Medical Foreign Bodies
-
Upload
celso-silva -
Category
Technology
-
view
4.971 -
download
3
description
Transcript of Medical Foreign Bodies
![Page 1: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/1.jpg)
Armed Forces Institute of PathologyWashington, DC
![Page 2: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/2.jpg)
MEDICAL FOREIGN BODIES: MEDICAL FOREIGN BODIES: A review of histopathologic and A review of histopathologic and
spectroscopic findingsspectroscopic findings
Michael R. LewinMichael R. Lewin--Smith, MB, BSSmith, MB, BSChief, Division of Environmental PathologyChief, Division of Environmental Pathology
Department of Environmental & Infectious Disease Sciences,Department of Environmental & Infectious Disease Sciences,Armed Forces Institute of PathologyArmed Forces Institute of Pathology
![Page 3: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/3.jpg)
Disclaimer
The opinions or assertions contained herein are the private views of the presenter and are not to be construed as official or as reflecting the views of the US Department of the Army, the Department of Defense, or the Department of Veterans Affairs.
![Page 4: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/4.jpg)
INTRODUCTION 1
• Medical exogenous or “foreign” materials are found in many types of anatomic pathology specimens.
• Most are incidental findings seen in histological or cytological material removed for other purposes, (e.g. dermal suture granulomas, lubricant in Pap smears).
• Some are removed because they are the cause of an undiagnosed lesion, (e.g. remote nylon suture placement), or are mimicking a pathologic condition (e.g. dental amalgam tattoo mimicking malignant melanoma).
![Page 5: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/5.jpg)
INTRODUCTION 2
• Many medical foreign bodies are easily recognized by routine light microscopy, and do not pose a diagnostic problem for the pathologist.
• However, on occasion a fuller characterization becomes important especially to rule out other entities, such as infectious organisms, or endogenousmaterials, (e.g. melanin vs. dental amalgam), and in some instances can confirm the diagnosis, (e.g. cutaneous deposits of silver in argyria).
![Page 6: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/6.jpg)
INTRODUCTION 3
Medical materials may be found in tissue:-1. As an expected result of the therapeutic or
diagnostic intent, (e.g. suture granuloma)2. As an unexpected result of therapeutic or
diagnostic intent, (e.g. barium sulfate aspiration)3. As a result of unintended use or misuse of the
material, (e.g. constituents of oral medication within blood vessels of IVDUs)
4. As an artifact, (e.g. transport of biopsy on gauze)
![Page 7: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/7.jpg)
INTRODUCTION 4
• The pathologist’s task of characterizing medical foreign bodies may be hampered by:-
1. Lack of relevant clinical history2. Lack of familiarity with morphological
features, (esp. recently introduced materials)3. Lack of familiarity with, and access to
additional studies and methods for characterization
![Page 8: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/8.jpg)
INTRODUCTION 5
• Medical uses of exogenous materials are widespread, and will likely increase.
• New medical materials and devices will continue to appear in pathology specimens.
• Infrared spectroscopy, Raman laser spectroscopy, and scanning electron microscopy with energy dispersive X-ray analysis are non-destructive techniques that can help to characterize medical “foreign bodies” in pathology specimens, even when very limited material is available.
![Page 9: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/9.jpg)
Scanning Electron Microscopy with Energy Dispersive X-ray Analysis
(SEM/EDXA)● First introduced in the 1960s● Is a method for determining the elemental composition of a
particle that can be localized in a tissue section● Generally provides qualitative information, but methods for
quantitative SEM/EDXA are available particularly for materials for which laboratory standards of known composition are available
● Elements with atomic numbers less than 6 (carbon), are not detectable without special adaptations. (5 B, 4 Be, 3 Li, 2 He, 1 H).
![Page 10: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/10.jpg)
SEM/EDXA Samples
● Routinely we place an unstained 5µm section on a carbon disc, and place the adjacent section from the paraffin block on a glass slide for H&E staining.
● Localize area of interest on H&E and compare to the carbon disc
● No coating necessary, but background contains carbon (C)
![Page 11: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/11.jpg)
SEM/EDXA Samples [cont.]
• If only an original stained section is available on glass, SEM/EDXA can still be useful, (e.g. for silver in argyria) .
• Remove coverslip • Background glass examined away from the
specimen, will contain elements in glass, (usually Si, O, Ca). (Na, Mg, Al, Cl, K, variably present).
• Occasionally a stained section can be transferred to a carbon disk.
• Consider possibilities of stain artifacts, (High mag)
![Page 12: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/12.jpg)
Electron gun
(SEM)Energy Dispersive X-Ray Spectroscopy (EDX)• Electron beam causes inner-shell electron to be ejected
• As outer electrons “fill-in”, X-rays emitted
• Energies of X-rays are characteristic
• Elemental composition
Emitted X-rays
Electron beam
specimen
Energy Diagram Spectrum
C
O
SiP
Energy (keV)
![Page 13: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/13.jpg)
Argyria: Scanning electron microscopy
5 µm
![Page 14: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/14.jpg)
Argyria: SEM/EDXA demonstrates presence of silver (Ag), sulfur (S) and selenium (Se).
5 µm
![Page 15: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/15.jpg)
Argyria: SEM/EDXA mapping for sulfur (S), silver (Ag), and selenium (Se).
![Page 16: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/16.jpg)
Infrared and Raman Laser Spectroscopy (IR) & (Raman)
• Became available in 1940s (IR), 1960s (Raman), with subsequent developments
• Gives a molecular “fingerprint” that can be compared to reference spectra
• Unstained 5µm section adjacent to H&E stained section or carbon disc section placed on aluminum coated (reflective) glass slide or semi-reflective slide (more expensive)
![Page 17: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/17.jpg)
Vibrational Microspectroscopy:(Infrared and Raman laser)
• Advantages– Rapid– Non-destructive– High-quality spectra– Identification
• Limitations– Spatial resolution
10µm (IR), 0.5µm (Raman)
– Sample thickness– Special slide material
![Page 18: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/18.jpg)
Infrared Spectroscopy• Absorption of infrared light
• Probes energies of molecular vibrations (and rotations)
• Molecular “fingerprint”
• Non-destructive
• 10-µm spatial resolution
Light source
Energy Level Diagram Spectrum (%T or %R)
ν1ν2ν3
ν3
ν2
ν1∆ν3 ∆ν2 ∆ν1 Absorption
Eo
![Page 19: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/19.jpg)
Silicone infrared spectroscopy (I.R.)
![Page 20: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/20.jpg)
Silicone infrared spectroscopy (I.R.)
![Page 21: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/21.jpg)
∆ννο+∆ν
∆ννο-∆ν
0νο
Anti-Stokes (I)Stokes (III)
Rayleigh (II)
virtual states E1
Eο
ν1
ν2
∆ν
νο I II IIIPhoton
absorbedPhotonemitted
Energy Level Diagram
hνο
RayleighScattering
(II)hνο
Anti-Stokes
Scattering (I)
h(νο+∆νο)Stokes
Scattering (III)
h(νο-∆νο)
LASER
Raman Spectroscopy• Inelastic scattering phenomenon• Laser based technique• Probes energy of molecular
vibrations• Molecular “fingerprint”• Low light effect• 0.5-µm spatial resolution
![Page 22: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/22.jpg)
Nylon Raman Microspectroscopy
(two excitation wavelengths)
![Page 23: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/23.jpg)
MATERIALS
• Silicone, Cellulose, Nylon, Polypropylene• Polylactic/polyglycolic acid copolymer• Dental amalgam• Acrylic polyamide plastic embolization material• Barium sulfate• Silver (Argyria)• Polystyrene sulfonate, Crospovidone (PVP)• Talc
![Page 24: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/24.jpg)
Silicone ((poly)dimethylsiloxane)
• Silicon: Si, element• Silica: SiO2, inorganic (mineral) form of Si• Silicone: R2SiO, an organic form of silicon• Medical silicone: poly(dimethylsiloxane)• Oil, gel, rubber/elastomer
![Page 25: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/25.jpg)
Medical Uses of Silicone
• Implants: breast, testis, others• Coating for needles, sutures, syringes, pacemakers • Antifoams for gastric bloating/flatulence• Maxillofacial reconstruction (elastomer)• Post vitrectomy (proliferative retinopathy)• Tubing, G.I., I.V., and intra-arterial• Hydrocephalus shunts• Arthroplastic implants, hand and foot• Other
![Page 26: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/26.jpg)
Silicone: Breast implant histopathology
• LOCAL:• Fibrous capsule, may become mineralized.• Inflammatory cells: Macrophages, T-cells,
giant cells, occasional plasma cells• “Pseudosynovium”: Ultrastructurally contains
macrophage-like and secretory cells, no basal lamina, few cell junctions
![Page 27: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/27.jpg)
Silicone: Breast implant histopathology
• SILICONE MIGRATION:• RUPTURED IMPLANTS: Breast (silicone
granuloma), lymph nodes, lung, pleural cavity, kidney, liver, ovary, adrenals, pancreas, brain, skin & joints
• NON-RUPTURED IMPLANTS: Capsule, lymph nodes, skin, scar, synovium, alveolar macrophages, spleen, liver (Kupffer cells)
![Page 28: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/28.jpg)
Silicone: identification in tissue
• By light microscopy, refractile, colorless, non-staining, non-birefringent (“non-polarizable”), gel-like substance
• Found within phagocyte vacuoles or extra-cellularly, especially lining partially “washed-out” spaces
• More easily seen in thicker sections, lowering condenser, (finger under the condenser), phase contrast or darkfield microscopy
• Identification by infrared (I.R.) and/or Raman spectroscopy
![Page 29: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/29.jpg)
Breast capsule “pseudosynovium”: H&E
![Page 30: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/30.jpg)
Refractilematerial in capsule; H&E
![Page 31: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/31.jpg)
Perivascular silicone, near breast prosthesis, H&E
![Page 32: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/32.jpg)
Silicone infrared spectroscopy (I.R.)
![Page 33: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/33.jpg)
Silicone (short arrows) in giant cell with asteroid body (long arrow); H&E (lymph node)
![Page 34: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/34.jpg)
Silicone in giant cell with asteroid bodies; (lymph node), H&E
![Page 35: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/35.jpg)
Silicone: Axillary lymph node
![Page 36: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/36.jpg)
Cellulose
• Present in tissue as cotton, wood splinter, food particles (aspiration), IVDU (microcrystalline cellulose from oral medications), contaminants
• Does not stain well with H&E• Birefringent under polarized light• GMS +• Unmodified cellulose is PAS +• Esters e.g. cellulose acetate may be PAS -
![Page 37: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/37.jpg)
Cellulose (cont.)
• Generally Sirius red +, (use amyloid procedure); stains pink to red
• Other direct cotton dyes that have been suggested are Congo red & Bismarck brown.
• Identification by Infrared Spectroscopy
![Page 38: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/38.jpg)
Cellulose, subcutaneous tissue : fibro-adipose tissue, acute inflammation (H&E)
![Page 39: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/39.jpg)
Cellulose, birefringent under polarized light (H&E)
![Page 40: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/40.jpg)
Sirius red (a modified cotton dye)
For connective tissue For amyloid
![Page 41: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/41.jpg)
CellulosePAS : GMS
![Page 42: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/42.jpg)
IR Spectroscopy: Characteristic of cellulose
Adjacent tissue
Birefringent material
Gauze (cellulose)
![Page 43: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/43.jpg)
Wood splinter (H&E)
![Page 44: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/44.jpg)
CELLULOSE H&E : Polarized
![Page 45: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/45.jpg)
CELLULOSE
Sirius red GMS PAS
![Page 46: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/46.jpg)
NYLON
• Sutures, (instruments, wound dressings)• Circular, elliptical or cylindrical structures• Colorless to brownish in H&E sections• Brightly birefringent under polarized light• Identification by infrared spectroscopy,
(Because of C-N linkage, IR spectrum is close to tissue protein, but peaks narrower; area examined needs optical localization)
![Page 47: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/47.jpg)
Subcutaneous Nylon suture granuloma
![Page 48: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/48.jpg)
Nylon suture granuloma, H&E, (polarized right)
![Page 49: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/49.jpg)
Nylon infrared spectroscopy
![Page 50: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/50.jpg)
Nylon Raman Microspectroscopy
(two excitation wavelengths)
![Page 51: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/51.jpg)
Nylon suture granuloma H&E
Nylon
Silicone
![Page 52: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/52.jpg)
Silicone infrared spectroscopy (I.R.)
![Page 53: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/53.jpg)
Polypropylene
• Non-absorbable meshes for hernia repair, (Marlex®, Prolene®, Surgipro®)
• Emergency abdominal wall reconstruction• Non-absorbable sutures; Prolene®• Colorless rounded structures on H&E• Brightly birefringent under polarized light• Will stain with 72 hour Oil red O• Identification by infrared spectroscopy (IR)
![Page 54: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/54.jpg)
Polypropylene mesh, inguinal hernia repair, (H&E)
![Page 55: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/55.jpg)
Polypropylene mesh H&E; polarized
![Page 56: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/56.jpg)
Polypropylene mesh H&E; polarized
![Page 57: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/57.jpg)
Polypropylene mesh 72hr. Oil red O, polarized (right)
![Page 58: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/58.jpg)
Polypropylene infrared spectroscopy
Polypropylene
Birefringent material
![Page 59: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/59.jpg)
Poly-L-lactic acid and Polyglycolic acid copolymers
Poly-L-lactic acid and polyglycolic acid copolymers (PLLA/PGA) have been investigated as resorbable surgical fixation devices, (and are used in resorbable sutures).
Case example: 8 months prior to biopsy, pt. underwent mandibular surgery with reconstruction using PLLA/PGA screws & plates. By light microscopy, weakly eosinophilic to grey irregularly shaped fragments of material with variable birefringence were seen.
![Page 60: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/60.jpg)
Mandibular biopsy, PLLA/PGA, 8 months post-op: H&E
![Page 61: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/61.jpg)
Mandibular biopsy, PLLA/PGA, 8 months post-op ; H&E Polarized light
![Page 62: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/62.jpg)
Infrared Spectra: (I.R.) mandibular biopsy at 8 months post-op
PLLA/PGA
![Page 63: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/63.jpg)
PLLA/PGA screw Raman spectra
500
1000
1500
2000
2500
3000
Int
10000
20000
30000
40000
50000
60000
70000
Int
500 1000 1500 2000 2500 3000 3500 Raman shift (cm-1)
Mandible biopsy
Plastic material
Polylactic acid - Polyglycolic acid screw
![Page 64: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/64.jpg)
Specimen X-ray: Mandibular biopsy;
25 months post-operatively
Remodelledbone in former PLLA/PGAscrew hole
![Page 65: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/65.jpg)
Bone biopsy : 25 months
post-operatively:
H&E
Remodelledbone in former
PLLA/PGA screw hole
![Page 66: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/66.jpg)
Dental amalgam
• Dental amalgam is a multiphasic material containing silver (Ag), tin (Sn), mercury (Hg), and lesser amounts of copper (Cu).
• Incidental tattooing of buccal mucosa may occur during dental procedures.
• Prolonged tissue implantation leads to loss of mercury, (and tin), and persistence of silver with sulfur (S) and selenium (Se) deposition.
![Page 67: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/67.jpg)
Amalgam Tattoo
• Black/brown mucosal discoloration• May be of clinical concern (r/o melanoma)• In H&E sections, black granular material in
submucosa, (not removed by melanin bleach)• Identification by SEM/EDXA
![Page 68: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/68.jpg)
Dental amalgam tattoo (Photograph courtesy of the Department of Oral & Maxillofacial Pathology, AFIP)
![Page 69: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/69.jpg)
Dental amalgam tattoo, buccal biopsy, (H&E)
![Page 70: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/70.jpg)
Dental amalgam tattoo, buccal biopsy (H&E)
![Page 71: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/71.jpg)
Amalgam tattoo melanin bleach
![Page 72: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/72.jpg)
Amalgam tattoo SEM/EDXA(glass slide) silver, sulfur and selenium
![Page 73: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/73.jpg)
Amalgam tattoo SEM/EDXABackground (glass slide), carbon, oxygen,
sodium, silicon, calcium
![Page 74: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/74.jpg)
Acrylic polyamide plastic embolization material
• Embolization microspheres have been developed for tumor embolization and treatment of vascular malformations.
• Uterine artery embolization for treatment of fibroids• Several materials have been used, (polyvinyl alcohol,
collagen, dextran, and trisacryl-co-polymer crosslinked with gelatin).
• The latter has the IR spectral characteristics of acrylic polyamide plastic.
![Page 75: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/75.jpg)
Acrylic polyamide plastic embolization product
• Acrylic polyamide plastic embolization particles, appear as rounded often folded circular eosinophilic to weakly basophilic objects usually in an intravascular location.
• May have “Venetian blind effect”• Diameter depends on product used, and plane of
section, but in our tissue examples <700µm• Partial birefringence when stained with Sirius red,
but not in other stained sections• Oil red O, AMP, PAS negative• Mucicarmine and Sirius red positive
![Page 76: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/76.jpg)
Intravascular acrylic polyamide plastic, (uterus), (H&E)
![Page 77: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/77.jpg)
Acrylic polyamide plastic with “foreign body” giant cell reaction (H&E)
![Page 78: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/78.jpg)
Intravascular acrylic polyamide plastric, uterus, (Movat)
![Page 79: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/79.jpg)
Acrylic polyamide plastic with “Venetian blind” effect ? Pseudo-parasite (H&E)
![Page 80: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/80.jpg)
Acrylic polyamide plastic with “Venetian blind” effect, (Trichrome)
![Page 81: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/81.jpg)
Acrylic polyamide plastic embolization microspheres, SEM
![Page 82: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/82.jpg)
SEM of authentic example of trisacryl-polymer-gelatin embolization product selected for IR
spectroscopy comparison
100µm
![Page 83: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/83.jpg)
Acrylic polyamide plastic (embolization microsphere) infrared spectroscopy
Trisacryl-co-polymer with gelatin
Intravascularmaterial
![Page 84: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/84.jpg)
Modern Pathology (2006) 19, 922-930
![Page 85: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/85.jpg)
Barium sulfate
• Radiologic contrast medium, especially for G.I. tract imaging
• Aspiration into lung as a complication of upper G.I. studies
• Birefringent granular crystalline material may appear pale brownish/green in H&E-stained sections, often within macrophages
• (“Micropulverized BaSO4” non-birefringent)• Identification by SEM/EDXA
![Page 86: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/86.jpg)
Barium sulfate aspiration (longstanding),canine lung, (autopsy), (H&E)
![Page 87: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/87.jpg)
Barium sulfate aspiration, canine lung, (H&E), polarized (right)
![Page 88: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/88.jpg)
Radiohistology as a New Diagnostic Method for Barium Granuloma
• De Mascarel A, Merlio JP, Goussot JF, Coindre JM. Arch. Pathol. Lab Med. 1988;112:634-636.
• 4 cases lower G.I. barium granulomas• Hx.s of barium enema 3 weeks to 20
months before bx.• Gastroenterologists suspected carcinoma
in 2 of 4
![Page 89: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/89.jpg)
Barium sulfate “Radiohistology”
![Page 90: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/90.jpg)
Barium sulfate: Scanning electron microscopy/energy dispersive X-Ray analysis (SEM/EDXA)
![Page 91: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/91.jpg)
Barium sulfate: Infrared spectroscopy (IR)
0
5
10
15
20
25
30
35
40%
Ref
lect
ance
40
50
60
70
80
90
100
110
%R
efle
ctan
ce
10001500200025003000 3500
Wavenumbers (cm-1)
Lung tissue – foreign material
(canine)
Barium sulfate - reference
Tissue protein
![Page 92: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/92.jpg)
Argyria
• “A permanent ashen-gray discoloration of the skin, conjunctiva, and internal organs that results from long-continued use of silver salts” Dorland’s Illustrated Medical Dictionary 28th Edition
• A rare dermatosis due to avoidance of silver-containing medicinals and decreased occupational exposure.
• New cases do still arise• Attempts at chelation Rx. generally unsuccessful• May be localized, (e.g. site of occupational injury)
![Page 93: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/93.jpg)
Argyria (cont.)
• Most prominent clinical manifestation cosmetic• Skin pigmentation is due to silver deposits and
stimulation of melanocytes.• In H&E sections, black grains with preferential
deposition along basement membranes, elastic fibers, (and in macrophages within organs).
• Identification by SEM/EDXA • Often sulfur and selenium collocate with silver.
![Page 94: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/94.jpg)
Argyria, skin punch biopsy, H&E
![Page 95: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/95.jpg)
Argyria; dermo-epidermal junction (H&E)
![Page 96: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/96.jpg)
Argyria; Eccrine gland, (H&E)
![Page 97: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/97.jpg)
Argyria; Subcutaneous blood vessel (H&E)
![Page 98: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/98.jpg)
Argyria; Sebaceous gland (SEM fields brown) (H&E)
![Page 99: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/99.jpg)
Argyria; SEM on glass slide
12 µm
![Page 100: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/100.jpg)
Argyria: SEM/EDXA glass slide
![Page 101: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/101.jpg)
Argyria; SEM/EDXA silver granule with sulfur on glass slide
Ag
![Page 102: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/102.jpg)
Argyria: Scanning electron microscopy carbon disc
5 microns
![Page 103: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/103.jpg)
Argyria: SEM/EDXA demonstrates presence of silver (Ag), sulfur (S) and selenium (Se).
5 mircons
![Page 104: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/104.jpg)
Argyria: SEM/EDXA mapping for sulfur (S), silver (Ag), and selenium (Se).
![Page 105: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/105.jpg)
Polystyrene sulfonate
• Sodium polystyrene sulfonate (Kayexalate)• Cation-exchange resin, prepared in the sodium
phase• Sodium ions released in exchange for
potassium ions mainly in the colon• Used in the Rx. of hyperkalemia• Admin. orally (suspension) or by enema
![Page 106: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/106.jpg)
Polystyrene sulfonate [cont.]
• In H&E sections; basophilic sheets with linear markings
• Very weakly birefringent• In a study of pediatric cases material was
present within air spaces without eliciting an inflammatory response
• Identification by infrared spectroscopy
![Page 107: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/107.jpg)
Polystyrene sulfonate, pediatric lung, aluminized slide, (unstained)
for IR spectroscopy
![Page 108: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/108.jpg)
Polystyrene sulfonate infrared spectra
10
20
30
40
50
60
%T
2
4
6
8
10
%T
1000 1500 2000 2500 3000 3500 4000 Wavenumbers (cm-1)
LUNG BIOPSY
POLYSTYRENE
SULFONATE
![Page 109: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/109.jpg)
Polystyrene sulfonate Raman spectra (dispersive and FT)
![Page 110: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/110.jpg)
Polystyrene sulfonate: Adult Lung: (H&E)
![Page 111: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/111.jpg)
Polystyrene sulfonate within giant cell : Adult lung: H&E
![Page 112: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/112.jpg)
CROSPOVIDONE (poly[N-vinyl-2-pyrrolidone])
• Crospovidone is a form of polyvinylpyrrolidone (PVP) formed by “pop-corn polymerization”.
• Used in oral medications as a disintegrant• Basophilic, “coral-like”, non-birefringent
particles on H&E• Not widely metabolized
![Page 113: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/113.jpg)
CROSPOVIDONE [cont.]
• PAS negative, Mucicarmine positiveMucicarmine positive• Stains with Congo Red• Pale brown to grey with GMS• Alcian blue stains red, blue in giant cells• Movat yellow-orange, blue-green in giant cells• Identification by infrared spectroscopy =
Polyvinylpyrrolidone (PVP)
![Page 114: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/114.jpg)
Polyvinylpyrrolidone Pathology(Non-Crospovidone)
• Subcutaneous pseudosarcomatous PVP granuloma
• Thesaurosis (hair sprayer’s lung)• Mucicarminophilic histiocytosis•• Source of errorSource of error signet ring cell gastric
adenocarcinoma
![Page 115: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/115.jpg)
Pulmonary vessel, with “foreign-body” giant cell reaction to cellulose (A) and crospovidone (B&C) (H&E)
![Page 116: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/116.jpg)
Infrared spectra
Crospovidone in tissue
Crospovidone in tissue
Cellulose in tissue
![Page 117: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/117.jpg)
Cellulose, (birefringent) and crospovidone (non-birefringent) Lung, (H&E), polarized (left)
![Page 118: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/118.jpg)
Modern Pathology 2003;16 (4): 286-292.
![Page 119: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/119.jpg)
Crospovidone powder, H&E (x480)
![Page 120: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/120.jpg)
Crospovidone powder: Infrared spectrum
![Page 121: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/121.jpg)
Crospovidone powder; PASD (x100)
![Page 122: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/122.jpg)
Crospovidone, lung, intravascular, PASD (x100)
![Page 123: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/123.jpg)
Crospovidone powder ; Mucicarmine, (x100)
![Page 124: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/124.jpg)
Crospovidone, lung; Mucicarmine (x50)
![Page 125: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/125.jpg)
Crospovidone & cellulose, lung,polarized : GMS (x57)
![Page 126: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/126.jpg)
Pulmonary pathology of I.V. administration of oral tablet suspensions
•• Pulmonary Pulmonary angiothromboticangiothrombotic granulomatosisgranulomatosiscaused by talc, cornstarch and/or microcrystalline cellulose has been widely reported.
• The development of subsequent fatal pulmonary hypertension and cor pulmonale has been emphasized.
• Ordinary illicit heroin reportedly doesn’t contain enough insoluble crystalline debris to cause extensive pulmonary angiothrombosis.
![Page 127: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/127.jpg)
TALC (MgSiO4)
• Pleurodesis, talcosis, operative sites, inactive ingredient in medications, IVDU
• Micaceous, colorless and birefringent• Oil red O stain may be positive• Identification SEM/EDXA as containing
magnesium, silicon and oxygen• Infrared spectroscopy characteristic
![Page 128: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/128.jpg)
Birefringent pieces of talc (MgSi04) in breast tissue of implant patient
![Page 129: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/129.jpg)
Talc infrared spectroscopy
![Page 130: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/130.jpg)
Talc, Pleura, (H&E)
![Page 131: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/131.jpg)
Talc, pleura, (H&E), polarized (right)
![Page 132: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/132.jpg)
Talc, pleura, PAS, polarized (right)
![Page 133: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/133.jpg)
Talc, Pleura, (SEM)
![Page 134: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/134.jpg)
Talc, (MgSiO4), pleuraSEM : EDXA
![Page 135: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/135.jpg)
Talc energy dispersive X-ray analysis (EDXA) elemental maps
OxygenCarbon
Magnesium Silicon
![Page 136: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/136.jpg)
Summary
• Many types of medical “foreign bodies” may be present in histopathology specimens.
• Familiarity with these materials may help pathologists avoid possible sources of diagnostic error.
• Adequate clinical history is extremely helpful.• Close collaboration with expert spectroscopists and
toxicologists, helps characterize many materials .• Accurate characterization can benefit patents,
clinicians, regulatory agencies, and other interested parties.
![Page 137: Medical Foreign Bodies](https://reader031.fdocuments.us/reader031/viewer/2022020110/54c22f304a7959e3458b45d6/html5/thumbnails/137.jpg)
Acknowledgements
• VF Kalasinsky, Ph.D.• The late FB Johnson, M.D.• FG Mullick, M.D., Sc.D.• JF Tomashefski, M.D.• CS Specht M.D., LA Murakata, M.D.• Mr. A. Shirley, Mr. D. Landry• AFIP Staff, colleagues, and contributors