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Cut surface shows fishflesh-like sarcomatous appearance with foci of calcification erectile dysfunction after radiation treatment for rectal cancer buy 20mg tadalis sx fast delivery, cystic spaces and areas of haemorrhages and necrosis experimental erectile dysfunction drugs purchase tadalis sx 20 mg overnight delivery. Microscopically zma impotence purchase tadalis sx mastercard, classic synovial sarcoma shows a characteristic biphasic cellular pattern composed of clefts or gland-like structures lined by cuboidal to columnar epithelial-like cells and plump to oval spindle cells impotence restriction rings buy tadalis sx 20 mg with visa. Reticulin fibres are present around spindle cells but absent within the epithelial foci. The spindle cell areas form interlacing bands similar to those seen in fibrosarcoma. Myxoid matrix, calcification and hyalinisation are frequently present in the stroma. An uncommon variant of synovial sarcoma is monophasic pattern in which the epithelial component is exceedingly rare and thus the tumour may be difficult to distinguish from fibrosarcoma. Most alveolar soft part sarcomas occur in the deep tissues of the extremities, along the musculofascial planes, or within the skeletal muscles. The tumour is composed of epithelial-like cells lining cleftlike spaces and gland-like structures, and spindle cell areas forming fibrosarcoma-like growth pattern. This feature distinguishes the tumour from paraganglioma, with which it closely resembles. Some of the common locations are the abdomen, paratesticular region, ovaries, parotid, brain and thorax. Microscopically, characteristic small and round tumour cells having epithelial, mesenchymal and neural differentiation. Classic synovial sarcoma shows a biphasic cellular pattern: cuboidal to columnar epithelial-like cells and plump to oval spindle cells. Alveolar soft part sarcoma occurs in the deep tissues of the extremities, along the musculofascial planes, or within the skeletal muscles. Granular cell tumour is a benign tumour occurring in the tongue and subcutaneous tissue of the trunk and extremities. Clear cell sarcoma occurring in the subcutaneous soft tissues has some similarities with cutaneous melanoma. Desmoplastic small round cell tumour is a rare and highly malignant tumour occurring in male children and juveniles, most often in the abdomen. Systemic Pathology Granular cell tumour is a benign tumour of unknown histogenesis. The most frequent locations are the tongue and subcutaneous tissue of the trunk and extremities. Grossly, the tumour is generally small, firm, grey-white to yellow-tan nodular mass. Histologically, the tumour consists of nests or ribbons of large, round or polygonal, uniform cells having finely granular, acidophilic cytoplasm and small dense nuclei. The tumours located in the skin are frequently associated with pseudoepitheliomatous hyperplasia of the overlying skin. Grossly, the tumour is somewhat circumscribed and has nodular appearance with central necrosis. Microscopically, the tumour cells comprising the nodules have epithelioid appearance by having abundant pink cytoplasm and the centres of nodules show necrosis and thus can be mistaken for a granuloma. Microscopically, it closely resembles malignant melanoma, and is therefore also called melanoma of the soft tissues. It has been growing rapidly and lately he has noticed that he has started having tightness of shirt on this side due to increase in size of swelling. On examination, the swelling is 6 x 4 cm size, firm to hard subcutaneous mass which is fixed to underlying soft tissues. The cell bodies may be arranged in layers as in the cerebral cortex, or may be aggregated as in the basal ganglia. The cell body possesses a large, round, centrally-placed nucleus having finely granular nuclear chromatin and a prominent nucleolus. Besides Nissl substance, other special features of the cytoplasm of neuronal cell body are the presence of microtubules, synaptic vesicles and neurofilaments which are a form of intermediate filaments specific to neurons. Neuromelanin is found in neurons in the substantia nigra and pigmented nucleus of the pons. Neurons respond to injury in a variety of ways depending upon the etiologic agent and the pathologic processes. These include central chromatolysis, atrophy and degeneration of neurons and axons, and intraneuronal storage of substances. Neuropil is the term used for the fibrillar network formed by processess of all the neuronal cells. It includes 3 types of cells: astrocytes, oligodendrocytes and ependymal cells. Neuroglia is generally referred to as glia; the tumours originating from it are termed gliomas, while reactive proliferation of the astrocytes is called gliosis. The two main divisions of the brain-the cerebrum and the cerebellum, are quite distinct in structure. Mesodermal tissues are microglia, dura mater, the leptomeninges (pia-arachnoid), blood vessels and their accompanying mesenchymal cells. The predominant tissues comprising the nervous system and their general response to injury are briefly considered below: 1.
Failure to take insulin and exposure to stress are the usual precipitating causes erectile dysfunction pills free trial cheap tadalis sx 20 mg without a prescription. Severe lack of insulin causes lipolysis in the adipose tissues erectile dysfunction blogs buy tadalis sx line, resulting in release of free fatty acids into the plasma impotence questions purchase cheap tadalis sx on line. These free fatty acids are taken up by the liver where they are oxidised through acetyl coenzyme-A to ketone bodies erectile dysfunction treatment portland oregon generic 20mg tadalis sx with mastercard, principally acetoacetic acid and -hydroxybutyric acid. Such free fatty acid oxidation to ketone bodies is accelerated in the presence of elevated level of glucagon. Once the rate of ketogenesis exceeds the rate at which the ketone bodies can be utilised by the muscles and other tissues, ketonaemia and ketonuria occur. If urinary excretion of ketone bodies is prevented due to dehydration, systemic metabolic ketoacidosis occurs. Clinically, the condition is characterised by anorexia, nausea, vomitings, deep and fast breathing, mental confusion and coma. It is caused by severe dehydration resulting from sustained hyperglycaemic diuresis. The loss of glucose in urine is so intense that the patient is unable to drink sufficient water to maintain urinary fluid loss. The usual clinical features of ketoacidosis are absent but prominent central nervous signs are present. Thrombotic and bleeding complications are frequent due to high viscosity of blood. The contrasting features of diabetic ketoacidosis and hyperosmolar non-ketotic coma are summarised in Table 25. It may result from excessive administration of insulin, missing a meal, or due to stress. Late complications are largely responsible for morbidity and premature mortality in diabetes mellitus. These complications are briefly outlined below and have been discussed in detail in relevant chapters. Atherosclerosis Diabetes mellitus of both type 1 and type 2 accelerates the development of atherosclerosis. There are 2 types of lesions involving retinal vessels: background and proliferative (page 489). Besides retinopathy, diabetes also predisposes the patients to early development of cataract and glaucoma. Infections Diabetics have enhanced susceptibility to various infections such as tuberculosis, pneumonias, pyelonephritis, otitis, carbuncles and diabetic ulcers. This could be due to various factors such as impaired leucocyte functions, reduced cellular immunity, poor blood supply due to vascular involvement and hyperglycaemia per se. In symptomatic cases, the diagnosis is not a problem and can be confirmed by finding glucosuria and a random plasma glucose concentration above 200 mg/dl. The severity of clinical symptoms of polyuria and polydipsia is directly related to the degree of hyperglycaemia. In asymptomatic cases, when there is persistently elevated fasting plasma glucose level, diagnosis again poses no difficulty. The American Diabetes Association (2007) has recommended definite diagnostic criteria for early diagnosis of diabetes mellitus (Table 25. The following investigations are helpful in establishing the diagnosis of diabetes mellitus: I. The possible ill-effects of accelerated atherosclerosis in diabetes are early onset of coronary artery disease, silent myocardial infarction, cerebral stroke and gangrene of the toes and feet. Gangrene of the lower extremities is 100 times more common in diabetics than in non-diabetics. Diabetic microangiopathy Microangiopathy of diabetes is characterised by basement membrane thickening of small blood vessels and capillaries of different organs and tissues such as the skin, skeletal muscle, eye and kidney. The pathogenesis of diabetic microangiopathy as well as of peripheral neuropathy in diabetics is believed to be due to recurrent hyperglycaemia that causes increased glycosylation of haemoglobin and other proteins. Diabetic nephropathy Renal involvement is a common complication and a leading cause of death in diabetes. Four types of lesions are described in diabetic nephropathy (page 664): i) Diabetic glomerulosclerosis which includes diffuse and nodular lesions of glomerulosclerosis. Diabetic neuropathy Diabetic neuropathy may affect all parts of the nervous system but symmetric peripheral neuropathy is most characteristic. The basic pathologic changes are segmental demyelination, Schwann cell injury and axonal damage (page 884). The pathogenesis of neuropathy is not clear but it may be related to diffuse microangiopathy as already explained, or may be due to accumulation of sorbitol Table 25. More sensitive and glucose specific test is dipstick method based on enzyme-coated paper strip which turns purple when dipped in urine containing glucose. The main disadvantage of relying on urinary glucose test alone is the individual variation in renal threshold. Thus, a diabetic patient may have a negative urinary glucose test and a nondiabetic individual with low renal threshold may have a positive urine test. Besides diabetes mellitus, glucosuria may also occur in certain other conditions such as: renal glycosuria, alimentary (lag storage) glucosuria, many metabolic disorders, starvation and intracranial lesions. However, two of these conditions-renal glucosuria and alimentary glucosuria, require further elaboration here. Renal glucosuria is a benign condition unrelated to diabetes and runs in families and may occur temporarily in pregnancy without symptoms of diabetes. Ketonuria Tests for ketone bodies in the urine are required for assessing the severity of diabetes and not for diagnosis of diabetes. However, if both glucosuria and ketonuria are present, diagnosis of diabetes is almost certain.
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The hyalinised centre is surrounded by concentric laminations of collagen which is further enclosed by more cellular connective tissue impotence causes and cures generic tadalis sx 20 mg mastercard, dust-filled macrophages and a few lymphocytes and plasma cells erectile dysfunction in diabetes management effective 20 mg tadalis sx. Coal macules composed of aggregates of dustladen macrophages and collagens are seen surrounding respiratory bronchioles shakeology erectile dysfunction order tadalis sx 20 mg line. The alveoli and respiratory bronchioles surrounding the coal macule are distended erectile dysfunction icd 9 code 2012 discount tadalis sx online mastercard. Therefore, a number of occupations engaged in silceous rocks or sand and products manufactured from them are at increased risk. Peculiar to India are the occupational exposure to pencil, slate and agate-grinding industry carrying high risk of silicosis (agate = very hard stone containing silica). According to an Indian Council of Medical Research report, it is estimated that about 3 million workers in India are at high potential risk of silica exposure employed in a variety of occupations including construction workers. An infrequent acute form of silicosis called accelerated silicosis produces irregular fibrosis adjoining the alveoli which is filled with lipoproteinaceous exudate and resembles alveolar proteinosis (page 475). However, if not specified, silicosis refers to the common chronic form of the disease characterised by formation of small collagenous silicotic nodules. Besides, it depends upon a number of other factors such as total dose, duration of exposure, the type of silica inhaled and individual host factors. The mechanisms involved in the formation of silicotic nodules are not clearly understood. The following sequence of events has been proposed and schematically illustrated in. New macrophages engulf the debris and thus a repetitive cycle of phagocytosis and necrosis is set up. Some silica-laden macrophages are carried to the respiratory bronchioles, alveoli and in the interstitial tissue. Some of the silica dust is transported to the subpleural and interlobar lymphatics and into the regional lymph nodes. The silicotic nodule consists of hyaline centre surrounded by concentric layers of collagen which are further enclosed by fibroblasts and dust-laden macrophages. The collagenous nodules have cleft-like spaces between the lamellae of collagen which when examined polariscopically may demonstrate numerous birefringent particles of silica. In time, the patient may develop features of obstructive or restrictive pattern of disease. The chest radiograph initially shows fine nodularity, while later there are larger and coalescent nodules. In general, if coal is lot of dust and little fibrosis, asbestos is little dust and a lot of fibrosis. Prolonged exposure for a number of years to asbestos dust produces three types of severe diseases: asbestosis of lungs, pleural disease and tumours. In nature, asbestos exists as long thin fibrils which are fire-resistant and can be spun into yarns and fabrics suitable for thermal and electrical insulation and has many applications in industries. Particularly at risk are workers engaged in mining, fabrication and manufacture of a number of products from asbestos such as asbestos pipes, tiles, roofs, textiles, insulating boards, sewer and water conduits, brake lining, clutch castings etc. There are two major geometric forms of asbestos: Serpentine consisting of curly and flexible fibres. It includes the most common chemical form chrysotile (white asbestos) comprising more than 90% of commercially used asbestos. It includes the less common chemical forms crocidolite (blue asbestos), amosite (brown asbestos), tremolite, anthophyllite and actinolyte. However, the group of amphibole, though less common, is more important since it is associated with induction of malignant pleural tumours, particularly in association with crocidolite. In view of long-term harmful effects of asbestos exposure, it has been mostly replaced with synthetic mineral fibres such as fiberglass in developed countries since 1975 but it continues to be used in developing countries of the world. How asbestos causes all these lesions is not clearly understood but the following mechanisms have been suggested. The inhaled asbestos fibres are phagocytosed by alveolar macrophages from where they reach the interstitium. Some of the engulfed dust is transported via lymphatics to the pleura and regional lymph nodes. The asbestos-laden macrophages release chemo-attractants for neutrophils and for more macrophages, thus inciting cellular reaction around them. Asbestos fibres are coated with glycoprotein and endogenous haemosiderin to produce characteristic beaded or dumbbell-shaped asbestos bodies. Fibroblastic proliferation may occur via macrophagederived growth factor such as interleukin-1. Alternatively, fibrosis may occur as a reparative response to tissue injury by lysosomal enzymes released from macrophages and neutrophils or by toxic free radicals. A few immunological abnormalities such as antinuclear antibodies and rheumatoid factor have been found in cases of asbestosis but their role in the genesis of disease is not clear. There is high incidence of bronchogenic carcinoma in asbestosis which is explained on the basis of the role of asbestos fibres as tumour promoters or by causing cell death of the airways so that it is exposed to the carcinogenic effect of cigarette smoke. The development of pleural mesothelioma in these cases is probably by carrying of asbestos fibres via lymphatics to the pleura. Grossly, the affected lungs are small and firm with cartilagelike thickening of the pleura. The sectioned surface shows variable degree of pulmonary fibrosis, especially in the subpleural areas and in the bases of lungs.
Infiltrating (formerly diffuse type) carcinomas have poorly-defined invasive border erectile dysfunction los angeles buy tadalis sx 20 mg overnight delivery. The diagnosis of this condition has been made possible by extensive work on histogenesis of gastric cancer by Japanese pathologists by the use of fibreoptic endoscope and gastrocamera erectile dysfunction pump as seen on tv order genuine tadalis sx on-line. Early gastric carcinoma must be distinguished from certain related terms as under: Epithelial dysplasia is cellular atypia seen in intestinal metaplasia such as in atrophic gastritis and pernicious anaemia erectile dysfunction instrumental buy tadalis sx 20mg line. Carcinoma in situ in the stomach is a state of severe cellular atypia or dysplasia impotence unani treatment in india 20mg tadalis sx otc, without invasion across the basement membrane of the glands. Advanced gastric carcinoma has following 5 patterns: i) Ulcerative carcinoma. The tumour appears as a flat, infiltrating and ulcerative growth with irregular necrotic base and raised margin. Histologically, ulcerative carcinomas are poorlydifferentiated adenocarcinomas, which invade deeply into the stomach wall. Gastric carcinoma, gross appearance of subtypes and their corresponding dominant histological patterns. Histologically, fungating or polypoid carcinomas are welldifferentiated adenocarcinomas, commonly papillary type. Histologically, it may be an adenocarcinoma or signet-ring cell carcinoma, extensively infiltrating the stomach wall, but due to marked desmoplasia cancer cells may be difficult to find. The tumour grows like masses having gelatinous appearance due to secretion of large quantities of mucus. Histologically, mucoid carcinoma contains abundant pools of mucin in which are seen a small number of tumour cells, sometimes having signet-ring appearance. For confirmation of cancer in a pre-existing gastric ulcer, the characteristic microscopic appearance of peptic ulcer should be demonstrable with one portion of the base or the margin of the ulcer showing carcinomatous changes. The differences between a benign and malignant gastric ulcer are summarised in Table 18. Direct spread Direct spread by local extension is the most common feature of gastric carcinoma. The spread occurs mainly from the loose submucosal layer but eventually muscularis and serosa are also invaded. After the peritoneal covering of the stomach has been invaded, transcoelomic dissemination may occur in any other part of the peritoneal cavity but ovarian masses (one sided or both-sided) occur more commonly, referred to as Krukenberg tumours (page 740). The tumour may directly involve other neighbouring structures and organs like lesser and greater omentum, pancreas, liver, common bile duct, diaphragm, spleen and transverse colon. Lymphatic spread Metastases to regional lymph nodes occur early, especially in the scirrhous carcinoma. The groups of lymph nodes involved are along the lesser and greater curvature around the cardia and suprapancreatic lymph nodes. The luminal surface of the stomach in the region of pyloric canal shows an elevated irregular growth with ulcerated surface and raised margins. B, Malignant cells forming irregular glands with stratification are seen invading the layers of the stomach wall. The wall of the stomach in the region of pyloric canal is markedly thickened and fibrotic while the mucosal folds are lost. D, Microscopy shows characteristic signet ring tumour cells having abundant mucinous cytoplasm positive for mucicarmine (inbox). The usual clinical features are as under: i) Persistent abdominal pain ii) Gastric distension and vomiting iii) Loss of weight (cachexia) iv) Loss of appetite (anorexia) v) Anaemia, weakness, malaise. The most common complication of gastric cancer is haemorrhage (in the form of haematemesis and/or melaena); others are obstruction, perforation and jaundice. Therefore, the prognosis is generally poor; 5-year survival rate being 5-15% from the time of diagnosis of advanced gastric carcinoma. However, 5-year survival rate for early gastric carcinoma is far higher (93-99%) and hence the need for early diagnosis of the condition. Other Carcinomas Besides the various morphologic patterns of adenocarcinoma just described, other carcinomas that occur rarely in the stomach are: adenosquamous carcinoma, squamous cell carcinoma and undifferentiated carcinoma, all of which are morphologically similar to such tumours elsewhere. Leiomyosarcoma Leiomyosarcoma, though rare, is the commonest soft tissue sarcoma, the stomach being the more common site in the gastrointestinal tract. Age Sex Duration of symptoms Location Gross features a) Size b) Shape c) Mucosal folds d) Ulcer bed 6. Microscopically, leiomyosarcoma is characterised by high cellularity and presence of mitotic figures. Leiomyoblastoma (Epithelioid Leiomyoma) this is a rare tumour, the behaviour of which is intermediate between clearly benign and malignant tumour. Microscopically, it is characterised by round to polygonal cells with clear perinuclear halos. Carcinoid Tumour Carcinoid tumours are rare in the stomach and are usually non-argentaffin type but argentaffinomas also occur. Lymphomas of Gut Primary gastrointestinal lymphomas are defined as lymphomas arising in the gut without any evidence of systemic involvement at the time of presentation. Secondary gastrointestinal lymphomas, on the other hand, appear in the gut after dissemination from other primary site. Gastric lymphomas constitute over 50% of all bowel lymphomas; other sites being small and large bowel in decreasing order of frequency.
