Virtual Slidebox
Presented by the MGH Pathology Service

62 year old F with diarrhea.

Clinical summary
42 yo M with cecal tumor.

48 yo M with jaundice. Whipple

MICROSCOPIC FEATURES

• In adults, usually a nonspecific pattern of chronic hepatitis and cirrhosis
• Eosinophilic hyaline globules can be seen on H+E, predominantly in periportal hepatocytes
• Portal inflammation is variable (predominantly lymphocytic), and interface hepatitis usually mild or absent
• Bile ductular reaction seen only in endstage disease
• In neonates, there may be a picture of neonatal hepatitis, with canalicular cholestasis, giant cell transformation, ballooned hepatocytes, and loss of bile ducts

Read more on Alpha-1 antitrypsin deficiency, cirrhotic stage…

79 year old with gastric tumor and long history of gastritis and duodenitis.

Asian male in his 40’s with jaundice

7 year old with history of previous polyps. F/U colonoscopy shows several new polyps as shown here. Has frequent nosebleeds!

MICROSCOPIC FEATURES

• Marked lymphoplasmacytic infiltrate in the lamina propria, with associated damage of the fundic glands (“lymphoepithelial lesions”)
• Loss of oxyntic glands (parietal and chief cells) may result in “antralization” of body/fundus
• Metaplasia (pyloric, intestinal, and pancreatic) may be seen
• Affects body/fundus but spares the antrum (vs. atrophic gastritis)
• Changes can be variable depending on severity and duration of disease

Read more on Autoimmune gastritis…

MISCELLANEOUS

• IHC confirmed a gastric phenotype of the dysplastic glands (positive for MUC5AC and negative for MUC2), corresponding to the “non-adenoma-like” type. p53 was also positive, while p16 was negative.

MICROSCOPIC FEATURES

• Superficial acute inflammation in the squamous epithelium
• Keratotic debris and fibrinopurulent exudates are commonly seen
• Organisms may be seen by H+E (round yeast forms and pseudohyphae)

DIFFERENTIAL DIAGNOSIS

• Herpes esophagitis

Read more on Candida esophagitis…

Female with dysphagia

Male with dysphagia

MICROSCOPIC FEATURES

• Nests of cells with neuroendocrine features (polygonal cells with round nuclei with “salt-and-pepper” chromatin and no nucleoli)
• The cytoplasm is eosinophilic or amphophilic, and may contain granules
• The cells are monomorphic, and mitoses are rare
• The stroma is usually delicate and vascular but can become dense and fibrous
• May form tubules or acini, with PAS-positive luminal material

Read more on Carcinoid tumor, incidental…

Female in her 30’s with iron deficiency anemia. Duodenal biopsy.

MICROSCOPIC FEATURES

• Numerous metaphase mitoses in crypt epithelium, especially “ring” mitoses
• There may also be epithelial pseudostratification, loss of goblet cell polarity, villus blunting, and increased apoptotic figures

DIFFERENTIAL DIAGNOSIS

Read more on Cholchicine toxicity…

55 y/o F with gallbladder polyp

34 year old M with diarrhea.

9 y/o M with iron deficiency anemia, weight loss, and diarrhea. Biopsy of distal esophagus

MICROSCOPIC FEATURES

• Marked expansion of portal tracts by lymphocytic infiltrates. The extent of the infiltrate is beyond what is seen in chronic viral hepatitis, where portal tracts tend to have a relatively tight “cuff” of inflammation around them.
• The lymphocytic infiltrate is sheet-like and monotonous, rather than mixed and with a follicle-like architecture, as is usually seen in chronic viral hepatitis. In some cases, the lymphoid cells may show atypia.
• There is no interface hepatitis at the edge of the infiltrate, and there are no apoptotic hepatocytes in the lobule
• There is no associated periportal fibrosis, as is usually seen with the inflammatory infiltrates of chronic viral hepatitis

Read more on Chronic lymphocytic leukemia, involving liver…

18 year old F with diarrhea.

MICROSCOPIC FEATURES

• Portal tracts are expanded by a mixed lymphoid infiltrate, which focally extends into the lobules
• The infiltrate contains lymphocytes, plasma cells, eosinophils, and scattered Reed-Stenberg cells
• The infiltrate may also involve bile ducts
• Sinusoidal dilatation and peliosis hepatis may also be present
• Epithelioid granulomas are found in ~10% of cases, usually in the portal tracts

Read more on Classical Hodgkin lymphoma, involving liver…

78 yo male with chronic watery diarrhea

65 year old with clinical picture of celiac disease, unresponsive to gluten-free diet.

MICROSCOPIC FEATURES

• Spindle cell proliferation infiltrating the lamina propria, with interspersed ganglion cells, sometimes forming nests
• There may be associated distortion of the crypt architecture
• In ganglioneuromatous polyposis (see below), multiple exophytic polyps are formed
• Diffuse ganglioneuromatosis (see below) is centered in the myenteric plexus and extends into the lamina propria, and can lead to transmural involvement and stricture formation

Read more on Colonic ganglioneuroma…

50 year old with history of multiple skin lesions. Polyp found on routine colonoscopy.

19 yo with small intestinal obstruction. Ileal mass was surgically removed

MICROSCOPIC FEATURES

• Marked lymphoid follicular hyperplasia, with prominent germinal centers, and chronic inflammation of the lamina propria
• Variable crypt inflammation and architectural distortion
• Aphthous ulcers may develop

DIFFERENTIAL DIAGNOSIS

Read more on Diversion colitis, with superimposed ulcerative colitis…

Female in her 40’s with abnormal LFTs.

MICROSCOPIC FEATURES

• Cords, nests, or single tumor cells embedded in myxoid matrix, with variable sclerosis and calcification
• Tumor cells may be dendritic (spindle- or stellate-shaped) or epithelioid, and have intracytoplasmic vascular lumina that may contain erythrocytes. These spaces should not be mistaken for signet-ring cells or glandular spaces
• Often multifocal or composed of confluent nodules
• At the edge, the tumor spares portal tracts and spread along sinusoids, causing atrophy of liver plates, and eventually obliterating central veins

Read more on Epithelioid hemangioendothelioma…

MICROSCOPIC FEATURES

• Nests of large polygonal cells, with abundant eosinophilic granular cytoplasm, separated by fibrous stroma
• The fibrous stroma is composed of thick, hyalinized bundles of collagen, arranged in parallel lamellae
• Cells may have cytoplasmic hyaline globules (containing alpha1-antytripsin), “ground glass”-like pale bodies (containing fibrinogen), Mallory’s hyalin, and bile
• Nuclei are large, hyperchromatic, and vesicular, with prominent nucleoli, but mitoses are uncommon

Read more on Fibrolamellar carcinoma…

64 yo M with Barrett’s esophagus. Esophageal biopsy.

Cholecystectomy

22 y/o female with stomach ache

55 y/o M with polyp

MICROSCOPIC FEATURES

• Giardia lamblia trophozoites (pear-shaped organisms, sometimes with two nuclei) seen on the luminal surface, with no tissue invasion
• Usually normal-appearing intestinal mucosa, but can sometimes see villous blunting, and a mixed inflammatory infiltrate in the lamina propria (neutrophils, lymphocytes, and plasma cells)

Read more on Giardiasis…

Male in his 30’s, s/p bone marrow transplant. Liver biopsy.

Female in her 30’s with an esophageal ulcer. Esophageal biopsy.

MICROSCOPIC FEATURES

• Non-caseating epithelioid granulomas in association with features of H. pylori gastritis (see below)
• Diffuse superficial chronic inflammation
• Neutrophils present at the neck region (“pititis”)
• Large lymphoid follicles may be present
• Regenerative epithelial changes with foveolar hyperplasia

Read more on H. pylori gastritis, granulomatous…

• Proliferation of bland-appearing hepatocytes arranged in cords, without portal tracts or biliary epithelium
• Abnormal-appearing arteries (“unpaired arteries”) and thin-walled vessels are scattered throughout the tumor
• Cells may form pseudorosettes around canaliculi, but not acini
• Cells often contain fat or glycogen, so that the lesion looks paler than adjacent normal liver
• Bile production, hyaline globules, megamitochondria, and Mallory’s hyaline may be present
• May occasionally display focal mild atypia (especially when associated with androgenic steroid use) but mitoses are almost never seen
• May show various degenerative changes: evidence of prior hemorrhage; sinusoidal dilatation; large blood-filled (pelioid) spaces; myxoid stroma; fibrosis; necrosis; infarction
• Usually solitary but can be multi-focal; when >10, sometimes referred to as adenomatosis

Read more on Hepatic adenoma…

MICROSCOPIC FEATURES

• Composed of blood-filled spaces lined by a single layer of bland endothelium
• Contains variable amounts of fibrous stroma
• Vascular spaces may contain organizing fibrin or thrombi
• May undergo various degenerative changes with time, such as sclerosis, calcification, and involution

Read more on Hepatic hemangioma…

MICROSCOPIC FEATURES

• Non-caseating epithelioid granulomas centered in portal tracts
• Lymphoplasmacytic “cuff” of inflammation surrounding granulomas
• Necrosis is uncommon, and tuberculomas are very rare
• Hepatic parenchyma is otherwise fairly normal in appearance

Read more on Hepatic tuberculosis…