
Tumour with a lobulated growth pattern composed
of neoplastic chondrocytes separated by bands of
collagenous connective tissue
The neoplastic cells lie in lacunae surrounded by
abundant chondroid matrix. The nuclei are
moderately pleomorphic nuclei some binucleate
forms are seen
Chondrosarcoma of right femur
47
Case 6 A 20 year old woman presented with a
painful right rib. She was febrile and
leukocytosis was present. Imaging showed an
expansile mass eroding through the cortex.
48
Case 6 cont
frequent mitotic activity
The tumour cells show immunoreactivity with CD99
Electron microscopy showed undifferentiated cells
with abundant glycogen and rudimentary cell
junctions
Ewings Sarcoma/ peripheral neuroectodermal
tumour. (PNET)
49
Case 6 cont
Cytogenetic studies showed a major cell (line)
with a t (11 22) translocation.
50
Lower GIT

• 6 cases

51
Case 1 43-year-old female, lethargy and anaemia
Normal mucosa
Atrophic duodenal mucosa
blunting broadening and oedema of the villi
lamina propria is expanded by a mild infiltrate
of neutrophils in addition to increased numbers
of chronic inflammatory cells
increased numbers of intra-epithelial lymphocytes
normal villous architecture
Coeliac Disease
52
Case 2 45-year-old male subtotal colectomy for
severe ulcerative colitis not responsive to
medical therapy
Shallow ulcers
Section of colon with caecum and appendix -
distal four fifths of the mucosa are erythematous
with a nodular appearance
Architectural distortion of the glands including
branching and shortening
severe acute on chronic inflammatory cell
infiltrate consisting of polymorphs, lymphocytes
and plasma cells
normal villous architecture
Focus ulceration
Moderate to severe active chronic ulcerative
colitis
53
Case 3 37-year-old male resection of distal
ileum and proximal colon (right hemicolectomy)
for structuring secondary to ___________________
Mucosal surface of the small bowel appears
ulcerated and congested showing a cobblestone
appearance
Wall appears markedly thickened and there is a
stricture involving the distal terminal ileum
14cm terminal ileum, caecum and 13cm ascending
colon - serosal surface shows fat wrapping (blue
arrows)
Focal full thickness mucosal ulceration extending
into the submucosa
Lamina propria is markedly inflamed 
Transmural chronic inflammation with numerous
lymphoid aggregates
Active Crohn's disease with ulceration and
stricturing
54
Case 3 37-year-old male resection of distal
ileum and proximal colon (right hemicolectomy)
for structuring secondary to ___________________(
continued)
granulomata
Section of normal colon
55
Case 4 21-year-old male, appendicitis
Pus within the lumen of the appendix (blue arrows)
Pus and blood in the lumen 
The distal two thirds of appendix is swollen and
congested with a patchy coating of purulent
material over the serosal surface
focal ulceration of the mucosa (green arrows)
extensive acute transmural inflammation which
extends into the mesentery with an accompanying
fibrinopurulent peritonitis
Acute suppurative appendicitis
56
Case 5 67-year-old male, obstructing carcinoma in
the sigmoid colon with liver metastases
Moderately differentiated adenocarcinoma invading
through the full thickness of bowel wall into the
sub-serosal tissues
Irregular islands showing a cribriform
architecture in a desmoplastic stroma
Circumferential constricting tumour
Polyp
epithelial cells are disorderly and have large
pleomorphic columnar nuclei and prominent
nucleoli
Tubular adenoma showing low grade dysplasia
Contrast between the normal glands and the
dysplastic glands which are lined by crowded
pseudostratified epithelium
Carcenoma of sigmoid colon
57
Inflammatory Skin

• 7 cases

58
Case 1 64 year old woman presented with localized
rash tip of nose
Sections show epidermis and dermis. There is
follicular plugging, basal vacuolar change,
thickening of the basement membrane and a
lichenoid inflammatory infiltrate and a
superficial and deep perivascular and periadnexal
lymphocytic infiltrate. There is no evidence of
malignancy.
Lupus erythematosus
59
Case 2 43 yo woman presented with annular
urticarial rash that heals with staining
Sections show epidermis, dermis and subcutis.
There is mild acanthosis overlying a superficial
and deep perivascular neutrophilic, lymphocytic
and eosinophilic infiltrate accompanied by dermal
oedema. Many of the dermal vessels are lined by
plump endothelium accompanied by nuclear dust and
red cell extravasation. No panniculitis is seen.
Direct immunofluorescence shows prominent
vascular C3 and perivascular fibrinogen in
keeping with vasculitis.
Urticarial vasculitis
60
Case 3 65 year old man presented with shiny moist
erythematous plaques on penis.
Sections show ulcerated dermis only. No
epithelium is present for assessment. The dermis
shows oedema, dilated capillaries and a dense
lymphoplasmacytic infiltrate. Focal histiocytic
aggregates are noted on the surface
Zoons balanitis
61
Case 4 62 year old man with multiple dystrophic
nail plates
Sections show nail bed epithelium and underlying
stroma. There is flattening of the rete ridges,
patchy basal vacuolar change and focal
dyskeratosis, overlying a superficial
perivascular lymphocytic infiltrate with a focal
lichenoid appearance. No neutrophils are present.
The appearances are compatible with lichen planus
Lichen planus
62
Case 5 27 year old woman presented with livedo
racemosa
Erythema ab igne (EAI, or "dermatitis ab igne")
refers to skin that is reddened due to long-term
exposure to infrared radiation. (thankyou
wikipedia)
Sections show epidermis, dermis and subcutis.
There is flattening of the rete ridges and intact
basal layer with no diagnostic abnormality
overlying a sparse superficial dermal
perivascular lymphocytic and histiocytic
infiltrate. No abnormality in the dermal elastic
fibres is noted.
Erythema ab igne
63
Case 6 43 year old woman recently had plant
extract body wrap cosmetic treatment
Sections show epidermis and dermis. There is
irregular acanthosis and elongated rete ridges
with extensive basal vacuolar change and
prominent dyskeratosis, including foci of
dyskeratosis overlying a sparse lichenoid
inflammatory infiltrate with scattered
eosinophils. No deep dermal inflammatory
infiltrate is seen
Allergic Contact Dermatitis
64
Case 7 57 year old man with a history of diabetes
initially presented with a lesion on the right
leg clinically diagnosed as necrobiosis lipoidica
diabeticorum (NLD). Recently CXR and CT showed
pulmonary granulomata and mediastinal
lymphadenopathy, accompanied by multiple
cutaneous annular lesions with scaling on limbs
and face
Sections show epidermis, dermis and subcutis. The
epidermis is raised with flattening of the rete
ridges overlying a non-necrotising nodular
superficial and mid dermal granulomatous
inflammatory infiltrate, consisting of tightly
packed nodules of epithelioid histiocytes and
multinucleated giant cells accompanied by a
sparse patchy lymphocytic infiltrate and
sclerotic collagen. Occasional eosinophils are
noted. No fungal pathogens are identified with a
PAS stain
Sarcoidosis
65
Female Genital Tract

• 5 cases

66
Case 1 32 years. Pap smear 4 weeks ago
possible high grade squamous abnormality
Colposcopy aceto-white area and abnormal
vessels
Cervical transformation zone mucosa shows
extensive cervical intra-epithelial neoplasia
CIN involving the surface squamous epithelium and
extending into endocervical crypts
crowded and disorganised epithelial cells
exhibiting nuclear hyperchromasia and
irregularity with prominent mitotic and apoptotic
activity
Cervical Intraepithelial Neoplasia (non-invasive)
67
Case 2 A 47 year old female with a history of
irregular PV bleeding and post coital bleeding.
No Pap smear for 17 years.
Extensive and almost circumferential cervical
tumour along the distal endocervical canal
Invasive, moderately to poorly differentiated
squamous carcinoma (yellow arrows) focal CIN
(green arrow)
Cords and nests of keratinocytes
Keratinisation is seen in a few areas but the
tumour cells exhibit marked nuclear pleomorphism
Squamous Cell Carcinoma
68
Case 3 35 years. Menorrhagia and irregular PV
bleeding for 8 months, not controlled on medical
therapy. Hysterectomy.
Multiple intramural fibroids and partly
submucosal fibroid
Features of benign leiomyomas comprising
fascicles of uniform smooth muscle cells well
demarcated from the adjacent normal myometrium 
Multiple benign leiomyomas and an endometrial
polyp
69
Case 4 65 year old female. Post menopausal
bleeding. Endometrial curette
Partly necrotic tumour mainly situated on the
posterior and left lateral walls
Invasive adenocarcinoma of endometrioid type
Well formed glands lined by stratified columnar
cells showing low to intermediate grade
cytological abnormality
Endometrioid adenocarcinoma invading outer half
of myometrium
70
Case 5 5 years. Family history of ovarian and
breast cancer. Vague abdominal pain and
increasing abdominal swelling for 6 months. CT-
ascites and bilateral ovarian masses
Omentum shows extensive tumour involvement
Solid growth pattern with focal papillary and
glandular structures
Partly cystic ovarian masses
Pleomorphism
Numerous mitotic figures (48/10 high power
fields) including abnormal forms
The tumour infiltrates the capsule of both
ovaries and is confirmed to be present within the
omentum
Adenocarcinoma ovarian origin - widespread
intra-abdominal malignancy with omental 'cake'
71
Lymphoreticular System

• 6 cases

72
Case 1a Supraclavicular lymph node resection.
Normal lymph node architecture is replaced by
clusters, cords and fascicles of cells
Mixed epithelioid and spindled morphology
Abundant brown pigment consistent with melanin is
focally identified
Immunohistochemistry shows the tumour cells to
positive for melanoma markers S100
Metastatic Malignant Melanoma
73
Case 1b Total thyroidectomy and right modified
radical neck dissection, and subsequent FNA of
cervical lymph node
Metastatic papillary carcinoma of thyroid
Cellular FNA
cystic degeneration 
Well formed papillary structures with
fibrovascular cores
Cells have round to oval nuclei with nuclear
grooves and scattered intranuclear inclusions
Papillary carcinoma of thyroid with lymph node
metastases
74
Case 1c Sentinel lymph node fatty tissue
containing two lymph nodes.
Large round to oval nuclei, coarse chromatin and
prominent nucleoli
Lymph note partially infiltrated by metastatic
breast carcinoma
Immunohistochemical stain for cytokeratin (AE
13) is positive confirming epithelial nature of
cells
Invasive ductal carcinoma with metastasis to the
sentinel axillary lymph node
75
Case 2 A. Bilateral mastectomy December 2005 for
locally advanced right breast carcinoma. Past
history of local injections of silicon into
breasts in Thailand many years ago. B.
Post-mastectomy chest wall nodule superior to
scar
A
Central cystic spaces lined by foreign body type
giant cells (blue arrows) in a background of
chronic inflammation and dense fibrosis 
Localized granulomatous reaction
B
Cells associated with amorphous material and
clear vacuoles
Clumps of macrophages
Multinucleated giant cells
Silicon granuloma extensive fibrosis in A,
benign foreign body giant cell response in B
76
Case 3 51-year-old male, seven week history of
weight loss and fevers, right submandibular
lymphadenopathy.
Lymph node shows extensive necrotizing
granulomatous inflammation large areas of
necrosis (blue arrow)
Lymph node cut surface shows multiple foci of
yellow-white discoloration
Palisading epithelioid histiocytes (green
arrows) 
Multinucleated giant cells of Langhans type
Small numbers of acid fast bacilli are identified
with the Zeihl-Neelsen stain
Necrotising granulomatous lymphadenitis -
Tuberculous lymphadenitis
77
Case 4 43yo man, recent FNA of a left axillary
lymph node was suggestive of lymphoma with a
mixed population of large cells with irregular
lobulated nuclei and prominent nucleoli (blue
arrows) and smaller lymphoid cells
FNA
Normal architecture is effaced by closely packed
lymphoid follicles of variable size
normal architecture is effaced by closely packed
lymphoid follicles of variable size
Centre of the follicles comprises a mixture of
small centrocytes with hyperchromatic nuclei and
larger centroblasts showing regular nuclei
outlined as and multiple basophilic nucleoli
Follicular non-Hodgkins lymphoma
78
Case 5 This 56-year-old male, presented with
anaemia and enlarged inguinal lymph nodes but no
axillary or cervical lymphadenopathy. A CT scan
shows mild intra-abdominal lymphadenopathy. No
fevers or night sweats
Effacement of the normal lymph node architecture
by infiltrate
Infiltrate of numerous large atypical cells
showing mononuclear, bi-nucleated and
multinucleated forms as well as mummified forms 
Polymorphous background population including
small lymphocytes, eosinophils and plasma cells
Classic Reed-Sternberg cells
Hodgkin disease, mixed cellularity type.
79
Case 6 23 year-old female, history of rheumatoid
arthritis, bilateral submandibular
lymphadenopathy.
Lymph node shows a thickened capsule and
extensive suppurative lymphadenitis
Cortex is expanded by a number of granulomas
displaying central neutrophil-rich suppurative
necrosis
Suppurative granulomatous lymphadenitis - most
likely aetiology is cat scratch disease although
mycobacterial and fungal infection cannot be
entirely excluded
Cortex also expanded by surrounding epithelioid
histiocytes with occasional multinucleated giant
cells of Langhans type