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Dermatopathology_(4th_Year).ppt
- 1. DERMATOPATHOLOGY 1 BY: BRIG TARIQ SARFRAZ MBBS, DCP, MCPS, FCPS, FRCPath (UK) Fellow Royal College of Pathologists, London (UK) Head of Pathology Department Army Medical College, Rawalpindi
- 3. SKIN (NORMAL HISTOLOGY) 3 Three layers: 1. Epidermis 2. Dermis 3. Hypodermis (Subcutis)
- 4. NORMAL SKIN 4 & Ecrine sweat glands
- 7. Histology of Normal Skin
- 10. NORMAL SKIN HISTOLOGY Cont.. 10 EPIDERMIS: Epithelial layer, keratinzed stratified squamous epithelium, divided in four layers • Stratnum Corneum • Stratum Granulosum • Stratnum Spongiosum • Stratnum Basale Note: Extra layer (Stratnum Lucidum) present only in palms and soles
- 13. NORMAL SKIN HISTOLOGY (THICK SKIN) NORMAL SKIN HISTOLOGY (THICK SKIN) 13
- 14. NORMAL SKIN HISTOLOGY (Different types of Cells in Epidermis) 14 Granular cells
- 15. EPIDERMAL KERATINOCYTS NORMAL SKIN HISTOLOGY (Keratinocytes) 15
- 16. NORMAL SKIN HISTOLOGY (Melanin Pigment) 16
- 18. NORMAL SKIN HISTOLOGY (contd…) DERMIS Papillary dermis: • Blood vessels and lymphatic • Nerves • Collagen and Elastic fibers Reticular dermis: • Vascular plexus • Lymphatic • Nerve • Appendages(hair follicles, sebaceous glands & Swear Glands) • Compact collagen and Elastic fibers HYPODERMIS (SUBUTIS) • Adipose tissue NORMAL SKIN HISTOLOGY (contd..) 18
- 19. NORMAL SKIN HISTOLOGY NORMAL SKIN HISTOLOGY 19
- 20. NORMAL SKIN HISTOLOGY (Dermal Components) 20
- 21. NORMAL SKIN HISTOLOGY PILOSEBACEOUS UNITS NORMAL SKIN HISTOLOGY 21
- 22. NORMAL SKIN HISTOLOGY (Sebaceous Glands) 22
- 23. NORMAL SKIN HISTOLOGY (Ecrine Sweat Glands) 23
- 24. SWEAT GLANDS DUCT NORMAL SKIN HISTOLOGY (Ecrine Sweat Glands) 24
- 25. NORMAL SKIN HISTOLOGY (Apocrine Glands) 25
- 26. NORMAL SKIN HISTOLOGY (Apocrine Glands) 26
- 27. NORMAL SKIN HISTOLOGY (Dermal Blood Vessels) 27
- 28. NORMAL SKIN HISTOLOGY (contd…) HYPODERMIS (SUBUTIS) • Adipose tissue • Blood vessels • Nerve fibers • Connective tissue NORMAL SKIN HISTOLOGY (contd..) 28
- 29. NORMAL SKIN HISTOLOGY (HYPODERMIS / SUBCUTIS) 29
- 30. TERMINILOGY OF SKIN LESIONS (CLINICAL) • MACULE – Circumscribed erythematous flat lesion • PAPULE - Elevated solid area 5 mm or less • NODULE – Elevated solid area greater than 5 mm • PLAQUE - Elevated flat area greater than 5 mm • VESICLE – Fluid filled raised area 5 mm or less • BULLA - Fluid filled area greater than 5 mm • BLISTER – Common term for vesicle or bulla • PUSTULE – Discrete pus filled area • WHEAL - Itchy transient elevated area • EXCORIATION – Traumatic lesion, breaking the epidermis, causing raw linear area • LICHENIFICATION – Thickened rough skin
- 31. TERMINILOGY OF SKIN LESIONS (MICROSCOPIC) • HYPERKERATOSIS – Thickening of stratum corneum often associated with a qualitative abnormality of keratin • PARAKERATOSIS – Keratinization with relative nuclei in stratum corneum • ACANTHOSIS – Diffuse epidermal hyperplasia/thickening • PAPILLOMATOSIS – Surface elevation caused by hyperplasia and enlargement of contiguous dermal papillae • SPONGIOSIS – Intercellular edema in epidermis • HYPERGRANULOSIS – Hyperplasia of the stratum granulosum often due to intense rubbing • LENTIGINOUS – A linear pattern of melanocytic proliferation within the epidermal basal layer
- 32. TERMINILOGY OF SKIN LESIONS (MICROSCOPIC) • EROSION – Discontinuity of the skin showing incomplete loss of epidermis • ULCERATION – Discontinuity of skin showing complete loss of the epidermis, revealing dermiis • EXOCYTOSIS – Infiltration of the epidermis by inflammatory cells (MUNRO Microabscess in Psoriasis) • HYDROPIC SWELLING (Ballooning) – Intercellular oedema of keratinocytes often seen in viral infections • VACOULIZATION - Formation of vacoules • DYSKERATOSIS – Abnormal premature keratinization within the cells below stratum granulosum
- 34. HYPERKERATOSIS: •Thickening of stratum corneum •Quantitative abnormality of keratin DERMATOPATHOLOGY MICROSCOPIC TERMS 34
- 36. PARAKERATOSIS: Keratinization with retention of nuclei in stratum corneum Seen in Psoriasis DERMATOPATHOLOGY MICROSCOPIC TERMS (contd..) 36
- 39. HYPERKERATOSIS & PARAKERATOSIS PARAKERATOSIS HYPERKERATOSIS & PARAKERATOSIS 39
- 40. SPONGIOSIS Intercellular oedema of epidermis DERMATOPATHOLOGY MICROSCOPIC TERMS (contd..) 40
- 42. PAPILLOMATOSIS Papillae formation caused by epidermal hyperplasia. DERMATOPATHOLOGY MICROSCOPIC TERMS (contd..) 42
- 44. DERMATOPATHOLOGY TERMS FOLLICULAR PLUGGING: Increased amount of keratin in dilated pilosebaceous follicular ostia DERMATOPATHOLOGY TERMS 44
- 46. DERMATOPATHOLOGY MICROSCOPIC TERMS (Contd..) HYPERGRANULOSIS: Hyperplasia of stratnum granulosum DERMATOPATHOLOGY MICROSCOPIC TERMS (contd..) 46
- 48. ACANTHOSIS: •Diffuse epidermal hyperplasia •Thickening of epidermis DERMATOPATHOLOGY MICROSCOPIC TERMS (contd..) 48
- 50. ACANTHOLYSIS: Loss of intercellular connections resulting in loss of cohesion of keratinocytes DERMATOPATHOLOGY MICROSCOPIC TERMS (contd..) 50
- 52. 52 ACANTHOLYSIS
- 53. 53 ACANTHOLYSIS
- 54. DYSKERATOSIS: Abnormal keratinization occurring prematurely within individual cell or group of cells Two types: Acantholytic Dyskeratosis e.g Corps Ronds & Grains in Darier’s Disease Neoplastic Dyskeratosis e.g Actinic Keratosis. DERMATOPATHOLOGY MICROSCOPIC TERMS (contd..) 54
- 56. CORPS AND RONDS: • Solitary or small groups of dyskeratotic cells in upper malpighian and horny layer • Basophilic pyknotic nucleus with perinuclear halo GRAINS: • Small grain shaped cells with elongated nuclei, surrounded by homogenous basophilic material • Located in upper layer of epidermis and resemble parakeratotic cells DERMATOPATHOLOGY TERMS 56
- 60. HYDROPIC SWELLING (BALOONNING): Intercellular oedema of keratinocytes DERMATOPATHOLOGY MICROSCOPIC TERMS (contd..) 60
- 62. EXOCYTOSIS: Infiltration of epidermis by inflammatory or circulating blood cells. DERMATOPATHOLOGY MICROSCOPIC TERMS (contd..) 62
- 63. EXOCYTOSIS 63
- 64. EPIDERMOTROPISM: Presence of mononuclear cells within epidermis without spongiosis DERMATOPATHOLOGY TERMS 64
- 66. PAUTRIER’S ABSCESS: Collection of atypical lymphocytes in epidermis DERMATOPATHOLOGY TERMS 66
- 69. INTERFACE DERMATITIS: Obscuring of Dermoepidermal junction by inflammatory infiltrate. DERMATOPATHOLOGY TERMS 69
- 71. FESTOONING: Curving configuration of dermal papillae projecting into the base of bulla. DERMATOPATHOLOGY TERMS 71
- 73. GRANULOMA: Collection of histiocytes or epitheloid cells, giant cells of varying types DERMATOPATHOLOGY TERMS 73
- 75. GREN ZONE Narrow space found between epidermis and dermal lesion DERMATOPATHOLOGY TERMS 75
- 76. GRENZ ZONE GRENZ ZONE GRENZ ZONE 76
- 77. LEUKOCYTOCLASIA Fragmentation of leukocytes with resultant nuclear dust DERMATOPATHOLOGY TERMS 77
- 79. POLYMORPHISM: Variation in types of cells DERMATOPATHOLOGY TERMS 79
- 80. POLYMORPHIC CELL INFILTRATE POLYMORPHIC CELL INFILTRATE 80
- 81. PLEOMORPHISM Variation in appearance (shape & size) of nuclei of same type of cells DERMATOPATHOLOGY TERMS 81
- 83. HYPERCHROMATISM Increased intensity of nuclear staining DERMATOPATHOLOGY TERMS 83
- 85. ANAPLASIA: Atypical cellular maturation or reversion to undifferentiated state DERMATOPATHOLOGY TERMS 85
- 87. DISEASES OF SKIN • Disorders of Pigmentation & Melanocytes • Benign Epidermal tumours • Malignant Epidermal tumours • Tumours of Dermis • Tumours of Cellular Immigrants to the Skin • Disorders of Epidermal Maturation • Acute Inflammatory Dermatoses • Chronic Inflammatory Dermatoses • Blistering (Bullous) Diseases • Disorders of Epidermal Appendages
- 88. DISORDERS OF PIGMENTATION & MELANOCYTES • Vitiligo • Freckle • Melasma • Lentigo • Nevus (Mole) • Dysplastic nevus • Malignant Melanoma
- 89. Vitiligo – Localized loss of skin pigmentation – Autoimmune destruction of Melanocytes – Failure to TAN
- 90. • FRECKLES – Small tan to brown Macules – Darken when exposed to sunlight – Due to increase number of Melanosomes
- 91. • MELASMA – Mask like hyperpigmentation of cheeks – Associated with Pregnancy and Oral Contraceptives
- 92. LENTIGO
- 93. • Nevus (Mole): – Benign Neoplasm of Melanocytes – May be • Congenital ( will have hair growth) • Acquired
- 94. MELANOCYTIC NEVI TYPES of ACQUIRED • Junctional Nevus – Nevus cells at dermoepidermal junction • Compound Nevus – Nevus cells at dermoepidermal junction, extending to dermis • Intradermal Nevus – Nevus cells exclusively in dermis • Dysplastic Nevus – Precursor to malignant melanoma
- 95. Naevus / Mole:
- 96. VARIANTS OF NAEVOCELLULAR NAEVI • Congenital nevus • Blue nevus • Spindle and Epithelioid cell nevus (Spitz nevus) • Halo nevus • Balloon cell nevus • Dysplastic nevus
- 97. DYSPLASTIC NEVUS
- 98. MALIGNANT MELANOCYTIC LESIONS MALIGNANT MELANOMA
- 99. MALIGNANT MELANOMA • Most deadly of all skin cancers • Linked to acquired mutations caused by exposure to Ultra Violet (UV) Radiations in sun light • More common in white races and fair skin people • Cured, if diagnosed and treated at earliest stage
- 100. MALIGNANT MELANOMA (ETIOLOGY) • Exposure to sunlight UV-B • Heredity – XP – Albinism – Dysplastic Nevus Syndrome i.e. autosomal dominant • Previous dysplastic nevus • Exposure to chemical carcinogens
- 102. MALIGNANT MELANOMA (PATHOGENESIS) • Mutations in Cell Cycle Regulators (p16, NK4a, CDK4) • Mutations in Pro-growth Signaling Factors (e.g KIT), RAS & BRAF • Loss of PTEN Tumour Suppressor Gene • Mutations that activate Telomerase (TERT Gene mutation)
- 103. MALIGNANT MELANOMA (SITES) • Skin • Oral mucosa • Anogenital surfaces • Esophagus • Meninges • Eye
- 104. MALIGNANT MELANOMA CLINICAL FEATURES (ABCDEs) • A – Asymmetry • B – Irregular Borders • C – Variegated Colour • D – Increasing Diameter, >6mm • E – Evolution of changes (Rapid)
- 105. WARNING SIGNS IN A MOLE • Enlargement of preexisting mole • Itching or pain in preexisting mole • Development of a new pigmented lesion during adult life • Irregularity of the borders of a pigmented lesion • Variegation of color within a pigmented lesion
- 106. MALIGNANT MELANOMA
- 107. Malignant Melanoma
- 108. MALIGNANT MELANOMA (MICROSCOPIC FEATURES) • Tumour comprising spindle shaped or epithelioid cells • Radial / Vertical growth phase A.Radial Growth Phase (Different Forms) 1.Lentigo Maligna Melanoma 2.Superficial Spreading Melanoma 3.Acral / Mucosal Lentigenous Melanoma • Junctional activity present B.Vertical Growth Phase: 1.Depth of invasion in mm (Breslow Thickness) 2.Clark’s levels (Epidermis, Dermis, Subcutis)
- 109. MALIGNANT MELANOMA (MICROSCOPIC FEATURES) • Nuclear pleomorphism and hyperchromatism • Prominent eosinophilic nuclei • Frequent mitoses, including atypical mitoses • Junctional activity present • Pagetoid spread of tumour cells in epidermis • Shouldering effect • No maturation downward
- 110. Malignant Melanoma
- 111. MALIGNANT MELANOMA Evolution from Dysplastic Nevus
- 112. FAVOURABLE PROGNOSTIC ATTRIBUTES • Tumour depth of less than 1.7 mm (Breslow Thickness) • Clark’s levels • Absence or low number of mitoses • Presence of brisk Tumour Infiltrating Lymphocytes (TILs) • Regression • Female gender • Location on extremity skin
- 113. • CLARK’S LEVEL 1. Grade1: Melanocytes In situ 2. Grade2: Papillary Dermis 3. Grade3: Touching the Reticular 4. Grade4: Invading Reticular Dermis 5. Grade5: Invading Hypodermis
- 115. TUMOURS OF EPIDERMIS BENIGN • Seborrheic Keratosis • Keratoacanthoma • Fibroepithelial polyp • Epithelial cyst • Adnexal tumors PRE-MALIGNANT • Actinic Keratosis • Dysplastic Nevus MALIGNANT • Bowen’s Disease (Squamous cell Ca in Situ) • Squamous cell carcinoma • Basal cell carcinoma • Merkel cell carcinoma • Malignant Melanoma
- 117. SQUAMOUS CELL CARCINOMA ETIOLOGY • Sunlight (UV light) • Industrial carcinogens (Tars & oils) • Chronic ulcers • Draining osteomyelitis • Old burn scars (Marjolin ulcer) • Ingestion of Arsenicals • Ionizing radiation • Tobacco (oral mucosa) • Betal nut chewing (oral mucosa) • Immunosuppressive Therapy
- 119. SQUAMOUS CELL CARCINOMA MORPHOLOGY • Gross – In Situ non-invasive appear as sharply defined, red scaly plaques – Invasive lesions are Nodular, Hyperkeratotic and my Ulcerate sometimes • Microscopy – CIS have pleomorphism in all layers of epi – Invasive SCC may be • Well Differentiated: – Polygonal cells arranged in Lobules – Intercellular Keratinization • Moderately differentiated: – Keratin Pearls • Poorly differentiated: – Dyskeratosis(Intracellular Keratin Deposits) ~
- 121. BASAL CELL CARCINOMA
- 122. BASAL CELL CARCINOMA (Rodent ulcer) • Locally invasive that’s why called Rodent’s Ulcer • Activation of Hedgehog Signaling Pathway • Rarely metastasize • Risk Factors – Sun exposed areas(UV-B) – Incidence sharply rises with immunosuppression – Defects in DNA repair (Xeroderma pigmentosum) – Albinism
- 124. BASAL CELL CARCINOMA
- 125. BASAL CELL CARCINOMA (Rodent ulcer) • Gross – Pearly Papules – Telangiectatic Vessels on surface – May be highly locally invasive : RODENT’s Ulcer • Microscopy – Atypical , pleomorphic Basaloid cells showing two patterns • Multifocal Growths: – Extending over skin • Nodular lesion: – Basaloid masses invading dermis – Peripheral Palisading – Retraction Clefts
- 127. TUMOURS OF SKIN ADNEXAL (APPANDAGEAL) STRUCTURES
- 128. TUMOURS OF SKIN ADNEXAL (APPANDAGEAL) STRUCTURES • Ecrine Glands a) Ecrine Poroma, Ecrine Porocarcinoma b) Ecrine Spiradenoma, Malignant Spiradenoma c) Cylindroma, Hidradenoma (all have malignant counterpart) • Apocrine Glands a) Apocrine Adenoma, Apocrine carcinoma b) Apocrine Hydrocystoma • Sebaceous Glands Sebaceous adenoma, sebaceous carcinoma • Hair Follicle a) Trichoepithelioma b) Trichofolliculoma c) Trichilemmoma d) Pilomatrixoma
- 129. TUMOURS OF DERMIS
- 130. TUMOURS OF DERMIS • Benign Fibrous Histiocytoma • Dermatofibrosarcoma Protuberans (DSFP) • Xanthomas • Dermal Vascular Tumours Haemangiomas, Angiosarcoma, Kaposi Sarcoma • Tumours of Cells Immigrant to Skin Histiocytosis X, Mycosis Fungoides, Mastocytosis
- 131. DERMATOPATHOLOGY NON NEOPLASTIC / INFLAMMATORY DISEASES
- 132. ACUTE INFLAMMATORY DERMATOSIS • URTICARIA • ACUTE ECZEMATOUS DERMATITIS Contact Dermatitis Atopic Dermatitis Drug-Related dermatitis Photoeczematous eruption Primary Irritant Dermatitis • ERYTHEMA MULTIFORME
- 134. 1. Acanthosis 2. Hyperkeratosis 3. Spongiosis 4. Parakeratosis
- 135. Pathogenesis of Eczema Type 1 Hypersensitivity Reaction
- 136. CHRONIC INFLAMMATORY DERMATOSIS • Psoriasis • Seborrheic Dermatitis • Lichen Planus • Lupus Erythematosus
- 137. PSORIASIS
- 138. (Gross & Microscopic Appearance) GROSS • Pink to salmon coloured plaques, covered with silver white scales • Onycholysis of nails • Auspitz Sign(bleeding on scratching) MICROSCOPIC • Hyperkeratosis(Thickened Corneum) • Parakeratosis(Nuclei in corneum) • Munro abscess(Neutrophils collection in CORNEUM) • Thin granular layer • Spongiform Pustule of Kagoj
- 139. PSORIASIS
- 141. PSORIASIS
- 143. LICHEN PLANUS
- 144. (Gross & Microscopic Appearance) GROSS (6Ps): • Pruritic, Purple, Polygonal, Plane topped Papules and Plaques (6 Ps) • Disorder of skin and mucosa • Reticular White dots / lines (Wickham striae) MICROSCOPIC: • Interface dermatitis (lymphocytes along dermo-epi junction) • Peg shaped Rete ridges i.e. Saw Toothing • Basal cell vacoular degeneration • Civatte bodies (Papillary Dermis incorporated by Necrotic Basal Cells)
- 145. LICHEN PLANUS
- 146. LICHEN PLANUS
- 149. Vesiculobullous Disorders of Skin
- 151. ACENE VULGARIS
- 152. PATHOGENESIS OF ACNE Increased in sebaceous activity due to hormonal stimulation Keratin plug blocking outflow of sebum Lipase-synthesizing bacteria Propionibacterium acnes Hair follicle Inflammation (ACNE)
- 153. INFECTIONS & INFESTATIONS • Verrucae (Warts) • Molluscum Contagiosum • Impetigo • Superficial Fungal Infection • Anthropod bites, and Infestations • Pediculosis • Scabies
- 154. VERRUCA VULGARIS
- 155. SUPERFICIAL FUNGAL INFECTIONS TINEA PEDIS (ATHLETE’S FOOT) ONYCHOMYCOSIS Tinea capitis Tinea corporis Tinea cruris
- 156. TINEA CORPORIS
- 158. SCABIES
Editor's Notes
- Langerhans cells are the specialized dendritic cells present in the epidermis. The augment the innate immunity and act as APCs . Mnemonic for the layers of Epidermis( from upside down)} Come Corneum Lets Lucidum (in palms and soles only) Get Granulosum due to the intracellular Granules Some Spinosum (spines>cellular connections due to the desmosomes) Bread Basalis
- Mnemonic for the layers of Epidermis( from upside down)} Come Cornium Lets Lucidum (in palms and soles only) Get Granulosum Some Spinosum Bread Basalis
- Hair follicle+Errector pili muscle+Sweat Gland
- Monroe Microabcess
- Saw-tooth appearance as of in Lichen planus
- In pemphigus Vulgaris
- Typical SCC has nests of epithelial cells arising from the epi and infiltrating the dermis. The malignant cells are large, pleomorphic and anaplastic. Variable keratinization and intracellular bridging is present
- Pemphigus Vulgaris Bullous Pamphigoides Dermatitis Herpatiformis Erythea Multiforme Acne Vulgaris