The Lauren V. Ackerman Laboratory of Surgical Pathology Barnes-Jewish and St. Louis Children's Hospitals Washington University Medical Center Department of Pathology and Immunology Washington University School of Medicine St. Louis, Missouri Editors Peter A. Humphrey, MD, PhD Lou is P. Dehner, MD John D. Pfeifer, MD, PhD ®.Wolters Kluwer IL ippincott Williams & Wilkins Health Philadelphia • Baltimore • New York • London Buenos Aires • Hong Kong • Sydney • Tokyo Senior Executive Editor: Jonathan W. Pine, Jr. Product Managers: Marian Bdlus, Emilie Moyer Vendor Manager: Bridgett Dougherrty Senior Manufacturing Manager: Benjamin Rivera Director of Marketing: Caroline Foote Design Coordinator: Holly McLaughlin Production Service: Aptara, Inc. © 2012 by Department o£ Pathology and Immunology, Washington University School of Medicine First Edition © 2008 by Department of Pathology and Immunology, Washington University School of Medicine All rights reserved. This book is protected by copyright. No part of this book may be reproduced in any form by any means, including photocopying, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. Printed in China Library o£ Congress Cataloging-in-Publication Data The Washington manual of surgical pathology I editors, Peter A. Humphrey, Louis P. Dehner, John D. Pfeifer. -2nd ed. p.;cm. Surgical pathology Includes bibliographical references and index. Summary: "The aim of this book is to provide a practical manual that is helpful to pathologists and residents in the daily practice of surgical pathology. The text encompasses all anatomic sites in the human body. Each chapter covers tissue handling, gross examination, gross dissection and diagnosis, processing, slide preparation, microscopic diagnosis, special studies, and diagnostic reporting. The format of the book would be modded after the Washington Manuals for other specialties (such as Medical Therapeutics, Oncology, and Surgery)"-Provided by publisher. ISBN 978-1-4511-1436-2 I. Humphrey, Peter A. II. Dehner, Louis P., 1940- III. Pfeifer, John D. IY. Title: Surgical pathology. [DNLM: 1. Pathology, Surgical-Handbooks. WO 39] LC classification not assigned 617'.07---dc23 2012000549 Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of the information in a particular situation remains the professional responsibility of the practitioner. The authors, editors, and publisher have exerted every effort to ensure that drug sdection and dosage set forth in this text are in accordance with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new or infrequently employed drug. Some drugs and medical devices presented in the publication have Food and Drug Adminis- tration (FDA) clearance for limited use in restricted research settings. It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned for use in their clinical practice. To purchase additional copies of this book, call our customer service department at (800) 638-3030 or fax orders to (301) 223-2320. International customers should call (301) 223-2300. Visit Lippincott WJ.lliams & WJ.lkins on the Internet at LWW.com. Lippincott Williams & Wilkins customer service representatives are available from 8:30am to 6:00pm, EST. 10 9 8 7 6 5 4 3 2 1 My wife Kay, and children Tom and Jennifer-P.A.H. For the continued opportunity, joy, and satisfaction of working with great colleagues and house staff-L.P.D. P.J., S.M., and L.P.D., for their friendship and support-J.D.P. Contributors Ashima Agarwal, MD Danielle H. Carpenter, MD Instructor Surgical Pathology Fellow Department of Pathology and Immunology Department of Pathology and Immunology Washington University School of Medicine Washington University School of Medicine St. Louis, Missouri St. Louis, Missouri Hussam Al-Kateb, MSc, PhD Yumei Chen, MD, PhD Assistant Professor Molecular Genetic Pathology Fellow Associate Director of Cytogenomics and Department of Pathology and Immunology Molecular Pathology Washington University School of Medicine Department of Pathology and Immunology St. Louis, Missouri Washington University School of Medicine St. Louis, Missouri Rebecca D. Chernock, MD Assistant Professor Craig Allred, MD Department of Pathology and Immunology Professor Washington University School of Medicine Section Head, Breast Pathology St. Louis, Missouri Department of Pathology and Immunology Washington University School of Medicine St. Louis, Missouri Brian Collins, MD Associate Professor Catalina Amador-Ortiz, MD Section Head, Cytopathology Resident Department of Pathology and Immunology Department of Pathology and Immunology Washington University School of Medicine Washington University School of Medicine St. Louis, Missouri St. Louis, Missouri Catherine E. Cottrell, PhD Emily A. Bantle, MD Assistant Professor Chief, Dermatopathology Associate Director of Cytogenomics and Department of Pathology Molecular Pathology David Brant Medical Center Department of Pathology and Immunology Travis Air Force Base, California Washington University School of Medicine St. Louis, Missouri Nils Becker, MD Resident Kimberly G. Crone, MD Department of Pathology and Immunology Dermatopathologist Washington University School of Medicine Associated Dermatologists of West St. Louis, Missouri Bloomfield and Commerce Commerce Township, Michigan Elizabeth M. Brunt, MD Professor Section Head, Liver!GI Pathology Erika Crouch, MD, PhD Department of Pathology and Immunology Professor Washington University School of Medicine Department of Pathology and Immunology St. Louis, Missouri Washington University School of Medicine St. Louis, Missouri Dengfeng Cao, MD, PhD Assistant Professor Rosa M. Davila, MD Department of Pathology and Immunology Medical Director, Clinical Laboratory Washington University School of Medicine Barnes jewish West County Hospital St. Louis, Missouri St. Louis, Missouri y vi I CONTRIBUTORS Louis P. Dehner, MD Johann D. Hertel, MD, MA Professor of Pathology and Immunology Resident Professor of Pathology in Pediatrics Department of Pathology and Immunology Department of Pathology and Immunology Washington University School of Medicine Washington University School of Medicine St. Louis, Missouri St. Louis, Missouri Jena Beth Hudson, MD Samir K. El-Mofty, DMD, PhD Resident Professor of Oral and Maxillofacial Department of Pathology and Immunology Pathology Washington University School of Medicine Associate Professor of Otolaryngology St. Louis, Missouri and Head and Neck Surgery Phyllis C. Huettner, MD Associate Professor of Pathology Associate Professor of Pathology and Section Head, Head and Neck Pathology Immunology Department of Pathology and Immunology Associate Professor of Obstetrics and Washington University School of Medicine Gynecology St. Louis, Missouri Section Head, Gyn Pathology John L. Frater, MD Department of Pathology and Immunology Assistant Professor Washington University School of Medicine Department of Pathology and Immunology St. Louis, Missouri Washington University School of Medicine Michael E. Hull, MD St. Louis, Missouri Assistant Professor Joseph P. Gaut, MD, PhD Department of Pathology and Immunology Instructor Washington University School of Medicine Department of Pathology and Immunology St. Louis, Missouri Washington University School of Medicine Peter A. Humphrey, MD, PhD St. Louis, Missouri Ladenson Professor of Pathology and Immunology Omar Hameed, MD Chief of Anatomic and Molecular Associate Professor Pathology Department of Pathology, Microbiology Department of Pathology and Immunology and Immunology; Department of Surgery Washington University School of Medicine Vanderbilt University St. Louis, Missouri Medical Director, Surgical Pathology; Associate Medical Director, Anatomic Mohammad 0. Hussaini, MD Pathology Resident Vanderbilt University Medical Center Department of Pathology and Immunology Nashville, Tennessee Washington University School of Medicine St. Louis, Missouri George J. Harocopos, MD Assistant Professor of Ophthalmology and Michael Isaacs, BS Visual Sciences Director of Information Systems Assistant Professor of Pathology and Department of Pathology and Immunology Immunology Washington University School of Medicine Department of Ophthalmology and Visual St. Louis, Missouri Sciences Washington University School of Medicine Jason A. Jarzembowski, MD, PhD St. Louis, Missouri Assistant Professor Department of Pathology Anjum Hassan, MD Medical College of Wisconsin Assistant Professor Program Director, Perinatal Pathology Department of Pathology and Immunology Department of Pathology Washington University School of Medicine Children's Hospital of Wisconsin St. Louis, Missouri Milwaukee, Wisconsin CONTRIBUTORS vii Jeffery M. Klco, MD, PhD Jochen K. Lennerz, MD, PhD Research Instructor Pathologist Department of Pathology and Immunology Institute of Pathology Washington University School of Medicine University Ulm St. Louis, Missouri Ulm, Germany Michael J. Klein, MD James S. Lewis, Jr., MD Professor of Pathology and Laboratory Assistant Professor Medicine Department of Pathology and Immunology Department of Pathology and Laboratory Washington University School of Medicine Medicine St. Louis, Missouri Weill Cornell School of Medicine Pathologist-in-Chief and Director Helen Liapis, MD Department of Pathology and Laboratory Professor Medicine Section Head, Renal Pathology Hospital for Special Surgery Department of Pathology and Immunology New York, New York Washington University School of Medicine St. Louis, Missouri Friederike Kreisel, MD Assistant Professor Anne C. Lind, MD Department of Pathology and Immunology Associate Professor Washington University School of Medicine Section Head, Dermatopathology St. Louis, Missouri Department of Pathology and Immunology Washington University School of Medicine Elise L. Krejci, MD St. Louis, Missouri Staff Pathologist Sherman Hospital Ta-Chiang Liu, MD, PhD Elgin, Illinois Resident Department of Pathology and Immunology Hannah R. Krigman, MD Washington University School of Medicine Associate Professor St. Louis, Missouri Department of Laboratory Medicine and Pathology Dongsi Lu, MD, PhD University of Minnesota Assistant Professor Minneapolis, Minnesota Department of Pathology and Immunology Washington University School of Medicine Shashikant Kulkarni, PhD St. Louis, Missouri Associate Professor Medical Director, Cytogenomics and Changqing Ma, MD, PhD Molecular Pathology Resident Department of Pathology and Immunology Department of Pathology and Immunology Washington University School of Medicine Washington University School of Medicine St. Louis, Missouri St. Louis, Missouri Julie Elizabeth Kunkel, MD Mitra Mehrad, MD Staff Pathologist Resident Department of Pathology Department of Pathology and Immunology San Antonio Military Medical Center Washington University School of Medicine San Antonio, Texas St. Louis, Missouri Kathryn M. Law, MD ILKe Nalbantoglu, MD Instructor Assistant Professor Department of Pathology and Immunology Department of Pathology and Immunology Washington University School of Medicine Washington University School of Medicine St. Louis, Missouri St. Louis, Missouri viii I CONTRIBUTORS TuDong Nguyen, MD, PhD Jon H. Ritter, MD Assistant Professor Professor Department of Pathology and Immunology Director of Anatomic and Surgical Washington University School of Medicine Pathology St. Louis, Missouri Department of Laboratory Medicine and Pathology Deborah Novack, MD, PhD University of Minnesota Associate Professor of Internal Medicine Minneapolis, Minnesota Associate Professor of Pathology and Immunology Souzan Sanati, MD Washington University School of Medicine Assistant Professor St. Louis, Missouri Department of Pathology and Immunology Washington University School of Medicine Sushama Patil, MD St. Louis, Missouri Department of Pathology and Immunology Washington University School of Medicine Robert E. Schmidt, MD, PhD St. Louis, Missouri Professor Chief of Neuropathology Richard J. Perrin, MD, PhD Department of Pathology and Immunology Assistant Professor Washington University School of Medicine Department of Pathology and Immunology St. Louis, Missouri Washington University School of Medicine St. Louis, Missouri Kevin Selle, MT, HTL (ASCP) Lab Superoisor Arie Perry, MD Department of Surgical Pathology Professor of Pathology and Neurological Barnes-] ewish Hospital Surgery St. Louis, Missouri Director of Neuropathology Maria F. Serrano, MD Department of Pathology, Division of Neuropathology Physician Department of Pathology University of California San Francisco Kaiser Permanente San Rafael Medical School of Medicine Center San Francisco, California San Rafael, California John D. Pfeifer, MD, PhD David E. Spence, MD Professor of Pathology and Immunology Pathologist Professor of 0 bstetrics and Gynecology Department of Pathology Vice Chairman for Clinical Affairs Associated Pathologists at Erlanger Department of Pathology and Immunology Hospital Washington University School of Medicine Chattanooga, Tennessee St. Louis, Missouri Kiran R. Vij, MD Meredith E. Pittman, MD, MSCI Fellow in Clinical Cytogenomics Resident Department of Pathology and Department of Pathology and Immunology Immunology Washington University School of Medicine Washington University School of Medicine St. Louis, Missouri St. Louis, Missouri Samuel J. Pruden, II, MD, FACS Nathan C. Walk, MD Dermatopathology Fellow Pathologist/Dermatopathologist Department of Pathology and Immunology Department of Pathology Washington University School of Medicine Middlesex Hospital St. Louis, Missouri Middletown, Connecticut