Ditzels

This article collects ditzels, which are, in the context of pathology, little specimens that are typically one or two slides and usually of little interest.

The challenge in ditzels is not falling asleep... so one misses the unexpected (subtle) tumour.

The big table of ditzels

Specimen	Typical context (diagnosis)	System
Hernia sac	hernia	Gastrointestinal pathology
Stoma (reversal)	bowel obstruction, perforated viscus (peritonitis)	Gastrointestinal pathology
Sleeve gastrectomy	obesity	Gastrointestinal pathology
Vertebral disc	herniated disc	Neuropathology
Bands of Ladd	bands of Ladd	Paediatric pathology
Cholesteatoma	cholesteatoma	Paediatric pathology
Femoral head	hip fracture, hip OA	Orthopaedic
Bone reamings	hip fracture	Orthopaedic
Tonsil	tonsillitis	Head and neck pathology
Leg amputation	atherosclerotic peripheral vascular disease, trauma	Cardiovascular pathology
Lipoma	lipoma	Soft tissue pathology
Heterotopic ossification	contractures	Soft tissue pathology
Tubal ligation	completed family	Gynecologic pathology
Pressure ulcer (AKA decubitus ulcer)	ulcer, immobility	Dermatopathology
Vasectomy	completed family	Genitourinary pathology
Uvula	obstructive sleep apnea	Head and neck pathology
Stapes	otosclerosis	Head and neck pathology
Abdominal pannus	obesity	Dermatopathology (?)
Abdominal fat	query amyloidosis	Haematopathology (?)
Breast prosthesis	breast cancer/cosmesis	Breast pathology
Empyema peel	decortication for pneumonia	Pulmonary pathology

Gastrointestinal pathology

Hernia sac

General

• Hernia repair (herniorrhaphy).
• Pathologic findings are very unusual and if present known to the surgeon.
  • Thus, it has been advocated that one ought not examine 'em.

Microscopic

Features:

• Fibrous tissue.
• +/-Adipose tissue.
• +/-Mesothelial cells.

Notes:

• One should not see vas deferens.
• Things worthy of some comment: granulation tissue, inflammation.

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Incarcerated without mesothelium

SOFT TISSUE ("HERNIA SAC"), RESECTION/HERNIA REPAIR: 
- FIBROADIPOSE TISSUE WITH FAT NECROSIS -- CONSISTENT WITH HERNIA SAC. 
- NEGATIVE FOR MALIGNANCY.

Micro

The sections show fibrofatty tissue with hemosiderin-laden macrophages, plump activated fibroblasts with pale staining nuclei, histiocytes with small nuclei and abundant grey vacuolated cytoplasm, fat necrosis and focal necrosis of the fibrous tissue.

Mesothelial lining present

SOFT TISSUE ("HERNIA SAC"), RESECTION/HERNIA REPAIR: 
- FIBROADIPOSE TISSUE PARTIALLY COVERED BY MESOTHELIUM -- CONSISTENT WITH HERNIA SAC. 
- NEGATIVE FOR MALIGNANCY.

Inflamed

SOFT TISSUE ("HERNIA SAC"), LEFT, RESECTION/HERNIA REPAIR:
- FIBROADIPOSE TISSUE PARTIALLY COVERED BY MESOTHELIUM WITH FOCAL CHRONIC
  INFLAMMATION AND REACTIVE CHANGES -- CONSISTENT WITH HERNIA SAC.
- NEGATIVE FOR MALIGNANCY.

Gross only

SOFT TISSUE, RIGHT INGUINAL, HERNIORRHAPHY:
- HERNIA SAC (GROSS ONLY).

SOFT TISSUE, LEFT INGUINAL, HERNIORRHAPHY:
- HERNIA SAC (GROSS ONLY).

Stoma

Ostomy, ileostomy and colostomy redirect here.

General

See: Colon and Small intestine.

• Reversal of ileostomy or colostomy.
  • The (generic) encompassing term for ileostomy and colostomy is ostomy.

Stomas are created for a number of reasons:

• Perforated viscous/peritonitis.
  • Trauma.
  • Colorectal adenocarcinoma.
• Diverticulosis.

Microscopic

Features:

• Colonic-type or small intestinal-type bowel wall.
  • Lymphoid hyperplasia (abundant lymphocytes) - very common.
  • +/-Fibromuscular hyperplasia of the lamina propria and submucosa.
• Skin.
  • Typically has findings of mild irritation:
    • Mild dermal inflammation (usu. lymphocyte predominant).
    • Acanthosis (thickened stratum spinosum).
    • Hypergranulosis (thickened stratum granulosum).
    • Hyperkeratosis (thickened stratum corneum).

Notes:

• One is looking for malignancy (e.g. colorectal carcinoma), especially if that is in the history.

DDx:

• Colorectal adenocarcinoma.
• Crohn's disease.

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Colostomy

COLOSTOMY, COLOSTOMY REVERSAL:
- LARGE BOWEL WALL WITH SUBMUCOSAL FIBROSIS -- OTHERWISE WITHIN NORMAL LIMITS.
- SKIN WITHOUT SIGNIFICANT PATHOLOGY.
- NEGATIVE FOR DYSPLASIA AND NEGATIVE FOR MALIGNANCY.

Ileostomy

ILEOSTOMY, ILEOSTOMY REVERSAL:
- SMALL BOWEL WALL WITH SUBMUCOSAL FIBROSIS -- OTHERWISE WITHIN NORMAL LIMITS.
- SKIN WITHOUT SIGNIFICANT PATHOLOGY.
- NEGATIVE FOR DYSPLASIA AND NEGATIVE FOR MALIGNANCY.

Vagus nerve

General

• Seen from vagotomy.

Typical indication:

• Gastric outlet obstruction.

Notes:

• Left vagus nerve -> anterior vagal trunk.
• Right vagus nerve -> posterior vagal trunk.

Microscopic

Features:

• Peripheral nerve.

DDx:

• Smooth muscle.

IHC

• S-100 +ve.
• Desmin -ve.

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A. VAGUS NERVE, POSTERIOR, VAGOTOMY:
- PERIPHERAL NERVE WITHIN NORMAL LIMITS.

B. VAGUS NERVE, ANTERIOR, VAGOTOMY:
- SMOOTH MUSCLE WITHIN NORMAL LIMITS.
- PERIPHERAL NERVE NOT IDENTIFIED, SEE COMMENT.

COMMENT:
The tissue was stained with desmin and S-100; it is positive for desmin. S-100 marks only 
small nerves fibres that innervate the muscle.

Pediatric

Bands of Ladd

General

• Associated with intestinal malrotation.
• Removed by Ladd's procedure.
• Usually associated with duodenal and (other) small bowel obstructions.

Microscopic

Features:

• Benign fibrous tissue.

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Adhesive band, Ladd's procedure:
- Vascular fibrous tissue consistent with bands of Ladd.

Cholesteatoma

General

• Squamous epithelium in the middle ear - leading to accumulation of keratinaceous debris.
  • Keratosis obturans - accumulation in the external ear canal - is considered to be a different process; though some consider it a synonym.
• The etiology is not well understood.
  • Theories include migration/hyperplasia, and metaplasia.
• Rarely transforms into squamous cell carcinoma.

Classification

May be subdivided into:

• Acquired - due to trauma, surgery or infection.
• Congenital.

Gross

• Whitish mass in the middle ear.

Image:

• 

  Cholesteatoma. (WC)

Microscopic

Features:

• Keratinaceous debris - key feature.
• Squamous epithelium.
• Macrophages +/- giant cell (containing keratinceous debris).
• Chronic inflammation (lymphocytes).

DDx:

• Cholesterol granuloma.
• Squamous cell carcinoma.

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SOFT TISSUE (CHOLESTEATOMA), SITE NOT FURTHER SPECIFIED, REMOVAL:
- KERATINACEOUS DEBRIS, COMPATIBLE WITH CHOLESTEATOMA.

Soft tissue, left ear ("left ear keratosis"), excision:
- Keratinaceous debris, squamous epithelium and bone (consistent with cholesteatoma). 

Genitourinary pathology

Foreskin

Main article: Penis

General

Indications:

• Phimosis.

Main considerations:

• Squamous cell carcinoma.
• Lichen sclerosus, AKA balanitis xerotica obliterans.
• Lichen planus.
• Infection, e.g. syphilis, candidiasis.
• Zoon balantitis - abundant plasma cells.

Microscopic

Features:

• Usu. fibrotic dermis.
• +/-Inflammation.

DDx:

• See Penis.

Paraurethral cyst

General

• Rare.
• Benign.

Clinical:

• Presentation: mass lesion, dyspareunia or dysuria.
• Multipareous.

Microscopic

Features:

• Cystic space with epithelial lining - diagnosis based on epithelial lining.

Subclassification:

• Epithelial inclusion cyst.
• Müllerian cyst.
• Gartner duct cyst (AKA mesonephric duct cyst AKA Wolffian duct cyst).
• Skene duct cyst.

Labia

General

• Operation labioplasty.

Microscopic

Features:

• Squamous epithelium with compact keratin.
• Fibrous stroma.

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LABIA MINORA, RIGHT, LABIOPLASTY:
- BENIGN SKIN WITH A THIN LAYER OF COMPACT KERATIN FIBROTIC STROMA -- CONSISTENT
  WITH LABIA MINORA.

Head and neck pathology

Tonsillitis

Tonsil redirects here.

General

• Commonly removed (tonsillectomy) when enlarged.
• Very low probability of malignancy (<0.2%) in tonsilectomies in individuals <19 years old if no clinical suspicion.

Gross

• Symmetrical and equal size.

Note:

• Gross exam is considered sufficient if there is no asymmetry.

Microscopic

Features:

• Follicular hyperplasia - see lymph node pathology.
• +/-Colonies (clusters) of actinomycetes in the tonsillar crypts.

DDx:

• Non-Hodgkin lymphoma.

IHC

If there is a clinical suspicion - a panel to exclude (small cell) non-Hodgkin lymphomas:

• CD3.
• CD20.
• CD5.
• CD10.
• CD23.
• Cyclin D1.

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A. TONSIL, LEFT, TONSILLECTOMY:
- REACTIVE FOLLICULAR HYPERPLASIA.
- REACTIVE SQUAMOUS MUCOSA.

B. TONSIL, RIGHT, TONSILLECTOMY:
- REACTIVE FOLLICULAR HYPERPLASIA.
- REACTIVE SQUAMOUS MUCOSA.

Without squamous mucosa

A. TONSIL, LEFT, TONSILLECTOMY:
- REACTIVE FOLLICULAR HYPERPLASIA.

B. TONSIL, RIGHT, TONSILLECTOMY:
- REACTIVE FOLLICULAR HYPERPLASIA.

Obstructive sleep apnea

Uvula redirects here.

• Abbreviated OSA.

General

• Clinical diagnosis.
• May be treated with a resection of the uvula.
• Associated with obesity.

Microscopic

Features:

• Benign oropharyneal mucosa (stratified squamous epithelium).
• +/-Skeletal muscle.
• +/-Salivary glands (minor) - mucinous.

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UVULA, RESECTION:
- OROPHARYNGEAL MUCOSA, CONSISTENT WITH UVULA.

Cardiovascular pathology

Main article: Cardiovascular pathology

Vascular thrombus

Venous thrombus and arterial thrombus redirect here.

General

• Uncommonly comes to pathology.

Risk factors - think Virchow's triad:

• Stasis, e.g. atrial fibrillation.
• Hypercoagulable states, e.g. cancer - see risks factors venous thromboembolism.
• Endothelial injury.

Gross

See pulmonary embolism.

Features:

• Dull appearance.
• Laminations.

Microscopic

Features:

• Layers consisting of platelets and fibrin.
  • Classically alternating with layers of RBCs - known as Lines of Zahn.

Note:

• Multiple laminations (layers), in general, suggest that clot was formed in a dynamic environment, i.e. in the context of blood flow.

DDx:

• Tumour embolus - malignant cells.
• Thromboembolus - may require clinical history.
• Fat embolism.
• Amniotic fluid embolus - in the context of pregnancy/postpartum.
• Foreign body.

Images:

• www:
  • Lines of Zahn (utah.edu).
  • Lines of Zahn (ucsf.edu).
• WC:
  • Laminated thrombus - low mag. (WC).
  • Laminated thrombus - high mag. (WC).

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BLOOD CLOT, LEFT ILIAC ARTERY, THROMBECTOMY:
- THROMBUS.
- NEGATIVE FOR MALIGNANCY.

Micro

The sections show layers of red blood cells alternating with fibrin and white blood cells (Lines of Zahn).

Leg amputation

General - overview

Comes in two basic flavours:

• Above the knee ampuation (AKA).
• Below the knee ampuation (BKA).

Etiology:

• Diabetes mellitus - most common - see atherosclerotic peripheral vascular disease.
• Trauma.
• Infection - see chronic osteomyelitis.
• Drug use, e.g. cocaine.

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See Ditzels#Atherosclerotic peripheral vascular disease.

Toe amputation

General - overview

• Like leg ampuations.

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See Ditzels#Atherosclerotic peripheral vascular disease.

Atherosclerotic peripheral vascular disease

Diabetic foot redirects here.

• AKA peripheral vascular disease.

Main article: Atherosclerosis

General

• Very strong association with diabetes mellitus.

Gross

• +/-Ulceration.
• +/-Gangrene - black skin - subclassified:
  • "Wet" = moist/oozing fluid.
  • "Dry" = shriveled, no moisture apparent.
• +/-Loss of hair.

DDx - gross:

• Malignant melanoma.

Image:

• Gangrenous foot (WC).

Sections - grossing:

• Resection margin (check for viability).
• Gangrenous area.
• Blood vessels.
• Bone (check for osteomyelitis).

Microscopic

Features:

• Atherosclerosis.
• Coagulative necrosis (gangrene).
• Inflammation (wet gangrene).
  • Neutrophils.
  • Lymphocytes.
  • Plasma cells.
• +/-Thrombosis.
• +/-Chronic osteomyelitis.
• +/-Reactive fibroblasts.

Note:

• Ischemia may be associated with marked nuclear changes. Uninitiated eyes may think they are seeing a sarcoma.

DDx:

• Vasculitis associated with a connective tissue disorder.
• Drug use, e.g. cocaine.
• Chronic osteomyelitis.

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Leg amputation

LEFT LEG, BELOW KNEE AMPUTATION:
- MODERATE-TO-SEVERE ATHEROSCLEROSIS.
- COAGULATIVE NECROSIS OF SOFT TISSUE.
- NECROTIC BONE.
- MARROW CAVITY FIBROSIS WITH SIDEROPHAGES.
- RESECTION MARGIN WITH VIABLE TISSUE.

Revision

SKIN AND SOFT TISSUE, RIGHT UPPER LEG, REVISION OF AMPUTATION:
- ULCERATED SKIN WITH NECROTIC SOFT TISSUE WITH IMPETIGINIZATION, AND MICROABSCESS
  FORMATION.
- SEVERE ATHEROSCLEROSIS.
- NEGATIVE FOR MALIGNANCY.

Toe amputation

Mild

THIRD TOE, RIGHT, AMPUTATION:
- SKIN WITH MARKED DERMAL FIBROSIS.
- MILD ATHEROSCLEROSIS.
- NEGATIVE FOR MALIGNANCY.

SECOND TOE, RIGHT, AMPUTATION:
- SKIN WITH MARKED DERMAL FIBROSIS AND ULCERATION WITH IMPETIGINIZATION.
- MILD ATHEROSCLEROSIS.
- NEGATIVE FOR MALIGNANCY.

Moderate

SECOND TOE, LEFT, AMPUTATION:
- MODERATE ATHEROSCLEROSIS.
- BONE WITH A FATTY BONE MARROW CAVITY WITH FOCAL FAT NECROSIS AND RARE PLASMA CELLS.
- SKIN WITH FIBROUS DERMIS AND A NON-SPECIFIC DERMAL PERIVASCULAR LYMPHOPLASMACYTIC 
INFILTRATE.

SECOND TOE, LEFT, AMPUTATION:
- MODERATE ATHEROSCLEROSIS.
- BONE WITH A FATTY BONE MARROW CAVITY WITH FOCAL FAT NECROSIS AND RARE PLASMA CELLS.
- SKIN WITH FIBROUS DERMIS AND NON-SPECIFIC PERIVASCULAR LYMPHOPLASMACYTIC DERMAL INFILTRATE.

Severe

SECOND AND THIRD TOE, LEFT, AMPUTATION:
- SEVERE ATHEROSCLEROSIS.
- ACUTE AND CHRONIC OSTEOMYELITIS.
- GANGRENE.

GREAT TOE, LEFT, AMPUTATION:
- GANGRENE.
- SEVERE ATHEROSCLEROSIS.
- ULCERATED SKIN AND CHRONIC ISCHEMIC CHANGES.
- BONE WITH NO SIGNIFICANT PATHOLOGY.
- NEGATIVE FOR MALIGNANCY.

Orthopaedic

Femoral head

Main article: Femoral head

Bone reamings

General

• Taken during the surgical repair of a fracture, e.g. intramedullary nail placement.
• Done to rule-out a pathologic fracture; considered reliable for detecting malignancy.
  • Hassan et al. advocate against their use, suggesting the yield is low and a biopsy should be preferred.

Microscopic

Features:

• Fragments of bone (scattered trabeculae).
  • Necrotic bone = bone with empty lacunae, i.e. lacunae missing osteocytes.
• Bone marrow.
  • Megakaryocytes - large cells, multinucleated, eosinophilic cytoplasm.
  • Nucleated RBCs - perfectly round, dense nucleus, bright red cytoplasm.
  • Myeloid cells and precursors.
  • Adipocytes.

DDx:

• Metastatic carcinoma.

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BONE, LEFT FEMUR, REAMINGS:
- FEATURES CONSISTENT WITH A RECENT FRACTURE.
- NEGATIVE FOR MALIGNANCY.

Heterotopic ossification

• Abbreviated HO.

General

• Definition of heterotopic ossification: bone formation in soft tissue.
• Injury at site.
• May be seen in the context of tetraplegia.

Clinical:

• +/-Joint stiffness.
• +/-Swelling.
• +/-Pain.

Microscopic

Features:

• Lamellar bone - has layering/lines (best seen with polarized light).
• +/-Skeletal muscle (within the marrow space).

DDx:

• Myositis ossificans - inflammation, cellular.
• Osteosarcoma, extraskeletal.

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LESION ("HETEROTOPIC OSSIFICATION"), RIGHT FEMUR, EXCISION:
- BONE -- CONSISTENT WITH MUSCLE HETEROTOPIC OSSIFICATION.
- NEGATIVE FOR MALIGNANCY.

Micro

The sections show laminar bone with a marrow space containing adipose tissue and benign skeletal muscle. The osteocytes show no nuclear atypia. No mitotic activity is appreciated.

Other

Breast prosthesis

Breast expander redirects here.

General

• Commonly used for cosmesis in the context of breast cancer.

Gross

Specimen received in formalin labelled "right breast prosthesis" consists of a breast prosthesis measuring 13.5 x 12.5 x 4.5 cm. Seen on one side the number 356 is seen. The prosthesis is intact. No tissue is identified. No sections are submitted.

Images

• 

  Breast implants. (WC)

WP:

• Ruptured breast implant (WP).

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BREAST PROSTHESIS, RIGHT, REMOVAL:
- INTACT BREAST PROSTHESIS (GROSS ONLY).

Not intact

BREAST PROSTHESIS, LEFT, REMOVAL:
- BREAST PROSTHESIS WITH EVIDENCE OF PERFORATION AND LEAKAGE (GROSS ONLY).

De Quervain syndrome

Should not be confused with De Quervain's thyroiditis (subacute granulomatous thryoiditis).

• AKA de Quervain disease.

General

• Benign.
• Clinical diagnosis.

Clinical:

• Pain.

Treatment:

• Steroid.
• Surgery.

Microscopic

Features:

• Dense connective tissue consistent with tendon.

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FIRST EXTENSOR COMPARTMENT, RIGHT HAND, BIOPSY:
- DENSE CONNECTIVE TISSUE CONSISTENT WITH TENDON.
- FIBROUS TISSUE.

Tenosynovitis

General

• Uncommon pathology specimen.

Microscopic

Features:

• Dense connective tissue (tendon).
• Histocytes.
• +/-Psammoma bodies.

DDx:

• Calcific tendinitis.
• Giant cell tumour of the tendon sheath.
• Palmar fibromatosis.

IHC

Features:

• CD68 +ve.
• Beta-catenin -ve.

Note:

• Immunostains are usually not required for the diagnosis.

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TENOSYNOVIUM, LEFT MIDDLE FINGER, EXCISION:
- DENSE CONNECTIVE TISSUE (CONSISTENT WITH TENDON) WITH LYMPHOHISTOCYTIC INFILTRATE.
- NEGATIVE FOR GIANT CELLS. 
- NEGATIVE FOR MALIGNANCY.

Micro

The sections show dense connective tissue (tendon) containing a cluster of cells with indistinct cellular borders, abundant foamy grey cytoplasm, and round/oval pale-staining nuclei with small nucleoli (histiocytes). The cell cluster has a small number of interspersed lymphocytes, and the centre of the cell cluster has acellular hyaline material (degenerative tendon).

No calcification is identified. No giant cells are seen.

No nuclear atypia is apparent and no mitotic activity is appreciated.

Otosclerosis

Stapes redirects here.

General

• Clinical diagnosis.
• Causes conductive hearing loss.
• Etiology - genetic.
  • Over half a dozen genes have been identified.
  • Classically described as autosomal dominant.

Treatment:

• Stapedectomy (removal of the stapes).

Microscopic

Features (temporal bone):

• Classically divided into four phases:
  1. Osteoclastic phase:
     • Large spaces form in bone marrow.
  2. Replacement phase:
     • Bone replaced by basophilic web-like tissue.
  3. Fibril phase:
     • Fibrils deposited.
  4. Lamellar phase:
     • Lamellar bone forms around the blood vessels.

Features - (stapes):

• Unremarkable bone.^{[citation needed]}

DDx:

• Avascular necrosis ~ 25% of cases diagnosed as otosclerosis.
  • May be due to fat embolism.

Images:

• Stapes - sketch (WC).

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STAPES, RIGHT, STAPEDECTOMY:
- UNREMARKABLE BONE CONSISTENT WITH STAPES.

Missed stapes

STAPES, RIGHT, STAPEDECTOMY:
- BENIGN FIBROFATTY TISSUE.
- NO BONE IDENTIFIED.

Abdominal pannus

Main article: Obesity

General

• An apron-like excess of skin - following weight loss.
• Seen in obesity.

Microscopic

Features:

• Adipose tissue.

DDx:

• Lipoma.
• Liposarcoma.

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ABDOMINAL PANNUS, EXCISION:
- BENIGN SKIN AND ADIPOSE TISSUE.

ABDOMINAL PANNUS, EXCISION:
- BENIGN SKIN AND ADIPOSE TISSUE (GROSS ONLY).

Empyema

Empyema peel redirects here.

General

• Empyemas are often managed surgically.

• Classically, divided into three stages.
  • I - exudative stage (acute).
  • II - fibropurulent stage (acute).
  • III - organizational stage (chronic).

Etiologies - common:

• Pneumonia - most common.
• Iatrogenic.
• Trauma.

Microscopic

Features:

• Neutrophils (pus) - key feature.
• Lymphocytes.
• Plasma cells.
• Reactive fibroblasts.
• Reactive mesothelial cells - not common.

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PLEURA, LEFT, DECORTICATION:
- MIXED INFLAMMATORY WITH ABUNDANT NEUTROPHILS.
- REACTIVE FIBROBLASTS.
- NEGATIVE FOR MALIGNANCY.

See also

• Basics.
• Spine.