Department of Pathology, Sinai Hospital of Baltimore Pathology, Baltimore, MD, USA
KeywordsTonsilSinusitisCholesteatomaCarotidIntervertebral discParathyroidHeart valveGallbladderAppendixHerniaOsteoarthritisChalazionDebridement
Ditzel (slang): A word used to describe any part of the body that is not ordinarily appropriate for everyday conversation. “Susan is always walking down the hall with her ditzels hanging out” (www.urbandictionary.com/).
Ditzels are small specimens with limited educational potential. For the purposes of this chapter, these are all specimens with no suspicion or history of malignancy. They often have about three possible diagnoses and a reduced billing charge because of their limited complexity. Until you get experience with them, they slow you down inordinately at the grossing bench and at the microscope as you struggle to get the “right” wording and obsess over whether what you see is pathologic or normal. After all, it is really embarrassing to get a ditzel wrong. What follows is a list of typical features, things not to miss, and a suggested wording for unremarkable specimens. However, diagnosis style may vary across institutions, so take your cues from your own attendings.
Grossing: It is gross, all right. Document the extent of gangrene, ulcers, venous stasis, trauma, etc., as well as the level of amputation and the viability of the margin. In vascular or infectious disease, identify and section the vascular margin. Take representative sections from the worst area (soft tissue) and margin. Tissue from the bony margin is usually not necessary, but softened bone under an ulcer should be sampled.
Histology: Look for gangrenous necrosis (Figure 5.1), ulceration, scar, granulation tissue, and inflammation. Evaluate vessel for atherosclerotic disease and thrombus, and bone for osteomyelitis.
Gangrene . In this gangrenous ulcer of the toe, the epidermis is visible to the right (arrow), while the ulcer bed to the left shows an obliteration of epidermis and dermis, with a dense blue line of debris representing dying bacteria and cells (arrowhead).
Rule out: Invasive fungal disease in a neutropenic patient (requires more extensive sampling of the margin).
Sample sign-out: Left foot (amputation)—Foot with gangrenous necrosis. Atherosclerotic vessels with thrombus and 90 % occlusion. Surgical margin appears viable.
Grossing: The first section should be a cross section of the proximal margin, inked or otherwise marked as margin. Then cut off the tip and take a longitudinal section (U shaped). Breadloaf the remainder, and take one to two cross sections. Look for nodules, fecaliths, hemorrhage, and pus.
Histology: Normal histology is colonic mucosa with abundant lymphoid aggregates. Chronic inflammation is not significant, but neutrophils are, whether in the mucosa, wall (transmural inflammation; Figure 5.2), or serosa (serositis). Serositis without transmural inflammation suggests another abdominal source.
Appendicitis . In this close-up view, a small amount of residual colonic-type mucosa is visible (arrowhead), surrounded by mounds of fibrinopurulent debris (arrow).
Rule out: Carcinoid in the tip; pools of mucin in the wall, indicating a mucinous neoplasm. See Chapter 8 for a more detailed discussion of mucinous tumors.
Sample sign-out: Appendix (appendectomy)—Acute transmural appendicitis with serositis or histologically unremarkable appendix.
Carotid and Femoral Plaques
Grossing: Specimen is essentially a cast of the artery lumen. Take one block of representative cross sections; this usually requires light decalcification.
Histology: The inner layer of the elastic arterial wall has a variable amount of atherosclerotic debris, calcification, and/or thrombus (Figure 5.3).
Carotid plaque . This represents the intimal surface of the artery, in which there may be calcification, foamy macrophages (arrowhead), cholesterol clefts (arrow), or inflammatory debris.
Sample sign-out: Carotid artery, right (endarterectomy)—Calcified atherosclerotic plaque.
Chalazion of Eyelid
Grossing: Entirely submit; usually a small piece of tissue.
Histology: Lipogranulomas in the soft tissue, with giant cells and acute and chronic inflammation (Figure 5.4).
Chalazion . The squamous mucosa is inflamed (arrowheads), and the stroma shows granulomatous inflammation (arrow), and abundant inflammatory cells.
Rule out: Carcinoma, which can resemble the chalazion clinically. Stains for microorganisms are not necessary in routine cases.
Sample sign-out: Right upper eyelid (excision of mass)—Chalazion or conjunctival epithelium with lipogranuloma consistent with chalazion.
Cholesteatoma of Middle Ear
Grossing: A small, whole specimen is usually submitted.
Histology: A cyst is formed by keratinizing epithelium and filled with flaky keratin. Other features can include inflammation, cholesterol clefts, and foreign body giant cells (Figure 5.5).
Cholesteatoma . The specimen is dominated by layers of pink keratin; the thin epithelium can be seen surrounding the keratin nodule (arrow).
Rule out: Differential diagnosis of a middle ear mass includes inflammatory polyp, paraganglioma, middle ear adenoma, meningioma, and schwannoma.
Sample sign-out: Left middle ear (excision)—Cholesteatoma or fragments of keratinaceous debris (clinical cholesteatoma).
Grossing: Cut the corneal button into cross sections using a fresh blade, and submit in tissue paper or biopsy bag.
Histology: The normal cornea consists of an outer squamous epithelium, a hyalinized layer under that called the Bowman layer, a thick layer of paucicellular pink stroma, another hyalinized layer called the Descemet membrane, and thin endothelium (Figure 5.6). There may be disruptions or inflammatory changes to these components depending on the disease process. Bumps on the Descemet membrane are called guttae and are seen in Fuchs dystrophy and some other conditions.
Cornea. The normal layers of the cornea are (1) an outer squamous epithelium; (2) an acellular Bowman layer; (3) stroma, shown here with some cracking artifact; (4) the slightly bluish acellular Descemet membrane; and (5) nuclei of the thin endothelium.
Rule out: In the presence of acute inflammation or ulceration, rule out infectious organisms, including bacteria, Acanthamoeba, or herpes virus.
Sample sign-out: Left cornea (excision)—Descemet membrane with guttae consistent with the clinical history of Fuchs disease.
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Cysts of the Jaw (Odontogenic)
Grossing: The specimen usually consists of curettings; submit entirely.
Histology: Odontogenic cysts may be non-neoplastic, in which case they are named by their clinical location and presentation, including the common periapical cyst (an inflammatory cyst at the tooth root) and dentigerous cyst (a fluid inclusion cyst associated with an impacted tooth). These are lined by squamous or enamel epithelium with or without inflammation. Small islands of odontogenic epithelium may be seen in a dentigerous cyst. A cyst lined by a stellate reticulum-like epithelium, however, brings ameloblastoma into the differential, which is beyond the scope of this chapter.
Rule out: The keratocystic odontogenic tumor (KOT), formerly odontogenic keratocyst, is a neoplasm and should not be missed. This differs from the non-neoplastic cysts in that the squamous epithelium is flat at the base (no rete) and undulating at the surface, with parakeratosis (Figure 5.7).
(a) Keratocystic odontogenic tumor of jaw . The squamous epithelium has a flat basal layer without rete and a corrugated surface with parakeratosis (arrowhead). (b) In contrast, the dentigerous cyst shows a flat nonkeratinized squamous epithelium (arrow) with underlying islands of odontogenic epithelium (arrowheads).
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