TONEGAWATONEGAWA SusumuSusumu

1987 1987 Nobel prizeNobel prizeantibody diversityantibody diversity

BASELBASEL

old university

FREIBURGFREIBURG

TAWARA, SunaoTAWARA, Sunao1906 1906 cardiac conducting systemcardiac conducting system

LEISSIGEN / InterlakenLEISSIGEN / InterlakenSwitzerlandSwitzerland

IMAI Michiko et al. IMAI Michiko et al. 23.7.196923.7.1969Japanese direttissima routeJapanese direttissima route

EIGEREIGER north face - „top of Europe“ north face - „top of Europe“

Teaching Modules Teaching Modules in in

Pathology EducationPathology Education

Prof. Dr. Urs-N. Riede, Department of Pathology, University of FreiburgProf. Dr. Urs-N. Riede, Department of Pathology, University of Freiburg

Textbook: Textbook: Georg Thieme, Stuttgart – New York Georg Thieme, Stuttgart – New Yorkfirst edition 1986 second edition 1988first edition 1986 second edition 1988

Textbook: Textbook: Georg Thieme, Stuttgart – New York Georg Thieme, Stuttgart – New Yorkthird edition 1992 forth edition 1998third edition 1992 forth edition 1998

Textbook: Textbook: Georg Thieme, Stuttgart – New York Georg Thieme, Stuttgart – New Yorkfifth edition 2004 chinese editions 1998, 2004fifth edition 2004 chinese editions 1998, 2004

Color atlas: Color atlas: Georg Thieme, Stuttgart – New YorkGeorg Thieme, Stuttgart – New Yorkgerman edition 1998 german edition 1998

Color atlas: Color atlas: Georg Thieme, Stuttgart – New YorkGeorg Thieme, Stuttgart – New Yorkenglish edition 2008 greek edition 2009 english edition 2008 greek edition 2009

teaching in pathology:teaching in pathology:aims aims

- The pathologic diagnosis of a disease results The pathologic diagnosis of a disease results from the superposition of formal reaction from the superposition of formal reaction patterns. patterns.

- The diagnosis of formal reaction patterns The diagnosis of formal reaction patterns requires the analysis of a few structural and requires the analysis of a few structural and color changes.color changes.

- The stepwise analysis of the formal reaction The stepwise analysis of the formal reaction patterns elucidates the progress of a disease.patterns elucidates the progress of a disease.

Textbook: Textbook: Springer Heidelberg – New York – Tokyo 2009Springer Heidelberg – New York – Tokyo 2009

BASICS IN GENERAL AND SPECIAL PATHOLOGYBASICS IN GENERAL AND SPECIAL PATHOLOGY

new:new:learning moduleslearning modules

- structural patternstructural pattern- contour patterncontour pattern- consistency patternconsistency pattern- color pattern …color pattern …

teaching in pathology:teaching in pathology:modulesmodules

- Substructuring of a lesion into formal reaction Substructuring of a lesion into formal reaction patternspatterns

- Pathobiologic explanation of the reaction Pathobiologic explanation of the reaction patterns patterns

- Assembling of distinct reaction patterns to a Assembling of distinct reaction patterns to a diagnosisdiagnosis

- Reconstruction of the pathogenetic sequenceReconstruction of the pathogenetic sequence- Training by cases of a virtual autopsyTraining by cases of a virtual autopsy

quick-fix diagnosis:quick-fix diagnosis:

facial skin lesionsfacial skin lesions

The patient suffered from The patient suffered from lupus erythematodeslupus erythematodes

But why did she die?But why did she die?

diagnosis by pattern analysisdiagnosis by pattern analysis

color color redred

patternpattern - inflammation- inflammation- bleeding disorder- bleeding disorder

formal formal macrofocalmacrofocal

patternpattern - lupus erythema- lupus erythema

microfocalmicrofocal- purpura- purpura

distributiondistribution multiple multiple

patternpattern - septic purpura- septic purpura

patterns of expansionpatterns of expansionmacrofocalmacrofocal

skin erythemaskin erythema

microfocalmicrofocal

miliary TBCmiliary TBClung cancerlung cancer

macrofocalmacrofocal

secondarysecondarytumortumor

(uni-) (uni-) macrofocalmacrofocal

primary primary tumortumor

destructiondestruction

patterns of distribution patterns of distribution

microfocalmicrofocal

inflammationinflammation

multifocalmultifocal

systemicsystemic

generalisedgeneralised

bleeding bleeding disorderdisorder

discontinuousdiscontinuous

inflammationinflammation

cancercancer

cancercancer

dis-/continuousdis-/continuous

spreading patternsspreading patterns

inflammationinflammation

cancercancer

cavitarycavitary

cancercancer

lymphaticlymphatic

cancercancer

inflammationinflammation

cancercancer

haematogenoushaematogenous

coag

ulo

pat

hy

coag

ulo

pat

hy

infl

amm

atio

nin

flam

mat

ion

cancercancer

cancercancer

contour patternscontour patterns

instillation / infiltration:instillation / infiltration: - gaz- gaz > emphysema > emphysema - water- water > edema > edema - cells- cells > inflammation > inflammation

> malignoma> malignoma

fuzzycontours

melanomamelanoma

skin erythemaskin erythema

destruction:destruction: - ischemia- ischemia > infarction > infarction - inflammation- inflammation > abscess > abscess

proliferation:proliferation: > benignoma> benignomaretention:retention: > (pseudo) cyst> (pseudo) cyst

sharp sharp contourscontours

abscessabscess

lipomalipoma

cystcyst

structural patterns structural patterns

diffus

diffusediffuse

erythemaerythema

skinskin

netlikenetlikereticularreticular

lunglung

lymphangiosislymphangiosis fibromafibroma

whirledwhirledstripedstriped

musclemuscle

fat interpositionfat interposition

surface patternssurface patternspseudo-pseudo-membranemembrane

epidermisepidermismucosamucosa

subcutissubcutissubmucosasubmucosa

erosionerosion ulcerulcer polyppolyp

steric patternssteric patterns

hollow spherehollow sphere

cysticcysticpseudocysticpseudocystic

diffusediffuse

diffusediffuse

spheresphere- large: nodularlarge: nodular- small: granularsmall: granular

granular nodulargranular nodular

hard hard

fibrosisfibrosis

consistency patternsconsistency patterns

pulpy pulpy

proteolysisproteolysis

fluid fluid

firm-elastic firm-elastic

liquefactionliquefaction

liquid liquid

very hard very hard

ossificationossification

softsoft

soft tissuesoft tissue

brittle brittle

proteolysisproteolysis

siderosissiderosis

hemosiderinhemosiderin

icterusicterus

bilirubinbilirubin

cholestasischolestasis

bilebile

color patterns: e.g. color patterns: e.g. liver liver

leucemia (CLL)leucemia (CLL)

cell infiltrationcell infiltration

neutral fatneutral fat

melaninmelanin

melanomamelanoma

fatty degenerationfatty degenerationnormal (perfusion)normal (perfusion)

- hemoglobin- hemoglobin

normal normal

+ oxy-+ oxy-hemoglobinhemoglobin

cyanosiscyanosis

desoxy-desoxy-hemoglobinhemoglobin

carcinomacarcinoma

color patterns: color patterns: whitewhite

coagulationcoagulation

Tyndall-effect because ofTyndall-effect because of

- coagulation- coagulation

leukoplakialeukoplakia pleuritispleuritis

- increase of cells- increase of cells

myofibromamyofibroma

- increase of collagen- increase of collagen- increase of keratin- increase of keratin

- increase of fibrin- increase of fibrin

color patterns: color patterns: red red

pheomelaninpheomelanin

solar erythemasolar erythema

oxyhemoglobin oxyhemoglobin redred

tyrosinogenoustyrosinogenousyellow-redyellow-red

tyrosinogenoustyrosinogenousyellow-redyellow-red

porphyria / urinporphyria / urinlivoreslivores

desoxyhemoglobindesoxyhemoglobinredred

cyanosiscyanosisinflammation inflammation (chemosis)(chemosis)

patterns of hollow organspatterns of hollow organs

patterns of stenosispatterns of stenosisd

irec

tio

n o

f re

mo

val

dir

ecti

on

of

rem

ova

l

- thrombus/embolus- thrombus/embolus- neoplastic tumor- neoplastic tumor- inflammatory tumor- inflammatory tumor- foreign body - foreign body - ligatur / accretion- ligatur / accretion

post-post-

stenosisstenosis

pre-pre-

normalnormal

complicationscomplications

- retention- retention- dilatation- dilatation- inflammation- inflammation- hyperplasia- hyperplasia

- dysfunction- dysfunction- atrophy- atrophy

case historycase history

• 48 year-old patient48 year-old patient• cigarette smoker (27 pack years) cigarette smoker (27 pack years) • onset: flu-like symptoms (caugh, fatigue)onset: flu-like symptoms (caugh, fatigue)• x-ray: suspicion of pneumonia > antibioticsx-ray: suspicion of pneumonia > antibiotics• recurrent pericardial + pleural effusionsrecurrent pericardial + pleural effusions• back painback pain• accelerating respiratory insufficiencyaccelerating respiratory insufficiency• cachexia cachexia • exitusexitus

color patterncolor pattern of the lesion ?of the lesion ? - white > collagen increase- white > collagen increase- white > fibrin increase- white > fibrin increase- white > keratin increase- white > keratin increase- white > cell increase = tumor

tumor

cut face right cut face right lunglung

contour patterncontour patternof the lesion?of the lesion?

- sharp - sharp > encapsulation> encapsulation- sharp- sharp > destruction > destruction - fuzzy - fuzzy > edema> edema

- fuzzy > infiltration

fuzzy contour

infiltration: - water

- cells

cut face right lungcut face right lung

pulmonary lesionpulmonary lesion

colorcolor consistencyconsistencycontourcontour surroundingssurroundings

whitewhite

false false false

fuzzyfuzzy hardhard

false

infiltratinginfiltrating

lung cancerlung cancer

formal patternformal pattern of the lesionof the lesion - unifocal pattern- unifocal pattern- cystic pattern- cystic pattern- diffuse pattern- diffuse pattern- reticular pattern

cut face left cut face left lunglung

color patterncolor pattern of the lesion ?of the lesion ? - white > collagen increase- white > collagen increase- white > fibrin increase- white > fibrin increase- white > necrotic coagulation- white > necrotic coagulation- white > tumor

tumor

cut face left cut face left lunglung

progress of the lung cancerprogress of the lung cancer

formform distributiondistributioncolorcolor surroundingssurroundings

reticularreticular

false false false

whitewhite diffusediffuse

false

infiltratinginfiltrating

intrapulmonary tumor spreadingintrapulmonary tumor spreading (lymphangiosis) (lymphangiosis)

formal patternformal patternof the lesion ?of the lesion ? - cystic pattern- cystic pattern- reticular pattern- reticular pattern- diffuse pattern- diffuse pattern- multinodular pattern

surface of the visceral pleurasurface of the visceral pleura

color patterncolor patternof the lesionof the lesion - white > collagen increase- white > collagen increase- white > fibrin increase- white > fibrin increase- white > necrotic coagulation- white > necrotic coagulation- white > tumor

tumor

surface of the visceral pleurasurface of the visceral pleura

spreading patternspreading patternof the lesionof the lesion

- lymphogenous metastasis - lymphogenous metastasis - hematogenous metastasis- hematogenous metastasis- ductogenous metastasis- ductogenous metastasis

- cavitary metastasis

surface of the visceral pleurasurface of the visceral pleura

systemic complications of the lung cancersystemic complications of the lung cancer

formform stericstericcolorcolor spreadingspreading

reticularreticular

false false false

whitewhite multinodularmultinodular

false

cavitarycavitary

cavitary metastasiscavitary metastasis

color patterncolor pattern of the lesionof the lesion - bright red- bright red > bleeding> bleeding- wine red- wine red > porphyria> porphyria- yellow red- yellow red > pheomelanin> pheomelanin

cyanosiscyanosis

- dark-red > cyanosis

cut face right lungcut face right lung

stenotic pattern stenotic pattern complications of the lesioncomplications of the lesion

- - poststenotic atrophypoststenotic atrophy- poststenotic dysfunction - poststenotic dysfunction - prestenotic hyperplasia- prestenotic hyperplasia- prestenotic retention

post-stenotic

prestenoticprestenotic

stenosis

cut face right lungcut face right lung

local complications of the lung cancerlocal complications of the lung cancer

colorcolor stenotic patternstenotic patternformform consistencyconsistency

cyanosiscyanosis

false false false

diffusediffuse prestenoticprestenotic

false

proteolysisproteolysis

prestenotic retention pneumoniaprestenotic retention pneumonia

pathogenetic sequence pathogenetic sequence of the lesionsof the lesions

1 > 2 > 3 > 41 > 2 > 3 > 4 3 > 2 > 1 > 4 3 > 2 > 1 > 4 4 > 1 > 3 > 24 > 1 > 3 > 2

11

22

33

44

pathogenetic sequence pathogenetic sequence of the lesionsof the lesions

1 > 2 > 3 > 41 > 2 > 3 > 4 3 > 2 > 1 > 4 3 > 2 > 1 > 4 4 > 1 > 3 > 24 > 1 > 3 > 2 2 > 4 > 1 > 32 > 4 > 1 > 3

11

22

33

44

back to theory evaluation of student false

student‘s evaluation number of „false“

false

pathologic fulldiagnosispathologic fulldiagnosis

student:student: explorative partialdiagnoses explorative partialdiagnoses

teacher:teacher: formalpathogenetic patterns formalpathogenetic patterns

tissue lesiontissue lesion

expansion:expansion: macrofocal macrofocal> primary lesion> primary lesion

color:color: white white > tumor> tumor

contourcontour: fuzzy : fuzzy > malignoma> malignoma

stenosis:stenosis: prestenoticprestenotic> secondary lesion> secondary lesion> mucus retention> mucus retention

color: color: cyanosiscyanosis > no oxygenation> no oxygenation

consistency: consistency: pulpypulpy> inflammatory proteolysis> inflammatory proteolysis

primaryprimarylesionlesion

secondarysecondarylesionlesion