오늘 세포병리학회에서 연수강좌가 있어서 연세대학교 보건전문대학원으로 갔다. 연세대는 집이나 직장과 멀리 있지 않다는 굉장한 장점이 있다. 여러 버스가 있지만 272번으로 한방에..
갑상선이라는 제목만 보고 가서 가끔씩 오는 Liquid-based cytology (LBC)에 대한 내용이 나올 줄 알았는데, 병리학적인 소견에 대해서는 슬라이드 한 장도 나오지를 않았다. 이번 연수강좌에서는 갑상선 결절의 치료 지침 및 임상과 병리과와의 괴리(?), 초음파유도 세침흡인 검사시에 참고할 수 있는 초음파 소견에 대한 내용이 주된 내용이었다.
병원 규모가 커지다보면 필연적으로 발생하게 되는 각 과간의 대화부재로 인한 부분에 대한 것을 알 수 있었다고나 할까..
WHO 1982
Class I Normal glomeruli
Class II Pure mesangial alterations
Class III Focal segmental glomerulonephritis
Class IV Diffuse glomerulonephritis
Class V Diffuse membranous glomerulonephritis
Class VI Advanced sclerosing glomerulonephritis
ISN/RPS 2003
Class I Minimal mesangial lupus nephritis
Class II Mesangial proliferative lupus nephritis
Class III Focal lupus nephritis
Class IV Diffuse segmental (IV-S) or global (IV-G) lupus nephritis
Class V Membranous lupus nephritis
Class VI Advanced sclerosing lupus nephritis
비슷비슷한 분류… 못외우겠구만..
Reference:
J Am Soc Nephrol 2004; 15: 241-50.
Kidney Int 2004; 65: 521-30.
(동시출판)
Glomerular cell proliferation; This feature indicated the degree of glomerular endocapillary hypercellularity (mesangial, endothelial, and possibly infiltrating monocytes) leading to reduction of circulatory volume of glomerular capillary loops. The lesions were scored by the extent of loss of circulatory space due to segmental (or global) proliferative changes in less than 25% (1+), 25 to 50% (2+), or greater than 50% (3+) of glomeruli.
Leukocyte exudation; Exudation of more than two polymorphonuclear leukocytes per glomerulus was considered abnormal. Exudation was scored as mild (1+), moderate (2+), or extensive (3+).
Karyorrhexis and fibrinoid necrosis; Karyorrhexis was defined by the presence of pyknotic and fragmented nuclei. Fibrinoid necrosis was identified by the occurrence of intensely eosinophilic material within solidified segments of glomeruli. Fibrinoid necrosis was usually confirmed by Masson stain and was typically accompanied by karyorrhexis in involved glomeruli. The following scale of severity was used: karyorrhexis only or fibrinoid necrosis in less than 25% of glomeruli (1+), fibrinoid necrosis in 25 to 50% (2+) or greater than 50% (3+) of glomeruli. The assigned score was weighted by a factor of two because such lesions were considered to be disproportionately severe as previously suggested.
Cellular crescent; Proliferating extracapillary cells occupying one-fourth or more of the glomerular capsular circumference were considered cellular crescents. Determination of the predominant component of crescents (cellular or fibrous) was assisted by Masson staining. The crescent score was defined as follows: cellular crescents in less than 25% (1+), 25 to 50% (2+), or greater than 50% (3+) of glomeruli. The assigned score was weighted by a factor of two because such lesions were considered to be disproportionately severe.
Hyaline deposits; Eosinophilic material of a homogenous consistency along the circumference of the luminal surface of glomerular capillaries constituted the classical wire loop lesion. More extensive globular material occupying entire capillary loops were identified as hyaline thrombi. The hyaline material was considered to represent massive accumulation of immune complexes. Hyaline lesions were scored as few (1+), moderate (2+), or extensive (3+).
Interstitial inflammation; Infiltration of mononuclear cells (lymphocytes, plasma cells, macrophages) into interstitial spaces was assigned scores of mild (1+), moderate (2+), or extensive (3+).
Glomerular sclerosis; Glomerular capillary collapse with attendant expansion of mesangial matrix material and subsequent solidification was observed in both segmental and global patterns. Solidification occurring only segmentally or in global patterns in less than 25% (1+) of glomeruli, and global sclerosis in 25 to 50% (2+), or greater than 50% (3+) of glomeruli were designated.
Fibrous crescents; Structures composed predominantly or exclusively of fibrous tissue lining Bowman’s capsule in a circumferential patterns were considered as fibrous crescents. The crescent scores were defined as follows: fibrous crescents in less than 25% (1+), 25 to 50% (2+) or greater than 50% (3+) of glomeruli.
Tubular atrophy; Atrophic changes were identified by the thickening of tubular basement membranes, with or without tubular epithelial cell degeneration. Separation of residual tubules was typically observed. The severity of tubular atrophy was designated as mild (1+), moderate (2+), or extensive (3+).
Interstitial fibrosis; The deposition of periglomerular and peritubular fibrous tissue was judged primarily by the Masson stain. The severity of interstitial fibrosis was designated as mild (1+), moderate (2+), or extensive (3+).
Activity Index (AI) This index was defined as the sum of individual scores of the following items considered to represent measures of active lupus nephritis: glomerular proliferation, leukocyte exudation, karyorrhexis/fibrinoid necrosis (x2), cellular crescents (x2), hyaline deposits, and interstitial inflammation. The maximum score was 24 points for the Activity Index.
Chronicity Index (CI) This index consisted of the sum of individual scores of the following items considered to represent measures of chronic irreversible lupus nephritis: glomerular sclerosis, fibrous crescents, tubular atrophy, and interstitial fibrosis. The maximum score was 12 points for the Chronicity Index.
Electron microscopy; Generally two or three glomeruli were examined in each biopsy specimen. For the present study the location and extent of electron dense deposits were quantitated on a scale of 0 to 4+, corresponding to a range of absent to massive. The deposits present in each of the following five locations were individually scored: mesangial, subendothelial, subepithelial, intramembranous, and extraglomerular (peritubular and/or perivascular). In addition to immune deposit analysis, the presence or absence of tubuloreticular structures was noted in endothelial cells.
Reference: 찾고 있는 중.. ㅡ,.ㅡ
Virus 에 감염되었을 때의 핵의 변화로 Cowdry type A inclusion 이라는 표현이 있고, 드물게는 Cowdry type B inclusion 이라는 표현도 있다. 인터넷이나 책을 뒤지면 표현에 대한 정의가 조금 더 있기는 한데, 그걸로는 부족하다고 생각해서 공부하다 지쳐 의욕이 상실되었을 때 오늘 오후 4시쯤 그 근원을 찾아보기로 하였다. 🙂
인터넷에서 인용문헌에 Cowdry 가 있는 옛 논문을 찾았다. 구글님에 의하면 Experimental and Molecular Pathology, Vol 23, Issue 2, October 1975, 228-244 실린 “Identity of cowdry type B inclusions and nuclear bodies: Observations in reovirus encephalitis”라는 논문에서 Cowdry 님이 1934년에 쓰셨다는 논문을 확인할 수 있었다. 이 논문은 “The problem of intranucIear inclusions in virus diseases. 이며, Am. J. Pathol, 18, 527-550 이라고 되어 있었다. 이 논문이 학교에서 구독하고 있는지 확인해 보는 과정에서 Am. J. Pathol 이 아닌, Archives of Pathology 저널이라는 것을 확인할 수 있었고, 도서관 지하 1층에서 잠자고 있는 논문을 확인할 수 있었다. 내용은 다음과 같다. 앞 부분을 제대로 읽어보지 않고 해당 부분만 발췌했더니 내용을 잘 모르겠다. 하지만, 전자현미경 염색 과정에 따른 특징으로 분류를 한게 아닌가 하는게 드는 생각임. 병리학적 소견 기술이 상당 부분은 그 밥에 그 나물… 같은 느낌인지라. OTL
Cowdry type A inclusion
The nuclear reaction is total and proceeds
to complete degeneration. The inclusions are amorphous or particulate, but may
be condensed in rounded masses. The ground substance of the entire nucleus is
profoundly disturbed, and all the basophilic chromatic eventually marginates on
the nuclear membrane, except in the case of the salivary gland inclusions in
moles, which are more basophilic than acidophilic. After fixation the material
of which the inclusions are constructed is not easily removed by acetic acid,
alcohol, chloroform and other solvents. It contains little or no masked iron or
thymonucleic acid. Incineration shows that the yellow fever inclusions are
devoid of mineral matter. L.E. and E.J. Rector have found that the same
observation holds for mature herpetic inclusions. In interesting contrast, a
large amount of mineral, especially calcium, occurs in the nucleoli and
basophilic chromatin.
Cowdry type B inclusions
The reaction is localized in the certain
areas of the nucleus, where acidophilic droplets make their appearance. These
often look hyaline and may be of small or large size. The nucleoplasm in which
the inclusions are embedded may not be noticeably altered. Basophilic chromatin
fails to marginate on the nuclear membrane. It may be even accumulate to some
extent on the centrally placed inclusions. The process seldom goes on to
complete nuclear generation, and it is not accompanied by the marked reaction
of tissue frequently but not always present with the type A inclusions. Such
inclusions can be distinguished from nucleoli by: (1) recognition in the same
nucleus of nucleoli stained differently; (2) their range of variation in number
and size; (3) absence in them of detectable amounts of mineral and so on. It is
unsafe to assume that different B inclusions are of similar composition. Their
analysis has not been energetically pushed.
Reference: Archives of Pathology, 1934, Vol 18, 527-542