NBDE Part I Review

PATHOLOGY

V. Systemic Pathology*
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Cardiovascular
Respiratory
GI & Hepatobiliary
Genitourinary
Blood-lymphatic
Endocrine
Musculoskeletal
Genetic Diseases
Nervous System

* Excludes infectious
diseases which should be
covered in microbiology

Next histology review will also cover: Inflammation/Repair,

Immunopathology and Developmental Disturbances
(Genetic, Non-neoplastic, Neoplastic)

Pathology Diagnosis Paradigm

! Reactive
! Inflammatory (-itis), non-inflammatory, Infectious,
Traumatic , Autoimmune
! Classic signs and symptoms of inflammation?

! Developmental
!
!

Congenital or acquired malformation

Sometimes symmetric features or cystic

! Neoplastic (-oma)
! Benign (-oma) vs Malignant (-sarcoma/-carcinoma)

Pathology Diagnosis Paradigm

! Apply paradigm to cells/tissues/organs
! Often when normal anatomy/physiologic
function of tissue impaired, the signs and
symptoms follow accordingly
! Anatomy/Physiology is key to
understanding most Pathology, because
often what the tissue normally does
indicates how it will behave when it is
messed up or pathologic!

Cardiovascular
Diseases
Inter-related group of diseases

Cardiac Circulation

Systemic Circulation

Lungs

Lungs

Pathology Diagnosis Paradigm

Applied to Cardiovascular Pathology
! Reactive
! Inflammatory (-itis), non-inflammatory, Infectious,
Traumatic , Autoimmune
! Classic Signs and symptoms of inflammation?

! Developmental

! Congenital or acquired malformation

! Sometimes symmetric features or cystic

! Neoplastic (-oma)

! Benign vs Malignant

- What happens after damage or impairment of

normal anatomy/physiology in the heart
(muscles and vessels)

Angina Pectoris
! Lack of oxygen to the heart due to narrowed
!
!
!
!
!
!

or occluded coronary arterywhy?

Intermittent chest pain
Substernal pain - may radiate to left arm or
left mandible
Associated with exertion or stress
Stable (exertion), unstable (rest), or
Printzmetal variant (morning " coronary
artery spasm)
Relieved by rest and/or nitroglycerin
Increased risk for cardiac co-morbidity

Ischemic Heart Disease

! Due to decreased blood supply to
the heart " Coronary Artery Disease
(CAD)
! Contributing factors: Hypertension,
diabetes, smoking, higher lowdensity lipoprotein (LDL),
cholesterol
! Outcomes: angina pectoris,
myocardial infarction (heart attack),
or sudden cardiac death

Hypertension
! Sustained diastolic pressure > 90 mm Hg and

systolic pressure > 140 mm Hg (AHA)

! 90-95% (idiopathic), 5-10% (renal disease or renal
artery stenosis)
! Mechanisms: blood volume (Glucose, Na+),
peripheral resistance (i.e. atherosclerosis), renal
disease, adrenal disease, lung disease
! Increased risk for: Atherosclerosis, Thrombosis,
Myocardial Infarct (MI), Coronary artery disease
(CAD), Deep Venous Thrombosis (DVT),
Cerebrovascular Accident (CVA, stroke),
Congestive Heart Failure (CHF), and

Atherosclerosis

Atherosclerosis
! Plaque (atheroma) development with lipids,
cells, debris, new fibrous tissue
! Aorta, coronary, and cerebral arteries are
most commonly affected
! Risk factors: age (40-60 5x risk for MI);
sex (M > F); heredity; hyperlipidemia;
hypertension; smoking; and diabetes (2x
risk MI)
! Can lead to many cardiovascular
complicatons such as Aneurysm formation

Aneurysms
! Abnormal dilation of arteries or
veins
! Atherosclerosis is a major risk
factor
! Weakening of arterial wall
! Abdominal aorta frequently
affected
! Rupture can be fatal

Thrombosis
Virchows triad: Factors in thrombus formation
! Endothelial damage
! Inflammation " Thromboplastins and Factor XII
(Hageman) release " platelet and coagulation cascade
activation (hence clot/thrombus)

! Changes in blood flow

! Decreased rate or increased turbulence

! Changes in blood viscosity

! Increased viscosity " hypertension

Types of thrombi:
1. Pale (white): Arterial (fast-flowing)
2. Red: Venous (slow-flow traps RBCs)
Pathology exemplar: Disseminated Intravascular Coagulation

Organization

Recanalization

Embolism?
Which artery?

Myocardial Infarct
! Localized area of myocardial (muscle)
coagulative necrosis secondary to
inflammation
! Most common cause of death
! Etiology: Often secondary to thrombus
! If severe, leads to sudden cardiac death
! Scar tissue forms at site of infarct if
patient survives
! Muscle has poor ability to regenerate due
to cell cycle attributes of muscle cells,
therefore cancer is also rare in these cells

Red or Pale Infarct?

Scar / fibrosis
from previous
MI

Systemic Circulationhemodynamics!

Lungs

Lungs

DVT

Congestive Heart Failure (CHF)

! Inability to eject blood, left-sided

heart failure " right-sided heart
failure
! Commonly caused by hypertension,
valvular disease, vessel disease,
ischemic heart disease, tumor
! Clinical signs and symptoms:
dyspnea, paroxysmal nocturnal
dyspnea, cardiomegaly, tachycardia

Lungs

Lungs

Right-sided heart failure

! Commonly caused by left ventricular
failure, pulmonary congestion or
embolism, valvular disease (pulmonic
or tricuspid), cor pulmonale (due to
diseases of the lung or its vessels)
! Clinical signs and symptoms: Systemic
venous congestion, distended neck
veins, enlarged liver, peripheral edema

Lungs

Lungs

Congenital Heart Diseases*

! Right to Left Shunt

*Jose Gonzales PBL case

! Tetralogy of Fallot
! Ventricular septal defect, pulmonary stenosis, right ventricular
hypertrophy, overriding aorta

! Left to Right Shunt

!
!
!
!

Ventricular septal defect

Atrial septal defect
Patent ductus arteriosus
Persistent truncus arteriosus

!
!
!
!

Transposition of great vessels

Coarctation of aorta
Pulmonary stenosis, aortic stenosis
Complete heart block

! No Shunt

TEST QUESTIONS
! 112. Which of the following has the LEAST
ability to regenerate?
a. bone
b. liver
c. striated muscle
d. collagen
e. smooth muscle

! 16.8% correctly answered C

TEST QUESTIONS
! The next 2 questions refer to the following:
An 80 year-old female with a history of
myocardial infarction presents with a complaint
of pain under her complete dentures when
biting. She has worn them for 15 years, but
seldom removes or cleans them. Removal of
the dentures reveals diffuse erythema of
underlying mucosal tissue. Bone resorption is
noted from detectable reduction in height of the
alveolar ridges due to the ill-fitting denture.

TEST QUESTIONS
! 178. Each of the following statements correctly describes

myocardial infarction (MI) EXCEPT one. Which one is the

EXCEPTION?
a. Most acute MIs are caused by coronary artery
thrombosis.
b. Acute MI is the most common cause of death in
industrialized nations.
c. Pain from MI can usually be relieved by vasodilators
such as nitroglycerin.
d. Thrombolytic agents such as streptokinase often limit
the size of infarction.
e. Myocardial necrosis usually begins 20-30 minutes after
coronary artery occlusion.

! 16.1% correctly answered C

TEST QUESTIONS
! 182. Which of the following represents the
MOST likely pathologic change in
this patient's heart?
a. vegetations of the aortic valve
b. severe mitral valve thickening
c. hypertrophy of the left ventricle
d. necrosis in the right ventricle
e. scarring in the left ventricle

! 11.7% correctly answered E

Systemic Pathology
!
!
!
!
!
!
!
!
!

Cardiovascular
Respiratory
GI and Hepatobiliary
Genitourinary
Blood-lymphatic
Endocrine
Musculoskeletal
Genetic Diseases
Nervous System

Pathology Diagnosis Paradigm

! Reactive
! Inflammatory (-itis), non-inflammatory, Infectious,
Traumatic , Autoimmune
! Classic signs and symptoms of inflammation?

! Developmental
!
!

Congenital or acquired malformation

Sometimes symmetric features or cystic

! Neoplastic (-oma)

! Benign vs Malignant

- Apply paradigm to lungs

- Normal anatomy/physiologic function of tissue
impaired, so signs and symptoms follow
accordingly

Reactive
! Asthma
! Bronchitis
! Emphysema

Asthma
! Reversible bronchospasm
! Clinical manifestations: dyspnea,
cough, and wheezing
! 5% of adults, 7-10% of children
! Triggered by antigen (allergen)
! IgE, mast cells and eosinophils

Chronic Obstructive
Pulmonary Disease (COPD)
COPD
(Smoking)
Chronic Bronchitis
(Inflammation: obstruction)

Productive cough (chronic)

Dyspnea, wheezing
Cyanosis (low O2) + Edema=blue bloater

Emphysema
(Dilatation: alpha-1-antitrypsin deficiency, so
proteases (i.e. trypsin, elastase) unchecked)

Non-productive cough (chronic)

Dyspnea, tachypnea
Enlarged lungs causes barrel chest
Tachypnea (adequate O2 )=pink puffer

POOR PROGNOSIS = 5-year survival < lung cancer

Developmental
! Hypoplasia
! Hyperplasia
! Agenesis
! Dysgenesis (malformations)
! Cystic

Neoplastic
Typed as small cell and non-small cell
cancers

! Carcinoma
! Adenocarcinoma
! Mesothelioma

Lung Tumors
! Squamous Cell Carcinoma
! #1 cause of cancer deaths,
M:F=2:1, 40-70 yr
! Etiology: Cigarette smoking,
10x risk of death
! Symptoms: Chronic cough,
hemoptysis and hoarseness
! Mets: CNS, Liver, Bone, Kidney,
Adrenals

Lung Tumors
! Adenocarcinoma
! Glandular cancer, most cases related
to smoking, although some not
! 2nd to squamous cell carcinoma of
lung

! Mesothelioma
! Connective tissue cancer, rare
! Etiology is inhalation of inorganic
dusts: silicosis, anthracosis,
berylliosis, asbestosis

Systemic Pathology
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!
!
!
!
!
!
!
!

Cardiovascular
Respiratory
Gastrointestinal and Hepatobiliary
Genitourinary
Blood-lymphatic
Endocrine
Musculoskeletal
Genetic Diseases
Nervous System

Pathology Diagnosis Paradigm

! Reactive
! Inflammatory (-itis), non-inflammatory, Infectious,
Traumatic , Autoimmune
! Classic signs and symptoms of inflammation?

! Developmental
!
!

Congenital or acquired malformation

Sometimes symmetric features or cystic

! Neoplastic (-oma)

! Benign vs Malignant

- Apply paradigm GI
- Normal anatomy/physiologic function of tissue
impaired, so signs and symptoms follow
accordingly

Gastrointestinal Disease

Esophagus

Stomach

Small &Large Intestines

Appendix

Hiatal
Hernia

Chronic
Gastritis

Hemorrhoids

Appendicitis

Esophageal
Carcinoma

Acute
Gastritis

Crohn's
Disease

*Achalasia
DDx
covered in
case PBL032: Mrs.
Richardson

Peptic
Ulcers

Ulcerative
Colitis

Gastric
Carcinoma

Colonic
Diverticulosis
Colorectal
Carcinoma

Hiatal Hernia

Hiatal Hernia
! Opening for the esophagus widens
! Displacement of stomach above the
diaphragm
! 1-20% population; with aging
! 10% - heartburn, reflux of gastric
juices " esophagitis

Esophageal Carcinoma
! > 50 yrs; 3:1 male predominance
! 1-2% of all cancer deaths
! Smoking & alcohol abuse
! Dysphagia (difficulty in swallowing)
obstruction; anorexia; fatigue;
weakness & weight loss
! Prognosis: Poor

Gastrointestinal Disease

Esophagus

Stomach

Small &Large Intestines

Appendix

Hiatal
Hernia

Chronic
Gastritis

Hemorrhoids

Appendicitis

Esophageal
Carcinoma

Acute
Gastritis

Crohn's
Disease

Peptic
Ulcers

Ulcerative
Colitis

Gastric
Carcinoma

Colonic
Diverticulosis
Colorectal
Carcinoma

Chronic Gastritis
! Chronic inflammatory changes
mucosal atrophy & metaplasia
! Helicobacter pylori, gram- bacteria
! > 50 yrs; 50% are affected
! Upper abdominal discomfort,
nausea or vomiting

Acute Gastritis
! Acute Inflammatory process
! Transient
! Heavy use of NSAIDs (i.e. aspirin)
! Alcohol abuse
! Heavy smoking
! Severe stress (trauma, surgery)

Peptic Ulcers
! Chronic, solitary, exposed to actions
of acid-peptic juices
! 98% in the duodenum/stomach (4:1)
! Diagnosed in middle-aged adults
! In US, 2% of Males & 1.5% of
Females affected
! Impaired secretion of gastric acid
and pepsin
! Infection with Helicobacter pylori

Peptic Ulcers
! 2-4 cm in diameter
! Acute , burning pain
! Usually nocturnal (1-3 hrs after
meals)
! Relieved by food or antacids
! Complications: Bleeding,
perforation through the bowel wall

Gastric Carcinoma
! 3% of all cancer deaths in the US.
! Early Ca is Asymptomatic
(endoscopy)
! Advanced Ca : abdominal
discomfort/weight loss
! Early detection & Surgical
removal
! 5-year survival rate: 10%

Gastrointestinal Disease

Esophagus

Stomach

Small &Large Intestines

Appendix

Hiatal
Hernia

Chronic
Gastritis

Hemorrhoids

Appendicitis

Esophageal
Carcinoma

Acute
Gastritis

Crohn's
Disease

Peptic
Ulcers

Ulcerative
Colitis

Gastric
Carcinoma

Colonic
Diverticulosis
Colorectal
Carcinoma

Hemorrhoids
! Dilated veins of the anal & perianal
submucosal venous plexuses
! > 50 yrs
! venous pressure: pregnancy;
straining at stool (chronic
constipation)
! Bleed and become thrombosed
! Surgical Removal

Crohn's Disease
! Inflammatory bowel disease (IBD)
! Different than irritable bowel syndrome
(IBS)
! Regional Enteritis, Granulomatous
inflammation
! Small intestine & colon
! 1/3 patients - extraintestinal inflammatory
lesions in the joints, skin, liver or eyes
! 1-3/100,000 in US; 2nd & 3rd Decade

Crohns Disease
! Diarrhea, abdominal pain & fever
weight loss
! Relapse & Remitting Disorder
! Complications: Fistula; abdominal
abscesses; intestinal obstruction
! Sulpha drugs, corticosteroids
! Surgery
! Prognosis: Guarded.

Ulcerative Colitis
! Idiopathic inflammatory disease of
the colon
! 4-6/100,000 in US; Peak incidence
20-25 years
! extraintestinal inflammatory
lesions in the joints,skin,liver, or
eyes

Ulcerative Colitis
! Abdominal cramps, fever, weight
loss, bloody stool
! Chronic relapsing & remitting
disorder
! Complications: severe
diarrhea,massive hemorrhage, severe
colonic dilation with potential rupture
! Risk of Colon Cancer

Colonic Diverticulosis
! Outpouchings of the wall of the colon
! 50% of US: > 60 yrs
! Asymptomatic; 1/5:pain (left lower
quadrant)
! Occasionally Inflamed (Diverticulitis)
! Treatment: high-fiber diet or surgery
in severe cases

Colorectal Carcinoma
! 150,000 case diagnosed annually
in US
! 15% of all cancer deaths (58,000)
! Peak Incidence: 60-70 yrs
! Related to low fiber, high
carbohydrate, high fat diet
! Glandular origin
(Adenocarcinomas)
! Begin as Adenomatous Polyps

Colorectal Carcinoma
! Asymptomatic for years
! Fatigue & Anemia (due to bleeding)
! Detection: Digital Rectal Exam,
Fecal Test (occult blood loss),
Colonoscopy
! Surgical Excision
! 25-30%: disease beyond curative
surgery

Appendicitis
! 10% of population; 2nd & 3rd Decade
! Mild periumbilical discomfort

anorexia, nausea/vomiting right

lower quadrant tenderness deep
constant ache/pain
! Other GI diseases mimic Appendicitis
! Treatment: Surgical Removal
! Prognosis: Good

Hepatobiliary Disease

! Hepatic Necrosis
! Viral Hepatitis
! Drugs or chemicals

! Chronic Liver Disease

! Cirrhosis " alcohol or viral:
Covered in case PBL 118 - A Stitch in Time)

! Hepatocellular Carcinoma

Alcoholic Liver Disease

! Leading cause of liver disease
! 10 million Americans
! 200,000 deaths annually:
! Alcohol Abuse
! 25-30% hospital patients:
! Problems related to alcohol

Cirrhosis

! Chronic Liver Disease

! Loss of normal liver structure
! Loss of normal function

! Normal liver parenchyma

replaced by:
! Fibrosis & nodules of cells

Normal

Cirrhotic

Cirrhosis

Signs and Symptoms of

Hepatic Failure
! Jaundice
! Spider Angioma
! Hypoalbuminemia
" Edema
! Gynecomastia
! Tremor
! Coagulopathy
! Coma, death

Biliary Disease:
Gallstones (cholelithiasis)
! Common cause of biliary
!
!
!

disease
Abdominal pain
Cholesterol hyperseretion
or supersaturation 90%
Pigment 10%
! Black pigment
hemolysis
! Brown pigment
infection
! Mixed

TEST QUESTIONS
! 10. Each of the following is attributable to
hepatic failure EXCEPT one.
Which one is the EXCEPTION?
a. tremor
b. gynecomastia
c. mallory bodies
d. hypoalbuminemia
e. spider telangiectasia

! 17.5% correctly answered C

Systemic Pathology
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Cardiovascular
Respiratory
GI and Hepatobiliary
Genitourinary
Blood-lymphatic
Endocrine
Musculoskeletal
Genetic Diseases
Nervous System

Genitourinary
! Reproductive Pathology
(anatomic structures?)
!
!
!

Reactive
Developmental
Neoplastic

Signs and Symptoms for

each category?

! Kidney Pathology
(anatomic structures?)
!
!
!

Reactive (PBL case?)

Developmental
Neoplastic

Kidney Pathology
! Nephrotic Syndrome:
! Proteinuria
! Increased glomerular permeability

! Nephritic Syndrome:
! Hematuria, oliguria, uremia
! Acute nephritis/Acute glomerular disease
Chronic disease can lead to life-threatening renal failure.

Systemic Pathology
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!
!

Cardiovascular
Respiratory
GI and Hepatobiliary
Genitourinary
Blood-lymphatic
Endocrine
Musculoskeletal
Genetic Diseases
Nervous System

Hematology-Lymphoid
Red, White and Blue disorders
Blood Dyscrasias
Red Cell Disorders
Neoplastic

Polycythemia

Reactive

White Cell Disorders

Neoplastic

Anemia/
Thalassemia

Reactive
Leukemia/
Lymphoma/
Myeloma

Neutropenia

Hematology-Lymphoid
Blue disorders (bleeding)
Platelet pathology

Coagulation pathology

Thrombocytopenia
Thrombocytosis

Hemophilias
Von Willebrand disease

Red Cell Disorders

Red Cell Disorder

Increased Red Cell Destruction
Hemolytic Anemia

Decreased Red Cell Production

Diminished Erythropoiesis

Sickle Cell

Megaloblastic

Iron Deficiency

Folic Acid

Aplastic

Vitamin B12
(pernicious)

Examples of Red Cell Disorders

Variations of size, shape, or color

Examples of Red Cell Disorders

Myelophthisic Anemia 2 Leukemia
(Normocytic, Normochromic)

Megaloblastic Anemia
(macrocytic)

White Cell Disorders

Neoplastic
! Lymphoma (solid)
! Hodgkins, EBV (Reed-Sternberg cell)
! Non-Hodgkins (B or T cell)
! Leukemia (marrow"blood)
PBL Cases:
! Lymphoblastic/Myeloblastic
1) Lewis Kimble
! Myelophthisic Anemia
2) Prior Walters
! Multiple Myeloma (marrow"blood) Mass Appeal
! Plasma cell dyscrasia
! Monoclonal gammopathy
! Bence-Jones protein in urine
! Punched-out lesions of bone

Normal Lymph Node

Hodgkins Lymphoma
(Reed-Sternberg cells)

Punched-out lesions of
Multiple Myeloma

TEST QUESTIONS
! 170. The patient was found to be severely
anemic, showing normocytic, normochromic
erythrocytes. Which of the following BEST
characterizes this anemia?
a. hemolytic
b. pernicious
c. myelophthisic
d. chronic blood loss

! 17.5% correctly answered C

Systemic Pathology
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!
!

Cardiovascular
Respiratory
GI and Hepatobiliary
Genitourinary
Blood-lymphatic
Endocrine
Musculoskeletal
Genetic Diseases
Nervous System

Hypothalamus

Endocrine Diseases
! Pituitary
!
!
!

Gigantism
Acromegaly
Dwarfism

! Thyroid
! Hyperthyroidism
! Hypothyroidism

! Parathyroid
! Hyperparathyroidism
! Hypoparathyroidism

! Adrenal Cortex
! Cushings Disease
! Addisons Disease

! Pancreas
! Diabetes Mellitus

Gigantism
Hypersecretion of growth hormone
Before the closure of the epiphyseal
plates
Usually caused by a benign tumor:
pituitary adenoma
Manifestations:
Generalized increased size of the body
Disproportionately long arms and legs

Treatment: Surgical removal of the

adenoma

Acromegaly
Hypersecretion of growth hormone
(somatotropin)
- after closure of the Epiphyseal Plates

Enlargement the bones of the hand,

feet, facial skeleton
Prognathism with diastema

Hypertension & Congestive Heart

Failure

TEST QUESTIONS
Acromegaly is due to an excessive
production of which of the following?
A. Thyrotropin
B. Gonadotropin
C. Somatotropin
D. Adrenocorticotropin
!19.5% correctly answered C

Dwarfism
Hyposecretion of growth hormone
Alternately tissues lack of

responsiveness to growth
hormone
Short stature, small jaws & teeth
Hormone replacement therapy

Thyroid

! Hyper-thyroidism
! Graves Disease

! Hypo-thyroidism
! Cretinism
! Myxedema

Hyperthyroidism
Hypersecretion of thyroid hormone:
Graves Disease
Multinodular Goiter/Adenoma

More common in women (7-10x)

Graves
Disease
PBL Case:
The
Retired
Runner

Clinical Features
Wide, staring gaze (proptosis /

exophthalmos)
Nervousness, tremor, irritability
Tachycardia, Palpitations
Weight loss with increased appetite
Severe hyperthyroidism can lead to
Thyroid Storm: may be precipitated
by stress (dental procedures)

Hypothyroidism
Hyposecretion of Thyroid Hormone
Cretinism: Infants/Early Childhood
Myxedema: Older children/Adults

Cretinism
Impaired Development of CNS
Mental Retardation

Impaired Development of Skeletal

System
Short Stature

Protruding tongue

Before and After Thyroid Hormone

Replacement Therapy

Myxedema
Mental
Sluggishness
Obesity
Sensitivity to
cold

TEST QUESTIONS
Hypothyroidism in an adult results in
A.
B.
C.
D.

Myxedema
Thyrotoxicosis
Thyroid storm
Increased basal metabolic rate

Parathyroid
Secretes Parathyroid Hormone (PTH)
Counteracts Calcitonin from Thyroid

Controlled by the level of Ca+

Decreased serum Ca++ Release of PTH,
which causes release of Ca++ from
mineral stores (what tissue mainly?)
Two Types:
! Primary
! Secondary

Primary Hyperparathyroidism
Hyperplasia/Adenoma
Manifestations:
Painful Bones
(Fractures, Giant-cell lesions)
Renal Stones
(Urolithiasis)
Abdominal Groans
(Gallstones, Peptic Ulcer)
Psychic Moans (depression & lethargy)

Brown tumor Central Giant-cell Lesions of Bone

Note: teeth can show loss of

lamina dura on radiographs

Secondary
Hyperparathyroidism
! Usually secondary to renal failure
! Decreased serum calcium
! Increased parathyroid activity
Surgical Removal of the gland
Renal Transplant if renal failure
Prognosis: Good

TEST QUESTIONS
! The next question refers to the following: A 42 year-old female with

a history of hyperparathyroidism presents with a complaint of

bilateral pain in the temporomandibular joint on closing. She reports
that her ears are occasionally "clogged" and she sometimes
experiences a "ringing" sensation. The dentist determines that these
symptoms are related to her TMJ condition.

162. Given her reported hyperparathyroidism, this

patient is likely to show each of the following signs or
symptoms EXCEPT one. Which one is the
EXCEPTION?
a. urolithiasis
b. elevated serum calcium
c. tetanic muscular convulsions
d. central giant-cell bone lesions
e. loss of lamina dura surrounding multiple teeth

! 8% correctly answered C

In a parathyroid deficiency state, there is

A. An increase in serum calcium and a decrease
B.
C.
D.

in serum phosphate
A decrease in serum calcium and an increase
in serum phosphate
An increase in serum calcium and a normal
serum phosphate
A normal serum calcium and an increase in
serum phosphate

PTH=Break bone vs. CALCITONIN (from thyroid)=Build bone

Adrenal Cortex

! Hypercortisolism: Cushings
Disease

! Hypocortisolism: Addisons
Disease

Cushings Disease
Causes: Increased levels of
glucocorticoids
Endogenous, Exogenous

Manifestations
Hypertension & Weight Gain
Fat in the facial area (Moon Face) &
posterior neck & back (Buffalo Hump)
Diabetes & Osteoporosis
Mental Disturbances

Addisons Disease
Decreased levels of
glucocorticosteroids (adrenal
insufficiency)
Autoimmune destruction of the
gland; Infections; Metastatic
Neoplasms

Addisons Disease
Manifestations:
Weakness; G.I. Disturbances
Hyperpigmentation (MSH)

Treatment:
- Corticosteroid Replacement
Therapy

Pancreas
! Islets Of Langerhans
! Glucagon: Mobilization of stored
glucose into blood
! Hypersecretion?
! Hyposecretion?
! Insulin: Glucose transport from blood
into cells
! Hypersecretion?
! Hyposecretion?

Diabetes Mellitus
13 million people in the USA
Mortality rate of 54,000
Defective/Deficient Insulin
Mechanisms
Impaired glucose use & Hyperglycemia

Two Types: Type I & II

Type II most common

Type I
Younger onset
Manifestations: Polydipsia, Polyuria,

Polyphagia, Ketoacidosis
Autoimmune response
Antibodies to Islet cells
Most complications related to
Hyperglycemia or Glycosylated EndProducts
Treatment:
Insulin

Type II
Not related to autoimmune

mechanisms
Decreased Secretion/Insulin
resistance at receptor level
Onset over 30 years of age
Treatment:
Oral Hypoglycemic Drugs
Weight loss

TEST QUESTIONS
Glucosuria usually occurs in which of the
following?
A.
B.
C.
D.

Addisons disease
Diabetes mellitus
Cushings disease
Parkinsons disease

Why this clinical picture intraorally?

Systemic Pathology
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!
!
!
!
!
!
!
!

Cardiovascular
Respiratory
GI and Hepatobiliary
Genitourinary
Blood-lymphatic
Endocrine
Musculoskeletal
Genetic Diseases
Nervous System

Musculoskeletal
! Muscle Pathology
! Reactive
! Myositis (infection, trauma), Myasthenia Gravis
(autoimmune damage to Ach receptors)

! Developmental
! Muscular dystrophy, congenital or acquired
myopathies

! Neoplastic
! Rhabdo-myoma/-myosarcoma (striated muscle)
! Leio-myoma/-myosarcoma (smooth muscle)

Rhabdomyosarcoma
(common in children, rarer in adults)

Musculoskeletal
! Bone (skeletal) Pathology
! Reactive
! Osteomyelitis; Osteitis deformans (Pagets
disease); Osteoporosis

! Developmental
! Osteogenesis Imperfecta (PBL case?);
Osteopetrosis (Marble bone disease)

! Neoplastic
! Osteoma/Osteoblastoma/Osteosarcoma;
Many malignancies metastasize to bone
(more common than primary bone cancers)

Osteomyelitis

TEST QUESTIONS
! 160. The first clinical findings in prostatic cancer
are often the result of metastasis to which of the
following?
a. liver
b. brain
c. testes
d. adrenal gland
e. bone

! 14.6% correctly answered E

Systemic Pathology
!
!
!
!
!
!
!
!
!

Cardiovascular
Respiratory
GI and Hepatobiliary
Genitourinary
Blood-lymphatic
Endocrine
Musculoskeletal
Genetic Diseases (covered later)
Nervous System

Nervous System
! Reactive
! Meningitis; Encephalitis; Neuritis (Guillain-Barre Syndrome)
! Trauma: Contusion/Concussion/Hematoma
! Demyelinating: Multiple sclerosis
! Degenerative: Alzheimers disease, Parkinsons disease
! Developmental
! Spina bifida; cerebral palsy; neurofibromatosis (Von
Recklinghausens disease); Tuberous sclerosis (multiple
brain lesions)

! Neoplastic
! Schwannoma, Neuroma, Astrocytoma, Glioblastoma,
Ependymoma, Medulloblastoma; Meningioma;
Craniopharyngioma

NEOPLASIA

Definitions
! Hyperplasia = An abnormal increase in the number
of cells in a tissue
! Metaplasia = The replacement of one differentiated
cell type with another cell type
! Neoplasia = New tissue growth or tumor
(benign or malignant)

! Dysplasia = Altered tissue growth (usually precancerous)

! Anaplasia = The reversion of cells to an immature
or a less differentiated form, as occurs in most
malignant tumors
! Cancer = malignant tumor

or
Metaplasia

Cancer

Nomenclature
! Tumors are
classified by the
tissue presumed to
be the origin of the
tumor
! Carcinoma =
Epithelial tissue
cancer (including
ductal epithelium)
! Sarcoma =
Connective tissue
cancer

Benign
-oma
Adenoma
Fibroma
Lipoma
Leiomyoma
Hemangioma
Neuroma

Malignant
-carcinoma
-sarcoma
Adenocarcinoma
(breast or prostate
cancer)

Osteosarcoma
Exceptions:

Melanoma
Lymphoma
Brain tumors

Benignancy vs Malignancy

BEHAVIOR OF BENIGN
NEOPLASMS

! An orderly tumor
! Well-defined
borders or capsule
! Rarely infiltrative
! Non-metastasizing

BEHAVIOR OF MALIGNANT
NEOPLASMS
! Disorderly and
!
!
!
!
!
!

destructive growth
pattern
No capsule
Invasion
Metastasis
Rapid growth
Necrosis
Bizarre cytology

CARCINOGENESIS: How we get

to full-blown cancer or malignancy?

! Hyperplasia " Dysplasia " Anaplasia

(CANCER)

! Metaplasia " Dysplasia " Anaplasia

(CANCER)

Oncogenes, Tumor Suppressor Genes,

Mutagenesis and the Cell Cycle

or
Metaplasia

The Cell Cycle

Oncogenes
(i.e. Cyclin-D1)

Tumor Suppressor
Genes
(i.e. p53, Rb)

RETINOBLASTOMA
! Rb gene mutation

!
!
!

causes continuous
cell cycling because
of loss of tumor
suppression
1/20,000 infants
60% sporadic, 40%
inherited cancer
Knudsons two-hit
hypothesis

CERVICAL DYSPLASIA
! Precancerous

changes and
continuous cell
cycling
! HPV virus has
oncogenic
proteins
! Bizarre cytology:
Hyperchromatic
nuclei, atypical
mitosis, N/C,
prominent nucleoli,
pleomorphism

SQUAMOUS METAPLASIA "

DYSPLASIA " LUNG CANCER

Respiratory mucosa

Squamous metaplasia

PATHOLOGIC DIAGNOSIS-CANCER
! Biopsy (histopathology) Is The Gold
Standard For Diagnosing Cancer of
Tissues
! Frozen Section (during surgery)
! Permanent Section (after surgery)

Excisional
vs.
Incisional
Biopsy
10% Formalin Solution

Tissue
Embedding

Microtome Tissue Sectioning

Tissue Washing
and Staining (H&E)

Microscopic Evaluation for Diagnosis

Frozen
Section
Diagnosis
Cryostat
Freezing chamber
Tissue biopsy

CYTOLOGY
! Fine-needle
aspiration
(FNA) biopsy
! Fluids
! Pap smears

IMMUNOHISTOCHEMISTRY

FLOW CYTOMETRY

CYTOGENETICS

PATHOLOGY
GRADING and STAGING

PATHOLOGY GRADING
How closely do the cancer cells
resemble the normal cells from which
they arose?
! Well-differentiated (closely resemble normal)
! Moderately-differentiated (sort of resemble)
! Poorly-differentiated (dont resemble at all)
! This caries the worst prognosis in most cases

PATHOLOGY GRADING

PATHOLOGY STAGING
An anatomic assessment of the spread of
neoplasm within the body
How much cancer is present, and where?
i.e. TNM Staging System
More prognostically significant than
grading usually

PATHOLOGY STAGING
!
!
!

T = Tumor size
N = Nodal involvement
M = Metastasis to distant site

4 Stages: I, II, III, IV

! The higher you go, the worse the prognosis
(stage IV=widespread metastasis)

TUMOR SIZE

NODAL INVOLVEMENT

DISTANT METASTASIS

QUESTIONS?