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FOURTH EDITION
Gattuso’s
Differential
Diagnosis in
Surgical Pathology
Vijaya B. Reddy, MD, MBA Daniel J. Spitz, MD
The Harriet Blair Borland Chair of Chief Medical Examiner
Pathology Macomb and St. Clair Counties,
Professor and Chairperson Michigan
Department of Pathology Clinical Assistant Professor of
Rush University Medical Center Pathology
Chicago, Illinois Wayne State University School of
United States Medicine
Detroit, Michigan
Odile David, MD United States
Associate Professor and Director of
Cytopathology Meryl H. Haber, MD
University of Illinois at Chicago Borland Professor and Chairman
Chicago, Illinois of Pathology, Emeritus
United States Rush Medical College of Rush
University
Chicago, Illinois
United States
iii
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GATTUSO’S DIFFENENTIAL DIAGNOSIS IN SURGICAL PATHOLOGY,

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Contributors
SYLVIA ASA, MD, PhD BYRON CRAWFORD, MD

Professor Professor and Chair
Pathology Pathology
Case Western Reserve University LSU School of Medicine
Consultant in Endocrine Pathology Shreveport, Louisiana
Pathology United States
University Hospitals Cleveland
Cleveland, Ohio KOSSIVI DANTEY, MD
United States Assistant Professor
Consultant in Endocrine Pathology Drexel University College of Medicine
Pathology Pathology
University Health Network Allegheny Health Network
Toronto, Ontario Pittsburgh, Pennsylvania
Canada United States
ELIZAVETA BELYAEVA, MD VIRGINIA E. DUNCAN, MD, MS

Assistant Professor of Pathology and Laboratory Assistant Professor
Medicine Pathology
Tulane University School of Medicine University of Alabama at Birmingham
New Orleans, Louisiana Birmingham, Alabama
United States United States
PINCAS BITTERMAN, MD ADEL K. EL-NAGGAR, MD

Professor Emeritus Professor
Departments of Pathology and Obstetrics and pathology
Gynecology The University of Texas MD Anderson Cancer Center
Rush University Medical Center Houston, Texas
Chicago, Illinois United States
United States
MARK F. EVANS, PhD
DUSTIN E. BOSCH, MD, PhD Assistant Professor
Fellow Pathology and Laboratory Medicine
Department of Laboratory Medicine and Pathology Larner College of Medicine
University of Washington School of Medicine University of Vermont
Seattle, Washington Burlington, Vermont
ELIZABETH J. COCHRAN, MD HUMA FATIMA, MD

Professor Associate Professor
Department of Pathology Pathology
Medical College of Wisconsin University of Alabama at Birmingham
Milwaukee, Wisconsin Birmingham, Alabama
KUMARASEN COOPER, MBChB, DPhil

Professor of Pathology
Department of Pathology
Hospital of University of Pennsylvania (HUP)
Philadelphia, Pennsylvania
United States
vii
viii Contributors
SANDRA E. FISCHER, MD CRISTINA MAGI-GALLUZZI, MD, PhD

Associate Professor Director
Laboratory Medicine and Pathobiology Anatomic Pathology
University of Toronto Department of Pathology
Staff Pathologist Professor of Pathology
Laboratory Medicine Program Pathology
University Health Network University of Alabama at Birmingham
Clinician Investigator Section Head
Princess Margaret Cancer Centre Genitourinary Pathology
University Health Network Director
Toronto, Ontario Genitourinary Pathology Fellowship Program
Canada The C. Bruce Alexander Endowed Professorship in
Pathology
JULIA T. GEYER, MD Birmingham, Alabama
Associate Professor of Pathology and Laboratory United States
Medicine
Weill Cornell Medicine MEERA MAHALINGAM, MD, PhD, FRCPath
New York, New York Professor of Dermatology
United States Tufts University School of Medicine
Senior Lecturer
RICHARD J. GROSTERN, MD Pathology
Section Director Harvard Medical School
Ophthalmic Pathology Dermatopathology Section Chief
Department of Ophthalmology Department of Pathology and Laboratory Medicine
Rush Medical College of Rush University VA Integrated Service Networks (VISN1), New England
Chicago, Illinois West Roxbury, Massachusetts
RALPH H. HRUBAN, MD MARIA J. MERINO, MD

Professor Chief
Pathology and Oncology Translational Surgical Pathology
The Johns Hopkins University School of Medicine NCI
Baltimore, Maryland Bethesda, Maryland
ALIYA N. HUSAIN, MBBS IRA MILLER, MD, PhD

Professor Director of Orthopedic Pathology
Pathology Department of Pathology
University of Chicago Rush University Medical Center
Chicago, Illinois Chicago, Illinois
ALEXANDRA N. KALOF, MD ATTILIO ORAZI, MD, FRCPath

Associate Professor Pofessor of Pathology
Pathology and Laboratory Medicine Department of Pathology
Larner College of Medicine TexasTech University Health Sciences Center
University of Vermont El Paso, Texas
Burlington, Vermont United States
United States
HREEM N. PATEL, MD
NIKOLAJ P. LAGWINSKI, MD Assistant Professor
Associate Pathologist Ophthalmology
GI Insitute Rush University Medical Center
Ameripath Cleveland Chicago, Illinois
Oakwood Village, Ohio United States
United States
Contributors ix
SUNNY B. PATEL, BS, MD† JEFREE SCHULTE, MD

Resident Physician Assistant Professor
Department of Ophthalmology Department of Pathology and Laboratory Medicine
Rush University Medical Center University of Wisconsin School of Medicine and Public
Chicago, Illinois Health
United States Madison, Wisconsin
United States
ROBERT E. PETRAS, MD
Associate Clinical Professor of Pathology DAVID SUSTER, MD
Northeast Ohio Medical University Assistant Professor
Rootstown, Ohio Pathology
United States Rutgers University
New Jersey Medical School
MICHAEL R. PINS, MD Newark, New Jersey
Professor and Chair of Pathology United States
Pathology
Chicago Medical School of Rosalind Franklin University SAUL SUSTER, MD
of Medicine and Science Professor and Chairman Emeritus
North Chicago, Illinois Department of Pathology
United States Medical College of Wisconsin
Chairman of Pathology Milwaukee, Wisconsin
Pathology United States
Advocate Lutheran General Hospital and Advocate
Children’s Hospital PAUL E. SWANSON, MD
Park Ridge, Illinois Professor
United States Department of Laboratory Medicine and Pathology
University of Washington School of Medicine
SONAM PRAKASH, MBBS Seattle, Washington
Clinical Professor United States
Laboratory Medicine
University of California San Francisco CARMELA D. TAN, MD
San Francisco, California Associate Professor
United States Cleveland Clinic Lerner College of Medicine of Case
Western University
VIJAYA B. REDDY, MD, MBA Cleveland Clinic
The Harriet Blair Borland Chair of Pathology Cleveland, Ohio
Professor and Chairperson United States
Rush University Medical Center ELIZABETH THOMPSON, MD, PhD
Chicago, Illinois Assistant Professor
United States Pathology
The Johns Hopkins University School of Medicine
E. RENE RODRIGUEZ, MD Baltimore, Maryland
Professor United States
Cleveland Clinic Lerner College of Medicine of Case
Western University MICHELLE D. WILLIAMS, MD
Cleveland, Ohio Professor
United States Pathology
The University of Texas MD Anderson Cancer Center
JOHN J. SCHMIEG, MD, PhD Houston, Texas
Staff Hematopathologist United States
The Joint Pathology Center
Silver Spring, Maryland LEI YAN, MD, PhD
United States Assistant Professor
Rush University Medical Center
Chicago, Illinois
United States
†Deceased
x Contributors
MATTHEW M. YEH, MD, PhD MING ZHOU, MD, PhD

Professor Chair and Pathologist-in-Chief
Department of Laboratory Medicine and Pathology Pathology and Laboratory Medicine
University of Washington School of Medicine Tufts Medical Center
Adjunct Professor Tufts University School of Medicine
Department of Medicine Boston, Massachusetts
University of Washington School of Medicine United States
Seattle, Washington
United States
To Swathi, my shining star
VIJAYA B. REDDY
To my wife, Nancy, and my children, Vincent and Francesca

PAOLO GATTUSO
To my family, to whom I owe my appreciation of life and learning

ODILE DAVID
To my parents, for setting me on the right track, and to my wife, Jodi, for her continuous
support and encouragement
DANIEL J. SPITZ
To all of my former students, residents, fellows, and physician associates

from whom I have always learned more than I have been able to teach
MERYL H. HABER
Acknowledgments
We thank all our contributors for their expertise, knowl- Elsevier, and Michael Houston, Executive Content Strate-
edge, and invaluable role in the continued success of this gist, for his support and encouragement in the produc-
book. tion of a fourth edition. A special thanks to Ann Ruzycka
The editors also gratefully acknowledge the work of Anderson, Senior Content Development Specialist, and
authors who have contributed to this book in its previous Sharon Corell, Senior Project Manager, for their patience
editions. and competence in keeping the book on course over the
We thank Irma Parker for her assistance and persis- past year.
tence in contacting the contributors and ensuring the
timely submissions. We are thankful to our publisher, Vijaya B. Reddy, MD
xiii
Preface
The concept of this textbook was conceived just over 20 illustrating particular diagnostic characteristics continue
years ago by attending pathologists and residents in the to be a hallmark.
Department of Pathology of Rush Medical Center in Chi- In this current edition, 5 years since the previous, each
cago. This, the fourth edition, has gradually evolved into section has been reviewed and revised especially with the
a widely used textbook for practicing surgical patholo- application of diagnostic biomarkers. As in the third edi-
gists, residents, and others of the medical field interested tion, Dr. Vijaya Reddy oversaw these additions and revi-
in diagnostic pathology. Conceptually, it began as and sions, monitored the selection of new authors, prompted
remains a nonencyclopedic compendium of a wide vari- previous authors, added photomicrographs, and pursued
ety of surgical pathology specimens with which patholo- overall development. This volume is now more encom-
gists are confronted daily. No attempt was made to copy passing than before. It includes new and valuable diag-
or emulate already existing textbooks of pathology. nostic findings and, even though we have attempted to
Instead, the author’s goals were to produce a usable text make it more concise, it remains more than a thousand
in outline format with succinct text discussions and clear pages. We are gratified that over the past score of years
descriptions of differential diagnoses of pathologic enti- this textbook has been a helpful aid to pathologists in sur-
ties. A “Pearls” line or two is included to facilitate prompt gical pathology laboratories around the world. Selected
and accurate diagnosis. Each discussed entity is accom- updated references remain included, as are the many
panied by numerous carefully selected high-quality color “Pearl” paragraphs.
photographs, both macro and microscopic, of commonly
encountered specimens surgically removed. These images Meryl H, Haber, MD
xi
Chapter 1
Special Diagnostic Techniques in
Surgical Pathology
ALEXANDRA N. KALOF • MARK F. EVANS • KOSSIVI DANTEY • KUMARASEN COOPER
Chapter Outline
Light Microscopy 1 Cytogenetic Analysis 12
Tissue Processing Overview 1 Molecular Pathology Methods 17
Fixation 1
Introduction 17
Histologic Stains 3
Nucleic Acid Extraction Methods 17
Fluorescence Microscopy 6 Tissue Microdissection Methods 23
Electron Microscopy 7 Gel Electrophoresis Methods 26
Blot Hybridization Methods 27
Technical Overview 7
Amplification Methods 29
Ultrastructure of a Cell 7
Nanostring Technology 33
Immunohistochemistry 9 Microarray Technology 34
Introduction 9 Nucleic Acid Sequencing 35
Technical Overview 9 In Situ Hybridization 36
Flow Cytometry 11 Protein Analytic Methods 37
Introduction 11 Emerging Developments 39
Technical Overview 11 Resources 40
• S ectioning
LIGHT MICROSCOPY • Embedded in paraffin, which is similar in density to
tissue, tissue can be sectioned at anywhere from 3 to
TISSUE PROCESSING OVERVIEW
10 μm (routine sections are usually cut at 6 to 8 μm)
• F ixation • Staining
• Preserves tissues in situ as close to the lifelike state as • Allows for differentiation of the nuclear and cyto-
possible plasmic components of cells as well as the intercel-
• Ideally, fixation will be carried out as soon as possible lular structure of the tissue
after removal of the tissues, and the fixative will kill • Cover-slipping
the tissue quickly, thus preventing autolysis • The stained section on the slide is covered with a
• Dehydration thin piece of plastic or glass to protect the tissue from
• Fixed tissue is too fragile to be sectioned and must be being scratched, to provide better optical quality for
embedded first in a nonaqueous supporting medium viewing under the microscope, and to preserve the
(e.g., paraffin) tissue section for years
• The tissue must first be dehydrated through a series
of ethanol solutions
FIXATION
• Clearing
• Ethanol is not miscible with paraffin, so nonpolar • T
here are five major groups of fixatives, classified
solvents (e.g., xylene, toluene) are used as clearing according to mechanism of action: aldehydes, mercuri-
agents; this also makes the tissue more translucent als, alcohols, oxidizing agents, and picrates
• Embedding • Aldehydes
• Paraffin is the usual embedding medium; however, • Formalin
tissues are sometimes embedded in a plastic resin, • Aqueous solution of formaldehyde gas that pen-
allowing for thinner sections (required for electron etrates tissue well but relatively slowly; the stan-
microscopy [EM]) dard solution is 10% neutral buffered formalin
• This embedding process is important because the • A buffer prevents acidity that would promote
tissues must be aligned, or oriented, properly in the autolysis and cause precipitation of formol-
block of paraffin heme pigment in the tissues
1
2 Chapter 1 — Special Diagnostic Techniques in Surgical Pathology
• T issue is fixed by cross-linkages formed in the formalin- heme pigment that appears as black,
proteins, particularly between lysine residues polarizable deposits in tissue
• This cross-linkage does not harm the struc- • Common buffers include phosphate, bicarbonate,
ture of proteins greatly, preserving antigenicity, cacodylate, and veronal
and is therefore good for immunoperoxidase • Fixative solutions penetrate at different rates, depend-
techniques ing on the diffusibility of each individual fixative
• Glutaraldehyde • In order of decreasing speed of penetration: form-
• The standard solution is a 2% buffered glutaraldehyde, acetic acid, mercuric chloride, methyl
aldehyde and must be cold, buffered, and not alcohol, osmium tetroxide, and picric acid
more than 3 months old • Because fixation begins at the periphery, thick sec-
• Fixes tissue quickly and therefore is ideal for EM tions sometimes remain unfixed in the center, com-
• Causes deformation of α-helix structure in pro- promising both histology and antigenicity of the
teins and therefore is not good for immunoperoxi- cells (important for immunohistochemistry [IHC])
dase staining • It is important to section the tissues thinly (2 to 3 mm)
• Penetrates poorly but gives best overall cytoplas- • Should be at least a 10:1 ratio of fixative to tissue
mic and nuclear detail • Increasing the temperature, as with all chemical
• Tissue must be as fresh as possible and preferably reactions, increases the speed of fixation
sectioned within the glutaraldehyde at a thick- • Hot formalin fixes tissues faster, and this is often
ness of no more than 1 mm to enhance fixation the first step on an automated tissue processor
• Mercurials • Formalin is best at 10%; glutaraldehyde is gener-
• B-5 and Zenker ally made up at 0.25% to 4%
• Contain mercuric chloride and must be disposed • Formalin should have 6 to 8 hours to act before the
of carefully remainder of the processing is begun
• Penetrate poorly and cause tissue hardness but • Decalcification
are fast and give excellent nuclear detail • Tissue calcium deposits are extremely firm and do not
• Best application is for fixation of hematopoietic section properly with paraffin embedding because of the
and reticuloendothelial tissues difference in densities between calcium and paraffin
• Alcohols • Strong mineral acids such as nitric and hydrochloric
• Methyl alcohol (methanol) and ethyl alcohol acids are used with dense cortical bone because they
(ethanol) remove large quantities of calcium at a rapid rate
• Protein denaturants • These strong acids also damage cellular morphology
• Not used routinely for tissue because they dehy- and thus are not recommended for delicate tissues
drate, resulting in the tissues becoming brittle such as bone marrow
and hard • Organic acids such as acetic and formic acid are
• Good for cytologic smears because they act quickly better suited to bone marrow because they are not
and give good nuclear detail as harsh; however, they act more slowly on dense
• Oxidizing agents cortical bone
• Permanganate fixatives (potassium permanga- • Formic acid in a 10% concentration is the best all-
nate), dichromate fixatives (potassium dichro- around decalcifier
mate), and osmium tetroxide cross-link proteins
• Cause extensive denaturation PEARLS
• Some of these have specialized applications but are
• P rolonged fixation can affect immunohistochemical
used infrequently
results owing to alcohol precipitation of antigen at the cell
• Picrates
surface; to optimize antigenicity of the tissue for IHC, the
• Bouin solution has an unknown mechanism of action
American Society of Clinical Oncology/College of American
• It does almost as well as mercurials with nuclear
Pathologists (ASCO/CAP) guidelines recommend fixation
detail but does not cause as much hardness
of tissue destined for IHC in neutral buffered formalin for
• Picric acid is an explosion hazard in dry form
a minimum of 6 hours and a maximum of 48 hours (see
• Recommended for fixation of tissues from testis,
Wolff et al., 2007)
gastrointestinal tract, and endocrine organs
• Urate crystals are water soluble and require a nonaqueous
• Factors affecting fixation
fixative such as absolute alcohol
• Buffering
• If tissue is needed for immunofluorescence (e.g., kidney or
• Penetration
skin biopsies) or enzyme profiles (e.g., muscle biopsies),
• Volume
the specimen must be frozen without fixative; enzymes
• Temperature
are rapidly inactivated by even brief exposure to fixation
• Concentration
• For rapid intraoperative analysis of tissue specimens,
• Time interval
tissue can be frozen, and frozen sections can be cut with
• Fixation is optimal at a neutral pH, in the range of
a special freezing microtome (“cryostat”); the pieces of
6 to 8
tissue to be studied are snap-frozen in a cold liquid or cold
• Hypoxia of tissues lowers the pH, so there must
environment (−20°C to −70°C); freezing makes the tissue
be buffering capacity in the fixative to prevent
solid enough to section with a microtome
excessive acidity; acidity causes formation of
Chapter 1 — Special Diagnostic Techniques in Surgical Pathology 3
Figure 1.2 Masson trichrome stain. Cirrhosis of the liver charac-

terized by bridging fibrosis (blue) and regenerative nodule formation
(red).
Figure 1.1 Elastin/Alcian blue stain. Aortic cystic medial degen-
eration in Marfan syndrome. Elastin stain highlights fragmentation of
elastic fibers (brown-black) and pooling of mucopolysaccharides (blue)
• E lastic fibers are blue to black; collagen appears red;
within the media.
and the remaining connective tissue is yellow
• Masson trichrome stain
• Helpful in differentiating between collagen fibers
HISTOLOGIC STAINS
(blue staining) and smooth muscle (bright red stain-
• T he staining process makes use of a variety of dyes that ing) (Figure 1.2)
have been chosen for their ability to stain various cel- • Reticulin stain
lular components of tissue • A silver impregnation technique stains reticulin
• Hematoxylin and eosin (H&E) stain fibers in tissue section black
• The most common histologic stain used for routine • Particularly helpful in assessing for alteration in the
surgical pathology normal reticular fiber pattern, such as can be seen in
• Hematoxylin, because it is a basic dye, has an affinity some liver diseases or marrow fibrosis
for the nucleic acids of the cell nucleus • Jones silver stain
• Hematoxylin does not directly stain tissues but • A silver impregnation procedure that highlights
needs a “mordant” or link to the tissues; this is pro- basement membrane material; used mainly in kid-
vided by a metal cation such as iron, aluminum, or ney biopsies (Figure 1.3A)
tungsten
• The hematoxylin-metal complex acts as a basic dye, Fats and Lipids
and any component that is stained is considered to • O il red O stain
be basophilic (i.e., contains the acid groups that bind • Demonstrates neutral lipids in frozen tissue
the positively charged basic dye), appearing blue in • Sudan black stain
tissue section • Demonstrates neutral lipids in tissue sections
• The variety of hematoxylin stains available for use is • Mainly used in hematologic preparations such as
based partially on choice of metal ion used, which peripheral blood or bone marrow aspirations for
can vary the intensity or hue demonstration of primary granules of myeloid
• Conversely, eosin is an acid aniline dye with an affin- lineage
ity for cytoplasmic components of the cell
• Eosin stains the more basic proteins within cells Carbohydrates and Mucoproteins
(cytoplasm) and in extracellular spaces (collagen) • C
ongo red stain
pink to red (acidophilic) • Amyloid is a fibrillar protein with a β pleated sheet
structure
Connective Tissue • Amyloid deposits in tissue exhibit a deep red or
• E
lastin stain salmon color, whereas elastic tissue remains pale
• Elastin van Gieson (EVG) stain highlights elastic pink (Figure 1.4A)
fibers in connective tissue • When viewed under polarized light, amyloid depos-
• EVG stain is useful in demonstrating pathologic its exhibit apple-green birefringence (Figure 1.4B)
changes in elastic fibers, such as reduplication, • The amyloid fibril–Congo red complex demonstrates
breaks or splitting that may result from episodes of green birefringence owing to the parallel alignment
vasculitis, or connective tissue disorders such as Mar- of dye molecules along the β pleated sheet
fan syndrome (Figure 1.1) • The thickness of the section is critical (8 to 10 μm)
A
A
B
B
C
C Figure 1.4 Alzheimer disease. A, Congo red–positive core of Al-
zheimer disease plaque. B, Apple-green birefringence of amyloid core
Figure 1.3 Membranous glomerulopathy. A, Jones silver stain under polarized light. C, Bielschowsky stain highlighting Alzheimer
highlighting basement membrane “spikes” (arrow) along glomerular disease plaque (arrow) and neurofibrillary tangle within neuronal cell
capillary loops corresponding to basement membrane material sur- bodies (arrowhead).
rounding intramembranous immune complexes. B, Direct immu-
nofluorescence showing diffuse, granular staining of the glomerular
capillary basement membranes with goat antihuman immunoglobu-
lin G. This technique requires fresh-frozen tissue sections. C, Electron
microscopy showing intramembranous electron-dense immune com-
plexes within the glomerular capillary basement membranes. (Courte-
sy of Pamela Gibson, MD, University of Vermont/Fletcher Allen Health
Care, Department of Pathology, Burlington, VT.)
• M ucicarmine stain
• Demonstrates epithelial mucin in tissue sections
• Also highlights mucin- rich capsule of Cryptococcus
species
• Periodic acid–Schiff (PAS) stain
• Glycogen, neutral mucosubstances, basement mem-
branes, and fungal walls exhibit a positive PAS (bright
rose)
• PAS with diastase digestion: diastase and amylase act
on glycogen to depolymerize it into smaller sugar
units that are then washed out of the section
• Digestion removes glycogen but retains stain-
ing of other substances attached to sugars (i.e.,
mucopolysaccharides)
• Alcian blue stain
• May be used to distinguish various glandular epithe-
lia of the gastrointestinal tract and in the diagnosis
of Barrett epithelium Figure 1.5 Luxol fast blue stain. Demyelination in multiple sclerosis
• pH 1.0: acid sulfated mucin positive (colonic-like) (colorless regions).
• pH 2.5: acid sulfated mucin (colonic-like) and acid
nonsulfated mucin (small intestine–like) positive
• Neutral mucins (gastric-like) negative at pH 1.0 and
2.5
Pigments and Minerals

• F
erric iron (Prussian blue), bilirubin (bile stain), cal-
cium (von Kossa), copper (rhodanine), and melanin
(Fontana-Masson) are the most common pigments and
minerals demonstrated in surgical pathology specimens
Nerves and Fibers

• B ielschowsky stain
• A silver impregnation procedure that demonstrates
the presence of neurofibrillary tangles and senile
plaques in Alzheimer disease (Figure 1.4C)
• Axons stain black
• Luxol fast blue stain Figure 1.6 Aspergillus organisms in the lung stained by Grocott me-
• Demonstrates myelin in tissue sections thenamine silver stain.
• Loss of staining indicates myelin breakdown second-
ary to axonal degeneration
• Gray matter and demyelinated white matter should • G rocott methenamine silver (GMS) stain
be almost colorless and contrast with the blue- • Demonstration of fungi or Pneumocystis organisms
stained myelinated white matter (Figure 1.5) (fungi may also be demonstrated by PAS- amylase
stain) (Figure 1.6)
Hematopoietic and Nuclear Elements • Warthin-Starry and Steiner stains
• T oluidine blue stain • Silver impregnation technique for spirochetes (e.g.,
• Demonstrates mast cells in tissue Borrelia burgdorferi, Treponema pallidum) in tissue
• Giemsa, Wright, and May-Grünwald stains sections
• For cellular details, including hematopoietic (periph- • Note: all bacteria are nonselectively blackened by
eral blood or bone marrow) and cytology preparations silver impregnation methods such as the Warthin-
• Leder stain (chloracetate esterase) Starry and Steiner stains
• Identification of cytoplasmic granules of granulo- • These methods are more sensitive for small gram-
cytes and myeloid precursors negative bacteria (e.g., Legionella species, Helicobacter
pylori, and Bartonella species) than tissue Gram stain
Microorganisms: Bacteria, Fungi, Parasites • Ziehl-Neelsen method for acid-fast bacteria (AFB)
• B rown and Brenn Gram stain • Detect the presence of acid-fast mycobacteria (bright
• Demonstration of gram- negative (red) and gram- red) in tissue sections (background light blue)
positive (blue) bacteria in tissue (Figure 1.7)
• Giemsa stain • Fite method should be used to demonstrate Mycobac-
• Demonstration of bacteria, rickettsia, and Toxo- terium leprae or Nocardia species, both of which are
plasma gondii in tissue sections weakly acid fast
Selected References FLUORESCENCE MICROSCOPY

Bancroft JD, Gamble M. Theory and Practice of Histochemical Techniques.
5th ed. Philadelphia: Elsevier; 2001. • Tissue is exposed to short- wavelength ultraviolet (UV)
Carson FL. Histotechnology: A Self-Instructional Text. 2nd ed. Chicago: light (2500 to 4000 angstroms) through a mercury or halo-
American Society for Clinical Pathology (ASCP) Press; 1997. gen lamp; the energy is absorbed by molecules that then
Wolff AC, Hammond ME, Schwartz JN, et al. American Society of Clini-
cal Oncology/College of American Pathologists guideline recom-
release the energy as visible light (4000 to 8000 angstroms)
mendations for human epidermal growth factor receptor 2 testing • In immunofluorescence techniques, antibodies are
in breast cancer. Arch Pathol Lab Med. 2007;131:18–43. labeled with a fluorescent dye such as fluorescein iso-
thiocyanate (FITC)
• Direct immunofluorescence
• Fluorescein-labeled antihuman globulin primary
antibodies are applied to frozen, unfixed tissue sec-
tions to locate and combine with antibodies, com-
plement, or antigens deposited in tissue
• Indirect immunofluorescence
• Unlabeled primary antibody is applied to the tissue
section, followed by application of an FITC-labeled
antibody that is directed against a portion of the
unlabeled primary antibody
• More sensitive and more expensive
• Primary application in surgical pathology is detec-
tion of autoimmune diseases involving the skin and
kidney (Table 1.1)
Selected References
D’Agati VD, Jennette JC, Silva FG. Non-neoplastic kidney diseases. In:
AFIP Atlas of Nontumor Pathology. Vol. 4. Washington, DC: Armed
Forces Institute of Pathology; 2005.
Figure 1.7 Ziehl-Neelsen stain for acid-fast bacilli. Abundant My- Kalaaji AN, Nicolas MEO. Mayo Clinic Atlas of Immunofluorescence in
cobacterium avian intracellulare organisms (red) within macrophages Dermatology: Patterns and Target Antigens. New York, NY: Informa
in the lung. Healthcare; 2006.
TABLE 1.1 IMMUNOFLUORESCENCE PATTERNS AND DISEASE ASSOCIATIONS

Disease Antibodies Pattern Histologic Manifestation
Skin
Pemphigus vulgaris Antidesmosomal Intercellular chicken-wire IgG in Suprabasal vesiculation
epidermis
Bullous pemphigoid Antiepithelial BM; anti- Linear IgG along BM; in salt-split Subepithelial vesiculation
hemidesmosome (collagen XVII skin, reactivity along roof
[BP180])
Epidermolysis bullosa EBA Ag Linear IgG along BM; in salt-split Subepithelial vesiculation
acquisita (EBA) skin, reactivity along floor
Dermatitis herpetiformis Antigluten Granular IgA, especially in tips of Subepithelial vesiculation
dermal papillae
Kidney
Anti–glomerular basement Anti-GBM COL4-A3 antigen Linear GBM staining for IgG, cor- Crescentic GN
membrane (anti-GBM) responding granular staining
disease for C3
Membranous Subepithelial deposits secondary to in Diffuse, granular GBM staining for Diffusely thickened glomerular
glomerulopathy situ immune complex formation IgG and C3 capillary loops with lacelike
(antigen unknown; associated splitting and “spikes” identi-
with lupus nephritis, hepatitis B, fied on Jones silver stain
penicillamine, gold, malignancy)
IgA nephropathy Deposited IgA polyclonal: possible IgA ± IgG, IgM, and C3 in mesan- Focal proliferative GN; mesangial
increased production in response gium widening
to exposure to environmental
agents (e.g., viruses, bacteria,
food proteins such as gluten)
Membranoproliferative Type I: immune complex Type I: IgG + C3; C1q + C4 Mesangial proliferation; GBM
glomerulonephritis Type II: autoantibody to alternative Type II: C3 ± IgG; no C1q or C4 thickening; splitting
complement pathway
BM, Basement membrane; GBM, glomerular basement membrane; GN, glomerulonephritis; Ig, immunoglobulin.
• N ucleolus
ELECTRON MICROSCOPY
• Dense, rounded basophilic structure that consists of
• T he electron microscope has a magnification range of 80% to 90% protein
1000 to 500,000 diameters (×) (the upper limit of light • Produces most of the ribosomal RNA (rRNA)
microscopy is approximately 1000 diameters), thereby • Mitotically or metabolically active cells have mul-
allowing for analyzing the ultrastructure of a cell tiple nucleoli
• There are two types of EM: • Chromatin
• Transmission EM • Heterochromatin: stainable, condensed regions of
• Scanning EM chromosomes seen as intensely basophilic nuclear
• Two-dimensional (2D) black-and-white image is material in light microscopy
produced • Euchromatin: nonstainable, extended portions of the
• Tissue either transmits electrons (producing chromosomes that consist of genetically active DNA
“lucent” or clear areas in the image) or deflects
electrons (producing electron “dense” or dark Cytoplasm
areas in the image) • P lasma membrane
• Useful in the diagnosis of nonneoplastic diseases • Appears as two electron-dense (dark) layers with an
of the kidney intervening electron-lucent (light) layer
• Three-dimensional (3D) black-and-white image • Basement membrane = basal lamina (lamina densa +
results as an electron beam sweeps the surface of lamina lucida) + lamina reticularis + anchoring fibrils +
the specimen and releases secondary electrons microfibrils
• Lower resolution than transmission EM and used • Lamina densa
primarily in the research setting to study cell sur- • Electron-dense membrane made up of type
face membrane changes IV collagen fibers coated by a heparan sulfate
• Application in surgical pathology: EM is a useful proteoglycan
diagnostic technique to supplement morphologic, • Approximately 30 to 70 nm thick with an underly-
immunohistochemical, cytogenetic, and molecular ing network of reticular collagen (type III) fibrils,
analysis of tissues which average 30 nm in diameter and 0.1 to 2 μm
• Immunoperoxidase techniques have largely replaced in thickness
EM for tumor diagnosis in surgical pathology • Mitochondria
• EM is useful in • The energy-producing component of the cell; these
• Renal, skin, myocardial, nerve, and muscle biopsies membrane-bound organelles undergo oxidative reac-
• Undifferentiated or poorly differentiated neoplasms tions to produce energy
• Diagnosis of lysosomal storage disorders • Energy generation occurs on the cristae, which are
• Ciliary dysmorphology composed of the inner mitochondrial membrane
• Visualization of infectious agents • Most cells contain shelflike mitochondrial cristae
• Steroid-producing cells (i.e., adrenal cortex) contain
tubular cristae
TECHNICAL OVERVIEW • Mitochondrial crystals are always pathologic
• T he main fixative used for EM is glutaraldehyde, which • Hürthle cell change occurs when the cytoplasm of a
penetrates tissues more slowly than formalin; cubes of cell becomes packed with mitochondria
tissue 1 mm or smaller are needed • Ribosomes
• Processing post fixation with osmium tetroxide, which • Sites of protein synthesis
binds to lipids in membranes for better visualization; • Usually responsible for the basophilic staining of the
dehydration with graded alcohols; infiltration with pro- cytoplasm on H&E-stained sections
pylene oxide and epoxy resin; embedding in epoxy resin • Endoplasmic reticulum
• 1-μm sections (semithin) are cut and stained with tolu- • Membrane-bound channels responsible for the trans-
idine blue to verify that the area of interest has been port and processing of secretory products of the cell
selected for EM • Granular or rough endoplasmic reticulum is abun-
• 100-nm sections (ultrathin) are cut and collected on dant in cells that actively produce secretory prod-
copper grids ucts (e.g., plasma cells producing immunoglobulin
• Tissues are stained with heavy metals (uranyl acetate [Ig] and pancreatic acinar cells producing digestive
and lead citrate) enzymes); the granular appearance is due to attached
• Electron dense: darker in color as a result of heavy ribosomes
impregnation with heavy metal • Smooth endoplasmic reticulum is abundant in cells
• Electron lucent: lighter in color that synthesize steroids (i.e., adrenal cortex, Sertoli-
Leydig cells) and in tumors derived from these types
ULTRASTRUCTURE OF A CELL of cells
• Golgi apparatus
Nucleus • Concentrates and packages proteins into secretory
• N
uclear membrane vesicles for transport to the cell surface
• N uclear pore • Prominent in cells that secrete proteins
TABLE 1.2 CYTOPLASMIC GRANULES

Type Size Morphology Product Cell Type/Tumor
Mucigen 0.7–1.8 μm Electron lucent Glycoprotein Mucin secreting
Serous, zymogen 0.5–1.5 μm Electron dense Proenzyme/enzyme Example: acinar cells of
pancreas
Neuroendocrine 100–300 nm Dense core Example: biogenic amines Neuroendocrine cells
Figure 1.9 Electron microscopy. Birbeck granules (arrow) in Lang-

Figure 1.8 Electron microscopy. Neuroendocrine granules in small erhans cell histiocytosis. (Photo courtesy of Janet Schwarz, Senior
cell carcinoma of the lung. Research Technician, Microscopy Imaging Center, University of Ver-
mont, Burlington, VT.)
Single Membrane–Bound Structures

TABLE 1.3 FILAMENTS AND TUBULES
• C ytoplasmic granules are classified based on size and
morphology (Table 1.2) Component Diameter Location
• Lysosomes Microfilaments (actin, 6–8 nm Cytoskeleton of all
• Contain enzymes that assist in digesting material to nonmuscle myosin) cells
be disposed of in the cell Intermediate filaments 10 nm
• Endogenous and exogenous pigments can be col- Cytokeratin >19 proteins Epithelial cells
lected in lysosomes; can be large and filled with 40–68 kD
undigested cellular components in lysosomal storage Glial fibrillary acid 55 kD Astrocytes
protein
disorders
Neurofilament 68, 160, 200 kD Neural tissue
• Dense core granules: seen in cells and tumors with neu-
Vimentin 57 kD Mesenchymal tissues
roendocrine differentiation (Figure 1.8) Desmin 53 kD Muscle
• Melanosomes and premelanosomes are specific single Microtubules 25 nm Neural derivatives (e.g.,
membrane–bound structures neuroblastoma)
• Weibel-Palade bodies are specific for endothelial cells
• Birbeck granules are seen in Langerhans cell histiocyto- kD, kilodaltons; nm, nanometers; 50 kD = ∼4 nm.
sis (Figure 1.9)
• T erminal web and rootlets in villi are seen in foregut
Filaments and Tubules derivatives (e.g., colon)
• F ilaments are classified based on size (Table 1.3) • Junctions are seen in virtually all cells except those of
• Microtubules are seen in association with the mitotic hematopoietic origin
spindle and in cells or tumors of neural origin (e.g., • Basal lamina is seen surrounding all endodermal and
neuroblastoma) ectodermal derivatives; cells with muscle differen-
tiation also may have a basal lamina, which may be
Cell Surface incomplete
• C ell processes are seen in cells that are capable of move-
ment; some tumors, such as schwannomas and menin- Extracellular Matrix
giomas, demonstrate interdigitating processes • C
ollagen shows a regular structure amyloid
• Villi are prominent and regular in cells or tumors of • Fibrils measuring approximately 10 nm in diameter,
glandular origin (Figure 1.10) with an electron-lucent core
• V arious techniques may unmask antigens, such as

digestion by enzymes (e.g., trypsin) or antigen retrieval
using heat, metallic mordants, or alkaline buffers
• Commonly used enzymes include peroxidase, alka-
line phosphatase, and glucose oxidase
• Most commonly used chromogen substrates pro-
duce brown 3,3’-Diaminobenzidine (DAB), or red
3-Amino-9-Ethylcarbazole (AEC) reaction products
• Definition of terms
• Polyclonal antibody: conventional antiserum pro-
duced by multiple plasma cells of an animal that had
been injected with an antigen; a polyclonal antibody
may have multiple determinants (binding sites)
• Monoclonal antibody: produced by fusion of a malignant
cell with a plasma cell producing antibody to a specific
Figure 1.10 Electron microscopy. Short villi lining an intracytoplas-
epitope; antibodies may be grown in tissue culture
mic lumen in adenocarcinoma of the breast. • Antibodies for the detection of cellular components
• Intermediate filaments (see Table 1.3)
• Other cellular and tissue components: (e.g., α1-
antitrypsin, myeloperoxidase, synaptophysin and
chromogranin, myoglobin)
• F
ibrils are straight, nonbranching, and arranged • Leukocyte antigens and Ig components commonly
randomly used in paraffin-embedded tissues
• T-cell
Selected References • CD1a: thymocyte; also marks Langerhans cells
Ghadially FN. Diagnostic Electron Microscopy of Tumors. Boston: • CD3: Pan–T-cell marker that shows cytoplasmic and
Butterworth-Heinemann; 1986. membrane staining
Ghadially FN. Diagnostic Ultrastructural Pathology. 2nd ed. Boston: • CD5: Pan–T-cell marker also expressed by some B-cell
Butterworth-Heinemann; 1998.
lymphomas
Ghadially FN. Ultrastructure of the Cell and Matrix. 4th ed. Boston:
Butterworth-Heinemann; 1997. • CD43: Pan–T- cell marker also expressed by some
B-cell lymphomas
• CD45RO (UCHL-1), CD4, CD8: T-cell markers
IMMUNOHISTOCHEMISTRY • B-cell
INTRODUCTION • CD20: Pan–B-cell marker
• Ig heavy and light chains: used for demonstration of
IHC combines anatomic, immunologic, and biochemical clonality in B-cell neoplasms
techniques to identify specific tissue components using • Myeloid
a specific antigen-antibody reaction labeled with a vis- • CD15 (Leu-M1): pan-myeloid antigen that also marks
ible reporter molecule. This binding is then visualized Reed-Sternberg cells of Hodgkin lymphoma
through the use of various enzymes that are coupled to • Monocyte and histiocyte
the antibodies being used. The enzyme acts on a chromo- • CD163, CD68
genic substrate to cause deposition of a colored material • Natural killer cell
at the site of antibody-antigen bindings. Hence IHC per- • CD57 (Leu-7)
mits the visualization and localization of specific cellu- • CD56 (neural cell adhesion molecules, NCAM,
lar components within a cell or tissue while importantly Leu-19)
preserving the overall morphology and structure of the • Megakaryocyte
tissue section. Key improvements in protein conjugation, • CD41
antigen preservation and antigen retrieval methods, and • Factor VIII–von Willebrand factor (vWF)
enhanced immunodetection systems have enshrined IHC • Ulex europaeus agglutinin-1 (UEA-1)
as a major adjunctive investigative tool for both surgical • Hormones and hormone receptors
and cytopathology. IHC is not only critical for the accu- • Presence may have prognostic significance
rate diagnosis of malignancies but also plays a pivotal role • Estrogen and progesterone receptors in breast
in prognostic evaluation (e.g., estrogen and progesterone carcinomas
receptors in breast cancer) and treatment strategies (e.g., • Androgen receptors
c-kit protein for gastrointestinal stromal tumors and HER- • Infectious agents
2-neu in certain breast cancers). • Oncogenes and oncogene products
• May correlate with prognosis
TECHNICAL OVERVIEW • bcl-1, bcl-2, bcl-6 in lymphoid neoplasms
• HER-2-neu and C-erbB2 in breast carcinomas (Figure
• F
ormalin cross- links proteins in tissues; success of 1.11)
immunohistochemical staining depends on the avail- • p53 tumor suppressor gene: mutations are seen in a
ability of an antigen after fixation variety of malignant tumors
Figure 1.11 Immunohistochemistry for HER-2-neu in a breast adeno- Figure 1.12 Immunohistochemistry for HepPar-1 highlighting strong
carcinoma showing (3+) membranous staining. cytoplasmic staining of normal hepatic parenchyma.
GROUND RULES FOR • A void preordering an IHC panel of antibodies before

QUALITY APPLICATION OF previewing the morphology; remember that IHC is
IMMUNOHISTOCHEMISTRY IN SURGICAL an ancillary or adjunctive technique to the quality
PATHOLOGY practice of surgical pathology and not vice versa
• Interpretation
• T echnique • Interpretation of IHC should always be made in the
• It is imperative that the pathologist work closely context of the known subcellular localization or dis-
with the immunohistotechnologist to optimize, vali- tribution of the targeted antigen (e.g., membranous,
date, and interpret the IHC assay for any particular cytoplasmic, nuclear, or perinuclear “Golgi pattern”
antibody reagent of immunoreactivity) (Figures 1.12 and 1.13)
• Adequate fixation of tissue or specimen in 10% • Controls
buffered formalin is essential to high-quality IHC; it • Finally, the importance of adequate incorporation
is probably better to overfix (because modern anti- of appropriate tissue and reagent (both positive
gen retrieval systems can unmask epitopes) rather and negative) controls in every run of IHC cannot
than underfix (because inadvertent alcohol fixa- be overemphasized; this is ultimately the highest
tion during tissue processing precipitates and masks form of quality control of the IHC assay and should
epitopes) be reviewed daily to avoid false-positive and false-
• It is best to use a polymer-based detection system, negative interpretation
which has the advantage of being avidin- biotin
free, thereby avoiding false immunoreactivity with
endogenous biotin A PRACTICAL TABULAR APPROACH TO
• Appropriate antigen retrieval systems should be USING IMMUNOHISTOCHEMISTRY FOR
optimized for each antibody (noting that different COMMON DIAGNOSTIC PROBLEMS
antibodies require unique systems, and some require
• B
ecause a complete technical overview of IHC and com-
none)
prehensive listing of available antibodies is beyond the
• Antibody choice
scope of this chapter, our goal is to provide a practical
• A generic screening panel of antibodies should be
approach to IHC application in surgical pathology; the
chosen initially, followed algorithmically by a spe-
following tables are presented as guidelines to assist with
cific panel to further characterize a neoplasm
the choice of an antibody panel when confronted with
• Avoid using a single antibody in isolation (because
certain differential diagnoses (Tables 1.4 through 1.36)
this may result in a potentially erroneous diagnosis),
and always use more than one antibody to target a PEARLS
specific antigen
• The choice of a panel of antibodies to target a spe- • T umors are not 100% specific or sensitive to a particular
cific antigen should always be made in the con- immunoreagent; interpretation of these tables should be
text of the morphology and clinical presentation used in this context to avoid diagnostic pitfalls
of any neoplasm; avoid use of the “buckshot” • Always target the IHC panel in the context of the
approach in hope that an IHC assay returns a posi- morphologic differential diagnosis
tive reaction
Selected References FLOW CYTOMETRY

Dabbs D. Diagnostic Immunohistochemistry. 2nd ed. Philadelphia:
Churchill Livingstone; 2006. INTRODUCTION
Jagirder J. Immunohistochemistry: then and now. Arch Pathol Lab Med.
2008;132:323–509. • F low cytometry is widely used to immunophenotypi-
Leong AS-Y, Leong TY-M. Newer developments in immunohistology. J cally detect clonal hematopoietic populations (e.g.,
Clin Pathol. 2006;59:1117–1126. leukemia and lymphoma)
Yaziji H, Barry T. Diagnostic immunohistochemistry: what can go
wrong? Adv Anat Pathol. 2006;13:238–246.
• When performed on peripheral blood, bone marrow,
and lymph nodal tissue, single- cell suspensions are
required
• Manipulation of solid tissue samples into single-cell
suspensions can sometimes compromise the integrity
of the cell surface
TECHNICAL OVERVIEW
• S ingle-cell suspension is split into multiple tubes
• Various fluorescent- labeled antibodies against differ-
ent cell surface antigens (each with a different attached
fluorochrome) are added to each tube
• One by one, the cells are run through the flow cytom-
eter; as the cells pass through the counting chamber,
multiple data points are collected
• Degree of forward light scatter (FSC): indicator of cell
size
• Degree of 90-degree light scatter or side scatter (SSC):
indicator of nuclear complexity and cytoplasmic
granularity
A
• Intensity of fluorochrome on the cell surface: detects
expression of cell surface antigens (e.g., CD45, leuko-
cyte common antigen)
• Gating: the cells of interest are digitally selected for
interpretation; for example, if lymphocytes are to be
examined, one would “gate” around the cells that
exhibit low side scatter (SSC) (little cytoplasmic granu-
larity) and strong CD45 (leukocyte common antigen)
expression (Figure 1.15)
• Typical findings in mantle cell lymphoma would
include a CD20-positive population (B-cells) exhibit-
ing coexpression of CD19 and CD5 (narrowing the dif-
ferential to small lymphocytic lymphoma and mantle
cell lymphoma), with light chain restriction support-
ing clonality. Lack of CD23 expression helps to exclude
small lymphocytic lymphoma, which would have an
immunophenotype similar to that of mantle cell lym-
B phoma, except for CD23 expression and dimmer light
Figure 1.13 Immunohistochemistry for TTF-1. A, Nuclear immu- chain expression. Follicular lymphoma would also
noreactivity in normal thyroid parenchyma. B, Nuclear immunoreac- consist of a population of CD20-positive B-cells that
tivity in pulmonary adenocarcinoma. express CD10 and lack CD5
TABLE 1.4 IMMUNOHISTOCHEMISTRY APPROACH TO UNDIFFERENTIATED TUMORS

Pan-CK EMA S-100 SALL4 LCA CD138
Carcinoma + + − −/v − −
Melanoma −/v − + − − −
Germ cell v − − + − −
Lymphoma − − − − + −
Anaplastic plas- − + − − −/+ +
macytoma/
myeloma
EMA, Epithelial membrane antigen; LCA, leukocyte common antigen; Pan-CK, pan-cytokeratin; SALL4, sal-like4; v, variable; +, positive; −, negative; −/+,
rarely positive.
Selected Reference • A fter staining of the chromosomes, specific chromo-

Carey JL, McCoy P, Keren DF. Flow Cytometry in Clinical Diagnosis. 4th
somal abnormalities can be detected
ed. Chicago: ASCP Press; 2007. • In surgical pathology practice at University of Ver-
mont Medical Center we routinely submit fresh
tissue in Hanks solution for cytogenetics in the fol-
CYTOGENETIC ANALYSIS
lowing cases
• T
echnical overview • All renal tumors (except for urothelial carcinomas of
• Fresh tissue is incubated in short-term culture, and the renal pelvis)
metaphase chromosomes are spread on glass slides • Any soft tissue tumor larger than 5 cm (including
adipocytic neoplasms) (Figure 1.16)
TABLE 1.5 IMMUNOPHENOTYPIC DISTRIBUTION • In addition, a portion of fresh tissue (1 cm3, if avail-
OF CYTOKERATINS 7 AND 20 able) is snap-frozen for potential molecular analy-
ses for tumor-specific translocations or for potential
Carcinoma Typea CK7 CK20
treatment protocols
Colorectal and Merkel cell − + • Oncogenes (Table 1.37) and tumor suppressor genes
Hepatocellular − − (Table 1.38) of importance in surgical pathology
Salivary gland + − • Cytogenetic abnormalities of importance in surgical
Lung, non–small cell carcinoma + −
pathology (Table 1.39)
Lung, neuroendocrine carcinoma − −
Breast, ductal + −
Ovarian, serous, and endometrioid + − Selected References
Endometrial and endocervical + − Gersen SL, Keagle MB. The Principles of Clinical Cytogenetics. 2nd ed.
Renal cell − − Totowa: Humana Press; 2004.
Prostatic − − Korf B. Molecular medicine: molecular diagnosis (part I). N Engl J Med.
Urothelial + + 1995;332:1218–1220.
Pancreas +/− +/− Korf B. Molecular medicine: molecular diagnosis (part II). N Engl J Med.
1995;332:1499–1502.
Mesothelioma + −
Richmond JA, Tang M, Cooper K. Cytogenetic and clinicopatho-
logic analysis of benign lipomatous tumors. Arch Pathol Lab Med.
CK, Cytokeratin; +, positive; −, negative; +/−, variably positive.
aOnly approximately 70% to 90% of these tumors follow the given 2005;129:553.
CK7/20 immunoprofile; therefore reliance solely on this profile to
determine the primary site of carcinomas is not recommended.
TABLE 1.6 SPECIFIC ANTIBODY REAGENTS TO IDENTIFY PRIMARY SITE OF METASTATIC CARCINOMA
Carcinoma Type Antibody Signal Localization Other Tumors Identified
Breast GCDFP-15 Cytoplasmic Salivary, sweat gland
Breast Mammaglobin Cytoplasmic Salivary, sweat gland
Breast GATA3 Nuclear Urothelial, Salivary glands
Colon CDX2 Nuclear Subset of pancreas, gastric
Hepatocellular HepPar-1 Ag Cytoplasmic Hepatoid carcinomas of
stomach, ovary
Hepatocellular pCEA or CD10 Bile canaliculi Hepatoid carcinomas
Hepatocellular GPC-3 Membranous and Melanoma, a subset of
cytoplasmic chronic active hepatitis
Lung and thyroid except mucinous TTF-1 Nuclear Neuroendocrine carcinoma
adenocarcinoma in situ (formerly extrapulmonary
mucinous BAC)
Lung squamous cell carcinoma p40 Nuclear —
Ovarian serous WT-1, p16 Nuclear Mesothelioma (WT-1)
Prostate NKX3.1 Nuclear
Prostate PSA, PAP Cytoplasmic
Squamous, urothelial, thymic p63 Nuclear Salivary gland, neuroendo-
crine, subset prostate
Thyroid Thyroglobulin Cytoplasmic —
Urothelial Uroplakin III Membranous —
Renal, clear RCC Membranous
BAC, Bronchoalveolar carcinoma; GATA3, GATA Binding Protein 3; GCDFP-15, gross cystic disease fluid protein-15; GPC-3, glypican 3; NKX3.1, NK3
Homeobox 1; PAP, prostatic acid phosphatase; pCEA, polyclonal carcinoembryonic antigen; PSA, prostate-specific antigen; RCC, renal cell carcinoma;
TTF-1, thyroid transcription factor-1; WT-1, Wilms tumor gene protein 1.
Modified from Kakar S, Gown AM, Goodman ZD, Ferrell LD. Best practices in diagnostic immunohistochemistry: hepatocellular carcinoma versus meta-
static neoplasms. Arch Pathol Lab Med. 2007;131:1648–1654; Bishop JA, Teruya-Feldstein J, Westra WH, et al. p40 (ΔNp63) is superior to p63 for the
diagnosis of pulmonary squamous cell carcinoma. Mod Pathol. 2012;25:405–415.
From Conner JR, Hornick JL. Metastatic carcinoma of unknown primary: diagnostic approach using immunohistochemistry. Adv Anat Pathol.
2015;22(3):149–167.
From Miettinen M, McCue PA, Sarlomo-Rikala M, et al. GATA3: a multispecific but potentially useful marker in surgical pathology: a systemic analysis of
2500 epithelial and nonepithelial tumors. Am J Surg Pathol. 2014;38(1):13–22.
TABLE 1.7 IMMUNOHISTOCHEMISTRY PANEL FOR INTERPRETATION OF LUNG MESOTHELIOMA AND

ADENOCARCINOMA
Epithelioid Mesothelioma Sarcomatoid Mesothelioma Adenocarcinoma (Percentage
Antibody (Percentage Positive) (Percentage Positive) Positive)
Epithelial Marker
Naspin A Negative Negative 83 (lung)
mCEA 3 — 81
Ber-Ep4 10 0 80
B72.3 7 0 80
CD15 (Leu-M1) 7 0 72
MOC-31 7 0 93
TTF-1 Negative 0 72 (lung)
Mesothelial Marker
Cytokeratin 5/6 83 13 15
Calretinin 82 88 15
WT-1 77 13 4
D2-40 86–100 0 36 (weak)
Mesothelin 100 0 —
BAP1 (loss of nuclear expression) 55.4 41.7 __
BAP1, BRCA1-associated protein 1; mCEA, monoclonal carcinoembryonic antigen; TTF-1, thyroid transcription factor-1; WT-1, Wilms tumor gene
protein 1.
Modified from Marchevsky AM. Application of immunohistochemistry to the diagnosis of malignant mesothelioma. Arch Pathol Lab Med. 2008;132:397–
401; Bishop JA, Sharma R, Illei PB: Naspin A and thyroid transcription factor-1 expression in carcinomas of the lung, breast, pancreas, colon, kidney,
thyroid, and malignant mesothelioma. Hum Pathol. 2010;41:20–25.
From Erber R, Warth A, Muley T, et al. BAP1 loss is a useful adjunct to distinguish malignant mesothelioma including the adenomatoid-like variant from
benign adenomatoid tumors. Appl Immunohistochem Mol Morphol. 2019 Jan 11. doi: 10.1097 [Epub ahead of print].
TABLE 1.8 IMMUNOHISTOCHEMISTRY PANEL FOR LUNG ADENOCARCINOMA AND BREAST

ADENOCARCINOMA
Immunostain Lung Adenocarcinoma (Percentage Positive) Breast Adenocarcinoma (Percentage Positive)
TTF-1 77 0
Naspin A 83 0
Mammaglobin 17 85
GCDFP-15 2 53
ER 4 72
ER, Estrogen receptor; GCDFP-15, gross cystic disease fluid protein-15; TTF-1, thyroid transcription factor-1.
Data from Takeda Y, Tsuta K, Shibuki Y, et al. Analysis of expression patterns of breast cancer-specific markers (mammaglobin and gross cystic disease
fluid protein 15) in lung and pleural tumors. Arch Pathol Lab Med. 2008;132:239; Striebel JM, Dacic S, Yousem SA. Gross cystic disease fluid protein
(GCDFP-15): expression in primary lung adenocarcinoma. Am J Surg Pathol. 2008;32:426; Bishop JA, Sharma R, Illei PB. Naspin A and thyroid transcrip-
tion factor-1 expression in carcinomas of the lung, breast, pancreas, colon, kidney, thyroid, and malignant mesothelioma. Hum Pathol. 2010;41:20–25.
TABLE 1.9 IMMUNOHISTOCHEMISTRY COMPARISON OF SPINDLE CELL AREAS IN METAPLASTIC CARCINOMA,

PHYLLODES TUMOR, AND FIBROMATOSIS OF THE BREAST
CD34 SMA 34βe12 Pan-CK β-catenin Desmin p63
Metaplastic carcinoma − +/− +/− −/+ − −/+ +
Phyllodes +/− +/− − − − −/+ −
Fibromatosis − +/− − − + − −
Myofibroblastoma + +/− − − − + −
Myoepithelial tumor − +/− +/− + − −/+ +/−
Pan-CK, Pan-cytokeratin; SMA, smooth muscle actin; +, positive; −, negative; +/−, often positive; −/+, rarely positive.
Modified from Dunne B, Lee AH, Pinder SE, et al. An immunohistochemical study of metaplastic spindle cell carcinoma, phyllodes tumor and fibromatosis
of the breast. Hum Pathol. 2003;34:1009–1015.
TABLE 1.10 USEFUL ANTIBODY PANEL TO DEMONSTRATE MYOEPITHELIAL AND BASAL CELLS IN BREAST
LESIONS TO DISTINGUISH BENIGN (+) FROM INVASIVE (−) CARCINOMA
Myoepithelial/Basal Cells Stromal Myofibroblasts
Smooth muscle heavy-chain myosin + (Cytoplasmic) −/+
p63 + (Nuclear) −
α-SMA + (Cytoplasmic) +/−
S-100 + (Nuclear and cytoplasmic) v
Calponin + (Cytoplasmic) −/+
D2-40a −/+ −
SMA, Smooth muscle actin; v, variable; +, positive; −, negative; −/+, rarely positive.
aD2-40 is a useful marker to highlight lymphatic endothelium in lymphovascular invasion (LVI) by carcinoma but may in addition occasionally stain myo-
epithelial and basal cells—hence the use of D2-40 to demonstrate that LVI should always be accompanied by p63/SMHCM immunohistochemistry.
Modified from Rabban JT, Chen YY. D2-40 expression by breast myoepithelium: potential pitfalls in distinguishing intralymphatic carcinoma from in situ
carcinoma. Hum Pathol. 2008;39:175–183.
TABLE 1.11 IMMUNOHISTOCHEMICAL PANEL APPROACH TO DIFFERENTIAL DIAGNOSIS OF

HEPATOCELLULAR CARCINOMA
Inhibin/
Arginase-1 HepPar-1 CK19 MOC-31 GPC-3 pCEA CDX-2 TTF-1 RCC Melan-A/D2-40
Hepatocellular carcinoma + + − −/+ + + − −a − −
Cholangiocarcinoma −/+ − +/− +/− − − − − −
Metastatic adenocarcinoma −
Colon − − − − + − − −
Thyroid, lung − − − − − + − −
Tumors with polygonal cells −
RCC − − + − − − + −
Adrenocortical carcinoma − − − − − +
Neuroendocrine tumorsb − − + − v
Hepatoid carcinoma (e.g., gastric, − +
ovary)
CK, Cytokeratin; p-CEA, canalicular pattern of staining; RCC, renal cell carcinoma; TTF-1, thyroid transcription factor-1; v, variable; +, positive; −, negative;
+/−, often positive; −/+, rarely positive.
aCertain TTF-1 antibody reagents may highlight the cytoplasm of liver cells (only nuclear immunoreactivity should be interpreted as being of thyroid or
lung origin in the correct clinical setting).

bStrong synaptophysin and chromogranin support neuroendocrine tumor; TTF-1 may notoriously highlight extrapulmonary neuroendocrine tumors.
Modified from Kakar S, Gown AM, Goodman ZD, Ferrell LD. Best practices in diagnostic immunohistochemistry: hepatocellular carcinoma versus
metastatic neoplasms. Arch Pathol Lab Med. 2007;131:1648–1654; Yan BC, Gong C, Song J, et al. Arginase-1: a new immunohistochemical marker of
hepatocytes and hepatocellular neoplasms. Am J Surg Pathol. 2010;34:1147–1154.
TABLE 1.12 IMMUNOHISTOCHEMISTRY PANEL INTERPRETATION FOR GASTROINTESTINAL AND ABDOMINAL

SPINDLE CELL TUMORS
ALK WT-1 DOG1 CD117 CD34 STAT6 SMA Desmin S-100 Protein β-Catenin
Leiomyoma −/+ − − + + −
Leiomyosarcoma (LMS)a +/− − −/+a + + −

Inflammatory myofibroblastic tumor + − − − +/− − −
Inflammatory fibroid polyp − − + +/− − −
Solitary fibrous tumor − − + + − − −
Desmoid fibromatosis − − − + −/+ − + (Nuclear)
Gastrointestinal schwannoma − − − − − +
Metastatic melanoma − +/− − − − +
Desmoplastic small round cell tumor + − − − − + −
GIST + + + +/− −/+ −/+
ALK, Anaplastic lymphoma kinase; GIST, gastrointestinal stromal tumor; SMA, smooth muscle actin; STAT6, Signal transducer and activator of transcription
(STAT) 6; +, positive; −, negative; +/−, often positive; −/+, rarely positive.
aRetroperitoneal LMS may be positive.
Modified from Miettinen M, Sobin LH, Sarlomo-Rikala M. Immunohistochemical spectrum of GISTs at different sites and their differential diagnosis with
a reference to CD117 (KIT). Mod Pathol. 2000;13:1134–1142; Sah SP, McCluggage WG. DOG1 immunoreactivity in uterine leiomyosarcomas. J Clin
Pathol. 2013;66:40–43; Hill DA, Pfeifer JD, Marley EF, et al. WT1 staining reliably differentiates desmoplastic small round cell tumor from Ewing
sarcoma/primitive neuroectodermal tumor: an immunohistochemical and molecular diagnostic study. Am J Clin Pathol. 2000;114:345–354.
From Coffin CM, Hornick JL, Fletcher CD. Inflammatory myofibroblastic tumor: comparison of clinicopathologic, histologic, and immunohistochemical
features including ALK expression in atypical and aggressive cases. Am J Surg Pathol. 2007;31(4):509–520.
Doyle LA, Vivero M, Fletcher CD, et al. Nuclear expression of STAT6 distinguishes solitary fibrous tumor from histologic mimics. Mod Pathol.
2014;27(3):390–395.
TABLE 1.13 IMMUNOPHENOTYPE OF PRIMARY OVARIAN AND METASTATIC COLORECTAL ADENOCARCINOMA

Mucinous Ovarian Tumors
Intestinal Type Endocervical Type Endometrioid Adenocarcinoma Metastatic Colorectal Adenocarcinoma
CK7 +++/+ +++ +++ −
CK20 −/+/+++ − − +++
mCEA + − − ++
STAB2 +++
CDX2 + − −/+ ++
ER − + + −
ER, Estrogen receptor; mCEA, monoclonal carcinoembryonic antigen; STAB2, Special AT-rich sequence binding-protein 2 (SATB2); +++, diffusely positive;
+, focally positive; −, negative.
Modified from McCluggage WG: My approach to and thoughts on the typing of ovarian carcinomas. J Clin Pathol. 2008;61:152–163.
From Conner JR, Hornick JL. Metastatic carcinoma of unknown primary: diagnostic approach using immunohistochemistry. Adv Anat Pathol.
2015;22(3):149–167.
TABLE 1.14 IMMUNOHISTOCHEMISTRY PANEL FOR PRIMARY AND METASTATIC ADENOCARCINOMA

OF THE OVARY
PAX2 PAX8 CK7 CK20 CDX2 DPC4
Primary mucinous, intestinal type − − + + +/− +
Primary endometrioid + + + − − +
Metastatic colorectal − − − + + +
Metastatic pancreas − − +/− +/− − −
Metastatic thyroid +
Metastatic renal +
Metastatic thymic +
CK, Cytokeratin; DPC, deleted in pancreatic carcinoma; +, positive; −, negative; +/−, often positive.
Modified from Ji H, Isacson C, Seidman JD, et al. Cytokeratins 7 and 20, Dpc4, and MUC5AC in the distinction of metastatic mucinous carcinomas in the
ovary from primary ovarian mucinous tumors: Dpc4 assists in identifying metastatic pancreatic carcinomas. Int J Gynecol Pathol. 2002;21:391–400;
Ozcan A, Liles N, Coffey D. PAX2 and PAX8 expression in primary and metastatic müllerian epithelial tumors: a comprehensive comparison. Am J Surg
Pathol. 2011;35:1837–1847.
TABLE 1.15 IMMUNOHISTOCHEMISTRY: HIGH-GRADE SEROUS CARCINOMA AND POORLY DIFFERENTIATED

ENDOMETRIOID ADENOCARCINOMA OF THE OVARY AND ENDOMETRIUM
WT-1 p53 p16 β-Catenin
Serous +++ +++ +++ Membranous
Endometrioid −/+ −/+/+++a −/+ Membranous/nuclear
WT-1, Wilms tumor gene protein 1; +++, diffusely positive; +, focally positive; −, negative.
aThe +++ expression corresponds to some high-grade carcinomas.
Data from McCluggage WG. My approach to and thoughts on the typing of ovarian carcinomas. J Clin Pathol. 2008;61:152–163.
TABLE 1.16 IMMUNOHISTOCHEMISTRY APPROACH TO OVARIAN SEX CORD–STROMAL TUMORS AND

ENDOMETRIOID ADENOCARCINOMA
FOXL2 Inhibin Calretinin CD99 EMA Pan-cytokeratin
Granulosa cell tumor + + + + − −/+
Sertoli-Leydig cell tumor +/− + + + − +/−
Endometrioid − − − + +
adenocarcinoma
EMA, Epithelial membrane antigen; +, positive; −, negative; +/−, often positive; −/+, rarely positive.
Modified from Mount SL, Cooper K. Tumours with divergent müllerian differentiation of the uterine corpus. Curr Diagn Pathol. 2005;11:349–355; Al-Agha
OM, Huwait HF, Chow C, et al: FOXL2 is a sensitive and specific marker for sex cord-stromal tumors of the ovary. Am J Surg Pathol. 2011;35:484-494.
TABLE 1.17 IMMUNOHISTOCHEMISTRY APPROACH TO ENDOCERVICAL ADENOCARCINOMA AND

ENDOMETRIOID ENDOMETRIAL ADENOCARCINOMA
mCEA Vimentin ER/PR p16 HPV DNA
Endocervical + − − + +
Endometrial − + + −/+ −
ER/PR, Estrogen/progesterone receptor; HPV, human papillomavirus; mCEA, monoclonal carcinoembryonic antigen; +, positive; −, negative; −/+, rarely positive.
Modified from Staebler A, Sherman ME, Zaino RJ, Ronnett BM. Hormone receptor immunohistochemistry and human papillomavirus in situ hybridization
are useful for distinguishing endocervical and endometrial adenocarcinomas. Am J Surg Pathol. 2002;26:998–1006.
TABLE 1.18 IMMUNOHISTOCHEMISTRY IN THE DIFFERENTIAL DIAGNOSIS OF SQUAMOUS AND GLANDULAR

LESIONS OF THE UTERINE CERVIX
p16a MIB-1 (Ki-67)
LSIL (CIN I) +/− Increased
HSIL (CIN II-III) + Increased (full thickness)
Adenocarcinoma in situ + +
Atypical immature metaplasia − −/+
Reactive squamous or glandular atypia − +
Tubal metaplasia +/− −
CIN, Cervical intraepithelial neoplasia; HSIL, high-grade squamous intraepithelial neoplasia; LSIL, low-grade squamous intraepithelial neoplasia; +, positive;
−, negative; +/−, often positive; −/+, rarely positive. MIB-1, monoclonal antibody directed against the Ki-67 antigen, a nuclear antigen expressed by all
human proliferating cells.
aExpression of p16 (nuclear and cytoplasmic) is a surrogate marker for high-risk human papillomavirus (HPV), for example, HPV-16 and HPV-18. In LSIL,
the p16 expression may be confined to the lower one third or one half of the squamous epithelium or show focal immunoreactivity (the latter being
a pattern of expression, albeit cytoplasmic only, that may be seen in reactive squamous epithelia). HSIL p16 immunoexpression usually involves two-
thirds or full thickness of the squamous epithelium.
Modified from Kalof AN, Cooper K. p16INK4a immunoexpression: surrogate marker of high-risk HPV and high-grade cervical intraepithelial neoplasia.
Adv Anat Pathol. 2006;13:190–194.
TABLE 1.19 P57KIP2 IMMUNOREACTION AND HER-2 FLUORESCENCE IN SITU HYBRIDIZATION (FISH) ANALYSIS
IN MOLAR PREGNANCY
Villous Cytotrophoblasts Villous Stroma Syncytiotrophoblasts HER-2 FISH Analysis
Complete hydatidiform − − + Diploid
molar pregnancy
Partial hydatidiform mo- + + + Triploid
lar pregnancy
Hydropic abortion + + + Diploid
Note: p57KIP2 is a paternally imprinted, maternally expressed gene protein. Hence, complete moles comprising only paternal genes will not express this
protein.
Modified from Hoffner L, Dunn J, Esposito N, et al. p57KIP2 Immunostaining and molecular cytogenetics: combined approach aids in diagnosis of
morphologically challenging cases with molar phenotype and in detecting androgenetic cell lines in mosaic/chimeric conceptions. Hum Pathol.
2008;39:63; and LeGallo RD, Stelow EB, Ramirez NC, et al. Diagnosis of hydatidiform moles using p57 immunohistochemistry and her2 fluorescent in
situ hybridization. Am J Clin Pathol. 2008;129:749.
TABLE 1.20 IMMUNOHISTOCHEMICAL APPROACH FOR TROPHOBLASTIC LESIONS

Trophoblastic Lesion CK18 p63 hPL MIB-1 LI (%)
Exaggerated placental site +++ − +++ <1
Placental site trophoblastic tumor +++ − +++ >1
Placental site nodule +++ +++ −/+ <10
Epithelioid trophoblastic tumor +++ +++ −/+ >10
Choriocarcinoma +++ −/+ ++
Note: Expression of p63 highlights mononucleated trophoblasts corresponding to cytotrophoblasts, and human chorionic gonadotropin selectively stains
syncytiotrophoblasts; this combination is indicative of choriocarcinoma. CK, Cytokeratin; hPL, human placental lactogen; LI, labeling index; MIB-1, Ki-
67 proliferation marker; +++, diffusely positive; ++, focally positive; −, negative; −/+, rarely positive.
Modified from Shih IM, Kurman RJ. p63 Expression is useful in the distinction of epithelioid trophoblastic and placental site trophoblastic tumors by profil-
ing trophoblastic subpopulations. Am J Surg Pathol. 2004;28:1177–1183.
TABLE 1.21 IMMUNOHISTOCHEMISTRY FOR SELECTED GERM CELL TUMORS

SOX2 SALL4 c-kit OCT3/4 CD30 AFP GPC-3 D2-40 β-hCG
Germinoma − + + + − − − + −a
Embryonal carcinoma + + − + + − − − v
Yolk sac tumor − + − − − v + − −
Choriocarcinoma − +/− − − − − − − +
AFP, α-fetoprotein; β-hCG, β-human chorionic gonadotropin; GPC-3, glypican-3; SALL4, sal-like4; SOX2 (also known as SRY [sex determining region Y]-
box2); v, variable; +, positive; −, negative; +/−, often positive. Cao D, Li J, Guo CC. SALL4 is a novel diagnostic marker for testicular germ cell tumors.
Am J Surg Pathol. 2009;33:1065–1077; Gopalan A, Dhall D, Olgac S, et al. Testicular mixed germ cell tumors: a morphological and immunohisto
chemical study using stem cell markers, OCT3/4, SOX2 and GDF3, with emphasis on morphologically difficult-to-classify areas. Mod Pathol 2009;22:
1066–1074.
aExcept for syncytiotrophoblastic giant cells in seminoma.
Modified from Ulbright TM. The most common, clinically significant misdiagnoses in testicular tumor pathology, and how to avoid them. Adv Anat
Pathol. 2008;15:18–27; and Young RH. Testicular tumors: some new and a few perennial problems. Arch Pathol Lab Med. 2008;132:548–564.
TABLE 1.22 IMMUNOHISTOCHEMISTRY PANEL TO DISTINGUISH RENAL CELL NEOPLASMS

Melan
RCC CD10 CK7 AMACR CA IX A or HMB45 TFEB TFE3 CD117 PAX2 PAX8
Clear cell carcinoma +/− + − − + − − + +
Chromophobe − − +/− − − − + − +
carcinoma
Papillary carcinoma +/− −/+ +/− + − − − −/+ +
Oncocytoma − − −/+ − − − +/− − +
Xp11/TFE3 + − + + −
translocation
renal carcinoma
RCC with t(6,11) + +
AMACR, α-methylacyl coenzyme A racemase (P504S); CA IX, carbonic anhydrase 9; CK, cytokeratin; PAX2, paired box gene-2; PAX8, paired box gene-8;
RCC, renal cell carcinoma; TFE3, transcription factor E3; +, positive; −, negative; +/−, often positive; −/+, rarely positive.
Modified from Truong LD, Shen SS. Immunohistochemical diagnosis of renal neoplasms. Arch Pathol Lab Med. 2011;135:92–109; Ozcan A, de la Roza G,
Ro JY, et al. PAX2 and PAX8 expression in primary and metastatic renal tumors: a comprehensive comparison. Arch Pathol Lab Med. 2012;136:151–154;
Suárez-Vilela D, Izquierdo-García F, Méndez-Álvarez JR, et al. Renal translocation carcinoma with expression of TFEB: presentation of a case with distinc-
tive histological and immunohistochemical features. Int J Surg Pathol. 2011;19:506–509.
TABLE 1.23 SELECTED IMMUNOHISTOCHEMISTRY TABLE 1.24 IMMUNOHISTOCHEMISTRY

TO DISTINGUISH VASCULAR NEOPLASM APPROACH TO ATYPICAL GLANDULAR
Neoplasm IHC
PROLIFERATIVE LESION IN THE PROSTATEa
Basal Cell Markers
Angiosarcomaa CD31, CD34, ERG
(HMWCK 34βE12, AMACR
Epithelioid CD31, CD34, ERG, CAMTA1
Lesion CK5/6, p63) (p504S)
hemangioendothelioma
Pseudomyogenic AE1/AE3, FLI1, FOSB (96%) Atrophic glands + −
hemangioendothelioma Post–atrophic hyperplasia + −
Kaposi sarcoma HHV8, CD31, CD34, ERG Basal cell hyperplasia + −
Epithelioid hemangioma CD31, CD34, ERG, FOSB (54%) Atypical adenomatous +/− (patchy) −/+
hyperplasia (adenosis)
CAMTA1, Calmodulin binding transcription activator 1; ERG, ERG (Erythro- Prostatic intraepithelial + +
blast transformation-specific [ETS]-related gene); FLI1, Friend leukemia neoplasia
integration-1; FOSB, FBJ Murine Osteosarcoma Viral Oncogene Homo-
Prostate carcinoma −a,b +
log B; IHC, immunohistochemistry.
aAngiosarcoma is also cytokeratin and EMA positive (+). Al-Abbadi MA,
AMACR, α-methylacyl coenzyme A racemase; CK, cytokeratin; HMWCK,
Almasri NM, Al-Quran S, Wilkinson EJ. Cytokeratin and epithelial mem-
high-molecular-weight cytokeratin; +, positive; −, negative; +/−, often
brane antigen expression in angiosarcomas: an immunohistochemical
positive; −/+, rarely positive.
study of 33 cases. Arch Pathol Lab Med. 2007;131:288–292. aSee Figure 1.14.
Miettinen M, Wang ZF, Paetau A, et al. ERG transcription factor as an bRarely, p63 may demonstrate immunoreactivity in prostate carcinoma
immunohistochemical marker for vascular endothelial tumors and
(see Ali TZ, Epstein JI. False positive labeling of prostate cancer with
prostatic carcinoma. Am J Surg Pathol. 2011;35:432–441.
high molecular weight cytokeratin: p63 a more specific immunomarker
Doyle LA, Fletcher CD, Hornick JL. Nuclear expression of CAMTA1 distin-
for basal cells. Am J Surg Pathol. 2008;32:1890–1895).
guishes epithelioid hemangioendothelioma from histologic mimics. Am
Modified from Paner GP, Luthringer DJ, Amin MB. Best practices in di-
J Surg Pathol. 2016;40(1):94–102.
agnostic immunohistochemistry: prostate carcinoma and its mimics in
Hung YP, Fletcher CD, Hornick JL. FOSB is a useful diagnostic marker
needle core biopsies. Arch Pathol Lab Med. 2008;132:1388–1396.
for pseudomyogenic hemangioendothelioma. Am J Surg Pathol.
2017;41(5):596–606.
MOLECULAR PATHOLOGY METHODS NUCLEIC ACID EXTRACTION METHODS

Background
INTRODUCTION
• T he extraction of nucleic acids from pathology sam-
Molecular tests are widely relied upon as standard of ples involves cell lysis followed by selective DNA or
care assays in the diagnosis of a wide variety of patho- RNA isolation, and a quantity and quality assessment
logic conditions. Ongoing advances in molecular pathol- relative to the requirements of the end- diagnostic
ogy, genomics, epigenetics, proteomics, and infectious test
diseases research, as well as technological developments • Pathology samples: biopsy or surgical material (fresh
continue to expand the potential of molecular assays to or formalin-fixed, paraffin-embedded [FFPE] tissue),
improve disease characterization and patient care. This body fluids (amniotic, saliva, stools, urine), buccal cell
section provides an overview of the molecular techniques scrapes, cervical scrapes, fine-needle aspiration, hair
applicable to pathology practice. root, peripheral blood, primary cell culture.
TABLE 1.25 IMMUNOHISTOCHEMISTRY PANEL TO DISTINGUISH PROSTATE AND UROTHELIAL CARCINOMAS

GATA3 CK7 CK20 NKX3.1 PSA Uroplakin p63
Prostate carcinoma − −/+ −/+ + + − −/+
Urothelial carcinoma + +/− +/− − − +/− +
Notes: Only CK7/20 negativity (prostate carcinoma) and CK7/20 positivity (urothelial carcinoma) reliably distinguish between these two carcinomas.
Any other permutation is unreliable. Uroplakin is highly specific for urothelial carcinoma but has a low sensitivity, being focally present in approxi-
mately 50% to 60% of tumors. Expression of p63 is used more often to highlight basal cells in benign prostate glands but may rarely be positive in the
prostate carcinoma itself (see Ali TZ, Epstein JI. False positive labeling of prostate cancer with high molecular weight cytokeratin: p63 a more specific
immunomarker for basal cells. Am J Surg Pathol. 2008;32:1890–1895).
CK, Cytokeratin; PSA, prostate-specific antigen; +, positive; −, negative; +/−, often positive; −/+, rarely positive. GATA3, GATA binding protein 3.
Modified from Hammerich AH, Ayala GE, Wheeler TM. Application of immunohistochemistry to the genitourinary system (prostate, urinary bladder,
testis, and kidney). Arch Pathol Lab Med. 2008;132:432–440; Chang A, Amin A, Gabrielson E, et al. Utility of GATA3 immunohistochemistry in dif-
ferentiating urothelial carcinoma from prostate adenocarcinoma and squamous cell carcinomas of the uterine cervix, anus, and lung. Am J Surg Pathol.
2012;36:1472–1476.
TABLE 1.26 RECOMMENDED ANTIBODY PANEL FOR COMMON PLEOMORPHIC CUTANEOUS SPINDLE CELL
TUMORS
Cytokeratins Melanocytic Smooth
(Pan, HMW, (HMB-45, Muscle Endothelial
CD10 p63 CK5/6) S-100 Protein Melan-A) Actin Desmin (CD31, CD34)
Sarcomatoid − + + − − − − −
squamous cell
carcinoma
Melanoma − − −/+ + +/− − −/+ −
Atypical fibroxanthoma + −/+ − − − −/+ − −
Leiomyosarcoma − − −/+ − + +/− −/+
Angiosarcoma − − −/+ − − − − +
+, positive; −, negative; +/−, often positive; −/+, rarely positive.

Modified from Folpe AL, Cooper K. Best practices in diagnostic immunohistochemistry: pleomorphic cutaneous spindle cell tumors. Arch Pathol Lab Med.
2007;131:1517; Hultgren TL, DiMaio DJ. Immunohistochemical staining of CD10 in atypical fibroxanthomas. J Cutan Pathol. 2007;34:415–419; Dotto
JE, Glusac EJ. p63 is a useful marker for cutaneous spindle cell squamous cell carcinoma. J Cutan Pathol. 2006;33:413–417.
TABLE 1.27 MIB-1(KI-67) MEMBRANOUS AND CYTOPLASMIC STAINING

MIB-1 (Ki-67); Clone MIB-1, 1:700; Dako, Glostrup, Denmark Staining Pattern
Hyalinizing trabecular tumor of the thyroid Cytoplasmic staininga
Pulmonary sclerosing hemangiomas Membrane and cytoplasmic stainingb
aFrom Hirokawa M, Carney JA. Cell membrane and cytoplasmic staining for MIB-1 in hyalinizing trabecular adenoma of the thyroid gland. Am J Surg
Pathol. 2000;24:575–578.
bFrom Kim BH, Bae YS, Kim SH, et al. Usefulness of Ki-67 (MIB-1) immunostaining in the diagnosis of pulmonary sclerosing hemangiomas. APMIS.
2013;121:105–110.
TABLE 1.28A IMMUNOHISTOCHEMISTRY PANEL FOR THE INTERPRETATION OF LOW-GRADE (SMALL) B-CELL
LYMPHOMA
CD23 (%) CD5 (%) Cyclin D1 (%) CD10 (%) LEF1 (%) SOX11 (%)
SLL/chronic lymphocytic 85 80 0 0 92
leukemia
Mantle 2 80 75–100 2 94
Marginal zone 8 0 0 2
Lymphoplasmacytic 0–30 5 0 3
Follicular 0–25 0 0 85
Extranodal marginal 0 0 0 0
SLL, Small lymphocytic lymphoma; LEF1, lymphocyte enhancer-binding factor 1; SOX11, SRY (sex-determining region Y)–box 11.
Modified from http://surgpathcriteria.stanford.edu.
Ek S, Dictor M, Jerkeman M, et al. Nuclear expression of the non B-cell lineage Sox11 transcription factor identifies mantle cell lymphoma. Blood.
2008;111(2):800–805.
Menter T, Dirnhofer S, Tzankov A. LEF1. A highly specific marker for the diagnosis of chronic lymphocytic B cell leukaemia/small lymphocytic B cell lym-
phoma. J Clin Pathol. 2015;68(6):473–478.
TABLE 1.28B BASIC IMMUNOPHENOTYPIC APPROACH TO LYMPHOMAS OF SMALL B-CELL TYPE (CD20+ AND
LOW KI-67)
CD5
+ –
CD23/FMC-7 CD10
+/– –/+ – +
Chronic lymphocytic Mantle cell Marginal zone Follicular

leukemia/Small lymphoma lymphoma/ lymphoma
lymphoblastic (Cyclin D1+, lymphoplasmacytic
lymphoma (LEF1+) SOX11+) lymphoma
TABLE 1.29 ANTIBODY PANEL FOR DIFFERENTIAL DIAGNOSIS OF HODGKIN LYMPHOMA

CD30 CD15 CD20 CD45 (LCA) ALK
NLPHL (Nodular lymphocyte predominant Hodgkin − − + + −
lymphoma)
ALCL + − − −/+ +
DLBCL −/+ − + + −
ALCL, Anaplastic large cell lymphoma; ALK, alkaline kinase; DLBCL, diffuse large B-cell lymphoma; LCA, leukocyte common antigen; +, positive;
−, negative; −/+, rarely positive.
TABLE 1.30 IHC CLASSIFICATION OF DIFFUSE • T

here is increasing interest in the potential of liquid
LARGE B-CELL LYMPHOMAS INTO GERMINAL biopsy (blood/plasma/serum) samples for use in molec-
CENTER B-LIKE CELL (GCB) AND NON-GCB ular diagnostics. Diagnostic signals may be shed into
the circulation in the form of cell-free DNA or RNA
CD 10
(cfDNA/cfRNA) of diseased/normal tissue origin; cell-
free fetal DNA (cffDNA); circulating tumor cells (CTCs)/
circulating tumor DNA (ctDNA)/coding or noncoding
circulating tumor RNA (ctRNA), in particular RNA asso-
+ – ciated with exosomes
GCB BCL6 DNA Extraction Methods

• C
lassical methods were time consuming (∼3 days) and
required relatively large quantities of tissues (100 mg
to >1 g)
+ –
•
Extraction kits are now available that use glass- fiber
filters that selectively bind DNA following tissue treat-
MUM 1 NON–GCB
ments with a protease and chaotropic buffers (which
disrupt protein and DNA secondary structures); the
glass fibers, typically loaded in mini- columns, are
+ – washed and centrifuged to rinse away cellular debris,
extraction solution reagents, and pathology tissue pro-
NON–GCB GCB cessing chemicals; the DNA is then recovered from
the resin/glass-fiber by low-salt buffer rinses and cen-
Modified from Hans CP, Weisenburger DD, Greiner TC. Confirma-
tion of the molecular classification of diffuse large B-cell lym-
trifugation; pure DNA recovery from diverse pathol-
phoma by immunohistochemistry using a tissue microarray. Blood. ogy samples is possible within several hours by these
2004;103:275–282. procedures.
Another random document with
no related content on Scribd:
Tutto ciò che acquistava lo schiavo, l’acquistava per il padrone; ma
come già narrai nel capitolo delle Tabernæ, essendo la gran parte
della popolazione industriale schiava, i padroni trovavano di loro
convenienza di interessare i loro schiavi nei profitti delle loro
industrie e di lasciar loro la libera disposizione d’un peculio, il qual
valeva ad alimentare il lavoro loro. Se lo schiavo agiva in suo proprio
nome, in caso di frode veniva perseguitato coll’actio tributoria; ma se
agiva come mandatario del suo padrone, era obbligato come
qualunque altro mandatario.
Gli schiavi si compravano sul mercato, ivi portati dagli speculatori e
dai pirati e, se provenienti da nazione indipendente, godevano di
miglior favore. Gli schiavi spagnuoli e côrsi costavano poco, perchè
facili al suicidio per sottrarsi alla schiavitù; ma i Frigi lascivi e le
gentili Milesie erano in comparazione carissimi. Fu stabilita in
seguito una tariffa secondo l’età e la professione; sessanta soldi
d’oro per un medico, cinquanta per un notaio, trenta per un eunuco
minore de’ dieci anni, cinquanta se maggiore.
Ho detto più sopra che anche speculatori recavano gli schiavi al
mercato; ne recherò due esempj di reputati uomini: Catone li
comperava gracili ed ignoranti e fatti gagliardi ed abili, li rivendeva;
Pomponio Attico, l’amico di Cicerone, faceva altrettanto, per
rivenderli letterati.
Nella casa gli schiavi compivano tutti gli uffizii dai più elevati agli
umili; sed tamen servi, come diceva ne’ paradossi Cicerone,
parlando di quelli che erano applicati a’ più nobili servigi; epperò ve
n’erano varie classi. Vernæ chiamavansi gli schiavi nati nella casa
del padrone; ascrittitii quelli che per lo spazio di 30 anni stavano in
un campo e non potevano vendersi che col fondo; consuales quelli
che servivano al Senato; ordinarii quei dell’alta servitù, e avevan
sotto di essi altri schiavi; vicarii, mediastini, quelli che esercitavano
opere vili nella casa. Ciascun uffizio dava il nome allo schiavo:
nomenclator era quello che ricordava ed annunziava i nomi di coloro
che giungevano, ed alla cena il nome e i pregi delle vivande;
ostiarius e janitor il portinajo, atriensis quello che stava a cura
dell’atrio ed aveva la sorveglianza degli altri schiavi; tricliniarchas il
servo principale a cui spettava la cura di ordinare le mense e la
stanza da pranzo, archimagirus il maestro de’ cuochi o
sovrintendente alla cucina, dispensator il credenziere, pronus il
cantiniere, viridarius e topiarius lo schiavo il cui officio particolare
consisteva nell’occuparsi dell’opus topiarium, che comprendeva la
coltura e conservazione delle piante e degli arboscelli, la
decorazione dei pergolati e de’ boschetti, anagnostæ erano i lettori,
notarii o librarii gli schiavi segretari del padrone, silentiarius quel che
manteneva il silenzio e impediva i rumori: per servigio poi delle
dame, la jatromæa era la schiava levatrice; le cosmetæ e le psecæ
le schiave il cui ufficio era attendere alla toaletta delle signore ed
ajutarle a vestirsi ed ornarsi, come sarebbero le nostre cameriere;
sandaligerulæ quelle che portavano le pantofole delle loro padrone,
seguendole quando uscivan di casa; vestispicæ quelle che curavano
e rimendavano gli abiti della padrona; vestisplicæ quelle che le
custodivano, o come diremmo noi, guardarobiere; ornatrices le
schiave che attendevano all’acconciatura del capo della padrona,
focaria la guattera, ecc.
V’erano poi i pædagogiari, giovani schiavi scelti per la bellezza della
persona ed allevati nella casa dei grandi signori a’ tempi dell’impero
per servir da compagni e pedissequi dei figliuoli de’ loro padroni,
come anteriormente v’erano i pædagogi, che vegliavan alla cura ed
agli studj de’ medesimi, i flabelliferi, giovinetti d’ambo i sessi, che
portavano il ventaglio della padrona, i salutigeruli che recavano i
saluti e i complimenti agli amici e famigliari del padrone; i nani e
nanæ, pigmei cui si insegnavano musica ed altre arti per diletto de’
padroni; fatui, fatuæ e moriones erano quelli idioti deformi che si
tenevano per ispasso, i quali
acuto capite et auribus longis

Quæ sic moventur, ut solent asellorum
come li descrisse Marziale [100]; il coprea, o giullare per movere a

riso; perfino gli ermafroditi, che talora erano artificiali.
Nè son qui tutti, perchè il Gori nella sua Descriptio columbarii, il
Pignario De Servis e il Popma, De servorum operibus, enunciassero
con particolari nomi almeno ventitre specie di ancelle e più di
trecento di schiavi.
Quale poi gli schiavi ricevessero trattamento, può essere
immaginato, ricordando solo che Antonio e Cleopatra
sperimentassero sui loro schiavi i veleni, che Pollione ne facesse
gittare uno alle murene per avergli rotto un vaso murrino, e che
Augusto, che di ciò lo ebbe a rimproverare, non ristasse tuttavia di
farne appiccare uno che gli aveva mangiata una quaglia. Negli
ergastuli poi si accatastavan la notte schiavi e schiave a rifascio, i
più cattivi destinati alla fatica de’ campi e incatenati, epperò detti
compediti; e Seneca rammenta i molti ragazzi schiavi, che dovevano
aspettare da’ loro padroni, usciti alterati dalle orgie, infami oltraggi.
Vecchi poi, od impotenti, si abbandonavano barbaramente a morire
d’inedia.
Ho già detto altrove in questa opera il numero strabocchevole di
essi; ma a persuaderci della quantità, giovi il citare quel detto di
Seneca che avrebbesi dovuto paventar gran pericolo se gli schiavi
avessero preso a contare i liberi: quantum periculi immineret si servi
nostri nos numerare cœpissent [101]; ed era per avventura ad ovviare
un tale pericolo, che non venne adottato che gli schiavi avessero
abito particolare e distinto dai liberi. Infatti sa già il lettore, per quanto
n’ebbi già a dire, delle diverse insurrezioni di schiavi e delle guerre
servili che diedero grande travaglio ed a moltissimo temere di
propria sicurezza e libertà a Roma.
Ma la condizione miserrima di schiavo poteva in più modi cessare.
La legge rendeva libero lo schiavo che indicava l’assassino del suo
padrone, un rapitore, un monetario falso, od un disertore. Claudio
imperatore dichiarò libero lo schiavo che era stato vecchio ed
infermo abbandonato dal proprio padrone. Così diveniva libera la
donna che il padrone avrebbe voluto prostituire. Anche la
prescrizione era un modo di vindicarsi in libertà. Ma il modo più
comune era l’affrancamento, ed anche questo operavasi in tre guise:
vindicta, censu, testamento. La prima era una rivendicazione
simulata dello schiavo che il pretore abbandonava all’assertor in
libertatem, rinunziando il padrone a sostenere il suo diritto; le altre
due consistevano a dichiarare come affrancato lo schiavo, quando si
compiva l’operazion del censimento, od a legargli la libertà per
testamento. Quattro anni dopo l’era volgare, la legge Ælia Sentia e
quindici anni dopo di questa, la legge Junia Norbana crearono una
mezza libertà per gli schiavi fatti liberti senza aver esaurite le
pratiche legali.
In quanto alla formula dell’affrancamento per vindicta, consisteva nel
condurre il padrone avanti il pretore od altro magistrato competente
lo schiavo che voleva affrancare e ponendogli la mano sulla testa
che aveva fatto prima radere, o sovr’altra parte del corpo e
pronunciare le parole sacramentali: «Io voglio che quest’uomo sia
libero e goda dei diritti di cittadinanza romana» e così dicendo lo
faceva girar su di sè stesso come per scioglierlo colle sue mani, e il
magistrato, o per lui il pretore, lo toccava tre o quattro volte colla
bacchetta, vindicta, segno del potere, alla testa e con ciò restava
ratificato l’atto del padrone e lo schiavo era libero. Questa che
dicevasi manumissio gli conferiva i diritti di cittadino in modo
irrevocabile, ma aveva vincoli indistruttibili verso il suo antico
padrone. Se questi doveva difenderlo in giustizia e proteggerlo
contro ogni abuso del potere; il liberto doveva personalmente a lui
deferenza ed assistenza, non intentargli azione diffamatoria; venirgli
in ajuto di denaro, e se lo avesse ingiuriato, veniva multato d’esiglio,
e di condanna alle miniere, se avesse contro lui commesso atto di
violenza, e di ricaduta in ischiavitù, se colpevole di atti più gravi.
Finalmente partecipavano alla famiglia i Clienti. Ho già altrove in
quest’opera detto qualcosa di loro istituzione facendola rimontare ai
tempi di Romolo: ma forse a chi considera che la clientela sussisteva
dapprima in Grecia e nel restante d’Italia, parrà che essa fosse una
istituzione ancora più antica. Uopo è peraltro non si confondano i
clienti del primo tempo con quelli dell’epoca di Orazio. Quelli erano
piuttosto una specie di servi attaccati al padrone e quindi associati
alla religione ed al culto della famiglia. Avevano però le stesse cose
sacre del patrono, del quale anzi dividevano il nome, quello
aggiungendo della famiglia di lui. Nascevano per tal modo cotali
relazioni di reciprocanza e doveri, che il patrono non poteva persino
testimoniar in giudizio contro il cliente, mentre non lo fosse conteso
contro il cognato, perchè costui essendo legato da vincoli solo di
donna, non ha parte alla religione della famiglia, giusta il concetto di
Platone che la vera parentela consiste nello adorare gli stessi dei
domestici. Il patrono aveva pertanto l’obbligo di proteggere in tutti i
modi il cliente, colla sua preghiera come sacerdote, colla sua lancia
come guerriero, colla sua legge come giudice, e l’antico
comandamento diceva: se il patrono ha fatto torto al suo cliente,
sacer esto, ch’ei muoja.
I clienti del tempo d’Orazio erano invece gente che si legava alla
fortuna del patrono, non propriamente servi, ma persone che
speravano protezione da lui, che gli porgevano offerte e sportule e
che ne assediavano la casa dai primi albori del giorno e gli facevano
codazzo d’onore quando appariva in publico: ma a vero dire, per
quel che ne ho detto più sopra, non c’entravano punto colla vera
famiglia.
Abbiamo così passato in rassegna gli individui tutti, ed abbiamo
menzionate le discipline che regolavano la famiglia; abbiamo sentito
un riflesso di quanto era quel calore di vita morale che animava la
casa; or vediamone gli usi e le consuetudini della vita materiale.
Già il lettore conosce come si impiegasse la giornata e la sua
ripartizione generalmente accettata: conosce come il facoltoso e il
patrono avessero i proprj clienti e ricevesseli fin dalle prime ore del
mattino, questo comprendendo gli offici antelucani: sa del tempo
degli affari, di quello del pranzo, della pratica al foro e alla basilica,
del bagno, degli esercizi corporali, della cena e del passeggio, per
quanto ne ho già detto in addietro; resta a completarsi il quadro
domestico, col far assistere il lettore al triclinio, additandogli, come si
costituisse, che cosa vi si mangiasse, cosa il rallegrasse; col dirgli
degli abiti degli uomini e poscia co’ sollevare la cortina del gineceo,
per farlo spettatore della toletta d’una dama pompejana, e quando
dico pompejana, dico anche romana, perocchè si sappia — e l’ho
già più volte ripetuto — che uomini e donne delle provincia e delle
colonie si fossero perfettamente conformati ai costumi ed abitudini
dell’urbe, della città, cioè, per eccellenza, Roma.
Vi sarebbe tutto un trattato a comporre per dire convenientemente
dei pasti e banchetti de’ Romani, sì publici che privati, e infatti la
nostra letteratura vanta fra i testi di lingua le lezioni di Giuseppe
Averani Del vitto e delle cene degli antichi [102], delle quali mi varrò
alquanto pur io in queste pagine, e malgrado la molta erudizione di
lui e il sapere, non fu tutto da lui scritto nell’argomento. Io vedrò
modo di riassumere in breve quello che meglio importi di sapere.
Anzi tutto non posso passarla dallo accennare come il pasto si
ritenesse l’atto religioso per eccellenza. Opinione eguale o di poco
difforme è quella di parecchi padri della Chiesa Cristiana, che
dissero che mangiare è pregare e che pur il soddisfare a queste
necessarie pratiche abbiasi a fare alla maggior gloria di Dio. Era
inteso che a’ domestici prandj intervenisse sempre il genio tutelare
della casa, i lari o penati che si voglian dire. Era il focolare che aveva
cotto il pane e preparati gli alimenti; così a lui si doveva una
preghiera tanto al principio che alla fine del pasto. Prima di esso si
deponevano sull’altare le primizie del cibo, prima di bere si spargeva
la libazione del vino. Era la parte dovuta al dio. Erano antichissimi
riti: Orazio, Ovidio, Petronio cenavano ancora davanti al loro focolare
e facevano la libazione e la preghiera [103].
Come in tutti i popoli primitivi, anche i primi Romani eran sobrii e
frugali, paghi della sola polenta, ciò che in seguito si tenne per
indizio di barbarie:
Non enim hæc pultiphagus opifex opera fecit barbarus [104]
e dopo, la questione del mangiare venne poco a poco così

crescendo, da costituire una preoccupazione continua della loro
esistenza, ed anzi da considerare i varii pasti come altrettanti atti di
pietà. È inutile osservare come in questo punto di religione fossero
esatti e scrupolosi osservatori. Ebbero quindi il pasto del benvenuto
pel viaggiatore che arrivava; quello d’addio pel viaggiatore che
partiva; banchetto di condoglianza nove giorni dopo i funerali,
banchetto dopo i sacrificj, banchetto anniversario della nascita,
banchetto d’amici, di famiglia, di cortigiani, insomma banchetti per
tutte le occasioni. Persino la gioventù, la procace gioventù romana,
tanto dedita alle lascivie, al dir di Orazio, era tuttavia ancor più
ghiottona:
Donandi parca juventus

Nec tantum Veneris, quantum studiosa culinæ [105].
Tanto, in una parola, si trasmodò, che si dovette dal governo imporre

de’ freni alla gola. Già ho detto più sopra che fosse obbligatorio il
cenare a porte aperte sotto gli occhi di tutti; poi le leggi Orchia,
Fannia e Didia e Licinia, Anzia e Giulia prescrissero il numero di
convitati e la spesa dei banchetti privati, e il genere delle vivande,
esclusa l’uccellagione. Tiberio allargò meglio la mano e lasciò che le
spese fossero alquanto maggiori; ma con tutti questi freni, ognun sa
quanto lusso e quanta spesa si facesse da’ facoltosi romani. Basti
per tutti rammentare L. Lucullo. Egli aveva diversi cenacoli, e
ognuno di essi importava una determinata spesa quando vi si
doveva cenare. Quando ciò seguiva e. g. nella sala d’Apollo, era
prefisso che la cena costar dovesse trentaduemila lire della moneta
di oggi. Che si dirà poi de’ pazzi imperatori che, morta la republica,
ressero le sorti romane? Caligola in una cena gittò un milione e
cinquecentosessantaduemila lire delle nostre, il tributo cioè di tre
provincie; Nerone e Vitellio intimavano cene a’ loro cortigiani che
costavano circa settecentomila lire, e quel più pazzo imperatore che
fu Eliogabalo non ispendeva meno di lire sedici mila nella cena di
ciascun giorno.
L’asciolvere chiamavanlo essi jentaculum e facevanlo al mattino; il
pranzo, prandium, che sarebbe piuttosto la nostra seconda
colazione, seguiva all’ora sesta del giorno, cioè sul meriggio; per
taluni ghiottoni e per gli operai eravi più tardi la merenda, specie di
colazione che di poco precedeva la cœna, che era il pasto più
abbondante della giornata, il nostro pranzo odierno, verso l’ora nona
o la decima, cioè tra le tre e le quattro pomeridiane; ciò che non
toglieva che molti vi facessero succedere anche la commissatio,
colazione notturna, quella che noi chiamiamo la cena.
Poichè siam sull’argomento del mangiare, credo dir qualcosa
dapprima de’ conviti publici de’ Romani, quantunque, a vero dire,
non si contenga ciò nell’argomento delle case, di cui principalmente
trattiamo.
Si facevano essi da’ sacerdoti, da’ magistrati e poi si fecero talvolta
dagli imperatori.
I primi si chiamavano adiciali, perchè s’aggiungevano a’ banchetti
consueti molte vivande e avvenivano allora che i sacerdoti
imprendevano l’ufficio. Le più sontuose eran quelle de’ Pontefici,
come è detto in Orazio:
Absumet heres cœcuba dignior

Servata centum clavibus, et mero
Tinget pavimentum superbo
Pontificum potiore cœnis [106].
Nè minori eran quelle de’ Salii, testimonio lo stesso Orazio:
. . . nunc Saliaribus
Ornare pulvinar Deorum
Tempus erat dapibus, sodales [107].
Imbandivano le cene i magistrati al popolo quando conseguivan la

carica, come ho già fatto conoscere ne’ capitoli del teatro, e come
nota Cicerone nella quarta Tusculana in quelle parole: Deorum
pulvinaribus, et epulis magistratuum fides præcinunt [108]. Averani
ricorda che Marco Crasso sublimato al consolato, sacrificando ad
Ercole, apparecchiasse diecimila tavole, onde i convitati non
dovessero essere meno di cencinquantamila.
Più superbi e costosi erano i banchetti offerti al popolo da’ trionfanti.
Prima però si convitavano i soli amici, come nel libro Delle Guerre
Cartaginesi scrisse Appiano, parlando di Scipione, che arrivato in
Campidoglio, terminò la pompa del trionfo, ed egli, secondo il
costume, banchettò quivi gli amici nel tempio. Lucio Lucullo distribuì
al popolo oltre a diecimila barili di vino greco, allora in gran pregio,
che si beveva parcamente, e ne’ più lauti conviti una volta sola.
Giulio Cesare, che menò cinque magnificentissimi trionfi, banchettò
sempre il popolo, e in quelli che furono dopo il ritorno d’Oriente e di
Spagna imbandì ventidue mila tavole o triclini, come riferisce
Plutarco, con isquisite vivande e preziosi vini, sedendovi, cioè, non
meno di trecentotrentamila persone. Plinio, in aggiunta di questo
trionfo e di quello di Spagna e nel terzo consolato afferma che
Cæsar dictator triumphi sui cœna, vini Falerni amphoras, Chii cados
in convivia distribuit. Idem Hispaniensi triumpho Chium, et Falernum
dedit. Epulo vero in tertio consulatu suo Falernum, Chium, Lesbium,
Mamertinum [109].
Svetonio poi ricorda di lui che banchettasse il popolo anche in
onoranza della morte della propria figliuola.
In quanto agli imperatori, si sa di Tiberio che mandando a Roma gli
ornamenti trionfali, banchettò il popolo, e Livia e Giulia
banchettarono le donne: si sa degli altri che convitavano i senatori,
cavalieri e magistrati nella loro esaltazione, come Caligola e
Domiziano, secondo cantò Stazio:
Hic cum Romuleos proceres, trabeataque Cæsar

Agmina mille simul jussit discumbere mensis [110].
V’erano anche, oltre i surriferiti, de’ banchetti di cerimonia, detti

epulæ, ma erano, a vero dire, banchetti sacri, dati in onore di numi in
certe feste religiose. Dicevansi triumviri æpulones i sacerdoti
incaricati di tali banchetti. Silla e Cesare istituirono poi, il primo de’
settemviri, il secondo dei decemviri, onde ammanire siffatti banchetti
sul Campidoglio in onore di Giove. Dapes appellavansi più
propriamente gli alimenti che durante la festa s’offrivano agli dei.
Veniamo ora alle cene private.
Triclinium chiamavasi, come già sa il lettore, la sala da pranzo, e le
mense costituivansi di tre letti, lecti tricliniares, riuniti insieme in
guisa da formare tre lati di un quadrato, lasciando uno spazio vuoto
nel mezzo per la tavola e il quarto lato aperto, perchè potessero
passare i servi a porre su quella i vassoi. V’erano anche i biclinii o
lettucci da adagiarvisi due persone a’ lor desinari, e Plauto menziona
il biclinium nella commedia Bacchides, atto IV, sc. 3, vv. 84-117.
Diverse stanze tricliniari si scoprirono, come vedemmo, in Pompei,
quasi tutte piccole ed offriron la particolarità che, invece di letti
mobili, avessero stabili basamenti per adagiarvisi i convitati.
Questi triclinii ammettevano raramente molte persone: sette il più
spesso, nove talvolta; onde il vecchio proverbio Septem convivæ,
convivium; novem, convicium; ossia: sette, banchetto; nove,
baccano.
Ecco, ad esempio, la forma del triclinium, o tavola, e la distribuzione
del banchetto di Nasidieno, secondo la descrizione che ne è fatta
nella satira VIII del libro II d’Orazio:
2 3
V. Turinio Porcio
1 2
Fundanio Nasidieno
3 1
Vario Nomentano
Lec. Lectus
3 1 2
summus imus
S.
Mecenate Vibidio
Batatrone
Medius Lectus.
Da ciò si vede, come non sedessero, ma giacessero a tavola, e per
istare alquanto sollevati si appoggiavano col gomito sinistro al
guanciale. Solo le donne stavano prima assise, ma poi imitarono
presto gli uomini: i figli e le figlie pigliavano posto a piè del letto; ma
sino all’epoca in cui ricevevano la toga virile restavano assisi.
Queste mense erano spesso di preziosa materia e di ingente lavoro.
Così le descrive Filone nel Trattato della vita contemplativa, citato
dall’Averani: «Hanno i letti di tartaruga o di avorio, o d’altra più
preziosa materia, ingemmati per lo più, coperti con ricchi cuscini
broccati d’oro e mescolati di porpora o tramezzati con altri vaghi e
diversi colori per allettamento dell’occhio.» — Che ve ne fossero
anche d’oro lo attesta Marziale nel libro III de’ suoi Epigrammi, epigr.
31:
Sustentatque tuas aurea mensa dapes [111].
Eguale era la ricchezza nelle altre suppellettili e nei vasi: usavano

bicchieri e coppe di cristallo egizii e di murra, — che molti dotti e
gravi scrittori reputano possa essere stata la porcellana, ciò
potendosi confermare coi versi di Properzio:
Seu quæ palmiferæ mittunt venalia Thebæ

Murrheaque in Parthis pocula cocta focis [112], —
tazze d’argento e d’oro, cesellate o sculte mirabilmente e tempestate

di gioje e il vasellame tutto di non dissimil lavoro.
Nè bastavano queste preziosità, perocchè si giungesse anche a
disporre le soffitte de’ triclini in modo che si rivolgessero e
rinnovassero, come si adoprerebbe da noi degli scenari in teatro, e
l’una appresso all’altra si succedesse ad ogni mutar di vivanda. Ce
lo dice Seneca: Versatilia cœnationum laquearia ita coagmentat, ut
subinde alia facies, atque alia succedat et toties tecta quoties fercula
mutentur [113]. Come reggessero a tutte queste infinite portate,
ciascuna ricca di molte vivande, lo spiega l’invereconda costumanza,
pur menzionata da Cicerone ad Attico, di provocarsi con una piuma il
vomito.
Poichè sono a dire de’ Fercula, o portate, uopo è sapere fossero
essi come barelle piene di piatti di diverse vivande. Petronio, nel
Satyricon, alla cena di Trimalcione, ne descrive una che conteneva
dodici statue, da’ nostri scalchi addimandate trionfi, ciascuna delle
quali portava varii piatti. Ma Eliogabalo, scrive Averani, siccome
uomo per golosità e prodigalità sovr’ogn’altro mostruoso, in un
convito mutò ventidue volte la mensa di vivande: e vuolsi osservare
che ciascheduna muta di vivande era per poco una splendida cena;
e però ogni volta si lavavano, come se fosse terminata la cena.
Questi ventidue serviti rispondevano alle lettere dell’alfabeto,
venendo in tavola prima tutte le vivande, delle quali i nomi
cominciano per A, e poscia quelle i cui nomi principiano per B e
simigliantemente le susseguenti fino a ventidue. Si legge una simile
bizzarria nelle cene di Geta; e pare che Giovenale per avventura
accennasse che l’usassero i golosi del suo tempo, scrivendo nella
satira undecima:
Interea gustus elementa per omnia quærunt

Numquam Animo pretiis obstantibus [114].
Tornando alle soffitte, Nerone immaginò di far iscendere dalle

medesime una pioggia d’unguento e di fiori, per diletto de’ convitati.
Svetonio lo ricorda nella vita di questo Cesare, e il costume fu
adottato, e come nei teatri, pioggia di croco e d’altre profumate
essenze tolsero alle nari de’ voluttuosi conviva i graveolenti odori dei
diversi cibi.
Per mettersi a tavola non si tenevano tampoco gli abiti ordinarj:
ognuno vestiva una toga leggiera, detta synthesis, o cœnatoria, che
veniva fornita o dal padrone di casa, o che il convitato si faceva
recare dal proprio schiavo. I bassorilievi e i dipinti di banchetti, che si
trovarono o giunsero sino a noi, spiegano com’essa lasciasse o la
parte superiore del corpo nuda, o più abitualmente non avesse
cintura, talvolta avesse e talvolta non avesse maniche. Ne’ pasti
dimettevansi persino gli abiti di lutto, acciò la mestizia non
producesse indigestione. Si levavano i calzari, calcei, per mettere
dei sandali, soleæ, che poi si abbandonavano, a miglior pulitezza de’
preziosi tappeti, atteso che nel cavare i calzari, che Petronio dice
alessandrini, giovani schiavi versassero sì alle mani che ai piedi
acqua fresca ed anche gelata, sovente profumata. E profumi, come
essenze di nardo e di croco, spargevansi su’ capegli, che poi
incoronavan di rose, fiori ed erbe odorose che serbavano durante
tutta la cena. Anche il pavimento era tutto sparso di fiori e credevasi
che questi fossero altrettanti preservativi contro l’ebrietà. Dopo
spiegavansi le tovaglie, mantilia, portavasi i tovagliolini, mappæ, che
troviam ricordati da Marziale nel seguente epigramma:
Attulerat mappam nemo, dum furta timentur:

Mantile e mensa surripit Hermogenes [115].
Le tovaglie erano talvolta bianche come le nostre, molti nondimeno

le avevano di porpora o di broccato d’oro.
Fatti questi preparativi, ne’ banchetti più solenni, costumavasi
eleggere il re del festino: si portavano i dadi od astragali, tali, e si
gettavano le sorti per la scelta. Non avevano i dadi che quattro
faccie piane; 1 e 6 su due faccie opposte; 3 e 4 sulle due altre; 2 e 3
non erano segnati; ma quattro tali si gettavano insieme. Il miglior tiro,
chiamato venus, avveniva quando ciascuna faccia presentava un
numero differente, come, 1, 3, 4, 6 e chi l’otteneva veniva dichiarato
re. Era il tiro peggiore detto canis, quando tutti e quattro i numeri
riuscivano gli stessi. Fritillus dicevasi il bossolo, entro cui agitavansi
gli astragali e da cui si gittavano sulla tavola.
Eletto il re, tutti gli altri convitati dovevano, sotto pena d’ammenda,
eseguire gli ordini suoi. Egli fisserà il numero delle coppe che si
dovranno bevere, comanderà ad uno di cantare, all’altro, se poeta, di
improvvisar versi, designerà la persona, in onor della quale si dovrà
brindare. Se taluno infrangeva gli ordini, veniva dal re multato nel
bere un nappo di più e dicevasi cuppa potare magistra. Non si
confonda il re del convito col Tricliniarcha, che era quegli che aveva
su tutti gli altri servi addetti al banchetto la maggioranza e
l’amministrazione della mensa.
La cena regolare, cœna recta, componevasi, oltre del pane che
portavansi ne’ canestri, come c’insegna Virgilio
. . . . Cereremque, canistris
Expediunt, tonsisque ferunt mantilia villis [116],
il più spesso di tre serviti, talvolta fin di sei. Valeva il primo a

solleticar l’appetito e cominciavasi per consueto colle ova, onde
venne l’espressione d’Orazio cantare ab ovo usque ad mala, cantar
dalle ova alle frutta, e la attuale nostra cominciare ab ovo, per
significare che si pigliavan le mosse del dire dal principio più lontano;
ma poi si capovolse e le ova si recarono in fine. Poi seguivan
lattuche, fichi, olive, radici, ortaggi e salse acri e stimolanti la fame,
secondo avverte Orazio:
Acria circum
Rapula, lactucæ, radices, qualia lassum
Pervellunt stomachum, siser, alec, fæcula coa [117].
Cicerone conta in questo primo servito, ch’ei chiama promulsidem,

dal vin melato, mulsum, che si beveva, Petronio gustationem,
Apuleio antecœnia, Varrone principia convivii e Marziale gustum,
come noi appelleremmo antipasto e i francesi hors-d’œuvre; conta,
dicevo, anche la salsiccia, nell’epistola 16 del libro IX: I [118].
Il secondo servito, o anche secunda mensa, costituiva il pasto sodo,
e componevasi d’arrosti di vitella, di lepre, di oche, tordi, pesci,
gigotti e cosiffatte leccornie, delle quali parla distesamente Ateneo
nel libro XIV delle Cene dei Savi. E contavansi in esse le pasticcerie,
i latticinj, e mille cose dolci, che comprendevano sotto il nome di
bellaria. Non essendo ancor conosciuta la manipolazione dello
zuccaro, sebbene se ne avesse notizia come esistente presso gli
Indiani, servivansi in quella vece del miele, che sapevano impiegare
maravigliosamente [119]. — Noto qui che se aveansi coltelli e
cucchiai, non consta che conoscessero la forchetta; onde avendo a
prender tutto colle mani, Ovidio raccomanda agli amanti, che il
faccian con grazia affine di non lordarsi il viso.
Qui potrebbesi tutto distendere un trattato di gastronomia romana e
pompejana, ricordando i piatti più succulenti e peregrini di carni, di
selvaggina e di pesci, rammentando gli eroi della cucina, gli
Apicii [120], (i Carême e i Vatel di allora), onde anzi fu detta l’arte
culinaria arte d’Apicio, da quello principalmente vissuto sotto
Augusto e Tiberio, che consumò per la gola un ingente patrimonio, e
giunto alle ultime duecentocinquantamila lire, preferì uccidersi di
veleno, anzi che non potervi più soddisfare e lasciando dietro di sè
un partito fra i cuochi; ma cadrei troppo in lunghezze. Oltre di che già
sa il lettore dei cinghiali che Antonio faceva ad ogni ora cucinare per
averne uno pronto ad ogni istante; sa del garo pompejano, di cui già
gli tenni parola; delle murene che si ingrassavano ne’ vivai ed alle
quali Pollione gittò uno schiavo; e persino della grossa perla che il
figliuol del comico Esopo, strappata dall’orecchio della sua amica
Metella e stemprata nell’aceto, e che Orazio tramandò ricordata a’
posteri ne’ versi che piacemi rammentare:
Filius Æsopi detractam ex aure Metelli

(Scilicet ut decies solidum exsorberet), aceto
Diluit insignem baccam [121].
Gusto del resto pur diviso da Cleopatra e da Caligola, di cui narra

Svetonio: Pretiosissimas margaritas aceto liquefactas serbabat [122].
Egualmente dovrei dire de’ vini; ma già il lettore non ha dimenticato
che ne’ capitoli della Storia io l’avessi ad erudire dei tanti e celebrati
vini che produceva la Magna Grecia, del Falerno, del Sorrentino, del
Massico, del Celene, del Cecubo, del Pompejano, che bevean in
coppe coronate di fiori, sicchè allora aveva ragione di chiamarsi
questa nostra Italia Ænotria, quasi regione dei vini; ma non pareva
bastassero alla gola di que’ ghiottoni che furono i Romani, se ne
tirassero da Grecia, se dalla Rezia che comprendeva i vini del
Benaco e bresciani, i quali oggidì, se meglio conosciuti,
rivaleggerebbero co’ meglio rinomati di Germania e di Francia, dalla
Spagna, dalle Baleari, dalla Linguadoca e dalle Gallie, e tutti
ambissero di vecchia data, sì che si contassero per consolati e ne
tracannassero all’ubbriachezza uomini e donne, come lasciò Seneca
scritto: Non minus potant et oleo et mero vires provocant, atque
invitis ingesta visceribus per os reddunt et vinum omne vomita
remediuntur [123]. Nè priverò di commemorazione a questo punto
quel mio concittadino Novellio Torquato milanese [124], ricordato da
Plinio, ammesso a que’ tempi in Roma a’ primi onori della città, il
quale fu cognominato Tricongio [125], dal bere che faceva tre cogni di
vino tutto d’un fiato, senza nè riposarsi, nè respirare, nè lasciarne
pur una gocciola nel boccale da gittare in terra per far quel rumore
che addimandavano cottabo.
E a tutte queste sontuose mense private servivano molti schiavi, al
cenno del tricliniarca.
Prima era il coquus, che nella cucina confezionava le vivande e il cui
valore, al dir di Plinio, fu tempo che s’agguagliò alla spesa d’un
trionfo; poi il lectisterniator, che sprimacciava i letti su cui giacevano i
commensali; il nomenclator che annunziava le vivande e i loro pregi,
il prægustator, cui era commesso di gustare i piatti a tavola, onde
conoscere se fatti a dovere ed a tutela che non ascondessero
veleno, lo structor che disponeva le vivande su’ vassoi nei diversi
serviti e collocavali sul portavivande, che Petronio chiama
repositorium, e fungeva altresì da scalco, lo scissor che trinciava le
vivande, il carptor che le tagliava in parti; il pincerna o coppiere che
mesceva a’ convitati il vino ed erano per lo più eletti a tale ufficio i
meglio avvenenti e lindi giovinetti schiavi, e il vocillator che compiva
suppergiù la stessa cosa.
I banchetti poi rallegravansi con musicali istrumenti, come alla cena,
già ricordata, di Trimalcione descritta nel Satyricon; con danze di
leggiadre e lascive fanciulle, saltatrices, celebri in questo le ballerine
gaditane, ossia venute da Cadice, come le più avvenenti e procaci.
Donne simili veggonsi rappresentate nelle pitture pompejane, e per
lo più apparivano vestite d’un ampio e trasparente pezzo di drappo,
che sapevano avvolgere talora attorno alla persona in pieghe
graziose, talora lasciavano spandersi a modo d’un velo su parte del
corpo, e tal altra affatto rimovendo dalle membra e facendo
svolazzare per aria così da mostrarle tutte all’occhio degli spettatori.
Costume codesto pur in Grecia vigente allora ed esercitato dalle
auletridi, o suonatrici di flauto, che pria durante il banchetto facevano
intendere i suoni delle loro tibie e quindi, allorchè le vivande e i vini
avevano mandati i fumi alla testa e convertito in orgia il banchetto, si
mescolavano a’ lubrici conviva.
Quando poi, per dirla col Parini,
Vigor dalla libidine

La crudeltà raccolse,
si spinse il pervertimento fino a darsi a mensa spettacolo di lotte

gladiatorie, non ischifando avanti il pericolo che il sangue avesse
zampillato fin sulla sintesi e sul mantile o sovra il piatto medesimo.
A tutte queste distrazioni che allietavano le mense, Plinio il Vecchio,
secondo ne scrisse il nipote nelle sue Epistole, sappiamo com’egli
preferisse udir buone letture d’alcun autore greco o latino. Ma pochi
erano allora del gusto e dell’onestà dell’insubre magistrato e
letterato.
Finita la cena, se ne dividevano gli avanzi dell’ultimo servito fra i
convitati; ciascuno era libero d’inviar quanto gli fosse piaciuto a’
parenti od agli amici. Qualche parasita, che fornì materia alle arguzie
di Marziale, li serbava per goderseli l’indomani.
V’erano poi di quelli che non avevan portato seco il tovagliolo alla
cena, e che poi si intascavano quello che aveva loro fornito il
padrone di casa: e il medesimo Marziale li ha personificati in
Ermogene, quello stesso che già ricordai, il quale non avendo potuto
involare i tovaglioli, perchè nel timore di vederseli rubati, nessuno gli
aveva portati, pur d’esercitare l’industria sua, aveva pensato di rubar
la tovaglia:
Ad cœnam Hermogenes mappam non attulit umquam
A cœna semper retulit Hermogenes [126].
Ciò fatto, si recavano dagli schiavi i calzari, si accendevano le torcie

per rischiarare i convitati che toglievan congedo dall’anfitrione e,
quand’erano in senno, salutavansi fra loro augurandosi la salute del
corpo e dello spirito.
Sovente erano alla porta attesi da’ loro schiavi con le lanterne di
Cartagine, non tanto per illuminare le tenebre, giacchè allora per le
vie non fosse illuminazione, o per proteggerli dai ladri, quanto per
respingere gli attacchi de’ giovinastri, perocchè a que’ tempi anche
figli di buone famiglie si recassero a piacere di assalire i viandanti in
ritardo, di applicar loro una buona bastonatura, o far loro qualche
cattivo scherzo, come nel primo quarto del nostro secolo vedemmo
praticarsi egualmente in Milano dalla Compagnia della Teppa. Si sa
che Nerone imperatore aveva pure di simili gusti, e si camuffava
perfin da schiavo, affine d’abbandonarvisi le notti, e di brutti pericoli
egli corse per ciò, e la sua vita stessa fu posta a repentaglio più
d’una volta.
Rivelati i misteri della mensa antica, cerchiamo adesso di indagare
quelli della toaletta, nè forse riusciranno meno interessanti. Dovendo
ricordare anche le vesti femminili, farò pur un cenno di poi delle
maschili e di quelle particolari agli schiavi e così imporrò fine a
questo capitolo, nel quale la sovrabbondante materia mi affaticò a
contenermi nei limiti proporzionati dell’opera.
Ho già superiormente accennate le diverse schiave od ancelle
addette al servizio delle matrone: ora veggiamole in movimento
intorno a queste. — Sono tutte silenziose e nude fino alla cintura ad
attendere il cenno della padrona che si risvegli sul suo letto d’avorio
incrostato d’oro e di gemme nel cubiculo vicino. Si risveglia
finalmente, e, vinta l’inerzia lasciatale dal sonno, facendo crepitare le
dita, le chiama, e senza far rumore entrano le più favorite cubiculari
e l’aiutano a scendere dalle sofici piume. La sua faccia è ancora
tutta impiastricciata della mollica di pane inzuppata nel latte di
giumenta, che nel coricarsi si è applicata onde serbar morbida e
liscia la pelle, suppergiù come le moderne signore, pel medesimo
scopo, si ungono della inglese pomata, il cold cream. Gli adoratori
del giorno non la ravviserebbero in quel punto. Oltre quella
maschera screpolata di disseccata mollica, invano le cerchereste il
volume di sua superba capellatura, nè le ben arcuate sopracciglia,
nè le perle della bocca. A ricostruire la sua bellezza, ella entra nel
gabinetto attiguo. Una schiava ne custodisce l’ingresso, perocchè
occhio profano non debba sorprendere i misteri della sua artifiziata
toaletta, giusta il precetto d’Ovidio, erudito maestro nell’arte d’amare:
Hinc quoque præsidium læsæ petitote figuræ:

Non est pro vestris ars mea rebus iners.
Non tamen expositas mensa deprendat amator
Pyxidas: ars faciem dissimulata juvet.
Quem non offendat toto fex illita vultu
Cum fluit in tepidos pondere lapsa sinus? [127]
. . . . . . . . . . . . . . . . . . . .
Multa viros nescire decet; pars maxima rerum
Offendat, si non interiora tegas [128].
Anzi, aggiunge il Poeta:

Tu quoque dum coleris, nos te dormire putemus [129].
E le cosmete si pongono all’opera. Con tepido latte di giumenta

appena emunto l’una rammollisce le arse molliche della faccia e la
lava; l’altra mastica le pastiglie greche che debbonsi applicare, dopo
avere sullo specchio di metallo fiatato e provato aver ella sano e
profumato l’alito; una terza l’imbelletta col rossetto, fucus; una
quarta, sciolto in una conchiglia il nero, le tinge le sopracciglia; poi
v’ha chi pulisce col dentifricium i denti e colloca i posticci nelle
gengive, assicurandoli con un filo d’oro. Il medesimo Ovidio
dell’artificio del liscio ne dettò un poema: De Medicamine faciei, che
non ci giunse per altro completo.
Succedono alle cosmete le parrucchiere, Calamistræ, ajutate dai
ciniflones, dai cinerarii e dalle psecas [130]. L’opera loro è tutto un
faticoso lavorio. Scelgono esse il colore ai capelli che richiede la
moda, e però usavan del sapo, pallottole di sego e semi di faggio,
per colorirli di un color bruno chiaro; o si facevano giungere
capellature sicambre, quando il color favorito era il rosso e vi
spendevano di grosse somme; oppur si tingevano a celare la
canizie. È sempre lo stesso Ovidio che di tutto ciò ne ammonisce:
Femina canitiem Germanis inficit herbis;

Et melior vero queritur arte color.
Femina proceda densissima crinibus emptis;
Proque suis alios efficit ære suos [131].
Talvolta disponevano i capelli a ricevere la tintura, lavandoli con

acqua di calce, estirpando prima i canuti colla volsella, che noi
diremmo pinzetta. Pettinati, poscia calamistrati, unti e profumati, il
pettine o quello più precisamente detto il discerniculum [132] e la
mano industre acconciano in mille fantasie le chiome ed i ricci,
spesso raccolti in reticelle o nastri di seta o di porpora. Vi raffigurano
elmi, galeri, grappoli od eriche, corymbia, mitre orientali; vi infiggono
spilloni aurei ed effigiati, acus domatorio, e topazj e rubini e ametiste
e perle e, dopo tutto, la dama si specchia nel lucidissimo disco

Gattusos Differential Diagnosis in Surgical Pathology 4Th Edition Vijaya B Reddy Full Chapter

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Gattuso's Differential Diagnosis in

Surgical Pathology 4th Edition Vijaya B

GATTUSO’S DIFFENENTIAL DIAGNOSIS IN SURGICAL PATHOLOGY,

Previous editions copyrighted 2015, 2010, 2002.

Library of Congress Control Number: 2020949417

Executive Content Strategist: Michael Houston

Printed in the United States.

Last digit is the print number: 9 8 7 6 5 4 3 2 1

SYLVIA ASA, MD, PhD BYRON CRAWFORD, MD

ELIZAVETA BELYAEVA, MD VIRGINIA E. DUNCAN, MD, MS

PINCAS BITTERMAN, MD ADEL K. EL-­NAGGAR, MD

ELIZABETH J. COCHRAN, MD HUMA FATIMA, MD

KUMARASEN COOPER, MBChB, DPhil

SANDRA E. FISCHER, MD CRISTINA MAGI-­GALLUZZI, MD, PhD

RALPH H. HRUBAN, MD MARIA J. MERINO, MD

ALIYA N. HUSAIN, MBBS IRA MILLER, MD, PhD

ALEXANDRA N. KALOF, MD ATTILIO ORAZI, MD, FRCPath

SUNNY B. PATEL, BS, MD† JEFREE SCHULTE, MD

MATTHEW M. YEH, MD, PhD MING ZHOU, MD, PhD

To my wife, Nancy, and my children, Vincent and Francesca

To my family, to whom I owe my appreciation of life and learning

To all of my former students, residents, fellows, and physician associates

Figure 1.2 Masson trichrome stain. Cirrhosis of the liver charac-

Pigments and Minerals

Nerves and Fibers

Selected References FLUORESCENCE MICROSCOPY

TABLE 1.1 IMMUNOFLUORESCENCE PATTERNS AND DISEASE ASSOCIATIONS

TABLE 1.2 CYTOPLASMIC GRANULES

Figure 1.9 Electron microscopy. Birbeck granules (arrow) in Lang-

Single Membrane–Bound Structures

• V  arious techniques may unmask antigens, such as

GROUND RULES FOR • A void preordering an IHC panel of antibodies before

Selected References FLOW CYTOMETRY

TABLE 1.4 IMMUNOHISTOCHEMISTRY APPROACH TO UNDIFFERENTIATED TUMORS

Selected Reference • A  fter staining of the chromosomes, specific chromo-

TABLE 1.7 IMMUNOHISTOCHEMISTRY PANEL FOR INTERPRETATION OF LUNG MESOTHELIOMA AND

TABLE 1.8 IMMUNOHISTOCHEMISTRY PANEL FOR LUNG ADENOCARCINOMA AND BREAST

TABLE 1.9 IMMUNOHISTOCHEMISTRY COMPARISON OF SPINDLE CELL AREAS IN METAPLASTIC CARCINOMA,

TABLE 1.11 IMMUNOHISTOCHEMICAL PANEL APPROACH TO DIFFERENTIAL DIAGNOSIS OF

lung origin in the correct clinical setting).

TABLE 1.12 IMMUNOHISTOCHEMISTRY PANEL INTERPRETATION FOR GASTROINTESTINAL AND ABDOMINAL

Leiomyosarcoma (LMS)a +/− − −/+a + + −

TABLE 1.13 IMMUNOPHENOTYPE OF PRIMARY OVARIAN AND METASTATIC COLORECTAL ADENOCARCINOMA

TABLE 1.14 IMMUNOHISTOCHEMISTRY PANEL FOR PRIMARY AND METASTATIC ADENOCARCINOMA

TABLE 1.15 IMMUNOHISTOCHEMISTRY: HIGH-­GRADE SEROUS CARCINOMA AND POORLY DIFFERENTIATED

TABLE 1.16 IMMUNOHISTOCHEMISTRY APPROACH TO OVARIAN SEX CORD–STROMAL TUMORS AND

TABLE 1.17 IMMUNOHISTOCHEMISTRY APPROACH TO ENDOCERVICAL ADENOCARCINOMA AND

TABLE 1.18 IMMUNOHISTOCHEMISTRY IN THE DIFFERENTIAL DIAGNOSIS OF SQUAMOUS AND GLANDULAR

TABLE 1.20 IMMUNOHISTOCHEMICAL APPROACH FOR TROPHOBLASTIC LESIONS

TABLE 1.21 IMMUNOHISTOCHEMISTRY FOR SELECTED GERM CELL TUMORS

TABLE 1.22 IMMUNOHISTOCHEMISTRY PANEL TO DISTINGUISH RENAL CELL NEOPLASMS

TABLE 1.23 SELECTED IMMUNOHISTOCHEMISTRY TABLE 1.24 IMMUNOHISTOCHEMISTRY

MOLECULAR PATHOLOGY METHODS NUCLEIC ACID EXTRACTION METHODS

TABLE 1.25 IMMUNOHISTOCHEMISTRY PANEL TO DISTINGUISH PROSTATE AND UROTHELIAL CARCINOMAS

+, positive; −, negative; +/−, often positive; −/+, rarely positive.

TABLE 1.27 MIB-­1(KI-­67) MEMBRANOUS AND CYTOPLASMIC STAINING

Chronic lymphocytic Mantle cell Marginal zone Follicular

TABLE 1.29 ANTIBODY PANEL FOR DIFFERENTIAL DIAGNOSIS OF HODGKIN LYMPHOMA

TABLE 1.30 IHC CLASSIFICATION OF DIFFUSE • T

PINCAS BITTERMAN, MD ADEL K. EL-NAGGAR, MD

SANDRA E. FISCHER, MD CRISTINA MAGI-GALLUZZI, MD, PhD

TABLE 1.1 IMMUNOFLUORESCENCE PATTERNS AND DISEASE ASSOCIATIONS

TABLE 1.2 CYTOPLASMIC GRANULES

• V arious techniques may unmask antigens, such as

GROUND RULES FOR • A void preordering an IHC panel of antibodies before

TABLE 1.4 IMMUNOHISTOCHEMISTRY APPROACH TO UNDIFFERENTIATED TUMORS

Selected Reference • A fter staining of the chromosomes, specific chromo-

TABLE 1.13 IMMUNOPHENOTYPE OF PRIMARY OVARIAN AND METASTATIC COLORECTAL ADENOCARCINOMA

TABLE 1.15 IMMUNOHISTOCHEMISTRY: HIGH-GRADE SEROUS CARCINOMA AND POORLY DIFFERENTIATED

TABLE 1.20 IMMUNOHISTOCHEMICAL APPROACH FOR TROPHOBLASTIC LESIONS

TABLE 1.21 IMMUNOHISTOCHEMISTRY FOR SELECTED GERM CELL TUMORS

TABLE 1.22 IMMUNOHISTOCHEMISTRY PANEL TO DISTINGUISH RENAL CELL NEOPLASMS

TABLE 1.25 IMMUNOHISTOCHEMISTRY PANEL TO DISTINGUISH PROSTATE AND UROTHELIAL CARCINOMAS

TABLE 1.27 MIB-1(KI-67) MEMBRANOUS AND CYTOPLASMIC STAINING

TABLE 1.29 ANTIBODY PANEL FOR DIFFERENTIAL DIAGNOSIS OF HODGKIN LYMPHOMA