# Patho micro block III
## Liver / Biliary Tract
* PA0060 （42） Acute hepatitis, liver, 82M
* Zonal distribution: zone 3, central area 白; portal area 藍藍的
* Lobular hepatitis: **necroinflammatory** activity mainly in **parenchyma**
* Hepatocellular damage
* injury 圓腫白 ballooning change
* apoptosis 紅 or necrosis (hepatocyte dropout, focal necrosis 被取代)
* Inflammatory infiltration
* lymphocytes & plasma cells
* 可能有 neutrophils & eosinophils
* PA0062 （44） Chronic hepatitis, liver, 30M
* **Necroinflammatory** activity mainly in **portal or periportal (interface)**
* Chronicity (**fibrosis** & ductular reaction)
* 
* PA0182 （46） Massive necrosis, liver, 35F
* Extensive **confluent necrosis**: mainly **panlobular**, 而且 **multilobular**
* **Ducultar / Bile duct proliferation**
* Regenerative nodules: 和 residual hepatocye island 不同在於其邊界圓圓的
* sinusoid 有發炎細胞, canalicular 有 cholestasis
* PA0064 （47） Submassive necrosis, liver, 6mM
* Extensive confluent necrosis: mainly in **zone 3**, 可能到 zone 2
* Ductular / Bile duct proliferation
* PA0075 （59） Cirrhosis, liver, 64M
* Diffuse process, abnormal hepatocytic **nodules** surrounded by **fibrous tissue**
* 可能有 ductular proliferation, interface hepatitis (往 parenchyma 浸潤)
* large cell change (N & C 都變大)

## Liver and Biliary Tract (2)
* PA0069　（53）　Neonatal hepatitis (giant cell hepatitis), liver, 4mM
* **Panlobular giant-cell transformation**: Hepatocytes 會形成很多 giant cells
* **Lobular disarray**: trabecula 排列不整齊, necrosis and swelling
* hepatocellular and canalicular cholestasis
* portal mononuclear inflammation
* vs. biliary atresia: bile duct 沒有明顯的 ductal proliferation
* PA0065 （48） Biliary atresia, liver, 2mF
* Extrahepatic biliary tree obstruction
* Bile duct **inflammation, fibrosis, obliterans** (管腔破壞縮小 stricture)
* Change within liver:
* Ductular or canalicular cholestasis
* **Ductular reaction**: proliferation & neutrophils
* PA0265 （45） Primary biliary cirrhosis, liver, 36F
* PBC
* Autoimmune cholangiopathy, **lymphocytic** **destruction of *intrahepatic* bile duct (lymphoplasma cells infiltration)**
* 早期 **Portal lesion**: florid (鮮紅的) duct lesion
* patchy: 不一定每個 portal area 都有
* bile duct epi. 受傷 (*bile duct damage*, *周圍有 granuloma*)
* *Granuloma* (中心為 bile duct damage)
* 晚期 progressive lesion: fibrosis, 然後 biliary cirrhosis
* Jigsaw puzzle. 周圍 halo effect (edema)
* PA0068 （52） Primary sclerosing cholangitis, liver, 56M
* 膽管炎, PSC
* intrahepatic & extrahepatic
* 大膽管嗜中性球浸潤，背景慢性發炎
* 中小型膽道: **onion skin fibrosis** (同心圓)
* Tombstone scars: bile duct 晚期消失
## Liver and Biliary Tract (3)
* PA0214 （156） Obstructive cholestasis
* Cholestasis
* bile salt injury: periportal feathery degeneration, Mallory-Denk bodies
* Ductular reaction (三大要素)
* Ductal **proliferation**
* Stromal **edema**
* Infiltrating **neutrophils** in portal tract
* PA0074 （58） Steatosis (fatty change), liver, 50F: review
* Macrovesicular steatosis: 核推到一邊
* Microvesicular steatosis: 胞內多脂肪粒, 核在原處
* centrilobular zone (zone 3)
* PA0217 （159） Alcoholic hepatitis, liver
* Steatohepatitis:
* Hepatocyte damage: ballooning change, necrosis, Mallory-Denk body (clump, amorphous, eosinophilic material in ballooned hepatocytes made up of tangled skeins of intermediate filaments)
* Inflammatory cell infiltration: neutrophils
* **Steatofibrosis**:
* zone 3: pericellular (chicken wire fence pattern)
* C-P bridging fibrosis
* PA0211 （153） Hemosiderosis, liver, 54F (review)
* hemosiderin deposition: 金棕色、明顯反光、大小差異大、結塊狀
* hepatocyte injury: ballooning change
* PA0212 （154） Glycogen storage disease, liver, 29F (review)
* Type Ia: Abundant glycogen in hepatocytes cytoplasm
* Clear (空亮), with granular material, 可能有 Mallory body
* Thick cytoplasmic membrane (向細胞壁一樣厚, glycogen 將細胞質中的物質推到細胞邊緣形成的)
* Mosaic pattern: distended hepatocytes, obscure sinusoids (看不太到 sinusoids)
* 
* PA0076 （61） Nutmeg liver (centrilobular congestion and necrosis), liver (review)
* centrilobular congestion
* ischemic necrosis (portal 偏紅、zone 3 白、zone 2 congestion)
* hemorrhage/hemosiderin
* PA0070 （54） Budd-Chiari syndrome
* Centrilobular **severe** congestion, severe ischemic necrosis, severe hemorrhage/hemosiderin **(滲出的 RBC 取代掉 hepatocytes, sinusoid dilatation)**
* Hemorrahge 跟正常 hepatocyte 交界處 hepatocyte injury: ballooning change
* PA0215 （157） Cardiac sclerosis, liver
* centrilobular congestion and necrosis, hemorrhage/hemosiderin
* **Central vein lumen 高壓 dilated**
* **Centrilobular fibrosis**
* fibroblast
* 可能有 central-central bridging fibrosis
* **Fibrous band** 向外延伸
* PA0067 （51） Focal nodular hyperplasia, liver, 7M
* Well-demarcated, poorly encapsulated tumor
* **Central stellate scar**
* Malformed vessels with eccentric or concentric **fibromuscular hyperplasia** (central scar 中或 tumor 周圍有血管，血管壁增厚)
* **Ductular reaction** (proliferation, 可見許多小 ductules, 藍圓細胞核的細胞形成長條) along fibrous septal margin
* 沒有 dysplasia

@ liver abscess, alcoholic hepatitis, NAFLD (non-alcoholic fatty liver disease, 肥胖、糖尿病、高血脂): neutrophils; 其他: lymphocytes

## Liver and Biliary Tract (4) + Head and Neck
* PA0071 (55) Hepatocellular carcinoma, liver, 56M
* Malignant epithelial tumor with hepatocellular differentiat
* 有 capsule (裡面會有 ductular proliferation), 邊界清楚
* 肝細胞分化:
* Polygonal, **核在中心, vesicular nuclei (空亮), prominent nucleoli**
* hyaline globule (保留分泌東西的能力), bile plug, glycogen, lipid
* **Trabecular pattern** (厚度厚, 比正常 trabecula 厚 [>=3層] thickened) lined with **endothelial cells**
* 
* Pseudoglandular pattern: dilated canaliculi-like structure, 有 bile 或 proteinaceous material
* Nuclear atypia, cellular dysplasia: **N/C 高**, 核膜 irregular, 核仁大
* tumor 以外:
* portal-portal bridging fibrosis
* interface hepatitis (portal inflammation 往 interface 之外擴散)
* PA0184 （60） Cholangiocarcinoma, liver, 74M
* Malignant epithelial tumor with biliary epithelial differentiation (liver 長出的 adenocarcinoma)
* Malignant epi.: cohesive, infiltrative (紅 hepatocytes 在藍 tumor nests 之間), desmoplasia (fibrous or connective tissue 增生), cytological dysplasia
* **Glandular differentiation**
* glands with single-layed cuboidal cells, in very desmoplastic stroma
* 核大, nuclear membrane 不規則, N/C 高
* PA0078 （62） Chornic cholescystitis, gallbladder, 71F
* **Rokitansky-Aschoff sinus**: epi. (正常 columnar epi., 沒有 dysplasia, N/C 低, 核小小圓圓) 凹進 lamina propria, muscular wall, subserosa
* PA0045 （30） Warthin's tumor, parotid gland, 43M
* Dense lymphoid stroma (tumor 裡面很多 lymphocytes), 中間有 germinal center (偏紅)
* Cystic or cleft-like spaces (有 proteinaceous secretion)
* Tumor stroma 周圍**兩層 oncocytic epithelium** (向 space 分泌 proteinaceous material)
| Space-sided (cyst側) | Lymphoid-sided (stroma側) |
|:----------- | ----------------------- |
| palisading columnar with granular cytoplasm (紅紅柱狀) | cuboidal (方形) |

## Head and Neck (2), Alimentary system
* PA0043 （28） Ameloblastoma, mandible, 14M
* Arises from odontogenic epithelium, shows **no ectomesenchymal differentiation**. Locally invasive.
* 長得像 epithelial component of the enamel organ, 有 **fibrous stroma**
* 外: Ameloblast-like columnar to cuboidal peripheral cells (hyperchromatic nuclei, **palisading pattern with reverse polarity** [遠離 basement membrane, 靠近 central core])
* 內 (Central core): stellate reticulum 遺跡 (**cystic change**, spindle/angular-shaped cells)
* 
* PA0260 （190） Nasopharyngeal carcinoma, nasopharynx (non-keratinizing squamous cell carcinoma, undifferentiated subtype)
* 可能為 solid sheet (一整片), irregular island (不規則島狀), trabeculae (管條狀), **discohesive** sheet (結合性差的散布型)
* **Lymphoepithelioma** (在 lung, GI 稱為 lymphoepithelioma-like carcinoma [LELC])
* **Syncytial** (細胞界線模糊, 細胞質連成一片), round to oval **vesicular nuclei** (空亮核), large central **nucleoli** (大核仁)
* 
* 
* 
* 
* PA0048 （33） Adenocarcinoma, signet ring cell type (signet ring cell carcinoma), stomach, 47M
* Malignant (**invasive** [侵犯 submucosa, muscle wall, subserosa], nuclear atypia [有 dysplasia, mitosis], cohesive [**some degree of discohesiveness**])
* 
* 
* 
* Glandular differentiation (mucin, **signet ring cell** [核被推到一邊])
* 
* PA0049 （34） Adenocarcinoma, intestinal type, stomach, 86M
* 和 signet ring cell type 相比，**cohesive**、**gland differentiation (會有 cyst)**
* @ intestinal metaplasia (goblet cells, microvilli)
| foveolar gland | pyloric gland |
| -------- | -------- |
| |  |
* 
* @ **glands infiltrate 到其他地方**
* 
* 
* 
* @ diffuse type vs. intestinal type adenocarcinoma 
* PA0055 （36） Neuroendocrine tumor (carcinoid tumor), ileum, 74M
* 長在 submucosa (muscularis mucosae & muscularis propria 之間)
* 
* Cytology (neuroendocrine differentiation): uniform cells, round-oval **stippled nucleus** (顆粒感 stippled chromatin (**salt and pepper**))
* 
* 
* @ trabeculae
* 
* @ acinar
* 
* 
* 
## Alimentary system (2)
* PA0054 （35） Crohn’s disease, small intestine, 36M
* Active colitis (basal plasmacytosis [lamina propria (basement membrane 下，包含 muscularis mucosae)], **cryptitis** [neutrophils within epithelium], **cryptal abscess** [neutrophils in crypt lumen])
| cryptitis | cryptal abscess |
| -------- | -------- |
|  |  |
* Chronicity (crypts 亂, **blunting villi**, **pseudopyloric metaplasia**, granulation tissue [capillaries, inflammatory cells, edema], scar)
* 
* 
* 
* 
* 
* @ **transmural disease (inflammation)**, **non-caseating granuloma**
| submucosa | muscle | subserosa |
| -------- | -------- | -------- |
| | | |
* PA0250 （40） Ulcerative colitis, large intestine
* Active colitis (basal plasmacytosis [lamina propria (basement membrane 下，包含 muscularis mucosae)], cryptitis [neutrophils within epithelium], cryptal abscess [neutrophils in crypt lumen])
* 
* Chronicity (crypts 亂, **goblet cells 變少**, pseudopyloric metaplasia)
* 
* @ inflammatory process is limited to the mucosa and submucosa, pseudopolyp, no granuloma
* 
* 
* PA0079（63）Chronic pancreatitis
* Fibrosis
* **Atrophy/Dropout of acini** (深藍紫色, 碎片 [autolysis], **白色空隙**或被 fibrous band 取代)
* 
* 
* residual of islets of Langerhans (淺色, neuroendocrine 分化 [外分泌腺先萎縮])
* cystic dilation of pancreatic duct, mucinous metaplasia (mucin 更多，性質不同)
* PA0248（187）IgG4-related autoimmune pancreatitis
* **Storiform fibrosis** (席紋樣纖維化)
* 
* 
* 
* **Lymphoplasmacytic** sclerosing pancreatitis
| | |
| -------- | -------- |
|  |  |
* Obliterative phlebitis (閉塞性靜脈炎)
| venulitis | obliterans phlebitis |
| -------- | -------- |
|  |  |