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第13章-内分泌[英文]
第13章-内分泌[英文]
第13章-内分泌[英文]
第13章-内分泌[英文]
第13章-内分泌[英文]
第13章-内分泌[英文]
第13章-内分泌[英文]
第13章-内分泌[英文]
第13章-内分泌[英文]
第13章-内分泌[英文]
第13章-内分泌[英文]
第13章-内分泌[英文]
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第13章-内分泌[英文]

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  • 1. Chapter 13 Diseases of Endocrine System OBSERVATIONAL METHODS OF SPECIMEN Thyroid gland. Macroscopically, the butterfly-shaped, reddish-brown thyroid gland is located below the level of the cricoid, which composed of two lateral lobes and connected by a median tissue called the isthmus. The gland is enclosed in a connective tissue capsule, which makes the surface smooth, and the cut surface of the gland is light brown and translucent (Fig. 13-01). When observing we must note the size, shape, texture and the color of the thyroid; whether the surface is smooth, or if it has any nodes; whether the membrane thickened or integrated; whether there is any adhesion with the surrounding tissue; whether there is diffuse or focal enlargement on the cut surface; Note the size, number, color of the nodes; and whether it has capsule, clearly defined border or compression and invasion into the surrounding tissue; and if it has the changes of hemorrhage, necrosis, cystic degeneration, fibrosis and calcification. Microscopically, the thyroid gland is composed of follicles contained with colloid (Fig. 13-02a, b). The shape of the thyroid gland has close relationship with its function, thus the changes of its histological morphology can indicate its state of function. Lined by a single layer of follicular cells whose shape ranges from flattened to low columnar, with follicles enlarging, colloid plentiful and margin clear represents their inactive state, and active state when the epithelium columnar, follicle contracted or colloid deceased, and overactive when the epithelium high columnar or buckling into the follicles to form papillae, with the resorptive vacuoles of the colloid. Normal thyroid follicle alter with the periodical state of activity Adrenal gland. Macroscopically, the paired yellowish-brown adrenal gland are enclosed in a thin fibrous capsule (Fig. 13-03), with the right one pyramid-shaped, and the left one crescentic. The outer cortex presents yellowish, and inner medulla grey or brown on the cut surface. When observing we must note the size, shape of the adrenal gland, the thickness of cortex, and if it has hemorrhage or nodes on the cut surface, giving attention to the size, color, texture and relationship with surrounding tissue of the node. Microscopically, the cortex, which forms the bulk of the gland, are arranged in three distinct zones, comprises the outer, middle and inner zones- zona glomerulosa,
  • 2. zona fasciculate and zona reticularis respectively. The medulla consists chromaffin cells (Fig. 13-04) arranged in rounded groups or short cords which crowd around boundary blood vessels. Pituitary gland. Macroscopically, the pituitary gland seated in the sella turcica of the sphenoid bone, usually said to be the size and shape of a symmetrical pea. In humans the gland has two major lobes, the reddish-brown adenohypophysis and the pale-grey neurohypophysis(Fig. 13-05). Microscopically, adenohypophysial are arranged in intermingling columns and nests, interspersed with boundary capillary network. The adenohypophysial is classified into eosinophils, basophils and chromophobes according to the staining by haematoxylin and eosin (Fig. 13-06). Pancreas. Macroscopically, the human pancreas is a narrowly elongated gland, measures 17 to 20cm in length, 3 to 5cm in width, 1.5 to 2.5cm in thickness and weighs 82g, which is subdivided into the head, the body and the tail. The cut surface presents reddish-brown, soft texture and lobular architecture. Microscopically, the endocrine pancreas is mainly composed of pancreatic islets, which consists of clusters of cells cord interspersed with boundary blood vessels (Fig. 13-07). Islets contain the A cells, B cells, D cells and PP cells. AIMS 1. To be acquainted with the morphologic characteristics of simple goiter and toxic goiter. 2. To be acquainted with the features of thyroid adenoma and thyroid adenocarcinoma. 3. To understand the knowledge about the characteristics of subacute and Hashimoto’s thyroiditis. 4. To understand the knowledge about the features of adrenocortical adenoma and pheochromocytoma. 5. To understand the knowledge about the features of pituitary adenoma and insulinoma. CONTENTS
  • 3. Gross specimen Tissue section Disease of thyroid gland Simple goiter Simple goiter Toxic goiter Toxic goiter Subacute thyroiditis Subacute thyroiditis Hashimoto’s thyroiditis Hashimoto’s thyroiditis Thyroid adenoma Thyroid adenoma Thyroid adenocarcinoma Thyroid adenocarcinoma Tumor of adrenal gland Adrenocortical adenoma Adrenocortical adenoma Pheochromocytoma Pheochromocytoma Pituitary adenoma Pituitary adenoma Tumor of pancreas Islet cell tumor Islet cell tumor KEY POINTS OF SPECIMEN OBSERVATION 1. Diseases of the thyroid gland (ⅰ) Simple goiter Basic pathologic changes (1) Gross morphology ◆ Hyperplastic phase: There is diffuse enlargement of the gland, with smooth surface. Colloid phase: the cut surface is light brown, glassy and translucent; ◆ Nodular phase: The gland is enlarged by irregular nodules, which are clear defined by imperfect capsule or no capsule at all. Hemorrhage, calcification, and cystic changes can be seen on cut surface. (2) Histopathology ◆ Hyperplastic phase: The follicles are small and lined by crowed columnar cells, with scanty colloid; ◆ Colloid phase: The follicular epithelial are flattened or cuboid and colloid is abundant in the larger follicles; a few small follicles, with scanty colloid and proliferated, hypertrophic epithelium are seen; ◆ Nodular phase: There are fibrosis, hemorrhage and necrosis, accompanied by the colloid phase change noted previously and papillae formed in some follicles. Note the structural similarity inside and outside the nodes. Specimen observation Case abstract: Female, 45 years old. 10-year history of progressively enlarged anterior cervical mass. Examinations: there is a notable asymmetrically enlarged thyroid gland whose surface is nodular. The nodules are soft and well defined. B-
  • 4. ultrasound investigation suggests that there are hemorrhage and cysts in the nodules. The cervical lymph nodes are not enlarged. Gross specimen: (Fig. 13-08) There is enlarged and soft thyroid gland. Tracts of fibrosis separate the gland, resulting in multi-nodular goiter. The irregular nodules have no intact capsules and contain amounts brown gelatinous colloid. Secondary changes in the form of hemorrhage and cystic degeneration can be seen on cross section. Tissue section: (Fig. 13-09) The normal structure of thyroid gland is destroyed and is displaced by irregular nodules. The follicles in the nodules vary in size and colloid content. The colloid-filled follicles are lined by flattened or flat cuboid epithelium. Hemorrhage and calcification can be seen. Questions: How to differentiate the three stage of simple goiter microscopically? (ⅱ) Toxic goiter Basic pathologic changes (1) Gross morphology ◆ The thyroid gland is symmetrically enlarged, with the surface smooth and the texture soft. ◆ It has reddish-brown, muscle like appearance, with scanty colloid on the cut surface. (2) Histopathology ◆ The thyroid is composed of a mixture of large and small follicles containing less colloid, lined by cuboidal epithelium. ◆ Large ones are lined by columnar cells, crowed and often buckle into the follicles to form papillae, with thin, watery colloid and resorptive vacuoles adjacent to the epithelium. ◆ There is congestion, proliferation of lymphoid tissue and boundary blood vessels in the stroma. Specimen observation Case abstract: female, 28 years old. Eyes protruding for one year. Also suffered from agitation, excessive sweating, and weight loss despite good appetite. Physical examination: eyes protruding, hands tremor, moderate enlargement of thyroid gland. Heart rate: 100/m. marked elevation of the basal metabolic rate. Gross specimen: (Fig. 13-10) The thyroid gland is enlarged and firm. The cut surface
  • 5. is purple. Tissue section: (Fig. 13-11a,b) There is an increase in the amount of colloid and decrease in the number of resorptive vacuoles in follicles lined with less columnar epithelium. The congestion and lymphatic infiltration can be seen within in the stroma. Questions: What is the difference between the pathological and clinical features of toxic goiter and simple goiter? (ⅲ) Subacute thyroiditis Basic pathologic changes (1) Gross morphology ◆ The gland is asymmetrically enlarged and firm, adherent to the surrounding structure; ◆ Necrosis and fibrosis can be seen on the pale cut surface. (2) Histopathology ◆ Early lesions consist of scattered focal follicles lined by necrotic epithelium, infiltrated by eosinophils; ◆ There are foci of necrosis of follicles surrounded by neutrophils, eosinophils, and plasma cells infiltration which later change to a glanulomatous pattern, the center of which often contains irregular fragments of colloid surrounded by a foreign giant cell reaction; ◆ Later change is granulomas fibrosis . Specimen observation Case abstract: Female. 39 years old. 3-months of anterior cervical swelling associated with transitory pain. Physical examination: slight thyroid swelling with tenderness on palpation. The gland is poorly circumscribed. Tissue section: (Fig. 13-12a, b) Some follicles are destroyed. Their interior and the surrounding tissue are infiltrated by neutrophils, eosinophils, and plasma cells, and, by later macrophages. Foreign body giant cell-containing granulomas are present. It belongs to which kind of granulomatous inflammation? Questions: Whether and why do the clinical features of hyperthyroidism present in this patient?
  • 6. (ⅳ) Hashimoto’s thyroiditis (Chronic lymphocytic thyroiditis) Basic pathologic changes (1) Gross morphology ◆ The gland appears diffuse enlargement, firm and rubbery, lobular, gray or yellowish-gray on cut surface. (2) Histopathology ◆ The gland is densely infiltrated by lymphocyte with lymphoid follicles and fibrosis formation in the stroma. Follicles are atrophic and colloid content is reduced. Multinucleated giant cell is occasionally present. Specimen observation Gross specimen: (Fig. 13-13) The thyroid gland is symmetrically atrophic,firm and rubbery. Questions: What kind of clinical manifestation will the patient have? Tissue section: (Fig. 13-14a,b) The architecture of the glands is markedly modified by an intense interstitial infiltration with lymphoid cells. Elsewhere, discrete, small, solid islets of large polygonal cells replace the follicles. Elsewhere, degenerating follicles may be seen, lined by ragged cuboidal epithelium on a fragmented basement membrane; in their interior are broken-up colloid, macrophages and an occasional multinucleated giant cell. Lymphoid follicles and fibrosis can be seen in stroma. (ⅴ) Thyroid adenoma Basic pathologic changes (1) Gross morphology ◆ The tumor is usually spherical, smooth, completely encapsulated in various size; ◆ The tumor compress the adjacent gland, and the center may show areas of hemorrhage and cystic changes. (2) Histopathology ◆ Adenomas may exhibit a variety of patterns according to the histological morphology. ①embryonal type: tumor cells are small, arranged in cords and nests, with occasional imperfect minute follicles. ②fetal type: the tumor is composed of minute follicles; resemble the thyroid gland of the fetal.
  • 7. ③simple type: the tumor resembles the normal thyroid gland. ④colloid type: the tumor is composed of huge follicles filled with colloid. ⑤acidophilic cellular type : tumor cells are big, multilateral, and minute nucleated and with plentiful plasma, which contains densely eosinophilic granules, arranged in cords and nests, with scanty follicles. ⑥atypical type: the tumor cells are boundary, in active state, with a slight degree of atypia and nucleic mitosis, arranged in cords and nests, with scanty follicles and stroma, but with no capsule or vessels invasion. Specimen observation Case abstract: female, 43 years old. A lump on the neck on palpation. P. E.: a soft well circumscribed mass on the left neck with smooth surface. The mass is movable on swallowing. B-ultrasound examination: the mass is solid. Gross specimen: (Fig. 13-15) The tumor is round well circumscribed with completed capsule, surrounding with normal thyroid gland tissue. Tissue section: (Fig. 13-16a,b) (a) This adenoma is a well- differentiated neoplasm because it closely resembles normal tissue. The follicles of the adenoma contain colloid, but it is greater variability in size than normal. The nuclear of cuboid epithelium are large. The adenoma tissue is separated form normal tissue by fibrous capsule. Please make the classified diagnosis. (b) A: Embryonal type; B: Fetal type; C: Acidophilic cellular type; D: Colloid type. Questions: What is the pathological difference between nodular goiter and thyroid adenoma? (Ⅵ) Thyroid carcinoma Basic pathologic changes (1) Gross morphology ◆ The tumor is usually a spherical or nodular, firm mass. ◆ It has no capsule or imperfect capsule, attributable to its invasive feature. ◆ The cut surface presents gray, accompanied by secondary changes of hemorrhage, necrosis, fibrosis and calcification. ◆ Cystic formation and papillae structure may be seen in some papillary carcinoma. (2) Histopathology
  • 8. The tumor is classified into three types: papillary, follicular and medullary carcinoma. 1) Papillary carcinoma ◆ The tumor is consisted of branching papillae with fibrovascular interstitial core, where psammoma bodies may be present. ◆ The papillae are covered by a single layer or multilayer of cuboidal or columnar cells in various differentiations. Usually the cells have groundglass-nuclei. Some papillary carcinomas form some proportion of colloid-filled follicle. Nuclear grooves can be present. 2) Follicular carcinoma ◆ The cell range from well differentiated to markedly anaplastic and can be arranged in small follicles or in solid nests, without psammoma bodies. The focal or diffuse hyalinization may be seen in the plasma. 3) Medullary carcinoma ◆ The tumor cells are spherical or multilateral, arranged in solid nests, papillae or follicles, with granular amphophilic cytoplasm and medium-sized nucleus, separated by a densely vascularized stroma, hyalinized collagen, and amyloid. Huge calcification is common. Specimen observation Case abstract: Female, 13 years old. Left cervical node progressive swelling and hoarseness for 5 months. Physical examination: left side of the neck had a palpable lymph node about 3.0cm. There is a solitary, firm and poorly circumscribed nodule about 1.2cm. Radioactive iodine uptake is lower than normal thyroid gland tissue. Gross specimen: (Fig. 13-17) The lump is round, pale, poorly circumscribed and without capsule. The cross section is whitish. Tissue section: (Fig. 13-18a, b, c) Make the classification diagnosis according to the tumor shape and its arrangement. ( a ) The tumor is consisted of branching papillae with fibrovascular core and a single or stratified lining of cuboidal or high columnar cells. The cells and nuclei vary in size and shape. (b) Follicular carcinoma. (c) Medullary carcinoma. Questions: Which type has the better prognosis, and which type has the worse? 2. Tumor of adrenal gland
  • 9. (ⅰ) Adrenocortical adenoma Basic pathologic changes (1) Gross morphology ◆ The adenomas are varies in size, usually a single, spherical and circumscribed nodule. ◆ The cut surface is yellowish-brown, with hemorrhage and necrosis. (2) Histopathology ◆ The tumor cells are arranged in cords or solid masses. ◆ The tumor cells have abundant lipid content. ◆ There are boundary dilated blood sinusoids among the cells. Specimen observation Case abstract: Female, 41 years old, presented with a complaint of disturbance of menstruation and decreased libido. Past history: hypertension and osteoporosis. Physical examination: moon face and centripetal fat deposition, acne of face. CT: a round, homogenous, well-circumscribed nodule on left adrenal gland. Gross specimen: (Fig. 13-19) There is a nodular mass on left adrenal gland with complete capsule and yellowish brown cut surface. Tissue section: (Fig. 13-20) adenomas are composed of regular large cells with uniformly abundant lipid, arranged in nodules and cords surrounded by blood sinusoids. Questions: What are the histological differences between the adrenal adenoma and other adenoma? What kind of syndrome does the patient present? Which disease may have this syndrome? (ⅱ) Pheochromocytoma Basic pathologic changes (1) Gross morphology ◆ The tumor varies in size, with capsule, usually soft. The cut surface is irregularly yellowish-white to reddish-brown. The larger tumors often have areas of necrosis, hemorrhage, and cyst formation. (2) Histopathology ◆ The tumor cells are characteristically arranged in well-defined nests bound by a delicate fibrovascular stroma. The cells vary considerably in size and shape and have a finely granular basophilic or amphophlic cytoplasm. Intracytoplasmic
  • 10. hyaline globules are common. The nuclei are usually round or oval with prominent nucleoli. Specimen observation Gross specimen: (Fig. 13-21) Describe by self-observation.. Tissue section: (Fig. 13-22a, b) Describe by self-observation. Question: What are the differences of pathologic changes compared with the adrenal adenoma? 3. Pituitary adenoma Basic pathologic changes (1) Gross morphology ◆ Pituitary adenomas are usually solid and soft and gray, pink or yellowish-brown in color. Cystic, hemorrhagic, and necrotic changes may occur. Some adenomas are well circumscribed and some are invasive. (2) Histopathology ◆ The tumor cells are spherical, and multilateral, arranged in masses, cords, nests, sinusoidal, and papillary structure, with plentiful plasma, round or oval nucleus, and delicate fibrovascular stroma, which are classified into eosinophils, basophils and chromophobes according to the staining by haematoxylin and eosin. Nuclear pleomorphism and multinucleated cells are readily detected. Specimen observation Gross specimen: (Fig. 13-23) the circumscribed pituitary gland is enlarged, yellowish-brown. Tissue section: (Fig. 13-24) the tumor is composed of uniform small round cells, which have round or oval nucleus. The stroma is hyper-vascularized. 4. Islet cell tumor Basic pathologic changes (1) Gross morphology ◆ The tumors are well-defined and soft with complete or imperfect capsule. The cut surface shows gray or gray-red, accompanied by fibrosis and calcification. (2) Histopathology ◆ The tumors are usually composed of small, relatively uniform cuboidal cells with round or oval atypical nuclei, arranged in various pattern, separated by
  • 11. fibrovascular. Specimen observation Tissue section: (Fig. 13-25a,b,c,d) The tumor is circumlated by a thin fibrous capsule, with normal pancreas seen on the right. The tumor is composed of small, relatively uniform cuboidal cells arranged in cords or glandular structure, with its sinusoid stroma. (d)The insulinoma can be detected by immunohistochemical staining with antibody for insulin. CASE DISCUSSION Clinical case Case abstract. Female, 38 years old Chief complaint. For half a year, neck thicker, tachycardia, temperature intolerance and weight loss of 5kg despite good appetite. Present history. During the past half-year, neck thicker, tachycardia, temperature intolerance and weight loss for five kg despite good appetite, without distinct cause. Past history. Liable to get cold. Physical examination. Neck: thyroid diffusely enlarged, movable with swallow, smooth and soft with bruit. Skin: warm moist skin, hands trembling when stretching out. Eyes: eyes prominent. Heart: pulse, 95/min, no murmurs, excessive first heartbeat. Laboratory examination. BMR +30% (Normal +10%); FT3 13.5pmol/L (2.3-6.3pmol/L), FT4 43.7pmol/L (10.3-24.5pmol/L), TSH 0.007mTu/L (0.4-4.0mTu/ L). Scanning for gamma-ray emission after administration of radioactive iodine shows thyroid diffusely enlarged and hot. Discussion 1. What is the diagnosis of this patient? 2. What are the pathological changes in thyroid gland? 3. What is the relationship between the pathological features and clinical features? PRACTICE REPORT 1. Illustrate the histological changes of simple goiter and toxic goiter.
  • 12. 2. Describe the gross characteristics of nodular goiter and thyroid adenoma; describe the microscopic features of the toxic goiter, simple goiter and thyroid adenoma. 3. Write speech outline for case discussion. QUESTIONS FOR REVIEW What are the pathological features of toxic goiter? What are the pathological characteristics and pathogenesis of the eyes? (Jinzhou Medical College Yang Chunyu, Gao Zhian)

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