Introduction.

Pathologic accumulations

Prof. Arvydas Laurinaviius

Vilnius University Faculty of Medicine
Department of Pathology, Forensic Medicine, and
Pharmacology

2017
Biologic data transformed into clinical information

Biologic sample

Patient

Clinical Pathology
decision
diagnosis

Diagnostic
Prognostic
Predictive
Preventive
Pathology test types

Autopsy
Biopsy
Cytopathology
Pathology - main methods
Macroscopic
Microscopic, histologic
Histochemiistry
Imunohistochemistry, imunofluorescence
Molecular
in situ hybridization (gene amplification, translocation...)
PCR (KRAS, BRAF, EGFR gene mutation, HPV, etc)
Next Gen Sequencing
Electron microscopy, ultrastructure
Digital image analysis
 Macroscopy
 Macroscopy
Prostatectomy
Prostatectomy, specimen selection for
microscopy
Residual samples utilised 1 week after diagnosis

Every second sample used for microscopy

Paraffin block

Formalin-fixed paraffin-embedded
Microtome: 3 m-thick sections
 Histology slides:
Hematoxylin-eosin stain (H&E)
 H&E
 Histochemistry
 Imunohistochemistry

CD8+
 Imunofluorescencence

IgG
 in situ hybridization

Her2 gene copy number in breast cancer tissue

 Digital image analysis
 Electron microscopy, kidney glomerulus
KAIR:
1. Prostatos vidutinikai - blogai diferencijuota adenokarcinoma (Gleason 3+4 (5%)=7), 40%
biopsinio stulpelio.
2. Prostatos vidutinikai - blogai diferencijuota adenokarcinoma (Gleason 3+4 (15%)=7), 85%
biopsinio stulpelio.
3. Prostatos vidutinikai - blogai diferencijuota adenokarcinoma (Gleason 3+4 (10%)=7), 95%
biopsinio stulpelio. Perineurinis naviko plitimas.
DEIN:
4. Prostatos audinys.
5. Prostatos audinys.
6. Prostatos vidutinikai - blogai diferencijuota adenokarcinoma (Gleason 4+3(10%)=7), 15%
biopsinio stulpelio.
General pathology

Typical processes in disease

General pathology:
Typical processes in diseased organism
Circulatory disorders

Injury Inflammation

Imunopathology Regeneration

Pathologic Atrophy&
accumulation sclerosis Neoplasia
Pathologic accumulations in
Cells

Extracellular compartments

Organ cavities (stones)

Sources

Endogenous

Normal substances, present in healthy

state
Abnormal, not present in healthy state
Egzogenous
Substances:

Protein-derived

Lipids

Carbohydrates

Pigments

Minerals
Clinical significance:

morphology of impaired metabolism

diagnostic value
Consequences:
Organ atrophy, sclerosis

Chronic organ insufficiency

Reversible and irreversible

Causes (etiology):
Inherrited enzymopathies

Acquired
Protein-derived

Amyloid
Paraproteins
Hyalin
Alcoholic hyalin in liver
 Kidney biopsy
01/1/2369

13-year-old girl with 2 year history of proteinuria,

now developing nephrotic syndrome

Kidney biopsy

0112369
H&E
Congo Red
Congo Red
Congo Red polarized light
Amyloid, Congo Red, UV light
~10 nm fibers on EM
Amyloid under podocytes
Amyloid:
macro stains as starch with iodine solution->
discovered by Rudolph Virchow, 19th century
micro - amorphous, eosinophilic
DIAGNOSIS:
Congo red histochemistry
Brick red
Polarized light apple green
UV light - orange
Amyloid:
Ultrastructure - 7,5-10 nm fibers
F component, 95 %

-sheet conformation

Plasma glicoprotein
P component, 5 %

Irreversible?
 Amyloid - biochemical
heterogeneity:
Over 25 types

Most commont

AA (amyloid associated)

AL (amyloid light chain)

AA amyloid:

Derived from SAA protein (normal regulation of active

inflammation)

If inflammation persists, SAA degradation may be

incomplete in macrophages

and form the F component of AA amyloid

Immunohistochemistry for AA protein
 AA amyloid secondary to a
complication of:
Tuberculosis
Bronchoectatic disease
Chronic osteomyelitis
Rheumatoid arthritis
Ulcerous colitis
Other persisting active inflammatory disorders
AL amyloid:

From monoclonal lg light chain, mostly - lambda

In plasma cell dyscrasias monoclonal gammopathies
Imcomplete proteolysis by macrophages AL F
component
 Imunofluorescencence for:

Ig kappa chains (-)

Ig lambda chains (+++)

AL amyloid in:

Multiple Myeloma
other B cell neoplasias
Can be idiopathic, without detectable B
cell abnormalities
Paraprotein (M gradient) in serum protein
electrophoresis
Bence-Jones protein in urine
Systemic (generalized) amyloidosis,
both AA and AL
 Diagnosis of systemic amyloidosis:

Kidney (or other injured organ) biopsy

Gingiva biopsy

Salivary gland biopsy

Rectum biopsy

Fat aspiration from abdomen wall

Prognosis:

bad, mainly irreversible progression

Treat main disiease

Early cases of AA and AL can be treated by arising
therapiesdymas, ypa ankstyvoms formoms
 Other (rare) types of amyloid:
systemic:
Due to hemodialysis, A2 m
Familial neuropathies, ATTR
localized:
Senile heart, ATTR
Senile brain (Alzheimers disease), A2
Thyroid medullary carcinoma, ACal
Pancreas Langerhans, AIAPP
Isolated atrial, AANF
Amyloid
Other (non-amyloid) paraprotein
deposition
Amyloid AL
Immunotactoid glomerulopathy
Light chain nephropathy
Myeloma (cast) nephropathy
 Amyloid AL
Immunotactoid glomerulopathy
Light chain nephropathy
Myeloma (cast) nephropathy

IF prie grandis
Hyalinosis
Blood plasma protein precipitates in connective tissue
and arteriole walls
In
Diabetes mellitus
Hypertensive disease
hyalin
hyalin
Kimmelstiel-Wilson nodules in diabetes
EM: amorphous accumulations
Intracellular protein
accumulations:
alkoholic hyalin aggregation of hepatocyte
cytoskeleton due to chronic ethanol consumption
 Mallory body,
alcoholic hyalin

Leukocyte infiltrates
Lipid accumulations:

Steatosis triglicerides in specialized cells (liver, kidney,

myocardium)
Fattining, obesity triglycerides in interstitium,
adipocytes
Cholesterol - Atherosclerosis
Inherrited ensymopathies
Steatosis (1):

Liver (due to antilipotropic deficiency):

Ethanol consumption
carbon tetrachloride, other hepatotoxic agents
Protein deficiency in food, starving
hypoxia
Steatosis (2):
Kidney:
Due to lipiduria in renal diseases

Myocardium:
Due to hypoxia (impaired oxydation of fatty acids)
Macroscopic - Tigroid heart
Cholesterol:
Aterosclerosis accumulation in the intima of arteries,
with inflammatory/sclerotic response
Atherosclerotic
plaque
Cholesterol crystals
Carbohydrates:

Diabetes mellitus glycogen accumulations

Inherited enzymopathies (glycogenoses)

 Pigment accumulations (1)

Carbon (anthrax), anthracosis:

Lung (common dust, smokers)

Lung (Coal miners, pneumoconiosis)

Skin (Tatoo)
 Pigment accumulations (2)
Lipofuscin - ageing pigments, fatty acid peroxydation,
residues of cell organells
Melanin - in melanocytes (normal skin, nevi,
melanomas)
Pigment accumulations (3)
Hemosiderosis:
systemic (hemolytic anemias, massive blood transfusions,
increased iron resorption, etc)
local (internal bleeding, increased permeability of capillaries)
Hemochromatosis
Jaundice (bilirubin, no iron)
Perls stain for iron
Perls stain for iron
Perls stain for iron
Minerals:
Calcium:
Dystrophic calcificaton
Increased affinity of injured tissues, without hypercalcemia
Metastatic
due hypercalcemia
hyperparathyreoidism,
D hipervitaminoz
Massive bone destruction

Silicium, etc
Calcium on H&E basophilic amorphous deposits
Calcium on H&E basophilic amorphous deposits
Van Kossu stain
for calcium
Stones:
Gall bladder Increased amount of
Kidney substance in the body
Urinary tract Increased local concentration
Bronchiolithiasis Stasis of secretion/exretion
Coprolithiasis Local inflammation
Sialolithiasis precipitates
Renal oxalosis
Inherited?
Ethylene glycol poisoning?
Hypervitaminosis C?
Short bowel syndrome?
Congo red, positive histochemical stain
Amyloid, Congo red, polarized light
Hyalinosis, PAS stain
Imunofluorescence - Ig lambda in AL amyloid
Pigmentas, H&E

Perls stain for iron

Steatosis, H&E
Robbins Pathology
Assessment strategy
Cummulative points = X20%+Y30%+Z50% =100 %
X daily control (during practical tasks)

Y stage control (colloquium)

Z final control (examination)

Cummulative point= X20% + Y30% + Z50% = 100%
X TESTS
During practical tasks, percentage of correct answers (from
0 to 100%).
If the student can not participate in the group's exercises at
a specified time due to justified reasons (medical, social), he
may attend and pay the same week in other classes of the
medical specialty, after having submitted the relevant
document to the teacher.
If the student did not participate in the exercise for an
unjustifiable reason, his test is estimated at 0 points.
Cummulative point= X20% + Y30% + Z50% = 100%
Y TEST
2 pathology tests (PA and PF) and 1 immunology test in Autum
3 pathology tests (PA and PF) in Spring
A percentage of correct answers is scored
Y tests are provided once at a set time, no repeats
During the autumn and spring semesters 1 test can be skipped
due to justifiable and documented reason (without impact to
the cumulative score). In other cases, a missed test is
estimated at zero score.
Autumn semester credits are given to students who took 80%
of the X tests and all Y tests.
Cummulative point= X20% + Y30% + Z50% = 100%
Z TEST
Students are exempted from the Z test, if
accumulated the X + Y test scores during the
course at 90% or more
Z test (computer test, duration 2 hours) consists of
10-15 tasks and clinical situations with multiple
choice questions (a total of approx 120 pathology
and 30 immunology questions)
A percentage of correct answers is scored
 Final grade is calculated based on
Distribution of students in two groups:
A: CP <50% (49.99 or less), B: CP 50% (50.00 or more)
Percentiles of distribution are calculated in each group: A group is
divided into 4 equal parts, B into 6 equal parts.

A group
Percentile of distribution (CPp) Final grade
:
CPp < 25 1
25 CPp < 50 2
50 CPp < 75 3
75 CPp 4
B group
CPp < 16,6(6) 5
16,6(6) CPp < 33,3(3) 6
33,3(3) CPp < 50 7
50 CPp < 66,6(6) 8
66,6(6) CPp < 83,3(3) 9
83,3(3) CPp 10
Y ir Z tests are alike, computerized test
Y ir Z tests are alike, multiple choice test