SEER Program

Self Instructional Manual for Cancer Registrars

Human Anatomy as Related to Tumor Formation

Book Four

Second Edition

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service

National Institutesof Health
SEER PROGRAM

SELF-INSTRUCTIONAL MANUAL FOR CANCER REGISTRARS

Book 4 - Human Anatomy as Related to Tumor Formation

Second Edition

Prepared by:

SEER Program

Cancer Statistics Branch

National Cancer Institute

Editor in Chief:

Evelyn M. Shambaugh, M.A., CTR

Cancer Statistics Branch

National Cancer Institute

Assisted by Self-Instructional Manual Committee:

Dr. Robert F. Ryan, Emeritus Professor of Surgery

Tulane University School of Medicine

New Orleans, Louisiana

Mildred A. Weiss

Los Angeles, California

Mary A. Kruse

Bethesda, Maryland

Jean Cicero, ART, CTR

Health Data Systems Professional Services

Riverdale, Maryland

Pat Kenny

Medical Illustrator for

Division of Research Services

National Institutes of Health
CONTENTS

BOOK 4: HUMAN ANATOMY AS RELATED TO TUMOR FORMATION

Page

Section A--Objectives and Content of Book 4 ............................... 1

Section B--Terms Used to Indicate Body Location and Position .................. 5

Section C--The Integumentary System ..................................... 19

Section D--The Lymphatic System ....................................... 51

Section E--The Cardiovascular System ..................................... 97

Section F--The Respiratory System ....................................... 129

Section G--The Digestive System ......................................... 163

Section H--The Urinary System .......................................... 241

Section I--The Reproductive System ...................................... 271

Section J--The Endocrine System ......................................... 327

Section K--The Skeletal System .......................................... 341

Section L--The Muscular System ......................................... 375

Section M--The Nervous System ......................................... 391

Section N--Sensory Organs ............................................. 409

Appendix A--Histologic Type/Primary Site .................................. 439

Appendix B--Rules for Determining Multiple Primaries For Lymphatic and

Hematopoietic Disease ............................................... 443

Appendix C--Other ICD-O-2 Codes To Be Considered One Primary When

Determining Multiple Primaries ......................................... 469

Selected Bibliography .................................................. 473

Index ............................................................. 477
ILLUSTRATIONS (Figures 1-82)

Page

Section B

1A. Planes of Reference and Directional Terms ........................ 7

lB. Main Body Cavities .......................................... 11

2. Abdominal Quadrants ......................................... 13

3. Anatomic Divisions of the Abdomen ............................. 14

Section C

4A. Layers of the Epidermis ....................................... 22

4B. Layers of the Skin: Epidermis and Dermis ......................... 23

5. Clark's Classification of Malignant Melanoma ....................... 41

6. Lymphatics of the Skin ........................................ 47

Section D

7. Relationship Between the Blood and Lymph Circulating Systems ........ 53

8A-8B. Lymphatic Drainage of Various Parts of the Body ................... 58

9A-9B. Structure of a Lymph Node .................................... 61

10. Spleen ...... . ............................................. 67

11. Thymus Gland .............................................. 67

12A. Lymph Nodes of the Head and Neck ............................. 73

12B. Lymph Nodes of the Thorax .................................... 77

13. Lymph Nodes of the Abdomen and Pelvis ......................... 80

Section E

14A. Blood Flow Through the Body .................................. 98

14B. Heart ..................................................... 99

14C. Muscle Wall of Heart ......................................... 99

14D. Blood Flow Through Heart .................................... 100

14E. Portal Circulation ............................................ 100

Section F

15. Respiratory System ........................................... 131

16. Nasopharyngeal Region and Paranasal Sinuses ...................... 139

17A. Larynx .................................................... 143

17B. The Anatomic Subsites of the Larynx ............................. 144

18. Lungs ..................................................... 153

Section G

19. Principal Parts of the Digestive System ............................ 165

20. Structure of the Intestinal Wall ................................. 166

21. Oral Cavity ................................................. 169

22. Lips ...................................................... 170

23. Dorsal Surface of Tongue ...................................... 173

24. Floor of Mouth ............................................. 177

25. Gingiva ................................................... 178

26. Hard and Soft Palates ......................................... 181

27. Salivary Glands .............................................. 185
ILLUSTRATIONS (Figures 1-82, cont'd)

Page

Section G (cont'd)

28. Oral Cavity Lymph Node Regions ............................... 192

29. Oropharynx and Hypopharynx .................................. 193

30. Divisions of the Esophagus ..................................... 203

31. Measurements of the Esophagus (from the incisors to the stomach) ...... 204

32. Esophageal Lymph Nodes ..................................... 205

33. Cross-Section of Esophagus .................................... 205

34. Stomach and Adjoining Structures ............................... 209

35. Structure of Colonic Wall ...................................... 220

36. Relationship of Bowel Wall and Serosa to Pericolic/Mesenteric Fat ...... 220

37. Lymphatic Drainage of the Colon and Rectum ...................... 222

38. Biliary System ............................................... 230

Section H

39. Principal Parts of the Urinary System ............................. 242

40. Kidney .................................................... 243

41. A Nephron ................................................. 248

42. Urinary Bladder ............................................. 261

43. Lymphatic Drainage of the Bladder .............................. 263

Section I

44. Female Pelvis (frontal view) .................................... 272

45. Female Pelvis (sagittal view) .................................... 273

46. Breast (sagittal view) ......................................... 297

47. Quadrants of the Breast ....................................... 301

48. Male Pelvis (sagittal view) ..................................... 312

49. Testis (sagittal view) .......................................... 313

50. Prostate Gland (sagittal view) ................................... 317

51. Prostate Gland (frontal view) ................................... 318

52. Lymphatic Drainage of the Prostate and Testes ..................... 322

Section J

53. Endocrine Glands ............................................ 328

54. Thyroid Gland and Parathyroid Glands ............................ 332

55. Pineal Gland ............................................... 332

56. Adrenal Gland .............................................. 334

57. Thymus Gland .............................................. 334
ILLUSTRATIONS (Figures 1-82 cont'd)

Section K

58. Axial Skeleton .............................................. 342

59. Osseous Tissue .............................................. 347

60. Hyaline Cartilage ............................................ 347

61. Classification of Bones ........................................ 351

62. Haversian System of the Bone, Adult Femur ....................... 355

63. Cranial Bones ............................................... 359

64. Facial Bones ................................................ 360

65. Bones of the Thorax .......................................... 362

66. Vertebral Column ............................................ 362

67. Appendicular Skeleton ........................................ 366

Section L

68. Muscle Types ............................................... 376

69. Histological Comparisons of Muscle Types ......................... 378

Section M

70. Nerve Cell (neuron) .......................................... 394

71. Cerebrum .................................................. 398

72. Spinal Cord ................................................ 398

73. Diagram Showing Brain, Ventricles, Meninges, Intermeningeal spaces .... 400

74. Cranial Nerves .............................................. 402

Section N

75. Eye ...................................................... 415

76. Eyeball (sagittal view) ......................................... 419

77. Eyeball (frontal view) ......................................... 419

78. Lacrimal Apparatus .......................................... 419

79. Lymphatic Drainage of the Head (sensory organs) ................... 423

80. Tongue: Areas of Taste ....................................... 428

81. Nose: Olfactory Receptors ..................................... 431

82. Ear: Coronal Section ......................................... 435
ACKNOWLEDGEMENTS

Portions of Book 4 were originally prepared for the Louisiana Regional Medical Program under

the direction of C. Dennis Fink, Ph.D., Program Director, HumRRO, and Robert F. Ryan, M.D.,

Chairman, School of Medicine, Tulane University, who served as Technical Advisor to HumRRO.

We would like to thank one person in particular for his careful review of this text and his guidance

and support. His suggestions have contributed much to this manual. We deeply appreciate the

assistance of J. David Bergeron, Assistant Professor, Department of Natural Sciences, Longwood

College, Farmville, Virginia.

The Committee members gratefully acknowledge the continuing assistance of Dr. Charles E.

Platz, Associate Professor, Department of Pathology, College of Medicine, University of Iowa, Iowa

City, Iowa, as our advisor.
SECTION A

OBJECTIVES AND CONTENT OF BOOK 4
2
SECTION A

OBJECTIVES AND CONTENT OF BOOK 4

The purpose of this book is to introduce you to human anatomy and to the neoplasms associated

with the various anatomical structures. If you thoroughly studied Book 3, The Composition of Medical

Terms, you will be prepared for the anatomical terms you will encounter in this book. If you acquire

a good background in anatomy, your work in abstracting will become easier. However, these manuals

can give you only a cursory glance at human anatomy. You will need to supplement your knowledge

with independent study. A bibliography of suggested texts and references is provided at the end of

this manual.

You will recall from the chapter on "Derivation of Cells and Tissues" (Section E of Book 2) that

as the cells of the embryo divide, they change their shape, structure, and their relationship to each

other to form three embryonic layers. From these three layers develop all the tissues, organs, and

organ systems of the body, each of which is specialized for the performance of specific functions.

Our study of anatomy will begin with the integumentary system (skin and its derivatives) followed

by the lymphatic, cardiovascular, respiratory, and digestive systems and continue with the urinary,

reproductive, endocrine, skeletal, muscular, nervous systems, and the sensory organs. However, as

an introduction to human anatomy, you will first study terms describing location and position within

the body.
4
SECTION B

TERMS USED TO INDICATE BODY LOCATION AND POSITION

5
6
SECTION B

TERMS USED TO INDICATE BODY LOCATION AND POSITION

llumerAor (cr&ntsL or

cephaLAc ) __j

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I

I

fl

g,.

&ntmrlor _ Pomt_orLor

B

Ill '

t tt '

I

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lnte_Lor (¢_tLd_L)

Solid lines = sagittal, midsagittal (median)

Dotted lines = transverse (horizontal)

Dashed lines = frontal (coronal)

Figure 1A. PLANES OF REFERENCE AND DIRECTIONAL TERMS

7
8
SECTION B

TERMS USED TO INDICATE BODY LOCATION AND POSITION

Positional Terms

There are a number of words commonly used to describe body location such as, posterior (in back

of), anterior (in front of), lateral (at the side of), and medial (near the middle of). There are also

pref'txes which are commonly used to describe location and position. As examples, the prefix bi

means "both" or "double," therefore, the term bilateral means "affecting both (two) sides." The prefix

para means '_oeside, near or adjacent," sub means "under," and supra means "above or over."

To understand the verbal descriptions contained within a medical record, it is necessary to know

the meaning of words and prefLxes which refer to location and position. This will enable you to

abstract more accurately the reports contained in a medical record.

Some positional terms refer to the location of an anatomical part relative to another body part

or location. The reference may be general; for example, cephal(o) is used as a prefix to denote

"towards the head." Caudal is often used as a prefix to denote "towards the tail (feet)."

Sometimes the location reference may be quite specific. For example, the reference may denote

a body organ or a specific structure such as the heart, cardi(o), or the rectum, proct(o).

There is no need for you to memorize long lists of these terms. As you encounter them, look

them up in your medical dictionary or in a book on medical terminology. Before long, you will be

familiar with most of them. It is recommended that every registry purchase at least one book on

medical terminology.

Anatomical Position

By world-wide agreement, the position of body organs and structures is described as though the

body were in anatomicalposition, that is,standing, looking straight ahead, arms at the side with palms

of the hands facing frontward (see Figure 1A).

The following list gives the "directional planes" and some of the relative positional terms used to

describe anatomical location. You are most apt to encounter these terms while reading an operative

record (report of surgery). Also, these terms often are used in the physical examination (see Figure

1A).

9
Directional Planes of the Body

Sagittal plane Any vertical section of the body which divides it into right and

left portions.

Midsagittal plane A vertical section at the midline of the body such that the

(Median) body is divided into equal right and left halves.

Frontal plane A vertical section of the body dividing it into front

(Coronal) (anterior) and back (posterior) portions.

Transverse plane Any horizontal section of the body dividing it into upper and

(Horizontal) lower portions.

Cavities of the Body

The spaces within the body which contain the internal organs are called the body cavities. There

are two main body cavities: the dorsal cavity and the ventral cavity (see Figure 1B).

• The dorsal cavity is divided into:

The cranial cavity containing the brain and the vertebral cavity containing the spinal cord.

Protective membranes covering the brain and spinal cord are called meninges.

• The ventral cavity is divided by the diaphragm into:

The thoracic and abdominopelvic cavities.

The thoracic cavity is subdivided into the right and left pleural portions and the

pericardial portion. The pleural portions contain the lungs covered by serous membranes

called pleurae. The pericardial portion encompasses the heart. In addition to the heart,

the area between the lungs (called mediastinum) contains the trachea, esophagus,

thymus, blood vessels, and lymphatic vessels and nodes.

The abdominopelvic cavity is subdivided into the abdorninalportion containing the liver,

gallbladder, stomach, spleen, pancreas, small and large intestines, kidneys, ureters; and

the pelvic portion containing the bladder, rectum, sigmoid colon, and reproductive

organs. Supportive and protective serous membranes covering these organs are

classified, in general, as peritoneum.

10
(Tranmve_8o view) (SaaLqtsL v_ow)

Figure lB. MAIN BODY CAVITIES

11
Relative Positional and Directional Terms

Anterior (ventral) Refers to the front (frontal plane) of or abdominal portion of

the body. The trachea lies anterior (ventral) to the esophagus.

Note: In official anatomical nomenclature the terms anterior

and ventral are used in reference to the ventral or belly surface

of the body. When speaking about the trunk of the body, the

term anterior or ventral can be used to mean "in front of."

However, for parts of the head, the ventral structure is the

underside or the side nearer to the belly. For instance, the

ventral surface of the brain is the lower surface.

Posterior (dorsal) Refers to the rear or back of the body. The kidneys are

posterior (dorsal) to the stomach.

Superior (cranial or Refers to points nearer to or towards the head. The heart is

cephalic) superior to the stomach.

Inferior (caudal) Refers to points nearer to or towards the tail or feet. The

pancreas is inferior (caudal) to the heart.

Medial Refers to a position nearer the middle (midsagittal plane) of

the body. The heart is medial to the lungs.

Lateral Refers to positions to the side of the body, to positions farther

away from the midsagittal plane. The ascending colon is lateral

to the small intestine; the lungs are lateral to the heart.

Proximal Refers to positions nearer the origin, an attachment, or a

reference point. The cecum is proximal to the ascending colon.

Distal Refers to positions farther away from the origin, a reference

point, source, or attachment. The rectum is located at the

distal end of the digestive system.

Superficial _Refers to locations near the surface of the body or a specific

organ. Most palpable lymph nodes are located superficially.

Deep Refers to locations within the body or organ. Lymph nodes

which drain organs and structures located in the abdominal

cavity are deep nodes.

12
External Refers to locations which are toward the outside of a body or

a specific organ, or outside a reference point. The ribs are

external to the thoracic cavity.

Internal Refers to locations which are within the inner portion of the

body, a specific organ, or a reference point. Internal may be

synonymous with deep. The lungs are an internal reference

point deep within the body.

Central Refers to the primary parts of the central nervous system (the

brain and spinal cord) or to any axis of symmetry.

Peripheral Refers to that part of a system outside the central portion. The

peripheral nervous system refers to the nerves connecting the

central nervous system to all other parts of the body. A

peripheral lesion is located away from (medially, laterally,

superior or inferior to) the middle of the organ.

Parietal Refers to the wails of a cavity. The parietal pleura is that

portion of the pleura closest to the chest wall.

Visceral Refers to the organs within the thoracic and abdominopelvic

cavities. The visceral pleura is that portion of the pleura

investing the lungs themselves.

Quadrant (quarter) One of the four corresponding parts, regions, or quarters into

which the body or its parts may be divided for a more precise

reference, such as the abdomen or each breast.

Figure 2. ABDOMINAL QUADRANTS

The abdominal quadrants 1 are __ __

abbreviated as follows:

RUQ - right upper quadrant j _ _ t

RLQ - right lower quadrant / J _7 _''': I_

LUQ - left upper quadrant auo _/-_ _LUO

LLQ - left lower quadrant RLO _-_ I.LO

1See Section I, The Reproductive System, for specific use of quadrant location for cancers of the

breast.

13
Figure 3. ANATOMIC DIVISIONS OF THE ABDOMEN

1. Hypochondriac regions (upper lateral regions) I_

2. Epigastric region (upper mid-region medial

to the hypochondriac regions)

3. Lumbar regions (midlateral regions)

4. Umbilical (navel)region I[

5. Inguinalregioniliac s)Orregions (lower lateral _._tk\, ,),)

6. Hypogastric or pelvic region (region

inferior to the lower border of the iliac

crest and medial to the inguinal regions)

_lllac

. rob t

On the following page is a practical exercise containing some commonly used terms. Use this test

to identify those terms which you need to study.

As you study each body system, you will be asked questions which require you to use your

knowledge about location terms. The questions might be something like this:

Q. Does the word suprarenal refer to a gland which is located above, below, distal to, or lateral

to the kidney?

Answer: above--the prefix supra means "above."

Q. Does the clavicle lie inferior to or superior to the maxilla (upper jaw)?

Answer: inferior to--inferior means "situated below or directed downward."

14
Practical Exercise

Listed below on the left are terms used to denote anatomic position and location. Match the

terms on the left with the definitions on the right. Caution: This is a somewhat difficult exercise

because two or more definitions may define a term in whole or in part. So, for each term, select all

the definitions which fit it at least in part.

Terms Definitions

a. anterior (ventral) 1. towards the side, away from the middle

b. distal 2. within

c. endo- 3. towards the back, in back of

d. epi- 4. above, beyond, excessive

e. extra- 5. away from the beginning of a structure

f. hyper- 6. near the surface of the body or a specific organ

g. hypo- 7. towards the head, above

h. inferior (caudal) 8. outside of, in addition to

i. inter- 9. towards the middle vertical body plane

j. intra- 10. within the body cavities

k. juxta- 11. near to front, in front of

1. lateral 12. above, superior to

m. medial 13. near, beside

n. para- 14. before, in front of

o. peri- 15. nearer to the beginning of, closer to

p. posterior (dorsal) 16. behind, back of, backward

q. pre- 17. around, about

r. proximal 18. near, adjoining

s. retro- 19. between

t. sub- 20. under, below, beneath

u. superficial 21. on, upon, over

v. superior (cephalic) 22. below, under, deficient

w. supra- 23. inside, within

x. visceral 24. towards the tail (feet), below, away from the

head

15
Answers to Practical Exercise

Note that the preferred definition is underlined when there is more than one possible answer.

Terms Definitions

a. anterior (ventral) 11. near to front, in front of

14. before, in front of

b. distal 15. away from the beginning of a

structure

c. endo- 2. within

23. inside, within

d. epi- 21. on, upon, over

e. extra- 4. above, beyond, excessive

8. outside of, in addition to

12. above, superior to

f. hyper- 4. above, beyond, excessive

12. above, superior to

g. hypo- 20. under, below, beneath

22. below, under, deficient

h. inferior (caudal) 20. under, below, beneath

22. below, under, deficient

24. towards the tail (feet), below,

away from the head

i. inter- 19. between

j. intra- 2. within

23. inside, within

k. juxta- 13. near, beside

18. near, adjoining

1. lateral 1. towards the side, away from the

middle

m. medial 9. towards the middle vertical body

plane

16
Answers to Practical Exercise (continued)

Terms Definitions

n. para- 13. near, beside

18. near, adjoining

o. peri- 13. near, beside

17. around, about

p. posterior (dorsal) 3. towards the back, in back of

16. behind, back of, backward

q. pre- 11. near to front, in front of

14. before, in front of

r. proximal 13. near, beside

15. nearer to the beginninl_ of,

closer to

18. near, adjoining

s. retro- 3. towards the back, in back of

16. behind, back of, backward

t. sub- 20. u.nder, below, beneath

22. below, under, deficient

u. superficial 6. near the surface of the body or

a specific organ

v. superior (cephalic) 4. above, beyond, excessive

7. towards the head, above

12. above, superior to

w. supra- 4. above, beyond, excessive

7. towards the head, above

12. above, superior to

x. visceral 10. within the body cavities

17
18
SECTION C

THE INTEGUMENTARY SYSTEM

19
20
SECTION C

THE INTEGUMENTARY SYSTEM

The skin (integument) covers the entire surface of the body. It consists of two layers (Figures 4A

and 4B): a thin outer layer called the epidermis 1 and an underlying thick layer, the dermis. 2 The

skin forms a pliable covering for the body and provides a barrier in preventing injury to underlying

tissues. Unbroken skin keeps out ever-present bacteria and other microorganisms and essentially

prevents body infections. It provides a nearly waterproof covering which enables the body to resist

dehydration at normal temperatures. Pigmentation (melanin) in the skin gives the body protection

against solar radiation.

Humans need to maintain a constant body temperature. Heat is continually produced in the body

by the oxidation of fats and carbohydrates. The blood transfers the heat throughout the body. The

skin's complex vascular pattern plays an important role in the regulation of the body temperature.

The surface evaporation of sweat is another mechanism for heat control. The skin has an excretory

function because of the rich supply of sweat and sebaceous glands that are embedded in the dermis.

lepidermis--The protective, outer layer of the skin.

Zdermis--The layer of skin under the epidermis consisting of dense vascular connective tissue; also

known as the corium.

21
Epidermis

The epidermis (Figure 4A) is composed of stratified squamous epithelium. It has several layers.

The cells of each of these layers change as they move from the basal layer up to the surface of the

skin. The layers (from the surface inward) are:

• Cornified (horny) cell layer (stratum corneum): An outer layer of overlapping flattened

scale-like (squamous) remnants of cells which have lost their nuclei and which are filled with

keratin, a water-insoluble protein.

• Clear-cell layer (stratum lucidum): A thin transparent layer consisting of a substance called

eleidin, a precursor of keratin. Since it is found only on the palms of the hands and the soles

of the feet, this layer does not appear in Figure 4A below.

• Granular-cell layer (stratum granulosum): A layer of cells containing granules of keratohyalin,

an earlier precursor of keratin.

• Prickle-cell layer (stratum spinosum)

• Basal-cell layer (stratum basale, formerly called stratum germinativum, also called Malpighian

layer): A layer of actively dividing columnar cells attached to a basement membrane (basal

lamina) which marks the junction of the dermis and epidermis.

Figure 4A. LAYERS OF THE EPIDERMIS

Cornifi corneum) ed-celi layer (stratum

Granular-cell granulosum) layer (stratum

P

Pspinosum) rickle-cell layer (stratum

Basal-cell layer stratum basale, (stratum germinativum)

The keratinized surface-cell remnants are continually worn away or shed while new cells are being

formed by the lower layers of the epidermis. As they are formed, they are pushed outward to the

surface, gradually flattened, and become filled with keratin. Keratin is a term derived from the Greek

word keras meaning "horny."

22
Melanocytes (pigment cells), located primarily in the basal layer of the epidermis, produce melanin

(a dark pigment). The presence of melanin is one of the factors which determine skin color. All

individuals except albinos have some melanin in their skins. It is vital for protection against the

harmful effect of ultraviolet radiation.

Dermis

The dermis (corium) constitutes the greater part of total skin thickness and contributes strength

and elasticity to the skin. The thickness of the dermis varies from 3 to 4 millimeters on the palms

of the hands and the soles of the feet to less than 1/2 millimeter on the eyelids. It is composed of

two layers of dense connective tissue:

• Papillary layer (stratum papillare): A thin layer which includes blood vessels, lymphatics, and

nerve endings.

• Reticular layer (stratum reticulare): A thicker, deep layer consisting of connective tissue and

containing sweat glands, sebaceous glands, and hair follicles. (The reticular layer of the dermis

merges with the subcutaneous tissue1.)

Figure 4B. LAYERS OF THE SKIN: EPIDERMIS AND DERMIS

1NaLp

1subcutaneous tissue--The loose connective tissue under the dermis.

23
24
Q1

a. What are the two primary layers of the skin?

1.

2.

b. A lack of what component of the basal-cell layer of the epidermis causes persons with fair skin

to sunburn more readily than those with darker skin?

c. Match the skin layer with the tissue type:

1. epidermis a. epithelium

2. dermis b. connective tissue

25
Answer: Q1

a. The two primary layers of the skin are:

1. epidermis

2. dermis or corium

b. Melanin. It causes the pigmentation of skin. It is produced by melanocytes. People

with fair skin who have little melanin will sunburn easily.

c. The skin layers and tissue type match as follows:

a 1. epidermis - epithelium

b 2. dermis - connective tissue

26
Epidermis is epithelial tissue derived from ectoderm; it contains no blood vessels. Dermis is dense

connective tissue which contains blood vessels, nerves, and glands.

Accessory_ Organs

The accessory organs or appendages of the skin are: sebaceous 1 glands, sweat or sudoriferous 2

glands, ceruminous 3 glands, and the nails and hair. (The mammary glands are specialized accessory

glands of the skin and will be discussed in The Reproductive System.)

1sebaceous--Secreting an oily substance, sebum; glands are situated in the dermis.

2sudoriferous--Secreting sweat; glands are situated in the dermis and subcutaneous tissue.

3ceruminous--Secreting a waxlike substance, cerumen; glands are located in the skin of the

external auditory canal.

27
28
Q2

Name the three glands of the skin:

1.

2.

3.

29
Answer: Q2

The three glands of the skin are:

1. Sebaceous glands

2. Sweat or sudoriferous glands

3. Ceruminous glands

3O
• The sebaceous glands are widely distributed in the skin except in the palms of the hands and

the soles of the feet. They develop from the follicular epithelium of the hair. Several of these glands

grow out from each hair follicle with direct connection to the hair root by a short duct. Through

these ducts is secreted sebum, an oil which coats the body hair at the surface of the skin.

• The sweat or sudoriferous glands are simple coiled tubular glands. The secreting portion of the

gland is coiled into a ball and lies in the deep part of the dermis. Sweat, the product of this gland,

passes upward through its duct into a pore which ol_ens on the surface of the skin. Sweat glands are

controlled by the central nervous system. Afferent" nerves carry impulses from the skin to the brain

informing it of environmental temperatures. The efferent 2 nerves, in turn, carry impulses from the

brain to the skin causing a reflex emergency mechanism to trigger the sweat glands to begin cooling

the body temperature by evaporation. This reflex action is also responsible for an immediate

withdrawal of your hand when you touch a hot surface.

• The ceruminous glands are thought to be modified sweat glands. The secretory portions of

these glands open directly into the skin or into the ducts of the sebaceous glands. Their function is

to lubricate the surfaces of the ear canals and the ear drum membranes (tympanic membranes) by

secreting ear wax.

• A hair is composed of keratinized cells compactly cemented together. Hair is distributed over

almost the entire body. It consists of the root, or portion below the surface, and the shaft, or portion

extending above the surface. The root is embedded in a pit-like depression called the hair follicle.

It widens at its lower end to include small vascular papillae (small loops of blood vessels). These

papillae provide nutrition for the growth of hair. Hair grows as a result of the division of the cells

of the root. The hair follicle is placed obliquely in the skin, and a small smooth muscle called the

arrector muscle, fastened to the side, causes the hair to stand up in cold or fright and gives the

appearance of goose flesh to the skin.

• Nails are comparable to the horny-cell layer (stratum corneum). Nail beds underlying the nail

consist of the deeper layers of the epidermis and the dermis. Blood in the dermal capillaries is

responsible for the nails' pink color. The white halfmoons at the base of the fingernails are called

lunulae.

1afferent--Conveying towards a center.

2efferent--Conveying away from a center.

31
32
Q3

Accessory skin organs are found mainly in the papillary/reticular layer of the dermis. (Circle one.)

Q4

a. Sebaceous glands secrete sweat/oil_q_/wax.(Circle one.)

b. Sudoriferous glands secrete sweat/oi_Ll/wax. (Circle one.)

c. Ceruminous glands secrete sweatJoi_Ll/waxfor the ear canals and the eardrum membranes.

(Circle one.)

33
Answer: Q3

Accessory skin organs are found mainly in the reticular layer of the dermis.

Answer: Q4

a. Sebaceous glands secrcte oil.

b. Sudoriferous glands secrete sweat.

c. Ceruminous glands secrete a wax for the ear canals and the

eardrum membranes.

34
Benign Tumors

There is a large group of benign skin tumors appearing as moles or birthmarks which are

designated by the term "nevus'a or "nevi" (plural). These tumors are proliferations of melanocytes

and are probably of neural crest z origin. They may be 1) junctional (at the dermal-epidermal

junction), 2) intradermal, or 3) compound (both). They may be pigmented or nonpigmented. The

giant pigmented nevi which are present at birth may become malignant.

Connective tissue tumors, such as dermatofibroma, fibroxanthoma, hemangioma, and

lymphangioma may arise in the dermis. Adenomas may arise in the glandular epithelium of the

sebaceous, sweat, or ceruminous glands.

lnevus--A benign tumor composed of melanocytes.

Zneural crest--A cellular band dorsolateral to the neural tube that gives rise to the cerebrospinal

ganglia. (For further information, study the embryology of the nervous system.)

35
Malignant Tumors

A variety ol" malignant tumors also arise in the skin and may derive from epithelial and/or

connective tissue of the skin and its appendages. Many ol" these are felt to be related to prolonged

exposure to sun rays. Individuals with light skin/decreased melanin are more susceptible. The most

common tumors are listed and described briefly below:

• Basal cell carcinoma: A malignant skin tumor composed of cells similar to those in the basal

layer of the epidermis

• Squamous cell (epidermoid) carcinoma: A malignant tumor having characteristics ofsquamous

cells

• Basosquamous cell carcinoma: A malignant skin tumor of mixed basal and squamous cells

• Bowen's disease: lntraepidermal (in-situ) squamous cell carcinoma

• Dermatofibrosarcc)ma (protuberans): A l'ibrosarcoma o1"the skin, a low grade malignant tumor

of the fibrous tissue of the dermis

• Sweat gland adenocarcinoma: A malignant tumc)r o['sudoril'crous glandular epithelium

• Sebaceous gland adenocarcinoma: A malignant tumor of sebaceous glandular epithelium

• Kaposi's (multiple idiopathic hemorrhagic) sarcoma: A multifocal malignant vascular tumor

characterized by bluish-red or brown plaques and nodules. Kaposi's sarcoma appears to be

an opportunistic carcinoma in the presence o1'AIDS (acquired immune deficiency syndrome).

• Mycosis fungicides: A malignant lymphtmla <_fthe skin characterized by erythema, scaling,

tumor Iormaticm, and ulceration

• Malignant melanoma: A malignant tumor of the mehmin-producing cells (melanocytes),

usually black-brown, although lesions may be nonpigmented (amelanotic)

Many cancer registries do not register basal and squamous cell carcinomas of the skin except for

selected sites, such as skin ol" external genital organs: vulva, penis, and scrotum.

36
Q5 Match the malignant tumors of the skin on the left with the best description on the right.

1. Bowen's disease a. A malignant lymphoma of the skin

2. Dermatofibrosarcoma b. Intraepidermal squamous cell carcinoma

3. Kaposi's sarcoma c. A multifocal malignant tumor characterized by

bluish red or brown plaques or nodules

4. Mycosis fungoides d. A malignant tumor of the fibrous

tissue of the dermis

5. Melanoma e. A malignant tumor of the melaninproducing cells

37
Answer: Q5

b 1. Bowen's disease Intraepidermal squamous cell carcinoma

d 2. Dermatofibrosarcoma A malignant tumor of the fibrous tissue of the dermis

__e 3. Kaposi's sarcoma A multifocal malignant tumor characterized by bluish

red or brown plaques or nodules

a..L 4. Mycosis fungoides A malignant lymphoma of the skin

5. Melanoma A malignant tumor of the melanin-producing cells

38
Malignant Melanoma

Malignant melanomas may arise directly from melanocytes at the dermal- epidermal junction or

within the basal cell layer and not from pre-existing moles. There are, however, some pre-existing

lesions in which melanomas are known to develop, namely:

giant hairy (pigmented) nevus

blue nevus

junctional nevus

intradermal nevus.

The B-K mole syndrome has recently been described by Clark and associates. Familial

melanomas frequently arise from the large, irregular moles which have been called "B-K moles" after

the first two families in which this syndrome was observed. Thus, if the diagnosis is made, all nevi

should be removed in these individuals to prevent the lesions from becoming invasive.

Most melanomas occur in the skin; however, they may occur elsewhere in the body, often in the

eye. Subungual melanoma, that is, melanoma beneath the nail, is not uncommon. When abstracting

a case of melanoma, or any skin cancer for that matter, the primary site of the lesion should be

carefully identified. Primary site classifications taken from the International Classification of Diseases

for Oncology (ICD-O), Second Edition, are as follows:

TOPOGRAPHY CODE FOR MELANOMAS (M-8720-8790)

C44.0 Skin of lip, NOS

C44.1 Eyelid

C44.2 External ear

C44.3 Skin of other and unspecified parts of face

(244.4 Skin of scalp and neck

C44.5 Skin of trunk

C44.6 Skin of upper limb and shoulder

C44.7 Skin of lower limb and hip

C44.8 Overlapping lesion of skin (overlaps the boundaries of two or more subcategories and whose point of origin cannot be determined)

C44.9 Skin, NOS

C51.0 - C51.2, C51.9 Skin of vulva

C60.0 - C60.1, C60.9 Skin of penis

C63.2 Skin of scrotum

Skin of the lip should not be confused with the lip itself which is considered to be part of the

digestive system. The skin of the upper lip extends from the vermilion border to the anterior nares;

the lateral borders are the nasolabial sulci 1. The skin of the lower lip extends from the lower

vermilion border to the lateral semicircular groove where the chin begins.

lnasolabial sulcus--A groove which runs downwards and laterally from the side of the nose to the

angle of the mouth.

39
The classification of cutaneous melanoma as to histologic type and depth of invasion has

undergone considerable study in recent years, particularly in the United States and Australia with the

evolution of similar classification schemes. The generally defined types of cutaneous melanoma are

described as follows:

• Lentigo maligna melanoma: A melanoma arising in a Hutchinson's melanotic freckle. The

atypical melanocytes are confined to the basal layer of the epidermis during the radial growth

phase. The entity is known as lentigo maligna or Hutchinson's melanotic freckle during the

period of its intraepidermal growth. It is found primarily in elderly persons.

• Superficial (radial) spreading type malignant melanoma: A melanoma characterized by gradual

radial enlargement over a period of several months or even years before the onset of its

vertical growth phase.

• Acral lentiginous melanoma: A specific biologic form of melanoma occurring commonly on the

palms of the hands and the soles of the feet. It may also occur in areas other than skin, i.e.,

in the mucous membranes and subungual areas.

• Nodular melanoma: A malignant tumor characterized by early and rapid dermal invasion with

no radial growth phase as a developmental stage. These tumors are in vertical growth from

onset.

• Malignant melanoma, unclassified: A malignant melanoma for which the radial growth phase

has not been determined.

Breslow 1 has emphasized the importance of measuring the thickness (vertical growth) of

penetration of the melanotic lesion. The measurement represents the thickness of invasion in

millimeters from the granular layer of the epidermis to the greatest depth of penetration of the tumor

into the dermis.

The measurement categories for thickness are as follows:

< 0.75 mm.

0.76 - 1.50 mm.

1.51 - 3.00 mm.

3.01 - 4.00 mm.

> 4.00 mm.

Note: < = less than, > = greater than, and the symbol < = less than o_ equal to

1Breslow, Alexander--He initiated the measurement of tumor thickness to evaluate the incidence

of recurrent disease in relationship to depth of invasion of the melanoma into the dermis.

40
The description of the level 1 of invasion of melanoma, sometimes called "Clark's2 Classification,"

describes five levels of invasion. The definitions of each level are as follows:

Level I Intraepidermal: Tumor confined to epidermis (in-situ) and does not penetrate the

basement membrane (basal lamina)

Level II Papillary dermis: Tumor invades only the superficial or papillary zone of the

dermis

Level III Papillary-reticular dermal interface: Tumor fills and expands the papillary dermis

extending to the interface of the papillary and reticular layers without invading the

reticular layer

Level IV Reticular dermis: Tumor invades the deep or reticular layer of the dermis

Level V Subcutaneous tissue: Tumor invades through the reticular dermis into the

subcutaneous tissue

Figure 5. CLARK'S CLASSIFICATION OF MALIGNANT MELANOMA

]For melanomas, it is recommended that the abstractor record both thickness (in ram.) and level

of invasion.

2Clark, Wallace H., Jr.--A pathologist identified with the classification of primary malignant

melanoma by "level" of invasion.

41
42
Q6

In which of the following would you not expect to find a primary malignant melanoma?

(Check one.)

[ ] Skin of ear

[] Eye

[ ] Liver

[ ] Vulva

Q7

Subungual melanoma occurs under the tongue/beneath the nail. (Circle one.)

Q8

Match each histologic type of melanoma on the left with the appropriate description on the right.

1. Lentigo maligna melanoma a. Characterized by radial growth phase for months or

years prior to onset of vertical growth phase

2. Superficial (radial) b. No radial growth phase

spreading malignant melanoma

3. Acral lentiginous melanoma c. Confined to the basal layer of the epidermis during

its radial growth phase

4. Nodular melanoma d. Occurring commonly on the palms of the hands and

the soles of the feet

43
Q9

"Clark's Classification" of malignant melanoma describes five levels of invasion. Place the

following terms in order from least invasive (I) to most invasive (V): papillary-reticular dermal

interface, subcutaneous tissue, papillary dermis, intraepidermal, and reticular dermis.

I

II

III

IV

V

44
Answer: Q6

Liver. Malignant melanomas may metastasize to the liver, but generally would not arise

there.

Answer: Q7

"beneath the nail" should have been circled. The term for "under the tongue" is sublingual.

Answer: Q8

c 1. Lentigo maligna melanoma Confined to the basal

layer of the epidermis during

its radial growth phase

a 2. Superficial (radial) Characterized by radial

spreading malignant growth phase for months

melanoma or years prior to onset

of vertical growth phase

d 3. Acral lentiginous melanoma Occurring commonly on the

palms of the hands and the

soles of the feet

b 4. Nodular melanoma No radial growth phase

Answer: Q9

Clark's Classification:

I Intraepidermal

II Papillary dermis

III Papillary-reticular dermal interface

IV Reticular dermis

V Subcutaneous tissue

45
Lymphatic Drainage of the Skin

The lymphatic drainage of the skin is to the superficial lymph nodes rather than to those situated

deep within the body. If these superficial lymph nodes are involved with tumor, they frequently can

be palpated.

The lymph nodes which receive direct (ipsilateral) lymphatic drainage from the skin are:

REGIONAL LYMPH NODES OF SKIN BY PRIMARY SITE

Head and Neck - cervical for all Thorax/chest wall/upper back

subsites

Lip: axillary

preauricular (parotid), facial, internal mammary

submental, submandibular intercostal

supraclavicular

Eyelid/canthus:

preauricular (parotid), facial, sub- Abdomen/lower back

mandibular, infra-auricular

femoral (superficial inguinal)

External ear/auditory canal:

preauricular (parotid),

postauricular (mastoid) Arm/shoulder

Face, Other*: axillary

preauricular (parotid), facial, spinal accessory for shoulder

submental, submandibular epitrochlear for hand,

forearm

Scalp/neck: Le_Jhip

preauricular (parotid), occipital,

spinal accessory (posterior femoral (superficial inguinal)

cervical) except for heel

postauricular (mastoid) popliteal for heel and calf

for scalp

supraclavicular, Scrotum/perineum

axillary for neck

femoral

inguinal

*Includes the skin of the cheek, chin, forehead, jaw, nose, temple

46
Figure 6. LYMPHATICS OF THE SKIN

(sulper_lcLa 1L LnliuA haL)

d_ll LarF :;

rc_hLesr

:!

i !

47
48
Q10

Match the regions of the skin on the left with the lymph node drainage on the right.

1. Head a. Supraclavicular and axillary lymph nodes

2. Upper extremity b. Submandibular and postauricular (parotid) lymph nodes

.3. Lower extremity c. Axillary and epitrochlear lymph nodes

4. Chest wall d. Femoral (superficial inguinal) and popliteal lymph nodes

49
Answer: Q10

The skin locations on the left match the lymph nodes on the right as follows:

b 1. Head Submandibular and postauricular (parotid) lymph nodes

c 2. Upper extremity Axillary and epitrochlear lymph nodes

d 3. Lower extremity Femoral (superficial inguinal) and popliteal lymph nodes

a 4. Chest wall Supraclavicular and axillary lymph nodes

5O
SECTION D

THE LYMPHATIC SYSTEM

51
52
SECTION D

THE LYMPHATIC SYSTEM

The lymphatic system and the cardiovascular system (Section E) together provide the internal

environment of the body. The blood carries food and oxygen to, and waste products from, the cells

of the body. The lymphatic system consists of a set of vessels and aggregations of lymphatic tissue

which collect and carry lymph 1 from the body tissues to the veins of the blood circulatory system.

Lymph vessels, like blood vessels, are distributed to nearly all parts of the body. The lymphatic

system carries fluid away from, and not to the tissues; consequently, it is not a continuous closed

circulation system as is the cardiovascular system. The lymph enters the system via the lymph

capillaries and flows into larger and larger collecting vessels until it finally empties into the subclavian

veins. Interposed along the lymphatics (lymph vessels) are many lymph nodes, structures which serve

as filters to clear the lymph of particulate matter. Lymphatic organs and tissues include lymph nodes,

the spleen, thymus, tonsils, and Peyer's patches of the small intestine. The lymph nodes, spleen, and

thymus have roles as hematopoietic 2 (lymphopoietic) 3 centers mainly producing lymphocytes.

Figure 7. RELATIONSHIP BETWEEN THE BLOOD AND LYMPH CIRCULATORY SYSTEMS

ArteriaL bLoad from hm&rt

V-nou- blood to h-----'T _

Lymph oodo•

and vmmmetm

BLood

vell_t i.O0

CoLLm ol

bod¥

tissue

BLood

c&p£LL_r£om

Lymph

cap/. ]Ltarl BLood

artorlotom

llymph--A clear watery fluid found in the lymph vessels (See page 63 for a more detailed

discussion.

2hematopoiesis--(hemopoiesis)--Formation and development of blood cells.

31ymohopoiesis--Formation and development of lymphatic tissue or cells (lymphocytes).

53
T-Cells Versus B-Ceils

The two principal classes of lymphocytes that can be recognized in an immune system are T and

B lymphoeytes. In recent years an attempt has been made to relate malignant lymphoma to the

normal cells of the immune system and to understand which parts of the immune system are involved.

The T-cells mature in the thymus and are involved in cell-mediated immunity, that is, the cells

themselves mediate the immune effect.

The B-cells derive from a bone-marrow precursor and mature in the chicken in an organ known

as the bursa Fabricius. In humans and other mammals there is no bursa Fabricius, but B-cells mature

in a bursa equivalent, which may be fetal liver. The B-cells, through their progeny, differentiate into

plasma cells. These are cells which can secrete antibodies and are known to form the humoral

component of the immune system, that is, they secrete products which mediate the effect; it is not

the cell itself that is involved in the immune mechanism.

54
Q1

The lymphatic system collects from the tissues of the body via the

lymphatic . Lymph isfiltered through the

, and finally it empties into the veins of the blood

circulatory system.

Q2

Some specific lymphoid organs and tissues are:

1.

2.

3.

4.

5.

55
Answer: Q1

The lymphatic system collects lymph from the tissues of the body via the lymphatic

capillaries. Lymph is filtered through the lymph nodes, and finally it empties into the

subclavian veins of the blood circulatory system.

Answer: Q2

Some specific lymphoid organs and tissues are:

1. Lymph nodes

2. Spleen

3. Thymus

4. Tonsils

5. Peyer's patches

56
Lymphatic Vessels

The function of the lymphatic vessels is to return lymph from the interstitial fluid 1 to the blood

circulatory system where it may be purified and recharged with nutrients and oxygen. In general,

lymphatic vessels resemble veins in structure, but have thinner walls, many more valves, and lymph

nodes located at intervals along their course. The valves are usually semilunar pairs with free edges

in the direction of current flow. In case of blockage, the valves are often unable to withstand much

increase in pressure and reverse (retrograde) flow may occur.

Lymphatics originating in the villi (finger-like projections) of the small intestine are called lacteals

and the fluid found in them after digestion is called chyle. 2 This fluid is milky in appearance from

absorbed fats.

The lymphatic capillaries originate as microscopic blind-end vessels which are located in the

intercellular spaces and are widely distributed throughout the body. Small lymphatics merge with

larger ones and they, in turn, with still larger vessels until they join (much like the branches of a tree)

to form the main lymphatic trunks: the right lymphatic duct and the thoracic duct. Lymph from the

entire body, except the right upper quadrant, drains eventually into the thoracic duct which flows into

the left subclavian vein at the point where it joins the left internal jugular vein. Lymph from the

upper right quadrant of the body empties into the right subclavian vein by way of the right lymphatic

duct.

Since most of the body lymph returns to the bloodstream via the thoracic duct, this vessel is much

larger than the right lymphatic duct--but it is much smaller than the large veins which it resembles

in structure. The thoracic duct varies in length from 35 to 48 era. It originates as a dilated structure,

the cisterna chyli, in the lumbar region of the abdominal cavity, and ascends by a winding course to

the root of the neck where it joins the left subclavian vein. Diagrammatic representation of lymphatic

drainage is shown for different parts of the body in Figures 8A and 8B.

1interstitial fluid--The extra-cellular fluid which bathes the cells and is drained away as lymph.

2chyle--The milky fluid taken up by the lacteals from the food in the small intestine during

digestion. It passes into the thoracic duct at the cisterna chyli.

57
Figures 8A-8B. LYMPHATIC DRAINAGE OF VARIOUS PARTS OF THE BODY

The shaded area is drained by the right lymphatic duct.

58
Q3

The lymphatic system collects lymph from body tissues in an ever-enlarging system of lymphatic vessels to form terminal lymphatic ducts which empty into that

carry the lymph back to the blood circulatory system.

Q4

The main lymphatic trunks are the and

the

Which of these ducts drains the greater part of the body?

Q5

The structure of the lymphatic vessels resembles veins with the major difference being that

the lymphatics have along their course.

59
Answer: Q3

The lymphatic system collects lymph from body tissues in an ever-enlarging system of

lymphatic vessels to form terminal lymphatic ducts which empty into veins that carry the

lymph back to the blood circulatory system.

Answer: Q4

The main lymphatic trunks are the right ly.__ghaticduct and the thoracic duct.

The thoracic duct drains the greater part of the body.

Answer: Q5

The structure of the lymphatic vessels resembles veins with the major difference being that

the lymphatics have lymph nodes along their course.

60
Lymph Nodes

Lymph nodes are oval or bean-shaped masses of lymphoid tissue, densely packed with lymphocytes.

They vary in size from a pinhead to a lima bean. They are each covered by a capsule of fibrous

connective tissue. The lymph moves through the afferent (towards the node) lymphatic vessels into

the node where it is filtered through sinus channels lined with reticuloendothelial cel!s I (or

histioeytes) and emerges by an efferent (away from the node) vessel (see Figure 9A for the internal

structure of a lymph node, and Figure 9B for the external view).

Figures 9A and 9B. STRUCTURE OF A LYMPH NODE

Kf£orent

Lymphatic weasels

lreticuloendothelial cells (or histiocytes)--Special cells which ingest and destroy old erythrocytes

and foreign substances; found mainly in the lymph nodes, liver, spleen, and bone marrow.

61
Lymph nodes accomplish two separate functions--defense and hematopoiesis.

• The defense functions are filtration and phagocytosis. 1 The lymph slowly filters through

the intricate structure of the sinus channels which remove the microorganisms and injurious

particles--for example, cancer cells and soot. Blockage of lymph nodes with obstruction

of the normal flow of lymph may cause edema, inflammation, and retrograde flow of lymph.

Thus, metastasis may occur in adjacent lymph nodes as a result of direct flow, or may occur

in lymph nodes accessible only by retrograde flow.

• The lymphoid tissue of the nodes produces nongranular white blood cells--lymphocytes.

It also produces plasma cells (plasmacytes) which are the cells that create gamma globulins

(antibodies). Production of these different blood cells is the hematopoietic (or lymphopoietic) function of the lymph nodes.

Lymph nodes tend to be grouped in certain areas of the body and are named according to their

location. For example, axillary nodes are located in the axilla, cervical nodes in the neck, mesenteric

nodes in the mesentery of the intestines, and so forth. It is essential that the cancer registrar be

familiar with the location of lymph nodes and the organs and tissues each lymphatic basin drains.

'phagocytosis--Thc engulfing of microorganisms, other cells, and foreign particles by certain cells

(phagocytes).

62
Lymph and Tissue Fluid

Tissue fluid (interstitial fluid) is the clear watery fluid which surrounds all cells. It is sometimes

referred to as "lymph," but technically lymph is derived from interstitial fluid. The word lymph should

only be used in reference to that tissue fluid which has entered the vessels of the lymphatic system.

Both lymph and tissue fluid resemble blood plasma in composition since tissue fluid reaches the

cells in the first place from the capillaries of the blood circulatory system. Tissue fluid fills the

microscopic spaces between the cells and carries oxygen and nutrients from the blood to the cells.

In returning with waste products from the cells, it enters the microscopic lymphatic capillaries as

"lymph" and, as described on page 49, returns to the blood circulatory system via the subclavian veins.

Thus, there is a continuous exchange of materials between the blood and the cells through the interstitial fluid.

63
64
Q6

The lymph nodes have two main functions:

1.

2.

Q7

Lymph nodes often have names specific to the area of the body in which they are located. See

if you can match the named nodes in the left-hand column with the location described in the

right-hand column. (Refer to Figures 6 and 8A and 8B, if necessary.)

Lymph Nodes Location Description

1. Axillary a. Behind and slightly above the elbow

2. Buccal b. In the mesentery of small intestine and colon

3. Cervical c. Lateral portions of neck

4. Epitrochlear d. In front of the sacrum

5. Iliac e. Face, around the cheeks

6. Inguinal f. Under the armpit

7. Intercostal g. Between the ribs

8. Mesenteric h. In the groin

9. Sacral i. Under the chin

10. Submental j. Around iliac blood vessels

Q8

The fluid located within the lymphatic system is called ; the fluid which surrounds the

cells and which carries oxygen and nutrients from the to the cells is called

65
Answer: Q6

The lymph nodes have two main functions:

1. Defense

2. Hematopoiesis (or lymphopoiesis)

Answer: Q7

._f..f 1. Axillary Under the armpit (axilla)

e 2. Buccal Face, around the cheeks

c 3. Cervical Lateral portions of neck

a 4. Epitrochlear Behind and slightly above the elbow

._j.. 5. Iliac Around lilac blood vessels

h 6. Inguinal In the groin

._.g_ 7. Intercostal Between the ribs

b 8. Mesenteric In the mesentery of small intestine and colon

d 9. Sacral In front of the sacrum

i 10. Submental Under the chin

Answer: Q8

The fluid located within the lymphatic system is called lymph; the fluid which surrounds the

cells and which carries oxygen and nutrients from the blood (or capillaries) to the cells is

called interstitial fluid (tissue fluid).

66
Spleen

The spleen, the largest lymphoid organ in the body, is located beneath the diaphragm in the left

upper quadrant directly posterior to the greater curvature of the stomach. It is designed to filter

blood. It is also a reservoir for blood cells--lymphocytes, plasma cells, and monocytes. Its reticuloendothelial cells phagocytize old, worn-out red blood cells. The spleen produces antibodies for the

defense of the body against microorganisms. Despite its many functions, the spleen can be removed

without causing death since most of its functions can be assumed by lymphoid tissue and reticuloendothelial cells elsewhere. There is some evidence that spleen regeneration may occur when cells spill

from the pulp of a damaged spleen, implant in the body, and grow. Sometimes several functional

mini-spleens develop following splenectomy for trauma.

Figure 10. SPLEEN Figure 11. THYMUS GLAND

kz

67
Thymus

The thymus is situated in the anterior mediastinal portion of the thoracic cavity and may extend

up to the lower edge of the thyroid gland. It is a two-lobed gland composed of lymphocytic and

epithelial tissue. A ductless gland, it is assumed to have an endocrine function, but the mechanism

of that endocrine function, if any, is really unknown at this time. The thymus is believed to play a

vital part in hematopoiesis and in immunity against infection. It manufactures or activates specific

lymphocytes called T-cells. The T-cells themselves mediate an immune effect. They seek out

malignant cells that have on their surface particular antigens lacking in normal cells, attach to the

surface antigen, and destroy the tumor cell.

Recent immunotherapy makes use of a complex interaction between macrophages I and T-cells

in protection against or treatment of specific cancers. Macrophages and T-ceils are also largely

responsible for the rejection of tissue transplants and for skin reactions to poison ivy and other

allergens.

The thymus probably completes most of its work by infancy or in early childhood and is largest,

relative to the rest of the body, when a child is about two years old. Its absolute size is largest at

puberty after which the thymus gradually atrophies until in very old age it becomes largely replaced

by fat. There is thought to be some association between thymic tumors and myasthenia gravis, a

neuromuscular disease (see Figure 11 for a diagram of the thymus gland).

Tonsils

The tonsils are small rounded masses of lymphoid tissue located in or about the entrance to the

pharynx. The palatine (faucial) tonsils are located in the lateral pharyngeal walls, the lingual tonsils

are located at the base of the tongue, and the pharyngeal tonsils (adenoids) in the posterior wall of

the nasopharynx. The circle of lymphoid tissue formed by these tonsillar areas is called Waldeyer's

ring. This tissue is believed to act as a supply source of phagocytes to the mouth and pharynx for the

purpose of destroying bacteria (see Figures 21A and 21B and Figure 23 for clarifying diagrams on the

location of the tonsils).

Peyer's patches

Peyer's patches are small aggregates of lymphoid tissue found in the lamina propria of the small

intestine, principally in the distal ileum.

lmacrophage--A phagocytic cell belonging to the reticuloendothelial system.

68
Q9

Match each lymphatic organ or tissue on the left with the appropriate description on the

right.

1. Spleen a. Waldeyer's ring

2. Peyer's patches b. Located in the intestines

3. Thymus c. Filters blood

4. Lymph nodes d. Manufactures T-cells

5. Tonsils e. Filters lymph

Q10

What lymphatic organ may also be an endocrine gland?

69
Answer: Q9

c 1. Spleen Filters blood

b 2. Peyer's patches Located in the intestines

d 3. Thymus Manufactures T-cells

e 4. Lymph nodes Filters lymph

a 5. Tonsils Waldeyer's ring

Answer: QIO

The thymus is a lymphatic organ and may also be an endocrine gland.

70
Lymphatic Drainage

Lymph nodes, most of which occur in groups and/or chains, are arranged along the lymphatic

vessels. The lymphatic drainage from the organs and tissues of the body is through these nodes--first

to regional nodes, then to more distant nodes. The lymphatics tend to parallel major blood vessels

(arteries and veins) and the groups of lymph nodes along these vessels are so named, e.g., the

superior mesenteric nodes are located along the superior mesenteric artery; the internal (upper deep)

jugular nodes follow the internal jugular veins.

The major groups of lymph nodes will be discussed briefly in this section. Within some of these

major categories are more specific groups of nodes which you will learn when we discuss the

lymphatic drainage of specific organs. All of the organs and tissues of the body have known drainage

patterns which are important in the spread of cancer. There may be several names for a particular

group of lymph nodes. Check with your medical consultant to avoid confusion over synonymous

names. Also see Book 6, Comparative Staging Systems for Cancer.

While blood-borne metastasis is most common for sarcomas, carcinomas tend to spread by way of

the lymphatics before entering the bloodstream. Primary tumors of the lymphatic system tend to

involve multiple areas of lymphoid tissue before blood-borne metastasis occurs.

The diagnostic workup for most cancer patients will include an inspection or exploration of the

most likely lymph-node drainage areas. Some lymph nodes are amenable to palpation by the

examining physician while others are located deep within the body and can only be examined at the 1 2

time of surgery or by lymphangiography, CAT scans, or MRI. Lymph nodes may therefore be

termed "accessible" or "inaccessible" depending on whether or not they are palpable by the physician

without surgical intervention.

llymphangiography--Radiographic visualization of lymphatic vessels and lymph nodes following

injection of radiopaque material.

2CAT--Computerized axial tomography.

3MRI--Magnetic resonance imaging.

71
Qll

Lymphatics tend to parallel forming groups or chains

of nodes which usually carry the same names as the blood vessels.

Q12

Sarcomas tend to spread by way of the , while carcinomas first tend to

spread by way of the w.

Q13

The diagnostic workup of a cancer patient should always include of accessible

lymph nodes. Inaccessible lymph nodes may be visualized at exploratory surgery or by

, , or

72
Answer: Qll

Lymphatics tend to parallel blood vessels forming groups or chains of nodes which usually

carry the same names as the blood vessels.

Answer: Q12

Sarcomas tend to spread by way of the blood, while carcinomas first tend to spread by way

of the lymph. Lymph node involvement is a frequent occurrence for carcinomas.

Answer: Q13

The diagnostic workup of a cancer patient should always include palpation of accessible

lymph nodes. Inaccessible lymph nodes may be visualized at exploratory surgery, by

lyrnphangiography, CAT scan, or MRI.

Figure 12A. LYMPH NODES OF THE HEAD AND NECK

73
L..._ph Nodes of Head and Neck

The lymph node drainage for most sites within the head and neck will be to cervical1 nodes. This

is a general term for nodes located in the neck or draining into the nodes of the neck. More

specifically, cervical nodes may be identified as:

• Occipital

• Mastoid (postauricular)

• Facial: infra-orbital, maxillary,buccinator, supramandibular

• Parotid: preauricular, subparotid, infra-auricular

• Sublingual (lingual)

• Retropharyngeal

° Submental

• Submandibular (submaxillary)

• Anterior cervical: prelaryngeal, pretracheal, paratracheal, laterotracheal

(recurrent laryngeal nerve chain)

• Internal jugular: upper and lower deep cervical (jugulodigastric and jugulo-omohyoid)

• Spinal accessory (posterior cervical)

• Transverse cervical (supraclavicular)

The term "supraclavicular nodes" is commonly used to include the transverse cervical nodes and the

lowest nodes of the internal jugular and spinal accessory chains.

The regional nodes for some of the anatomic sites in the head and neck area are, for example:

• Occipital and mastoid lymph nodes - skin of posterior scalp and neck

• Parotid lymph nodes - parotid gland, buccal mucosa, tympanic cavity, eyelids

• Retropharyngeal lymph nodes - pharynx, palate, nasal cavity

• Submental and submandibular lymph nodes - lip, anterior two-thirds of tongue, floor of mouth,

submandibular gland

° Internal jugular (upper and lower deep cervical) lymph nodes, tongue, floor of mouth, palate,

pharynx, larynx, thyroid gland

Refer to the Figures 6 and 28 if you need help in clarifying the locations of these lymph nodes.

1cervical--Pertaining to the neck, or to the neck of any organ or structure.

74
Q14

A general term for lymph nodes located in the neck is

Q15

A general term for lymph nodes of the transverse cervical chain and of the lowest nodes of the

internal jugular (upper and lower deep cervical) and spinal accessory chains is

Q16

List five examples of specific cervical nodes:

1.

2.

3.

4.

5.

Q17

What is another name commonly used for submandibular nodes?

75
Answer: Q14

A general term for lymph nodes located in the neck is cervical. You will learn more about

the specific names of cervical nodes in Book 6, Comparative Staging Systems for Cancer.

Answer: Q15

A general term for lymph nodes of the transverse cervical chain and of the lowest nodes

of the internal jugular (upper and lower deep cervical) and spinal accessory chains is

supraclavicular.

Answer: Q16

Any of the neck nodes mentioned on page 74 are considered cervical lymph nodes.

Answer: Q17

The submandibular nodes and submaxillary nodes are the same.

76
Lymph Nodes of the Thorax

The lymph nodes of the thorax may be classified as parietal I or visceral 2 depending upon

whether they are near the walls of the thoracic cavity or within the thorax, respectively. The primary

regional lymph nodes and the sites which these nodes drain in each of the areas of the thorax are:

• Parietal Area

Internal mammary (parasternal) lymph nodes - breast and chest wall

Intercostal lymph nodes - chest wall and pleura

Diaphragmatic lymph nodes - diaphragm, pleura

• Visceral Area

Anterior mediastinal lymph nodes - lung, pleura, trachea, thyroid, thymus, pericardium

Posterior mediastinal lymph nodes - lung, pleura, esophagus, pericardium

Tracheobronchial (carinal, peritracheal, hilar) lymph nodes - trachea, bronchus, lung, upper

esophagus

Figure 12B. LYMPH NODES OF THE THORAX

st_nst_rT

/

I _(ctTtty_ ,_...t,y:_ I

, - • , ] _ cart tT;'_ Uoataottnat :

Xparietal--Of or pertaining to the walls of a cavity.

Zvisceral--Contained within a body cavity; pertaining to the internal organs or viscera.

77
78
Q18

Lymph nodes of the thorax may be classified as if located in relation

to (near) the chest wall or if located deeper within the thoracic cavity.

Q19

Indicate whether the following lymph nodes are parietal or visceral using the initial letters P

and V:

Intercostal

Posterior mediastinal

Diaphragmatic

Tracheobronchial

Internal mammary

79
Answer: Q18

Lymph nodes of the thorax may be classified as parietal if located in relation to (near) the

chest wall or visceral if located deeper within the thoracic cavity.

Answer: Q19

The parietal and visceral lymph nodes are indicated by P or V as follows:

P Intercostal

V Posterior mediastinal

P Diaphragmatic

V Tracheobronchial

P Internal mammary

Figure 13. LYMPH NODES OF THE ABDOMEN AND PELVIS

8O
Lymph Nodes of the Abdomen and Pelvis

The parietal nodes of the abdomen and pelvis are situated behind the peritoneum 1 and are

commonly called retrol_eritoneal nodes. These nodes lie parallel to the aorta and the iliac arteries

(below the bifurcation Lof the aorta). The principal parietal nodes and some of the sites whose

lymphatics drain directly into these nodes are:

• Aortic (para-aortic) lymph nodes: kidney, suprarenal (adrenal) gland, ovary, testis, corpus uteri

• Iliac (common, internal, external) lymph nodes: uterus, vagina, ovary

• Sacral lymph nodes: rectum, uterus, prostate gland

The visceral nodes of the abdomen are located along the branches of the celiac artery (left gastric,

hepatic and splenic arteries) and the superior and inferior mesenteric arteries. These three major

arteries branch off the aorta as it passes through the abdomen. The regional lymph nodes which

drain the abdominal viscera and some of the sites which they drain are:

• Superior or left gastric lymph nodes: stomach, intrathoracic esophagus

• Inferior or right gastric lymph nodes: stomach, duodenum

• Splenic lymph nodes: stomach, spleen, body and tail of pancreas

• Superior mesenteric lymph nodes: jejunum, ileum, pancreas, ampulla of Vater

• Inferior mesenteric lymph nodes: descending colon, splenic flexure, sigmoid colon,

rectosigmoid, rectum

Refer to Figure 13 for a diagram of abdominal and pelvic lymph nodes.

The lymphatics following the course of the above named arteries carry the lymph back to nodes

located along the aorta; however, the aortic nodes are considered distant nodes for abdominal sites.

1peritoneum--The serous membrane lining the interior abdominal cavity and investing (covering)

the abdominal viscera.

2bifurcation--Division into two branches; in this example, division of the aorta into the right and

left common iliac arteries.

81
82
Q20

Lymph nodes of the abdomen may also be classified as visceral or parietal. The

lymph nodes are located along branches of the celiac, superior,

and inferior mesenteric arteries. Specific names for the lymph nodes located along branches of the

celiac artery are:

1.

2.

3.

Q21

The lymph nodes are located behind the peritoneum

along the aorta and the iliac arteries. They are commonly called lymph nodes.

Specific names for these lymph nodes are:

1.

2.

3.

83
Answer: Q20

Lymph nodes of the abdomen may also be classified as visceral or parietal. The visceral

lymph nodes are located along branches of the celiac and superior and inferior mesenteric

arteries. Specific names for the lymph nodes located along branches of the celiac artery

are:

1. Inferior or right gastric

2. Splenic

3. Superior or left gastric

Answer: Q21

The parietal lymph nodes are located behind the peritoneum along the aorta and the iliac

arteries. They are commonly called retroperitoneal lymph nodes. Specific names for these

lymph nodes are:

1. Aortic (periaortic)

2. Iliac

3. Sacral

84
Lymph Nodes of Upper and Lower Extremities

Located deep within the underarm and upper chest, the axillary nodes receive lymphatic drainage

from the breast, skin, and other tissues of the arm, hand, shoulder, chest wall, and upper back. The

lymphatics of the hand and forearm first drain through a few epitrochlear nodes situated just above

the bend of the elbow, dorsally.

Analogous to the epitrochlear nodes are the popliteal nodes located behind the knee. These

nodes drain the skin of the heel and posterior leg. The other lower extremity nodes are the femoral

(superficial inguinal) nodes located in the groin (the area between the abdomen and upper thigh).

The nodes associated with the upper and lower extremities and the sites which drain into these nodes

are:

• Axillary lymph nodes: Arm, hand, shoulder, chest wall, upper back, breast

• Epitrochlear lymph nodes: Forearm, hand

• Femoral (superficial inguinal) lymph nodes: Vulva, penis, anus, scrotum, perineum, I anterior

abdominal wall, lumbar region, lower back, lower extremities (excluding heel)

• Popliteal lymph nodes: Posterior leg, heel

See Figures 8A and 8B, for a diagram of lymph nodes of the upper and lower extremities.

lperineum--The skin-covered muscular region between the vagina and the anus in the female and

between the scrotum and the anus in the male.

85
86
Q22

Match the lymph nodes on the left with their most appropriate description of drainage on

the right:

Lymph Nodes Description of Drainage

1. Popliteal a. Arm

2. Axillary b. Forearm

3. Epitrochlear c. Heel

4. Superficial inguinal d. Thigh

87
Answer: Q22

c 1. Popliteal Heel

a 2. Axillary Arm

b 3. Epitrochlear Forearm

d 4. Superficial inguinal Thigh

88
Malignant and Benign Tumors

Benign tumors of lymphoid tissue are rare. Those of the lymphatic vessels, as you have already

learned, are known as lymphangiomas. Cancer registries may, or may not, elect to include these

tumors.

Malignant Lymphomas

Lymphomas are malignancies of the lymph nodes and other lymphatic structures, such as the

spleen, thymus, Waldeyer's ring (tonsils), Peyer's patches (ileum) of the small intestine, and lymphoid

nodules of the appendix as well as extralymphatic/extranodal sites such as stomach and skin.

There are two principal kinds of lymphomas:

1) Hodgkin's disease, which commonly arises in lymph nodes and other lymphatic structures,

makes up 19% of all lymphomas. Of the Hodgkin's disease cases reported, 99% are nodal.

2) Non-Hodgkin's lymphoma (NHL), which frequently arises in extralymphatic/extranodal sites

as well as in lymph nodes and other lymphatic structures, makes up 81% of all lymphomas. Of the

non-Hodgkin's lymphoma cases reported, 77% are nodal and 23% are extranodal.

The classification of NHL is discussed in detail in ICD-O-2 including a discussion of extranodal and

nodal lymphomas.

89
Hodgkin's disease. The histologic classification of Hodgkin's disease has changed over the years.

The original classification of Hodgkin's disease by Jackson and Parker in 1947 consisted of

paragranuloma, granuioma, and Hodgkin's sarcoma. These all have specific code numbers in ICD-O,

first edition, and ICD-O-2. However, such terms are rarely used any more. The Lukes-Butler

classification came into existence in the early 1960's and was modified at the Rye, NY Conference

in 1966 and was then called the Rye classification or modification. It represents a spectrum based

on the relative proportion of malignant cells seen, as follows:

• Lymphocytic predominance type (LP)

• Nodular sclerosis type (NS)

• Mixed cellularity type (MC)

• Lymphocytic depletion type (LD)

• Unclassified type (NOS)

Further additions or splits can be seen in ICD-O-2, such as splitting lymphocytic predominance by

whether it is diffuse or nodular.

One of the requirements for a diagnosis of Hodgkin's disease is the identification by the pathologist of Reed-Sternberg cells1 (malignant cells) in an appropriate cellular environment.

There is indirect evidence that Hodgkin's disease involves the T-cell component of the immune

system.

1Reed-Sternberg cell--Characteristic giant cell with large, inclusion-like nucleoli and double or

multiple nuclei.

90
Q23

Benign tumors of lymphoid tissue are frequent/rare. (Circle one.)

Q24

Malignant tumors of the lymphoid tissue may be divided into two general categories:

1.

2.

Q25

Name the four major types of Hodgkin's disease according tO the histologic classification:

1.

2.

3.

4.

Q26

One requirement for a diagnosis of Hodgkin's disease is identification by the pathologist of

the presence of cells.

91
Answer: Q23

Benign tumors of lymphoid tissue are rare. Tumor registries may, or may not, elect to

include these tumors.

Answer: Q24

The two general categories for lymphomas are:

1. Hodgkin's disease

2. Non-Hodgkin's lymphomas

Answer: Q25

The four major types of Hodgkin's disease according to the current histologic classification

are:

1. Lymphocytic predominance

2. Mixed cellularity

3. Lymphocytic depletion

4. Nodular sclerosis

Answer: Q26

One requirement for a diagnosis of Hodgkin's disease is the presence of Reed- Sternberg

cells.

92
Non-Hodgkin's Malignant LYmphoma. The classification of non-Hodgkin's lymphoma has

undergone many changes. Most diagnostic schemes will describe it in terms of two parameters:

pattern of growth and cell type. The most commonly used schemes describe the proliferative pattern

of growth as:

• Nodular (follicular)

° Diffuse

There are six systems used throughout the world to classify non-Hodgkin's lymphoma:

Rappaport classification

BNLI--British National Lymphoma Investigation

Dorfman Classification

Kiel Classification

Lukes-Collins

World Health Organization

Several special conferences and meetings have been held to resolve the confusion that resulted

from the various systems used and to reconcile the differences among them.

In 1979, the National Cancer Institute planned and sponsored a multi-institutional study of the

six histopathologic systems used in the classification of non-Hodgkin's lymphoma to assess their

clinical applicability and reproducibility. The results of the study, based on clinical correlations

(survival curves, age, sex, presenting sites, and stage of disease), were published as a summary and

description of a working formulation for clinical usage. 1 The summary does not represent a new

classification system, but rather, is "intended as a means of translation among all systems." It is

discussed in detail in the ICD-O-2 on pages xxxii-xxxvi.

1Cancer 49: 2112-2135, 1982.

93
Extralymphatic/Extranodal Sites

Lymphoid tumors may be described as "nodal" or "extralymphatic," sometimes called "extranodal,"

in reference to their sites of origin. Tumors classified as "nodal" include those arising in lymphatic

tissue, such as in the spleen or Waldeyer's ring, as well as those originating in lymph nodes.

Waldeyer's ring includes:

Base of tongue (lingual tonsil)

Oropharynx (palatine tonsil)

Nasopharynx (pharyngeal tonsil)

"Extralymphatic" refers to tumors originating in sites which are not primarily composed of lymphoid

tissue. The most common extralymphatic sites are:

Stomach

Skin (mycosis fungoides)

Small intestine (ileum) and appendix

These extralymphatic sites may represent the primary site of lymphoma or may be involved as

areas of metastatic spread from primary lymph node tumors. The cancer registrar must attempt to

determine from all of the evidence in the medical record whether the lymphoid tumor has originated

in or spread to these areas. This is not always readily determined. If in doubt, an opinion should be

sought from the clinician or pathologist to determine how the case can most accurately be entered

in the registry.

Rules for Determining Multiple Primaries for Lymphatic and Hematopoietic Diseases:

The tables entitled Ino'oduction and General Instt_uctions at the back of this manual are to be used

to help determine multiple primaries of the lymphatic and hematopoietic diseases.

RULES to follow are:

1. No topography (site) is to be considered in determining multiple primaries of lymphatic and

hematopoietic discases. Multiple primaries are determined by histology (see the tables at the back

of this manual).

2. The interval between diagnoses is NOT to enter into the decision.

Example: A lymphocytic lymphoma (M-9670/3) diagnosed in March, 1987 and an unspecified

non-Hodgkins's lymphoma (M-9590/3) diagnosed in April, 1988 would be considered one primary, a

lymphocytic lymphoma diagnosed in March, 1987 (the earlier diagnosis).

94
Q27

Non-Hodgkin's lymphomas may be described in terms of the predominant

and the degree of The proliferative pattern may

also be described as or

Q28

Lymphomas are primarily of origin, but two common

extralymphatic sites are and

95
Answer: Q27

Non-Hodgkin's lymphomas may be described in terms of the predominant cell type and the

degree of differentiation. The proliferative pattern may also be described as nodular or

diffuse.

Answer: Q28

You might have said lymphomas are primarily of lymph node origin, but two common

extralymphatic sites are the stomach and small intestine or any of the extralymphatic sites

listed on page 94.

96
SECTION E

THE CARDIOVASCULAR SYSTEM

97
TilE CARDIOVASCULAR SYSTEM

Ionatod blood

• blood

Figure 14A. BLOOD FLOW THROUGH THE BODY

(schematic approximation; not anatomic location of organs)

98
SECTION E

THE CARDIOVASCULAR SYSTEM

The cardiovascular (circulatory) system consists of the heart and a system of blood vessels (arteries,

capillaries, veins) through which blood is transported from the heart to the tissues of the body and

back again. Actually, the heart is a double pump, driving the blood through two circuits (Figures

14A-D):

• The pulmonary circuit conveys blood from the right side of the heart to the lungs and then

returns it to the left side of the heart (see page 105).

• The systemic circuit carries blood from the left side of the heart to the rest of the body and

returns it to the right side of the heart (see page 105).

If there were no mechanism for constantly changing or freshening the tissue fluid of the body, it

would soon become depleted of food and oxygen and become saturated with waste products. In

addition to its primary function of transporting various substances to and from body cells, the

circulatory system contributes to cellular metabolism, balance (homeostasis) of fluid volume,

balance of Ph (hydrogen-ion concentration), homeostasis of body temperature, and defense against

microorganisms.

Figure 14B. HEART Figure 14C. MUSCLE WALL OF HEART

Aorta E_pic_rdlum ( vlscer#l

Superior f_/_ /_ _ PerLcardlua ] Myocaircilum

Ten-. ce.Vik _ y !?/_ l'uLmonas'y ,.j___...._,___..._.._

Pl]_ro Seroum: Psrlet&L_ VJL.I_=eraL L*yeri

Ln]_erLor (. p 1_ e_rd_ uLm)

VgGkA qF_V_

_lth apace between
CIRCULATORY SYSTEM

Figure 14D. BLOOD FLOW THROUGH HEART

Figure 14E. PORTAL CIRCULATION
Q1

The cardiovascular system consists of an organ called the and a system of blood vessels:

, ., and

Q2

The cardiovascular system is comprised of two separate circuits:

1. The circuit conveys blood to the lungs and then returns it to the

side of the heart.

2. The circuit conveys blood to the rest of the body and then returns it to

the side of the heart.

Q3

The primary function of the cardiovascular system is to blood to and from the body

cells thus providing them with and and carrying away

Q4

The cardiovascular system also contributes to:

1.

2.

3.

4.

5.

101
Answer: Q1

The cardiovascular system consists of an organ called the heart and a system of blood

vessels: arteries, capillaries, and veins.

Answer: Q2

1) The pulmonary circuit conveys blood to the lungs and then returns it to the left side

of the heart.

2) The systemic circuit conveys blood to the rest of the body and then returns it to the

right side of the heart.

Answer: Q3

The primary function of the cardiovascular system isto transport (carry) blood to and from

the body cells thus providing them with food (nutrients) and oxygen, and carrying away

waste products.

Answer: Q4

The cardiovascular system also contributes to:

1) Cellular metabolism

"Metabolism" is usually the term applied to the over-all series of chemical reactions taking

place within the body cells in which oxygen and nutrients are consumed and carbon dioxide and other

wastes are produced in the release of energy.

2) Balance (homeostasis) of fluid volume

3) Balance of pH (a measure of hydrogen-ion concentration: A pH of 7.0 is neutral;

above 7.0 alkalinity increases and below 7.0 acidity increases.)

4) Homeostasis of body temperature

5) Defense against microorganisms

102
Heart and Pericardium

The heart is a hollow muscular organ about the size of a human fist lying within the mediastinum,

between the lungs, with its apex on the diaphragm. It has four chambers (see Figure 14B).

• Right and left atria

The atria are small receiving chambers much like big veins. The right atrium, which receives

blood from the systemic circulation, is larger than the left atrium, which receives blood from

the lungs only. Both atria have thinner walls than do the ventricles since they have less

pressure exerted on them than do the ventricles, just as veins have thinner walls than do

arteries.

• Right and left ventricles

The ventricles are large, contracting chambers with thick walls. The walls of the left ventricle

are thicker because the left ventricle must pump blood to the most distant parts of the body;

the right ventricle pumps blood only to the lungs.

The openings between the atria and ventricles, the atrioventricular orifices, are controlled by

cuspid valves:

• The tricuspid valve controls the opening between the right atrium and the right ventricle.

• The mitral (bicuspid) valve controls the opening between the left atrium and the left ventricle.

Semilunar valves control the opening from the right ventricle into the pulmonary artery and the

opening from the left ventricle into the great aorta.

The heart muscle (myocardium) receives its blood supply from the branches of the right and left

coronary arteries (Figure 14B). These vessels come off the ascending aorta just as this structure exits

from the left ventricle.

A small mass of modified cardiac muscle called the sinoatrial node and an additional mass now

termed the atrioventricular junction, along with an abundant nerve supply, contribute to the

stimulation and regulation of heart action.

103
The heart lies in a loose-fitting sac called the pericardium. This sac is composed of an outer

fibrous portion and an inner serous portion. The inner portion consists of two layers:

• The parietal layer lining the inside of the fibrous pericardium

• The visceral layer (epicardium) adhering to the exterior surface of the heart.

Between the parietal and visceral layers is a potential space, the pericardial space, which contains

a few drops of pericardial fluid. This fluid reduces friction during movement of the heart.

The walls of the heart are composed of three layers:

• The epicardium or outer layer of the heart (the visceral layer of the serous pericardium

described above)

° The myocardium or heart muscle

• The endocardium or inner lining of the four chambers of the heart.

104
The Heart As a Pump. You will recall that the heart receives blood from both systemic and

pulmonary circuits.

• The DEOXYGENATED BLOOD RETURNS to the right atrium of the heart FROM THE

SYSTEMIC CIRCUIT via the superior and inferior vena cavae. From the right atrium, the

blood moves through the tricuspid valve into the right ventricle. When the right ventricle

contracts, the tricuspid valve closes and the blood is forced through the pulmonary semilunar

valve into the pulmonary trunk which divides into the right and left pulmonary arteries. The

blood flows through the pulmonary arteries to the pulmonary capillaries where it absorbs

oxygen and releases carbon dioxide.

• The OXYGENATED BLOOD RETURNS to the left atrium of the heart FROM THE

PULMONARY CIRCUIT via the pulmonary veins. From the left atrium, the blood moves

through the mitral (bicuspid) valve into the left ventricle. When the left ventricle contracts,

the mitral valve closes, and the blood is forced through the aortic semilunar valve into the

aorta and into the systemic circulation.

The pumping action of the heart creates pressure on the walls of the blood vessels which can be

measured when your blood pressure is taken. Both the systolicI and the diastolic 2 values are

measured.

1systolic blood pressure--The force with which the blood is pushing against the artery walls when

the ventricles are contracting.

2diastolic blood pressure--The force with which the blood is pushing against the artery walls when

the ventricles are relaxed.

105
106
Q5

The heart has four chambers called right and left and right and left

Q6

The heart lies within a loose-fitting sac call the and is located in the

between the with its apex on the

Q7

The serous covering of the heart has two layers:

1) the layer

2) the layer

Q8

The heart walls are thickest in ventricles/atria because of the pumping action of these chambers.

(Circle one.)

Q9

Which veins contain oxygenated blood?

107
Answer: Q5

The heart has four chambers called the right and left atria and the right and left ventricles.

Answer: Q6

The heart lies within a loose-fitting sac called the pericardium and is located in the

mediastinum between the lungs with its apex on the diaphragm.

Answer: Q7

The serous covering of the heart has two layers:

1) The parietal layer

2) The visceral layer (epicardium)

Answer: Q8

The heart walls are thickest in the ventricles because of the pumping action of these

chambers.

Answer: Q9

The right and left pulmonaryveins contain oxygenated blood.

108
Q10

Deoxygenated blood from the body returns to the (side) by way of two major veins:

the and the The blood

from these vessels enters into the .(chamber). Blood is

moved through the valve into the (chamber).

When this chamber contracts, it forces blood through the valve into the

(vessel), sending blood to the to be oxygenated.

The oxygenated blood returns to the (side) of the heart by way of the

(vessels) and enters into the (chamber).

Blood is then moved through the valve into the

(chamber). When this chamber contracts, it forces blood through the

valve into the ., sending blood out

into the circulatory system.

109
Answer: QIO

Deoxygenated blood from the body returns to the right (side) of the heart by way of two

major veins: the superior vena cava and the inferior vena cava. The blood from these

vessels enters into the right atrium (chamber). Blood is moved through the tricuspid valve

into the right ventricle (chamber). When this chamber contracts, it forces blood through

the pulmonary semilunar valve into the pulmonary artery (vessel), sending blood to the

lungs to be oxygenated.

The oxygenated blood returns to the left (side) of the heart by way of the pulmonary veins

(vessels) and enters into the left atrium (chamber). Blood then is moved through the

mitral valve into the left ventricle (chamber). When this chamber contracts, it forces blood

through the aortic semilunar valve into the aorta, sending blood out into the systemic

circulatory system.

110
Blood Vessels

There are three kinds of blood vessels:

• Arteries--vessels that convey blood away from the heart. The pulmonary arteries carry

deoxygenated blood from the heart to the lungs; all other arteries carry oxygenated blood from

the heart to all other parts of the body.

• Veins--vessels that convey blood towards the heart. The pulmonary veins carry oxygenated

blood from the lungs to the heart; all other veins carry deoxygenated blood from all the other

parts of the body to the heart.

• Capillaries--microscopic vessels that carry blood from small arteries (arterioles) to small veins

(venules). More importantly, they are the site of exchange of oxygen, nutrients, carbon

dioxide, and waste products between the blood and the interstitial fluid.

The function of arteries 1 and arterioles 2 is to carry blood away from the heart to the capillaries.

Capillary blood delivers oxygen and nutrients to the tissue fluid and collects carbon dioxide and other

wastes from it. Finally, veins 3 and venules a return the blood from the capillaries to the heart.

Arteries have thicker walls than do veins since the arteries have more pressure exerted on them.

lartery--A vessel which conveys blood away from the heart to the various parts of the body.

2arteriole--A minute arterial branch, especially one just proximal to a capillary.

3vein--A vessel which conveys blood to or towards the heart from various parts of the body.

4venule--A minute vein, especially one distal to a capillary.

111
Portal System (portal circulation)

Veins from the spleen, stomach, pancreas, and intestines converge to form the portal vein which

carries blood and nutrients to the liver. The portal vein is formed by the joining of the splenic and

the superior mesenteric veins. However, blood from the gastric, pancreatic, and inferior mesenteric

veins drains into the splenic vein before it merges with the superior mesenteric vein.

In the liver the venous blood is processed in special structures called sinusoids. It mingles with

the arterial blood in the capillaries, exchanges nutrient material with the liver cells, and is eventually

drained from the liver by the hepatic veins that join the inferior vena cava.

If the portal circulation is interfered with (by certain types of liver disease, cancerous obstruction,

or heart failure), venous drainage from most of the abdominal organs is decreased or shut off. This

results in increased capillary pressure causing ascites (fluid in the abdominal cavity).

The liver is a frequent site of blood-borne metastasis because those tumors of the intestinal tract

which drain into the portal system are filtered out in the liver.

Primary malignancies of the liver (including intrahepatic bile ducts) are relatively rare in the

United States. They include:

• Hepatocellular carcinoma or hepatoma (arising from the liver cell)

° Intrahepatic bile duct carcinoma or cholangiocarcinoma (arising from the bile duct cell).

112
Qll

Name the three kinds of blood vessels and state their functions:

1.

2.

3. :(a)

(b)

Q12

What is the relationship of the portal system and the venous system?

Q13

What happens if the portal circulation is interfered with or blocked?

113
Answer: Qll

The three kinds of blood vessels and their functions are as follows:

1. Arteries: Carry blood away from the heart

2. Veins: Carry blood towards the heart

3. Capillaries: a) Carry blood from small arteries (arterioles) to small veins (venules)

b) Exchange nutrient material, oxygen, carbon dioxide, and waste

products between blood and interstitial fluid.

Answer: Q12

The portal system is part of the venous system. It is comprised of veins from the spleen,

stomach, pancreas, and intestines which converge to form the portal vein which carries

blood to the liver and the hepatic veins which convey the blood from the liver to the

inferior vena cava.

Answer: Q13

If portal circulation is interfered with, venous drainage from most abdominal organs isshut

off. This results in increased capillary pressure causing ascites.

114
Blood

Blood is the fluid which circulates through the heart, arteries, veins, and capillaries carrying food and

oxygen to all the cells in the body and returning waste products to points of separation from the

blood, i.e., the kidneys, lungs, and sweat glands. The composition of the blood is as follows:

Blood

I i

I t

Formed Elements (40-45%) Plasma (55-60%)

I I i I I

Erythrocytes ] Leukocytes Water, Proteins (6-8%)

RBC) ] (WBC) inorganic salts,

[ and gases (91-92%)

Thrombocytes

(Platelets)

The blood cells, or formed elements of the blood, are suspended in the fluid medium called plasma

which normally represents fifty-five to sixty percent of blood volume. The blood test which measures

the percent of cells compared to the total volume is called the hematocrit.

The clear liquid that separates from the blood when it is allowed to clot completely is called

"serum." Serum is essentially blood plasma from which fibrinogen has been removed in the process

of clotting.

Erythrocytes or red blood cells transport oxygen picked up in the lungs to tissues throughout the

body and return carbon dioxide to the lungs. The formation of red blood cells (erythropoiesis) takes

place in the bone marrow. After an average life of about four months, the red blood cells

(erythrocytes) are destroyed in the liver and spleen. The blood count (RBC) is normally 4.5-6.0

million cells per cu. ram. of blood for men and 4.5-5.5 million for women.

The hemoglobin or oxygen-carrying component of blood is measured in terms of grams percent

(gm. %) or grams per 100 milliliters (gm./100 ml.) of blood. The hemoglobin content of the blood

determines the amount of oxygen that it carries and is responsible for the red color of the erythrocyte

and of the blood.

The red blood cell count may be lowered due to anemia or hemorrhage. It may be increased as

a result of dehydration or of polycythemia 1 vera.

]polycythemia--Excess in the number of erythrocytes in the blood.

115
116
Q14

What are the three main types of blood cells?

1.

2.

3.

Q15

The blood cells are suspended in a fluid called

Q16

The blood test which measures the percent of cells compared to total volume is called the

Q17

By way of hemoglobin, erythrocytes or transport oxygen

picked up in the lungs to tissues in the body and return carbon dioxide to the lungs.

117
Answer: Qlg

The three main types of blood cells are:

1. Red blood cells or erythrocytes

2. White blood cells or leukocytes

3. Platelets or thrombocytes

Answer: Q15

The blood cells are suspended in a fluid called plasma.

Answer: Q16

The blood test which measures the percent of cells compared to total volume is called the

hematocrit.

Answer: Q17

By way of hemoglobin, erythrocytes or red blood cells transport oxygen picked up in the

lungs to tissues in the body and return carbon dioxide to the lungs.

118
Leukocytes, or white blood cells, function as a defense against invading microorganisms. The total

white blood cell count (WBC) is normally 5,000-10,000 per cu. mm. of blood, but may increase to very

high levels in cases of infection or as a reaction to treatment by radiation and/or chemotherapy.

There are several types of white blood cells. The relative percentages of the various cells found in

blood is called the white cell differential (see Book 5, Abstracting a Medical Record).

Leukocytes are produced in the bone marrow and in lymphoid tissue. Granulocytes (granular

leukocytes), lymphocytes and monocytes (agranular leukocytes or mononuclear leukocytes) originate

in the bone marrow, but multiply in the lymphoid tissue.

Platelets (thrombocytes) are formed in the bone marrow by fragmentation of large cells

(megakaryocytes). Platelets normally number 200,000 to 500,000 per cu. mm. of blood. Upon

disintegration they release a substance, thromboplastin, which combines with blood proteins and

calcium to form prothrombin which initiates the production of fibrin to form blood clots (coagulation). Sometimes a blood clot will form within the heart or blood vessels partially or totally

obstructing the vessel. Such a blood clot is called a thrombus. When a thrombus is dislodged and

moves to another location, it is called an embolus (thromboembolus).

119
120
Q18

White blood cells which are known as function as a defense or

protection against invading microorganisms (infection).

Q19

When a blood clot forms in and clogs a vessel, it is called a

121
Answer: Q18

White blood cells which are known as leukocytes function as a defense or protection

against invading microorganisms (infection) or as a reaction to treatment by radiation

and/or chemotherapy.

Answer: Q19

When a blood clot forms in and clogs a vessel, it is called a thrombus. When a blood clot

breaks loose from an area in a vein and travels to another area and becomes lodged there,

it is called an embolus.

122
Leukemia

Leukemia is a malignant disease of the blood-forming organs. As with other malignant diseases,

leukemia is characterized by an uncontrolled proliferation of cells, in this case the white blood cells

or leukocytes. However, an elevated leukocyte count usually represents a nonneoplastic reaction to

infection or treatment by radiation and/or chemotherapy.

Leukemias are classified according to the type and number (percent) of abnormal cells and the

rapidity of the clinical course. The predominant cell types are:

• Lymphocytic

• Myeloid/Granulocytic

• Monocytic

Leukemias are diagnosed by the microscopic detection of abnormal cells in the circulating

(peripheral) blood and in the bone marrow. These abnormal cells may be described as atypical,

immature, or "blast forms"--lymphoblasts, myeloblasts, or monoblasts. These are terms for immature

cells which have not yet developed into the mature forms, namely, lymphocytes, granulocytes, or

monocytes. The presence of myelocytes, metamyelocytes, or promyelocytes indicates granulocytic

(myelocytic) leukemia; prolymphocytes indicate lymphatic (or lymphocytic) leukemia, and

promonocytes indicate monocytic leukemia. In some cases the cells may be so undifferentiated or

immature that they are impossible to identify and the disease may be classified as stem cell or blastic

leukemia. You will recognize these terms in the outline (page 124) showing the development of

white blood cells from stem cells. During the development of blood cells in the bone marrow, the

primitive immature (unspecialized) stem cells change shape and structure several times in the course

of becoming mature differentiated (specialized) blood cells.

123
DEVELOPMENT OF WHITE BLOOD CELLS

Stem Cell

I

I I I

Lymphoblast Myeloblast Monoblast

I I I

Prolymphocyte Promyelocyte Promonocyte

I I I

Lymphocyte Myelocyte Monocyte

I

Metamyelocyte

I

Granulocyte

Leukemias may also be categorized as acute, subacute, or chronic. In acute leukemia the white

cell population will show a high proportion of blast forms, while in chronic leukemia the majority of

cells will be more mature. The clinical progression of disease is extremely rapid in acute leukemia,

but in chronic leukemia it may remain unchanged for a long period of time even without treatment.

The total white blood cell count (WBC) will be significantly elevated in most cases of leukemia

(leukocytosis). However, particularly in chronic leukemia, the leukocyte count may be normal or

actually below normal (leukopenia) in which case the disease may be classified as aleukemic

(subleukemic) leukemia.

A decreased plat elet count (thrombocytopenia) and a decreased hemoglobin level are

characteristic of patients with a diagnosis of leukemia.

There are variants of the major types listed above. Consult your medical dictionary and other

reference books for descriptions of unfamiliar terms. There are also diagnoses such as

erythroleukemia (Di Guglielmo's disease) and plasma cell leukemia which, although termed

leukemias, are actually neoplasms involving other blood cells and not leukocytes.

See Book 5, Abstracting A Medical Record for a review of definitions of hematologic terms and

normal values.

Note: Other neoplasms arising in bone marrow (multiple myeloma, plasmacytoma, plasma cell

myeloma) are closely related to the leukemias and will be discussed later in Section K, The Skeletal

System.

124
Q20

Malignant diseases of the blood-forming organs are called

Q21

Leukemias are characterized by uncontrolled of

and/or especially the presence of

or cells.

Q22

The classification of leukemias is determined by the:

1.

2.

3.

Q23

What are three predominant cell types?

1.

2.

3.

Q24

Leukemias may also be categorized as follows:

1.

2.

3.

125
Answer: Q20

Malignant diseases of the blood-forming organs are called leukemias.

Answer: Q21

Leukemias are characterized by uncontrolled proliferation of white blood cells and/or

especially the presence of abnormal or immature cells.

Answer: Q22

The classification of leukemia is determined by the:

1. Type of abnormal white blood cells

2. Number of abnormal white blood cells

3. Rapidity of the clinical course

Answer: Q23

Three predominant cell types are:

1. Lymphocytic

2. Granulocytic

3. Monocytic

Answer: Q24

Leukemias may also be categorized as follows:

1. Acute

2. Subacute

3. Chronic

126
Q25

Match the disease on the left with the characteristic on the right.

Disease Characteristic

1. Leukemia a. An uncontrolled excess of red blood cells

2. Polycythemia vera b. An uncontrolled excess of white blood cells

127
Answer: Q25

b 1. Leukemia An uncontrolled excess of white blood cells

a 2. Polycythemia vera An uncontrolled excess of red blood cells

128
SECTION F

THE RESPIRATORY SYSTEM

129
130
SECTION F

THE RESPIRATORY SYSTEM

The respiratory system consists of those organs and parts of the body that make it possible to

breathe. Respiration can be divided into two distinct phases: 1) external respiration and 2) internal

respiration.

° External respiration involves both inspiration (inhaling) and expiration (exhaling) of air.

Inspiration is the means by which oxygen is carried from the air into the lungs and then into the

blood. Expiration is the means by which carbon dioxide is returned from the blood to the lungs and

then expelled into the air.

• Internal respiration is concerned with the exchange of oxygen and carbon dioxide at the tissue

level: the passage of oxygen from the blood to the tissues and the return of carbon dioxide from the

tissues to the blood. First the oxygen is carried from the lungs by the red blood cells. Then carbon

dioxide is carried by the red blood cells to the lungs. The utilization of oxygen and the elimination

of carbon dioxide by the cells is called cellular respiration.

The respiratory system begins with the nose; at the other end of the system are the lungs. In

between the nose and the lungs are the nasopharynx, oropharynx, larynx, trachea, and bronchi. The

thorax, which houses most of the organs of the respiratory system, plays a major role in respiration.

The elliptical shape of the ribs and the angle of their attachment to the spine allows the thorax to

expand during inspiration. Thus, the lungs provide a place where large amounts of oxygen can be

taken from the air and quickly absorbed into the bloodstream. Conversely, large amounts of carbon

dioxide are discharged into the lungs where it is exhaled.

Figure 15. RESPIRATORY SYSTEM

131
132
Q1

Name the parts of the respiratory system between the nose and the lungs:

1.

2.

3.

4.

5.

Q2

The lungs are located in a body cavity called the

Q3

The primary purpose of the respiratory system is to make it possible for and

to exchange gases, namely, and

133
Answer: Q1

The parts of the respiratory system between the nose and the lungs are:

1. Nasopharynx

2. Larynx

3. Trachea

4. Bronchi

5. Oropharynx

Answer: Q2

The lungs are located in a body cavity called the thorax.

Answer: Q3

The primary purpose of the respiratory system is to make it possible for blood and ai.._rto

exchange gases, namely, carbon dioxide and oxygen.

134
Nose and Paranasal (Accessory_) Sinuses

The nose consists of the two nasal cavities formed by the maxilla and palatine bones and the nasal,

frontal, ethmoid, and sphenoid bones. On the lateral walls are three bony structures, one above the

other, which are called conchae (superior, middle and inferior), so-called because they resemble

shells. They may also be referred to as turbinates. The external orifices of the nose are the nostrils;

the posterior orifice, or the opening into the nasopharynx, is called the choana. The nasal cavities

are lined with mucous membrane.

The nose serves as a passageway for air going to and coming from the lungs. Air passes through

the nose and, then, into the nasopharynx. The nose filters the air of certain impurities, warms it, and

moistens it. In addition, the nose can detect the presence of certain types of chemicals which might

be irritating to the mucous lining of the respiratory tract. The nose serves also as the organ for the

sense of smell. Olfactory (odor) receptors are located in the nasal mucosa. The nose aids also in

phonation (the making of vocal sounds).

The paranasal sinuses are air cavities lined with mucous membrane. The frontal sinuses are

located in the bone of the forehead above the orbital cavities. The ethmoid sinuses are made up of

small air cells located between the upper nasal cavities and the orbits. The sphenoid sinuses are

wedge-shaped sinuses in the bone at the back of the orbital cavities. The maxillary sinuses (antrum

of Highmore) are located in the upper jawbone.

The external and internal carotid arteries supply blood to the nose and the paranasal sinuses. The

venous blood returns to the internal and external jugular veins.

The lymphatic vessels from the nose and the paranasal sinuses enter the retropharyngeal,

submental, submandibular (submaxillary), and the internal jugular (upper and lower deep cervical)

lymph nodes.

Malignant Tumors

While tumors of the nasal cavities are rare, the most common type is squamous cell (epidermoid)

carcinoma. Other types which occur less frequently are adenocarcinoma, adenoid cystic carcinoma,

melanoma, and lymphoma. A malignant tumor known as esthesioneuroblastoma or esthesioneuroepithelioma, which arises in the olfactory nerve, will be found occasionally in the nasal

cavities.

Ninety percent of the neoplasms of the paranasal sinuses are located in the maxillary sinuses.

Histologically, the tumors are similar to those found in the nasal cavities.

135
136
Q4

What are the purposes of the nose?

1.

2.

3.

4.

5.

Q5

Name the paranasal sinuses:

1.

2.

3.

4.

Q6

What is the most common histologic type of malignant tumor which you would expect to find in

the nasal cavities and paranasal sinuses?

137
Answer: Q4

1. Serves as a passageway for air going to and from the lungs.

2 Filters the air of impurities, warms it, and moistens it.

3. Detects the presence of chemicals which might be irritating to the mucous lining of the

respiratory tract.

4. Serves as the organ of smell.

5. Aids in phonation (the making of vocal sounds).

Answer: Q5

The paranasal sinuses are:

1. Frontal

2. Ethmoid

3. Sphenoid

4. Maxillary

Answer: Q6

The most common histologic type of malignant tumor which you would expect to find in

the nasal cavities and paranasal sinuses is squamous cell carcinoma.

138
Nasopharynx

The pharynx is a muscular structure lined with mucous membrane. It is divided into three parts:

the nasopharynx, located behind the nasal cavities; the oropharynx, located behind the oral cavity; and

the hypopharynx (laryngopharynx), located behind and lateral to the larynx. The oropharynx and the

hypopharynx are considered part of the digestive system and are discussed in Section G.

The nasopharynx is considered part of the respiratory system. Its subsites are:

• Posterior superior wall (vault) extends from the choana, or the opening of the nasal

cavities into the nasopharynx, posteriorly to a level opposite the soft palate. The

pharyngeal tonsils (adenoids) are located in this part of the nasopharynx.

• Lateral wall extends from the base of the skull on each side to the level of the soft

palate. The auditory (eustachian) tube from the middle ear opens into the lateral wall

just anterior to Rosenmuller's fossa (pharyngeal recess).

Lymphatics of the nasopharynx drain into submental, submandibular (submaxillary), and internal

jugular (upper and lower deep cervical): jugulodigastric, jugulo-omohyoid, and retropharyngeal

lymph nodes. The blood supply is via the external carotid arteries and internal jugular veins.

Malignant Tumors

Nasopharyngeal tumors are usually squamous cell carcinoma, lymphoepithelioma, salivary gland

type tumors, and, occasionally, lymphoma.

Figure 16. NASOPHARYNGEAL REGION AND PARANASAL SINUSES

139
140
Q7

The pharynx can be divided into three parts called the:

1.

2.

3.

Q8

The framework of the pharynx is composed of and lined with a

Q9

The lymphoid tissue found in the nasopharynx is located in the

also known as the

141
Answer: Q7

The pharynx can be divided into three parts called the:

1. Nasopharynx

2. Oropharynx

3. Hypopharynx (laryngopharynx)

Answer: Q8

The framework of the pharynx is composed of muscle and lined with a mucous membrane.

Answer: 09

The lymphoid tissue found in the nasopharynx is located in the pharyngeal tonsils also

known as the adenoids.

142
Larynx

The larynx or voice box is a small but complex structure situated in front of the hypopharynx and

contiguous with the upper end of the trachea. The larynx consists of nine pieces of cartilage. The

three single and more prominent pieces are:

• Thyroid cartilage (Adam's apple)

• Epiglottis which has a hinge-like action and forms a kind of lid over the opening of the larynx

when swallowing takes place

• The cricoid (signet-ring) cartilage, so named because it resembles a signet ring in shape. The

cricoid cartilage forms the inferior border of the larynx.

In addition there are three paired cartilages:

• Arytenoid cartilages (jar-like)

• Corniculate cartilages (horn-like)

• Cuneiform cartilages (wedge-like)

These cartilages are united by joints strengthened by various membranes and ligaments. The mucous

membrane lining of the larynx forms two horizontal folds, the false vocal cords. Below these are the

true vocal cords which are fibrous bands stretched across the hollow interior of the larynx. The space

between the true vocal cords is called the glottis. Air forced through these cords produces sound.

Figure 17A. LARYNX

/ zoo.,oo.,

,.._.. I/::-:::?IlgL Z4 i °"°0"" /: //0i ,

...........'I//7/ /._ j I

143
The larynx can be divided into three anatomic subsites: the supraglottis, glottis, and subglottis.

• The supraglottis includes the posterior (laryngeal) surface of the epiglottis, the aryepiglottic

folds, the arytenoids, and the ventricular bands (false cords). The epiglottis guards the

superior opening of the larynx. The aryepiglottic folds are folds of tissue which border the

epiglottis and make up the sides of the entrance to the larynx.

• The glottis consists of the true vocal cords including the anterior and posterior

commissures. The vocal cords stretch across the cavity of the larynx from the thyroid

cartilage to the anterior borders of the arytenoid cartilages.

• The subglottis lies below the true cords and extends to the inferior border of the cricoid

cartilage.

The laryngeal branches of the thyroid arteries supply the blood for the larynx. The venous

drainage is by way of the laryngeal tributaries of the thyroid veins into the internal jugular veins.

The principal lymph node drainage for the larynx is to the internal jugular and anterior cervical

nodes. Anterior cervical nodes are the prelaryngeal, pretracheal, paratracheal, and lateral tracheal

(recurrent laryngeal) nodes. Bilateral involvement is common, and spread to submandibular and

submental nodes may sometimes occur.

Figure 17B. THE ANATOMIC SUBSITES OF THE LARYNX

144
Malignant Tumors

The glottic region is the area of the larynx most commonly involved with cancer; however, these

tumors have the most favorable prognosis. The true vocal cords contain very few lymphatics, so the

probability of metastasis to regional nodes of an early cancer is small. In contrast, the supraglottis

has an abundant supply of lymphatics. Cancers of the supraglottis quickly spread to the cervical

lymph nodes. The subdigastric nodes of the internal jugular chain are commonly involved as well as

the prelaryngeal nodes. Thus, although supraglottic cancers rank second to glottic cancers in

frequency, the prognosis is worse for patients with these cancers. The rarest form of laryngeal cancer

arises in the subglottic region. Squamous cell carcinoma is the most common cell type of all laryngeal

cancers.

145
146
QlO

The three single cartilages in the larynx are the , , and

Qll

The three paired cartilages in the larynx are the ., , and

Q12

The vocal cords are formed by folds of mucous membrane; the vocal

cords are fibrous bands stretched across the hollow interior of the larynx.

Q13

The three major anatomical subsites of the larynx are:

1.

2.

3.

147
Answer: Q10

The three single cartilages in the larynx are the cricoid., thyroid, and epiglottis.

Answer: Qll

The three paired cartilages in the larynx are the arytenoid, corniculate

, and cuneiform.

Answer: Q12

The false vocal cords are formed by folds of mucous membrane; the tr._uevocal

cords are fibrous bands stretched across the hollow interior of the larynx.

Answer: Q13

The three major anatomical subsites of the larynx are:

1. Supraglottis

2. Glottis

3. Subglottis

148
Trachea

The trachea or windpipe is a tube composed of smooth muscle lined with mucous membrane, and

C-shaped rings of cartilage are embedded in the muscle. The trachea extends from below the cricoid

cartilage of the larynx to the carina, and is about 2.5 cm in diameter and about 10 cm long. The

trachea forms a major part of the passageway through which external air reaches the lungs, the simple

but vital function of this structure. The trachea is a rare tumor site.

Bronchi

At its lower end, the trachea divides into the right main stem bronchus and left main stem

bronchus (primary bronchi) at the carina. The walls of the bronchi are made of cartilage with a

ciliated mucous lining. The extrapulmonary portion of each bronchus enters the lung on its own side

and immediately divides into branches called lobar (secondary) bronchi. The secondary bronchi

continue to branch, forming bronchioles which become smaller and smaller, forming microscopic

branches which divide into alveolar ducts. At the terminal ducts are grape-like formations known as

alveolar sacs which provide surfaces where the exchange of air and carbon dioxide takes place.

The intrapulmonary (lobar) bronchi are lined with ciliated columnar, mucin-producing epithelium.

The walls are composed of a submucosa, smooth muscle, fibrous tissue and cartilage.

149
150
Q14

The windpipe or serves as a by which air can

reach the

Q15

The trachea divides into the and

which in turn divide into smaller branches

called , .... and

151
Answer: Q14

The windpipe or trachea serves as a passageway by which air can reach the lungs.

Answer: Q15

The trachea divides into the right main stem bronchus and left main stem bronchus which

in turn divide into smaller branches called lobar/secondary bronchi, bronchioles, alveolar

ducts, and alveolar sacs.

152
LHnRs

The lungs are cone-shaped organs of respiration which lie in the thoracic cavity, one on either side

of the mediastinum.

The rounded upper portion of each lung is called the apex; the base is the concave lower portion

resting on the diaphragm; and the hilus is the area on the medial surface through which the main

bronchus, pulmonary artery, pulmonary vein, nerves, and lymph vessels enter and leave each lung.

The left lung is partially divided by a fissure into an upper and lower lobe. Projecting from the lower

portion of the left upper lobe is an area called the lingula (coded to left upper lobe). The right lung

is divided by two fissures into three lobes (upper, middle, and lower).

Visceral pleura or mesothelium covers the outer surfaces of the lungs and adheres to them (See

Figure 18). Parietal pleura or mesothelium lines the thorax. The potential space between the

visceral and parietal pleura is called the (inter)pleural space or pleural cavity. The pleural space

contains a lubricating pleural fluid which eliminates friction during the breathing process. This fluid

drains to the mediastinal nodes. When the mediastinal nodes become inflamed or involved with a

disease process such as a malignancy, a pleural effusion develops. Breathing then becomes labored

and painful.

Figure 18. LUNGS

mloph_ju8

153
The lungs provide a place where large amounts of oxygen can be loaded quickly into the blood

and large amounts of carbon dioxide can be removed from it. The PULMONARY ARTERY from

the right side of the heart branches into two arteries which carry DEOXYGENATED blood to both

lungs. Each artery continues dividing and subdividing within the lungs forming smaller and smaller

vessels which end in capillaries which surround the alveolar sacs of the respiratory bronchioles. As

the blood passes through the pulmonary capillaries, it absorbs oxygen and releases carbon dioxide.

Then the newly OXYGENATED blood immediately returns through the venules (small veins) to the

PULMONARY VEINS which return to the left side of the heart.

The lung itself gets its nutriment supply from the bronchial arteries which branch off the aorta.

All regional lymph nodes for the lung and the pleura are above the diaphragm. They include the

intrathoracic, scalene, and supraclavicular. The intrathoracic lymph nodes can be divided into two

main groups: intrapulmonic and mediastinal.

1. Intrapulmonic:

Intrapulmonary (incl. interlobar, lobar, segmental)

Hilar (proximal lobar, pulmonary roots)

Peribronchial

2. Mediastinal:

Carinal (subcarinal/precarinal)

Mediastinal (anterior, posterior)

Peri/paratracheal (incl. tracheobronchial, lower peritracheal, azygos)

Pretracheal and retrotracheal (incl. precarinal)

Peri/paraesophageal

Aortic (peri/para aortic, subaortic, aorticopulmonary window,

ascending aorta or phrenic), above the diaphragm

Pulmonary ligament

If any of the above nodes are contralateral or bilateral, they are still considered regional, by the

American Joint Committee on Cancer (AJCC), but are put in a separate category (N3) along with

the supraclavicular and scalene nodes. Historically, these lymph nodes have been classified as

"distant."

"Vocal cord paralysis," "superior vena cava syndrome," and "compression of the trachea or the

esophagus" are classified as mediastinal lymph node involvement unless there is a statement of

involvement by direct extension from the primary tumor.

154
Q16

The main bronchus, pulmonary artery and veins, nerves and lymph vessels enter and leave through

the of the lung.

Q17

Describe the lobes of the lung:

a. Right lung:

b. Left lung:

Q18

covers the outer surface of the lung, while

lines the thorax.

155
Answer: Q16

The main bronchus, pulmonary artery and veins, nerves and lymph vessels enter and leave

through the hilus of the lung.

Answer: Q17

The lobes of the lung may be described as follows:

a. Right lung: The right lung has three lobes--upper, middle, and lower.

b. Left lung: The left lung has two lobes--upper and lower.

Answer: Q18

Visceral pleura covers the outer surface of the lung, while parietal pleura lines the thorax.

156
Malignant Tumors

Carcinoma of the lung originates in the mucosal lining of the bronchi, bronchioles, and alveoli.

The tumors may grow into the lumen of the bronchus or they may invade the wall of the bronchus

into the lung parenchyma. Most bronchogenic carcinomas arise near the hilus of the lung and will

extend along the main bronchus towards the carina into the mediastinum involving the organs and

structures located in the mediastinum--the pericardium, major blood vessels and nerves, trachea, and

esophagus--or they may extend peripherally to invade the pleura, chest wall, and ribs.

The histologic types of neoplasms which are commonly found in the lung are listed below:

• Squamous cell carcinoma is the most common type of bronchogenic carcinoma. It is

believed to arise as a result of irritation of the bronchial mucosa causing squamous

metaplasia progressing to squamous cell carcinoma. Cigarette smoking has been linked to

the increasing incidence of squamous cell carcinoma of the lung.

• Adenocarcinoma may arise from the mucous glands embedded in the submucosa, or, since

both adenocarcinoma and squamous cell carcinoma arise in the bronchus, it is thought that

all bronchogenic carcinomas may arise from the multipotential reserve cellsI of the

bronchial epithelium. Adenocarcinomas tend to occur more peripherally than do squamous

cell carcinomas.

• Adenosquamous carcinoma (adenoacanthoma) is a tumor of mixed histologic type.

• Undifferentiated carcinoma, which is indistinguishable as either squamous cell carcinoma

or adenocarcinoma, probably arises from the reserve cells. It may occur, for example, as

large cell, small cell, or oat cell variants. These carcinomas have a worse prognosis than

any of the above.

• Bronchiolar (alveolar) carcinoma arises in the terminal bronchioles or alveoli and is a rare

tumor type.

• Bronchial adenoma is somewhat of a misnomer for a tumor that is frequently invasive.

Variants are the carcinoid or cylindroid which are invariably malignant.

• Mesothelioma arises in the pleura or mesothelium that lines the pleural cavities and covers

the lungs. It may be either benign or malignant.

• Carcinoids arise from enterochromaffia (EC) cells which occur primarily in the submucosa

of the main bronchi.

The lung is one of the most common sites of metastatic disease since the body's blood flows

directly into this organ and all lymphatic drainage, whether direct or retrograde, eventually flows into

the lungs.

1reserve cells--Cells of the basal or germinal layer of the bronchial epithelium.

157
Clinical Manifestations

Clinical manifestations which are significant in the diagnosis of lung cancer are:

• Atelectasis (incomplete expansion--airless/functionless)

• Obstructive pneumonitis (inflammation)

° Superior vena cava syndrome (edema of the face, neck, and upper arms) caused by compression

of the superior vena cava (most often by enlarged mediastinal lymph nodes)

° Vocal cord paralysis caused by involvement of the recurrent laryngeal nerve

• Paralysis of the diaphragm as a result of phrenic nerve involvement

° Pleural effusion (accumulation of fluid in the interpleural space (pleural cavity))

These findings are used in the clinical assessment of lung cancer.

158
Q19

What is the interpleural space (pleurai cavity)?

Q20

Name the two groups of intrathoracic lymph nodes which drain the lung and pleura:

1.

2.

Q21

The most common type of bronchogenic carcinoma is

Q22

The type of cancer which may arise from mucous glands embedded in the submucosa is

Q23

is the most virulent type of bronchogenic carcinoma.

159
Answer: Q19

The interpleural space may be described as the space between the visceral pleura and

parietal pleura.

Answer: Q20

The two groups of intrathoracic nodes which drain the lung and pleura that you might have

mentioned are:

1. Intrapulmonary

2. Mediastinal

Answer: Q21

The most common type of bronchogenic carcinoma is squamous cell carcinoma.

Answer: Q22

Adenocarcinoma may arise from mucous glands embedded in the submucosa.

Answer: Q23

You might have said oat cell carcinoma or undifferentiated carcinoma is the most virulent

type of bronchogenic carcinoma.

160
Q24

Match the description on the left with one of the terms on the right:

1. Exchange of oxygen and carbon dioxide at a. thorax

the tissue level

b. paranasal sinuses

2. Smallest branches of bronchi

c. external respiration

3. Houses most organs of the respiratory system

d. hypopharynx

4. The beginning part of the respiratory system

e. trachea

5. A gaseous waste produced by body cells when oxygen

and food combine f. right lung

6. The part of the pharynx located behind and lateral g. internal respiration

to the larynx

h. nose

7. The region of the larynx which houses the true

vocal cords i. left lung

8. Thin hair-like structures which are attached j. glottis

to the mucous membrane epithelium lining the

respiratory tract k. visceral pleura

9. A passageway extending from the larynx to the 1. undifferentiated

bronchi carcinoma

10. Cartilage which acts as a lid for the larynx m. supraglottis

11. Lung having three lobes n. parietal pleura

12. Exchange of gases between air and blood o. oat cell carcinoma

in the lungs

p, epiglottis

13. Covering of the outer surface of the lung

q. mediastinum

14. Region between the lungs in chest cavity

which contains heart, aorta, esophagus, and trachea r. respiratory bronchioles

15. Collection of lymphoid tissue in nasopharynx s. adenoids

called pharyngeal tonsils

t. carbon dioxide

16. Branches from the trachea which act as passageways

into the air spaces of the lung u. interpleural space

17. The potential space between the visceral and v. main bronchi

and parietal pleura

w. cilia

161
Answer: Q24

_g_ 1. Exchange of oxygen and carbon dioxide internal respiration

at the tissue level

__.r 2. Smallest branches of bronchi respiratory bronchioles

a 3. Houses most organs of the respiratory system thorax

h 4. The beginning part of the respiratory nose

system

t 5. A gaseous waste produced by body cells carbon dioxide

when oxygen and food combine

d 6. The part of the pharynx located behind hypopharynx

and lateral to the larynx

_j.. 7. The region of the larynx which houses the glottis

the true vocal cords

w 8. Thin hair-like structures attached to cilia

the mucous membrane epithelium

lining the respiratory tract

e..e_ 9. A passageway extending from the larynx to trachea

the bronchi

_9_ 10. Cartilage which acts as a lid for the larynx epiglottis

_.f 11. Lung having three lobes right lung

c 12. Exchange of gases between the air and external respiration

the blood in the lungs

k 13. Covering of the outer surface of the lung visceral pleura

_q_ 14. Region between the lungs in chest cavity mediastinum

which contains heart, aorta, esophagus,

and trachea

s..L 15. Collection of lymphoid tissue in nasopharynx adenoids

called pharyngeal tonsils

v 16. Branches from the trachea which act as main bronchi

passageways into the air spaces of the lung

u__u_17. The potential space between the visceral interpleural space

and parietal pleura

162
SECTION G

DIGESTIVE SYSTEM

163
DIGESTIVE SYSTEM: Esophagus-Rectum

PRIMARY SITE MUCOSA SUB- MUSCULARIS SEROSA

MUCOSA PROPRIA

Epithelium : Lamina Muscularis

: Propria Mucosae

Esophagus Yes B Yes Yes Yes Yes No

(C15._) A

S

Stomach Yes E Yes Yes Yes Yes Yes

(C16._) M

E

Sm. Intestine Yes N Yes Yes Yes Yes Yes

(C17._) T

Colon Yes M Yes Yes Yes Yes Yes

(C18._) E

M

Rectosigmoid Yes B Yes Yes Yes Yes Yes

(C19.9) R

A

Rectum Yes N Yes Yes Yes Yes No

(C20.9) E

164
SECTION G

DIGESTIVE SYSTEM

The main organs of the digestive system form a muscular tube extending from the lips to the anus.

This tube is open at both ends and is referred to as the alimentary canal or the gastrointestinal (GI)

tract.

Organs which compose the GI tract are the mouth, pharynx, esophagus, stomach, small intestine,

colon, rectum and anus. There are other accessory organs and structures derived from the primitive

gut and located in either the main digestive tract or opening into it. These include the tongue, teeth,

gums, salivary glands, pancreas, gallbladder, bile ducts, liver, and appendix. The principal parts of the

digestive system are shown in Figure 19 below.

Figure 19. PRINCIPAL PARTS OF THE DIGESTIVE SYSTEM

165
The organs of the digestive system perform the vital function of altering the food so that it can

be used as nourishment by the body cells. The process of changing the chemical and physical

composition of food so that it can be utilized by the body is called digestion. The digestive system

provides the source of energy required for growth, maintenance, and function of the body. This

energy is derived from the assimilation of food by the cells of the body through a series of chemical

reactions called metabolism.

The walls of most of the organs of the gastrointestinal tract are made up of three main layers of

tissue:

• A mucous lining called the mucosa. It consists of a surface epithelium, a lamina propria, and,

in most of the length of the GI tract (lower esophagus, stomach, small intestine, colon, and rectum),

a muscularis mucosae.

° A submucosa of connective tissue in which are embedded blood and lymph vessels

• A muscularis propria or muscular layer

Most of the organs have a serosa or covering layer of visceral peritoneum which invests the organ

to a varying extent depending on the particular segment of the organ and its mesenteric attachments.

The cecum, transverse colon and sigmoid are almost completely invested with peritoneum, while the

ascending colon and descending colon are covered only on their anterior surfaces. The posterior

portions of these two segments of the colon are covered by loose areolar tissue.

Study the diagram below carefully so that you will recognize the names of the various tissue layers

of the organ wall. The depth of invasion of a neoplasm into the various layers of the wall is an

important measure of the spread of the tumor. You will utilize this information in Book 6 when you

study extent of disease and the staging of malignant tumors.

Figure 20. STRUCTURE OF INTESTINAL WALL

• " , '"?"."" "'_'. ......"?'

'.,/.i_,;j _vma. ., "." rJ

' "'"" _"" 'to )

Muse tar m m o ae I,_',_,'_,W,'?%_ z'_._'tff._d_ -_""_"J

• _ :'.".'_'_":_"I. -" _'j "

MuseulLar|s proprJLa : , • , . ' .... :; ....... = o- _,," o, ,

Longlt_dknst Layer _ '_ =

-_eroma
Q1

The main organs of the digestive system form a tube extending from the lips to the anus called

the canal or tract.

Q2

The main structures which compose the digestive/alimentary tract are the:

1. 5.

2. 6.

3. 7.

4. 8.

03

The three main tissue layers of the walls of the organs which make up the gastrointestinal

tract and their peritoneal covering (if present) are called:

1.

2.

3.

4.

Q4

The mucosa may be made up of three layers which are:

1.

2.

3.

167
Answer: Q1

The main organs of the digestive system form a tube extending from the lips to the anus

called the alimentary canal or digestive tract.

Answer: Q2

The main structures of the digestive/alimentary tract are:

1. Mouth

2. Pharynx

3. Esophagus

4. Stomach

5. Small intestine

6. Colon

7. Rectum

8. Anus

Answer: Q3

The three main tissue layers of the walls of the organs which make up the gastrointestinal

tract and their peritoneal covering (if present) are called:

1. Mucosa

2. Submucosa

3. Muscularis propria

4. Serosa

Answer: Q4

The three layers of the mucosa are:

1. Surface epithelium

2. Lamina propria

3. Muscularis mucosae

168
Mouth

The gastrointestinal tract begins with the mouth (oral cavity). The lips form the anterior wall of

the oral cavity; the cheeks (buccal mucosa) form the lateral walls; the hard and soft palates form the

roof; the floor of the mouth forms the base of the cavity. Structures within the mouth are the

tongue, gums (gingiva), and teeth. The entire cavity is lined with mucous membrane, but the

muscularis mucosae found in other parts of the gastrointestinal tract is not present in the mouth or

pharynx. The lamina propria and submueosa are, therefore, generally indistinguishable.

Food enters through the lips and is broken up and crushed by the action of the tongue and the

teeth. At the same time, it is mixed with the saliva produced by the salivary glands. Mastication thus

begins the first step in the digestive process.

The blood supply to structures of the oral cavity is from various branches of the external carotid

artery. The venous blood drains into the superficial or deep jugular veins.

Ninety percent of the malignant tumors arising in the oral cavity are squamous cell carcinoma.

Figure 21. ORAL CAVITY

A. ABOVE THE TONGUE B. BENEATH THE TONGUE

.o.._°-. ..... ..o

.o

..' "..... /" "'\

. _,.rd _IL.I. ._"-..

t....

"_-_.:]..'" Subl.lnttu_t / '. _ r'Ol_,? _,li_-_-"_-_.'

"_L_'.?".' '-] Ila.LJkvlltrT ELand '., _ .._FI,00r 0£ mOtAth

-... _ _,./

0,,£2. s

( DormeLI. mmrfa©o)

169
• Lips. The lips form the upper and lower anterior walls of the oral cavity. Each lip consists of

an exposed surface of modified epidermis known as the vermilion border and a labial mucosa*

(mucous membrane) which lines the inner surface of the lip. Striated muscle and fibroelastic

connective tissue lie beneath the surface.

"Lip" should not be confused with "skin of lip" which is not part of the digestive system.

The commissure is the point of union of the upper lip and the lower lip (corner of the mouth).

Malignant Tumors

The lower lip is the most common site of malignancy in the oral cavity. Malignant tumors of the

upper lip are relatively rare. The most common type of malignant tumor of the lip is squamous cell

(epidermoid) carcinoma.

Figure 22. LIPS

__/._J/SkJ.n o:I _pper Lip

Lower LIp

"--------Skin of Lower Lip

*Note: The latest revisions of the American Joint Committee define the lip as the vermilion surface

only. The mucosa of the lip is included with the buccal mucosa. The ICD-O provides separate code

numbers for labial mucosa (C00.3, C00.4) and vermilion surface (C00.0, COO.I)of the lip. You can

combine or separate as you wish. Historically, the mucosa of the lip has been defined as part of the

lip.

170
Q5

The lip consists of an exposed surface of modified epithelium called the

and an inner mucosal surface called the

Q6

The point of union of the upper and lower lips is called the

Q7

Lip lesions occur most frequently on the lip.

171
Answer: Q5

The lip consists of an exposed surface of modified epithelium called the vermilion border

and an inner mucosal surface called the labial mucosa.

Answer: Q6

The point of union of the upper and lower lips is called the commissure.

Answer: Q7

Lip lesions occur most frequently on the lower lip.

172
• Tongue. The tongue is a mobile mass of striated muscle covered by mucous membrane. It

attaches to the floor of the mouth and practically fills the oral cavity. The membrane on the

undersurface of the tongue is thin and forms a fold at the midline called the frenulum which extends

from near the tip of the tongue to the floor of the mouth. The mucous membrane on the dorsum

of the tongue is thick; and, over the anterior two-thirds, it is studded with papillae. 1 Functions of

the tongue are mastication, deglutition (swallowing) and articulation (in reference to speech). It also

has the faculty for producing the sense of taste.

The anterior two-thirds of the tongue is the freely movable portion which extends anteriorly from

the line of circumvallate papillae to the tip of the tongue and then posteriorly along the undersurface

to its junction with the floor of the mouth. Its topographical subdivisions are1. Lateral borders and tip (apex)

2. Dorsal (upper) surface

3. Ventral (under) surface

The base of the tongue (posterior one-third) is less mobile and extends posteriorly from the line

of circumvallate papillae to the base of the epiglottis. The hollow formed at the junction of the base

of the tongue with the epiglottis is called the vallecula. The lingual tonsils are aggregates of lymphoid

tissue located in the base of the tongue (see page 68 for a detailed discussion).

Figure 23. DORSAL SURFACE OF TONGUE

/Bp4 llLott tLs

_V&IL ILecuLs

//__ ____-_-GLommoept.LottALc ,oLd

"// _- _.PaLa'tlne tonoAL

' _ _ _ _Tcns_LLt&r pttLar

el tonaue tL v_r trailer tonalt )

L

%llldlL£mo

1papilla (plural - papillae)--Small nipple-shaped projection or elevation on which are located

numerous taste buds.

173
Malignant Tumors

Malignant lesions are more common on the anterior two-thirds than on the posterior one-third

of the tongue. Along with the lower lip, carcinoma of the anterior tongue is one of the most

common sites of malignant tumors of the oral cavity.

Squamous cell carcinomas constitute 90 percent of all malignant tumors of the tongue. The other

10 percent are made up primarily of lymphoepitheliomas and lymphosarcomas. Lymphosarcomas

will arise in the lymphoid tissue (lingual tonsil) found in the base of the tongue.

174
Q8

The tongue is composed of covered by

Q9

What marks the division of the anterior two-thirds of the tongue and the base of the tongue?

QIO

Which part of the tongue has the most malignant tumors?

175
Answer: Q8

The tongue is composed of muscle covered by mucous membrane.

Answer: Q9

The division of the anterior two-thirds of the tongue and the base of the tongue is the

(circum)vallate papillae.

Answer: QIO

The anterior two-thirds of the tongue has more malignant tumors than does the base of

the tongue.

176
• Floor of mouth. The floor of the mouth consists of a semilunar shaped area of loose, movable

mucosa, an underlying subserosa and the mylohyoid and hypoglossus muscles. It extends from

the inner surface of the lower alveolar ridge to the undersurface of the tongue. Its posterior

boundary on each side is the base of the anterior pillar of the tonsil. It is divided anteriorly

into two sides by the frenulum of the tongue and contains the ostia 1 of the submandibular

(submaxillary) and sublingual salivary glands.

• Retromolar area. The retromolar area (retromolar trigone) is the attached mucosa overlying

the ascending ramus of the mandible from the level of the posterior surface of the last molar

tooth to the apex superiorly (see Figure 24).

Malignant Tumors

The floor of the mouth is a relatively common site for intra-oral malignancies. Most of the floor

of the mouth lesions are squamous cell carcinomas. The remaining five percent are adenocarcinomas

arising in the minor salivary glands.

Figure 24. FLOOR OF MOUTH

.°,. °, ..... .,

."

w"

: °

/

B£aht

sublL • nll_a 1

OIt JLu o[

IuIbmlllldibiLIr i 0 It uuth

(three ptpdLtse) :

- • ;

."

', ,g

"......\..,,, /..-'.

lostium (plural - ostia)--An opening into a tubular organ, in this case, an opening through which

the secretions of the salivary glands flow into the mouth.

177
• Gums (gingiva). The gums are folds of mucosa which surround the base of the teeth. The

lamina propria is firmly attached to the underlying bone thus forming a fusion of mucous membrane

and periosteum called "mucoperiosteum."

The lower gum is the mucosa covering the alveolar process of the mandible. It extends from the

line of attachment of mucosa in the buccal gutter (sulcus) on the outer margin to the line of free

mucosa of the floor of the mouth on the inner side. Posteriorly it extends to the ascending ramus

of the mandible (retromolar trigone).

The upper gum is the mucosa covering the alveolar process of the maxilla. It extends from the

line of attachment of mucosa in the gingival buccal sulcus to the junction with the mucosa of the

hard palate. Its posterior margin is the upper end of the palatoglossal (pterygopalatine) arch.

Malignant Tumors

Cancer occurs more frequently on the lower than on the upper gingiva. It will sometimes invade

underlying bone, but can be distinguished from tumors originating in bone on the basis of the

histology. Malignant tumors of the gingival mucosa are almost always squamous cell carcinoma. A

rare odontogenic tumor (ameloblastoma, adamantinoma) originating in the tissues which form the

teeth may arise in the bone underlying the gingival mucosa.

Figure 25. GINGIVA

Siiubco taoeo us tissue

ulc ]L•

.............. :,.x: t t,,

...._i G£nlllsr&:

Labia I mucosa---_ _

178
Qll

Match the structures on the left with their descriptions on the right:

1. Gum a. A muscular organ covered with papillae attached to the floor

of the mouth

2. Floor of mouth b. Mucosal covering of alveolar process (ridge)

3. Tongue c. Area of loose, movable mucosa extending from the undersurface

of the tongue to the alveolar ridge

4. Lip d. Anterior wall of the oral cavity

179
Answer: Qll

b__ 1. Gum Mucosal covering of the alveolar process (ridge)

e.q._ 2. Floor of mouth Area of loose, movable mucosa extending from the tongue to

undersurface of the alveolar ridge

a__ 3. Tongue A muscular organ covered with papillae attached to the floor of

the mouth

d 4. Lip Anterior wall of the oral cavity

180
• Palate. The palate is the roof of the mouth separating the oral cavity from the nasal cavity and

nasopharynx.

The hardpalate consists of a mucosa and periosteum (mucoperiosteum). It covers the palatine

processes of the maxillary palatine bones. The submucosa and muscularis are absent from the

hard palate. It is a semilunar area which extends from the inner surface of the upper

(superior) alveolar ridge to the posterior edge of the palatine bone.

The softpalate consists of mucosa, submucosa, and the underlying palatine muscles. It extends

posteriorly from the edge of the hard palate to its free border. A soft tissue projection, located

medially on its free border, is the uvula.

• Buccal mucosa. The buccal mucosa lines the inner surface of the cheeks, the structure of

which is formed by the buccinator muscles. The anatomic limits of the buccal mucosa are the upper

and lower gingival buccal sulci, the labial (lip) mucosa anteriorly, and the anterior tonsillar pillars

posteriorly. Again, squamous cell carcinoma is the predominant cell type of the malignant tumors

arising in this area. (See the note on page 170 for grouping of mucosa of lip in the various staging

and coding systems.)

Figure 26. HARD AND SOFT PALATES

181
182
Q12

What is the palate?

Q13

In what way is the mucosa of the oral cavity different from that of the remainder of the digestive

tract?

Q14

What is the most common type of malignancy found in the oral cavity?

Q15

Match the structure on the left with the description on the right:

1. Buccal mucosa a. Covers the palatine muscles

2. Gum b. Lines the inner surface of the cheeks

3. Soft palate c. Covers the palatine processes of the maxillary bones

4. Hard palate d. Surrounds the base of the teeth

Q16

The ostia of the submandibular and sublingual glands are located in the

of the

Q17

What are the main structures which form the oral cavity?

1. 2.

3. 4.

5. 6.

7. 8.

183
Answer: Q12

The palate is the roof of the mouth separating the oral cavity from the nasal cavity and

nasopharynx.

Answer: Q13

You might have said that the mucosa of the oral cavity is different from the remainder of

the digestive tract because it has no muscularis mucosae.

Answer: Q14

The most common type of malignancy found in the oral cavity issquamous cell carcinoma.

Answer: Q15

b 1. Buccal mucosa Lines the inner surface of the cheeks

d 2. Gum Surrounds the base of the teeth

a__ 3. Soft palate Covers the palatine muscles

c__ 4. Hard palate Covers the palatine processes of the maxillary bones

Answer: Q16

The ostia of the submaxillary and sublingual glands are located in the floor of the mouth.

Answer: Q17

The main structures forming the oral cavity are:

1. Lips 6. Floor of mouth

2. Cheeks (buccal mucosa) 7. Gingiva

3. Tongue 8. Retromolar area (trigone)

4. Hard palate

5. Soft palate

184
Salivary Glands

There are three pairs of major salivary glands: the parotid, submandibular (submaxillary), and

sublingual glands.

• The parotid glands, the largest of the major salivary glands, lie below and in front of the ears.

They secrete primarily serous substances into the mouth by way of the parotid duct (Stensen's

duct).

• The submandibular glands lie in contact with the inner surface of the mandible. They secrete

primarily serous substances into the mouth by way of the submandibular duct (Wharton's duct).

• The sublingual glands lie beneath the mucosa of the floor of the mouth. They pour mucous

secretions into the mouth.

In addition, there are minor salivary glands scattered throughout the mucous membrane covering

of the lips, cheeks, palate, and tongue. The salivary secretions may be thin and watery (produced by

serous cells) or thick and viscid (produced by mucous cells).

The salivary glands moisten and lubricate the mouth with continuous secretions of saliva.

Malignant and Benign Tumors

Neoplasms arising in salivary gland tissue are predominantly mixed tumors (pleomorphic

adenomas). Since approximately 75 percent of these tumors are benign, they will not be reported

by most registries. Malignant tumors which you are likely to find are: mucoepidermoid carcinoma,

squamous cell carcinoma, adenoid cystic carcinoma, and adenocarcinoma. These tumors arise most

frequently in the parotid.

Figure 27. SALIVARY GLANDS

/

Ostla

.... Parotld duct

j._ ,-

JSubma adllOu taa. liar./

Sulb IAn_at / lllLand

185
186
Q18

Identify the major salivary glands below:

3.

Q19 ('-"

Most tumors arising in salivary gland tissue are

(type) tumors which are benign 75 percent of the time.

Q20

In which of the major salivary glands do most of the malignant tumors arise?

187
Answer: Q18

The major salivary glands are as follows:

1. Parotid

2. Submandibular (submaxillary)

3. Sublingual

Answer: Q19

Most tumors arising in salivary gland tissue are mixed tumors which are benign 75 percent

of the time.

Answer: Q20

Most of the malignant tumors which arise in the major salivary glands occur in the parotid

gland.

188
Lymph Node Drainage

The regional lymph nodes for the various parts of the oral cavity and salivary glands are the upper

cervical nodes which may be identified more specifically in relation to their areas of drainage.

Facial Lymph Nodes Sublingual Lymph Nodes

Lip Anterior 2/3 of tongue

Gum Floor of mouth

Buccal mucosa

Retropharyngeal Lymph Nodes

Parotid Lymph Nodes

Upper gum

Upper lip and commissure Palate (hard and soft)

Parotid gland

Buccal mucosa

Internal jugular (upper and lower

deep cervical)

Submental Lymph Nodes

Lip Lip

Tongue Tongue, all parts

Gum Floor of mouth

Floor of mouth Gum

Submandibular (submaxillary) gland Buccal mucosa

Palate Palate

Buccal Mucosa Submandibular (submaxillary) gland

Submandibular (submaxillary) Lymph Nodes

Lip

Buccal mucosa

Floor of mouth

Gum

Tongue, all parts

Palate

Submandibular (submaxillary) gland

The supraclavicular (transverse cervical) lymph nodes are distant nodes for most sites, including the

head and neck, except for skin of the lower neck and chest wall (see Figure 27 and Figure 28 for

locations of lymph nodes).

189
190
Q21

Match the sites on the left with the lymph nodes on the right:

1. Gum a. Facial

2. Buccal mucosa b. Internal jugular

3. Lip c. Retropharyngeal

4. Tongue d. Submandibular

Q22

Except for skin of the lower neck and chest wall, the lymph nodes

are always considered distant nodes.

191
Answer: Q21

c 1. Gum Retropharyngeal

a,b,d 2. Buccal mucosa Facial. internal jugular, and

submandibular

a,b,d 3. Lip Facial, internal jugular, and

submandibular

b,d 4. Tongue Internal jugular (upper deep) and

submandibular

Answer: Q22

Except for skin of the lower neck and chest wall, the supraclavicular (transverse cervical)

lymph nodes are considered distant nodes for all sites.

Figure 28. ORAL CAVITY LYMPH NODE REGIONS

PerotLd

LaL

192
Pharynx

The pharynx is divided into three regions: the nasopharynx, the oropharynx, and the hypopharynx

(laryngopharynx).

The nasopharynx lies behind the nasal cavities, above the soft palate, and below the base of the

skull. The oropharynx lies behind the buccal cavity, below the soft palate, and above the opening to

the larynx. The hypopharynx (laryngopharynx) is located behind, lateral and inferior to the larynx.

The nasopharynx has been discussed in detail in Section F, The Respiratory System.

The pharynx (throat) serves as a passageway for the respiratory and digestive tracts, since air must

pass through this structure before reaching the lungs, and food must pass through it to get to the

stomach. The pharynx is also important for phonation because by changing its shape the different

vowel sounds are formed. The pharynx is made of muscle which is lined with mucous membrane.

Embedded within this muscle are the palatine and pharyngeal tonsils. The tonsils are composed of

lymphoid tissue and may be considered part of the lymphatic system. However, they are located

within the respiratory and digestive systems. The adenoids or pharyngeal tonsils are located in the

nasopharynx. The faucial or palatine tonsils are located in the oropharynx. (The lingual tonsils, as

we have learned, are in the base of the tongue. It is the palatine tonsils that are commonly removed

by a tonsillectomy.)

The lymphatics for the pharynx drain into the cervical lymph nodes, namely, the internal jugular

(upper and lower deep cervical), and retropharyngeal lymph nodes. The blood supply is via the

external carotid arteries and internal jugular veins.

Figure 29. OROPHARYNX AND HYPOPHARY'NX

-_ jCho&na

193
Oropharynx. The air and food passageways cross in the oropharynx. The oropharynx extends from

the level of the free borders of the soft palate to the tip of the epiglottis.

The anatomical limits are as follows:

• The posterior oropharyngeal wall is that part of the posterior pharyngeal wall that extends from

a level opposite the free borders of the soft palate to the tip of the epiglottis.

• The lateral walls include the tonsillar pillars, tonsillar fossae, and the palatine (faucial) tonsils.

On each side, the anterior pillar (glossopalatine fold) extends from the base of the tongue to

the soft palate lying in front of the tonsillar fossa. The posterior tonsillar pillar (pharyngopalatine fold) lies in back of the tonsiUar fossa. The area between the two pillars, the tonsillar

fossa, houses the palatine tonsil, sometimes called the faucial tonsil.

• The anterior wall consists of the lingual (anterior) surface of the epiglottis and the

pharyngoepiglottic and glossoepiglottic folds which bound the vallecula (the hollow formed at

the junction of the base of the tongue and the epiglottis--see base of tongue).

Note: The latest revisions of the American Joint Committee include base of tongue and soft palate

in the oral pharynx rather than in the oral cavity. ICD-O provides separate code numbers in the oral

grouping: base of tongue (C01.9), soft palate (C05.1), and uvula (C05.2). Thus, these sites can be

grouped with the oral cavity (as they have been historically) or they can be included in the oral

pharynx.

194
Hypopharynx (laryngopharynx). The function of the hypopharynx is purely alimentary providing

a passage behind the larynx. The sites within the hypopharynx are the pyriform sinus, the postcricoid

area, and the posterior pharyngeal wall. The anatomical limits are as follows:

• The pyriform sinus extends from the pharyngoepiglottic fold to the upper edge of the

esophagus between the inner surface of the thyroid cartilage and the posterior lateral surface

of the thyroid and cricoid cartilages.

• The postcricoid area extends from the posterior surface of the arytenoid cartilages and the

aryepiglottic folds to the inferior surface of the cricoid cartilage. The lateral margin is the

anterior part of the pyriform sinus.

• The posterior hypopharyngeal wall is that part of the posterior pharyngeal wall that extends from

the level of the tip of the epiglottis to the inferior margin of the cricoid cartilage and laterally to the

posterior margins of the pyriform sinus.

Malignant Tumors

Malignant tumors of the pharynx are usually squamous cell carcinoma. Although tumors of

lymphoid tissue do arise in these areas, the frequency is relatively low compared to tumors of this

histologic type occurring elsewhere in the body.

195
196
Q23

What is another name for the hypopharynx?

Q24

What histologic type of malignant tumor do you usually expect to find in the pharynx?

197
Answer: Q23

Another name for the hypopharynx is the laryngopharynx.

Answer: Q24

You usually expect to find squamous cell carcinoma in the pharynx.

198
Q25

Match each structure on the left with its function on the right:

1. Hypopharynx a. Serves as a passageway for food only

2. Oropharynx b. Serves as a passageway for air only

3. Nasopharynx c. Serves as a passageway for both food and air (crossover)

Q26

Match each structure on the left with its location on the right:

1. Nasopharynx a. Behind the nasal cavities and above the soft palate

2. Oropharynx b. Behind the buccal cavity and below the soft palate

3. Hypopharynx c. Behind and lateral to the larynx

Q27

The pharynx is composed of and is lined with

199
Answer: Q25

a__ 1. Hypopharynx Serves as a passageway for food only

c.c_. 2. Oropharynx Serves as a passageway for both food and air (crossover)

b 3. Nasopharynx Serves as a passageway for air only

Answer: Q26

a___ 1. Nasopharynx Behind the nasal cavities and above the soft palate

b__ 2. Oropharynx Behind the buccal cavity and below the soft palate

c 3. Hypopharynx Behind and lateral to the larynx

Answer: Q27

The pharynx is composed of muscle and is lined with mucous membrane.

2OO
Q28

To which segment of the pharynx would you code a malignancy of each of the

following?

a. Tonsillar pillar

b. Postcricoid region

c. Pyriform sinus

d. Anterior surface of

the epiglottis

e. Pharyngeal tonsil

f. Laryngopharynx

g. Glossopalatine fold

h. Aryepiglottic fold

Q29

Match the tonsil on the left with its location on the right:

1. Adenoids a. Oropharynx

2. Palatine b. Base of the tongue

3. Lingual c. Nasopharynx

201
Answer: Q28

a. Tonsillar pillar - Oropharynx

b. Postcricoid region - Hypopharynx

c. Pyriform sinus - Hypopharynx

d. Anterior surface of

the epiglottis - Oropharynx

e. Pharyngeal tonsil - Nasopharynx

f. Laryngopharynx - Hypopharynx

g. Glossopalatine fold - Oropharynx

h. Aryepiglottic fold - Hypopharynx

Answer: Q29

c_._ 1. Adenoids Nasopharynx

a__ 2. Palatine Oropharynx

b__ 3. Lingual Base of the tongue

2O2
Esophagus

The esophagus is a muscular tube about ten inches (25 cm.) long extending from the hypopharynx

to the stomach. The peristaltic 1 motion of the esophagus moves food along to the stomach. The

esophagus lies posterior to the trachea and the heart, and passes through the mediastinum and the

hiatus, an opening in the diaphragm, in its descent from the thoracic to the abdominal cavity. The

esophagus can be divided into three segments or regions: 1) cervical, 2) thoracic, and 3) abdominal.

The location of esophageal lesions is frequently measured from the incisors (front teeth) and may be

approximated as follows:

• The cervical esophagus begins at the lower border of the cricoid cartilage and ends at the

thoracic inlet (suprasternal notch) approximately 18 cm measuring from the upper incisors.

• The upper thoracic esophagus extends from the thoracic inlet to the level of the tracheal

bifurcation, approximately 24 cm from the upper incisors.

• The mid-thoracic portion is the proximal half of the esophagus between the tracheal

bifurcation and the esophago-gastric junction. The lower level is approximately 32 cm

from the upper incisor teeth.

• The lower thoracic portion, 8 cm in length (includes the abdominal esophagus), is the

distal half of the esophagus between the tracheal bifurcation and the esophago-gastric

junction, approximately 40 cm from the upper incisor teeth.

The esophagus may also be described in terms of upper, mid, and lower thirds. This measurement

is not equivalent to the one just described as you can see from Figure 31. It may be approximated

as follows:

• The upper (proximal) third extends from the sixth cervical vertebra to the sixth thoracic vertebra.

• The mid third extends from the sixth thoracic vertebra to the ninth thoracic vertebra.

• The lower (distal) third extends from the ninth thoracic vertebra to the cardioesophageal

junction.

Figure 30. DMSIONS OF THE ESOPHAGUS

117Pophsrfm_

;! (?

1peristalsis (n); peristaltic (adj)--Wavelike, involuntary contractions provided by the combination

of longitudinal and circular muscles which propel the contents of the gastrointestinal tract.

2O3
Figure 31. MEASUREMENTS OF THE ESOPHAGUS

(FROM THE INCISORS TO THE STOMACH)

{:3

C5

C6

C6

I C7 ,-*

TI

;>Cervicalesophagus

Upper 18

t/3 < T3 L._

( pr oxJLmAL )

T+ Upperthoracicesophagus

zs -24

'I'6 -----

T7

wJ.,cIae thoracice;ophagus K

1/3 T8

Lower T i 0

L/3 <_ owerthoracicesophagus

( _LstsL ) 1 /'" "_,

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JunctLon

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i

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204
The inner wall of the esophagus is lined with mucosa. The mucosa can be subdivided into surface

epithelium, lamina propria, and muscularis mucosae. Beneath the mucosa lies the submucosa which

contains mucous glands, blood vessels, lymphatics, and nerves. The muscularis propria lies beneath

the submucosa. It consists of two layers of muscle, an inner circular and outer longitudinal layer.

This muscular layer is composed of striated muscle in the upper third, mixed striated and smooth

muscle in the middle third, and smooth muscle only in the lower third. There is no serosa on the

esophagus, but rather an external adventitia of fibrous connective tissue. The lack of a serosa

facilitates the spread of cancer beyond the primary site into adjacent tissues and lymph nodes.

Branches of the aorta and celiac artery supply blood to the esophagus. The venous drainage is

to the azygos, thyroid, and left gastric veins. The lymphatic vessels drain into the cervical,

mediastinal, and gastric lymph nodes depending on the segment of the esophagus from which they

originate.

Malignant Tumors

The neoplasms arising in the esophagus are primarily squamous cell (epidermoid) carcinomas.

Leiomyosarcomas of the muscle layers arise less frequently. The esophagus, despite its length, is an

uncommon tumor site.

Figure 32. ESOPHAGEAL LYMPH NODES Figure 33. CROSS-SECTION OF ESOPHAGUS

205
206
Q30

The esophagus is a muscular tube about ten inches long extending from the

to the and is divided into four anatomic segments:

1.

2.

3.

4.

Q31

The esophagus passes through the in its descent from the

cavity to the cavity.

Q32

The three main tissue layers of the wall of the esophagus are:

1.

2.

3.

207
Answer: Q30

The esophagus extends from the pharynx to the stomach and can be divided into four

anatomic segments:

1. Cervical

2. Upper thoracic portion

3. Mid-thoracic

4. Lower thoracic portion, including abdominal

Answer: Q31

The esophagus passes through the diaphragm (or hiatus in the diaphragm) in its descent

from the thoracic cavity to the abdominal cavity.

Answer: Q32

The three main tissue layers of the wall of the esophagus are:

1. Mucosa

2. Submucosa

3. Musculature (muscularis propria)

Remember there is no serosa on the esophagus, only an adventitia of loose connective

tissue.

208
Stomach

The stomach lies just below the diaphragm in the upper part of the abdominal cavity primarily to

the left of the midline under a portion of the liver. Factors which influence the precise location are

food ingestion and respiration (inspiration and expiration). Food leaves the esophagus and enters

into this elongated pouch-like structure by way of the cardiac orifice. The role of the stomach is the

mixing of food with gastric secretions by way of peristalsis to form chyme 1 and the ejection of the

chyme into the small intestine.

The main divisions of the stomach (Figure 34, below) are the cardia, the fundus (fornix), the body

(corpus), and the antrum:

• The cardia is the portion of the stomach surrounding the cardioesophageal junction, or cardiac

orifice (the opening of the esophagus into the stomach).

• The fundus is the enlarged portion to the left and above the cardiac orifice.

• The body, or corpus, is the central part of the stomach.

• Thepyloric antrum is the lower or distal portion above the duodenum. The opening between

the stomach and the small intestine is the pylorus, and the very powerful sphincter which

regulates the passage of chyme into the duodenum is called the pyloric sphincter.

Figure 34. STOMACH AND ADJOINING STRUCTURES

C_r d Jl.ac: orifice

BmoPh'au" _---_ j I ]

/ / / Pue, clum

lop&tL¢ nod@Is r (Lo_t pmtric) nodom

?.LmTf. x.,/

l • AI ¢ I

nodo •

PyLor I antrum

lchyme--The fluid content of the stomach after food has undergone gastric digestion.

209
The medial border of the stomach is called the lesser curvature, and the lateral border is called

the greater curvature. These designations are important in pinpointing the location of neoplasms.

A large fold of peritoneum called the greater omentum, or gastrocolic omentum, extends down

from the anterior surface of the stomach connecting the abdominal viscera. It contains fat cells,

blood and lymphatic vessels, and nerves. A similar fold called the lesser omentum, or gastrohepatic

omentum, extends between the liver and the lesser curvature of the stomach.

The mucosa (described earlier) is composed of three layers: the surface epithelium, the lamina

propria, and the muscularis mucosae. This middle layer (lamina propria) is thick and filled with

glands which secrete both mucous and enzymes. When the stomach is empty, the mucosa forms folds

called rugae 1. The submucosa is composed of dense connective tissue with large blood and lymph

vessels. The muscularis propria is composed of three muscular layers as compared to two in the

esophagus. These are called the longitudinal, circular, and oblique layers. This muscular wall serves

as a churn to help break up and mix food with the gastric juices. A serosa of visceral peritoneum

invests the outer surface of the stomach.

The blood supply to the stomach is derived from branches of the celiac artery. The venous

drainage is into the portal vein, either directly or by way of the splenic and superior mesenteric veins.

The regional lymph nodes are as follows:

Inferior (right) gastric: Splenic:

Greater curvature Gastroepiploic, left

Greater omental Pancreaticolienal

Gastroduodenal Peripancreatic

Gastrocolic Splenic hilar

Gastroepiploic, right

Gastrohepatic

Pyloric, incl. sub-/infrapyloric

Pancreaticoduodenal (Anteriorly along first part of the duodenal)

Superior (left) gastric:

Lesser curvature

Lesser omental

Gastropancreatic, left

Gastric, left

Paracardial; cardial

Cardioesophageal

Celiac

Hepatic (excl. gastrohepatic)

lrugae--ridges, wrinkles, or folds, as of mucous membrane.

210
The functions of the stomach are to:

1. Absorb water and glucose into the blood stream.

2. Secrete gastric enzymes. For example, rennin to clot milk; iipase to initiate the splitting of

fats; pepsinogen, which in the presence of hydrochloric acid forms pepsin, to begin protein

breakdown.

3. Secrete hydrochloric acid (Hcl) which kills bacteria, changes some minerals to salts which are

suitable for absorption in the intestine, and adjusts the pH of the chyme to permit the opening

of the pyloric sphincter.

4. Produce, in the gastric mucosa, the intrinsic factor which is necessary for the absorption of

Vitamin B12.

5. Secrete, in the pyloric glands, an alkaline mucous to neutralize the HCI.

6. Churn the food into a semi-liquid substance (chyme) and force it through the pyloric sphincter

into the duodenum.

Malignant and Benign Tumors

• Adenocarcinoma is the most frequent malignant lesion of the stomach. The spread of the

tumor is usually to regional lymph nodes and the liver. Later metastasis frequently occurs in

the lungs, brain, bone, and ovaries. A tumor known as Krukenberg tumor is found in the

ovary which represents a metastasis of adenocarcinoma of the gastrointestinal tract, usually

of the stomach, to the ovary.

• Lymphomas arise more frequently in the stomach than in any other extranodal site. Any

histologic type of lymphoma, including Hodgkin's disease, may occur.

° Leiomyosarcoma arises in the smooth muscles of the stomach wall.

° Squamous cell carcinoma occurs at the cardioesophageal junction.

• Linitis plastica is an advanced form of cancer which is characterized by a thickening of the

stomach wall causing it to lose its elasticity and become rigid like a leather bottle. It has,

therefore, been referred to as leather-bottle stomach.

• Leiomyomas and adenomas are the two most common benign tumors of the stomach.

211
Q33

The stomach lies just below the in the upper part of the

abdominal cavity. The main divisions of the stomach are the:

1.

2.

3.

4.

Q34

The three tissue layers of the stomach wall and its peritoneal covering are:

1.

2.

3.

4.

Q35

The three major regional lymph node chains are:

1.

2.

3.

212
Q36

Name three general functions the stomach performs:

1.

2.

3.

Q37

The most frequent malignant neoplasm of the stomach is

213
Answer: Q33

The stomach lies just below the diaphragm. Its main divisions are the:

1. Cardia

2. Fundus

3. Body or corpus

4. Pyloric antrum

Answer: Q34

The three tissue layers of the stomach wall and its peritoneal covering are:

1. Mucosa

2. Submucosa

3. Muscularis propria

4. Serosa

Answer: Q35

The three major regional lymph node chains are:

1. Superior (left) gastric

2. Inferior (right) gastric

3. Splenic

Answer: Q36

Some functions of the stomach are:

1. It churns or mixes food into a semi-liquid and forces it into the duodenum.

2. It secretes gastric juices (enzymes, hydrochloric acid, mucous, intrinsic factor).

3. It absorbs water and glucose.

Answer: Q37

The most frequent malignant neoplasm of the stomach is adenocarcinoma.

214
Small Intestine

The small intestine is a tube measuring about 2.5 cm. in diameter and over 20 feet (600 cm.) in

length coiled in loops which fill most of the abdominal cavity. It has three divisions--duodenum,

jejunum, and ileum:

• The duodenum is just below the pyloric portion of the stomach and is about 25 cm. long and

shaped somewhat like the letter C. It receives chyme from the stomach, bile from the

gallbladder, and pancreatic secretions from the pancreas. The common bile duct and

pancreatic duct join the duodenum at the ampulla of Vater. The duodenum becomes the

jejunum where the tube turns forward and downward.

° The jejunum continues for over 200 cm. and then becomes the ileum, although there is no

demarcation between the two divisions.

° The ileum is over 300 cm. long and joins the large intestine at the ileocecal valve.

The wall of the small intestine is composed of the same three main layers of tissue as the rest of

the gastrointestinal tract and is covered with serosa. Small aggregates of lymphoid tissue called

Peyer's patches are found in the lamina propria of the small intestine, principally in the distal ileum.

The small intestine completes the digestion of the material received from the stomach and moves

it along in peristaltic waves to the colon. Increased epithelial surface needed for absorption is

provided by circular folds and villi.1 The absorbed material which reaches the blood stream via the

intestinal capillaries and lymphatics includes 1) water, 2) carbohydrates, 3) fat, and 4) protein.

The lymphatic drainage of the small intestine is to lymph nodes along the branches of the superior

mesenteric and hepatic arteries. Duodenal nodes, in particular, may be described in terms of their

location in relation to adjacent organs, such as, the stomach (pyloric), gallbladder (cystic), bile ducts

(pericholedochal), pancreas (pancreaticoduodenal) and ampulla of Vater. The terminal ileum drains

to posterior cecal and ileocecal nodes of the superior mesenteric group.

Malignant and Benign Tumors

In spite of the relatively long length of the small intestine, tumors are rare. Thirty-five percent

of all tumors of the small intestine are benign. Only one-fourth of all tumors in this site are

adenocarcinomas, most frequently found in the duodenum. Lymphoma is the next most frequently

diagnosed tumor of the small intestine with carcinoid tumors (argentaffinomas) and leiomyosarcomas

accounting for the remainder.

lvillus--(plural - villi)--A small vascular process or protrusion, usually covered by epithelium,

especially such a protrusion from the free surface of a membrane.

215
216
Q38

The small intestine is about in length and is composed of three parts

which are:

1.

2.

3.

Q39

Name two functions of the small intestine:

1.

2.

Q40

What are some of the most common types of tumors found in the small intestine?

1.

2.

3.

4.

217
Answer: Q38

The small intestine is about twenty feet. (600 cm.) long. It is composed of three parts

which are:

1. Duodenum

2. Jejunum

3. Ileum

Answer: Q39

Two functions of the small intestine are:

1. Digestion

2. Absorption

Answer: Q40

Some of the most common types of tumors found in the small intestine are:

1. Adenocarcinoma

2. Lymphoma

3. Leiomyosarcoma

4. Carcinoid tumor

218
Large Intestine

The large intestine (the colon, rectum, and anus) is approximately five feet (150 cm.) long with

a diameter of about 6 cm., decreasing towards the lower end. The by-products of digestion pass from

the small intestine through the ileocecal valve to the large intestine. The ileocecal valve projects into

the large intestine preventing the contents of the colon from regurgitating into the small intestine.

The large intestine is divided into the following segments:

• The cecum is a large cul-de-sac at the lower end of the ascending colon (proximal to the

entrance of the ileum into the colon). It comprises the first 5 to 7 cm. of the large intestine.

The appendix is a blind sac opening into the cecum just below the ileocecal orifice.

° The ascending colon extends upward from the cecum on the right side of the abdomen to the

under surface of the right lobe of the liver where it turns to the left forming the hepatic

flexure.

° The transverse colon begins at the hepatic flexure passing horizontally across the abdomen,

below the liver and stomach and above the small intestine. On the left side of the abdomen

near the spleen, the colon turns downward at the junction of the transverse and descending

colon forming the splenic flexure.

• The descending colon starts at the splenic flexure and passes downward until it turns towards

the midline at the rim of the pelvis and continues downward to become the sigmoid colon.

° The sigmoid colon, sometimes called the pelvic colon, is curved like the letter S. The lower

part of the curve joins the rectum at the rectosigmoid junction.

• The rectum extends down to the anal canal. The upper part of the rectum, generally that part

above the peritoneal reflection, is often called the rectosigmoid. It extends from approximately

10 cm. up to 15 cm (measuring from the anal verge). The lower rectum is devoid of a

peritoneal covering and, therefore, has no serosa. It extends to approximately 10 cm.

(measuring from the anal verge).

° The anal canal constitutes the final 2.5 cm of the digestive tract. It begins at the anorectal

junction (dentate or pectinate line) and ends at the anal verge where the anal tube turns

outward to blend with the perianal skin. In contrast to the rest of the large intestine, the anal

canal is lined with squamous epithelium.

The main functions of the large intestine are reabsorption of water, minerals, and salts into the

blood stream and movement of unabsorbed solid material along until it is eventually eliminated from

the body as feces. Absorption takes place principally in the right colon; storage in and expulsion of

fecal material from the left colon.

219
The large intestine receives the fluid by-products of digestion from the small intestine. The water

is absorbed into the blood stream. However, the unabsorbed solid material is merely stored in the

colon and moved along by peristaltic action for elimination. Therefore, there are no villi present as

there are in the small intestine. The tissue layers are similar to those in the stomach: a mucosa of

surface epithelium, lamina propria and muscularis mucosae, a submucosal layer, and a muscularis

propria. The muscularis propria differs from other parts of the gastrointestinal tract in that the

longitudinal muscle layer is arranged in three fiat bands called taenia coli. These bands are not as

long as the intestine; consequently, it gives the wall a gathered (shirred) effect and creates sacs

(haustra). Little pouches of fat called appendices epiploica hang from the wall of the intraperitoneal

colon distending the serosa.

The colon is attached to the posterior abdominal wall by folds of peritoneum called mesenteries.

The cecum, transverse colon, and sigmoid are almost completely invested by peritoneum, but the

ascending and descending colon which lie along the posterior body wall (retroperitoneum) are

covered on the anterior surfaces only. This covering is called the serosa. The lower rectum is called

the extraperitoneal portion of the large intestine, lying as it does below the peritoneal reflection, i.e.,

outside of the peritoneal cavity.

Figure 35. STRUCTURE OF COLONIC WALL

R_- _._ w ee._ g/Muscutarts nuccsee

M_mcutar £m proprla

8ubeeroet ( connective

tissue and tot}

_aaroe& or visceral

perLtone_w

lde_enter_c tat

(sowet_mee\ceLLed perjcoLl¢ tot) Ser°s T (tree st_rtece)

L_moa _ BowelL waLL

•_ :', "_

,_., ,._. . _

_Jubaeroen L tot t

• etropor£ tones t tel

(sometimes ceLLed aerosol

or pertcolLlc £_t) (aonetJLsee celLte_ perJLcotlc tat)

Bowel (excL_dlng aacend_Lnl end Aecoadlnil; &ad DoecondAng CoLon OnLy

q/eecond_nii_ colon )

Figure 36. RELATIONSHIP OF BOWEL WALL AND SEROSA TO

PERICOLIC/MESENTERIC FAT

220
The blood supply to the wall of the large intestine is derived from branches of the superior and

the inferior mesenteric arteries. The superior mesenteric artery and its branches supply the right side

of the colon, hepatic flexure and just beyond the midline of the transverse. The inferior mesenteric

artery and its branches supply the left side of the colon and a portion of the left transverse. The

veins enter the inferior mesenteric vein and eventually the portal vein.

The lymphatics of the large intestine drain primarily into the superior and inferior mesenteric

lymph nodes before eventually reaching the cisterna chyli and thoracic duct. To refresh your memory,

turn to page 58 of the lymphatic system.

Epicolic lymph nodules lying beneath the serosa and paracolic lymph nodes in the adjacent

mesentery are found along the length of the colon. Lymph collected in the paracolic nodes drains

through the lymphatic vessels and intercalating lymph nodes in the mesentery toward the branching

of the superior and inferior mesenteric arteries from the aorta.

Perirectal lymph nodes drain, in addition, to nodes along branches of the internal iliac artery and

to sacral promontory nodes.

The branches of the major arteries and lymphatics are:

Superior Mesenteric Inferior Mesenteric

ileocolic left colic

right colic hemorrhoidal, superior

mid-colic sigmoidal (sigmoid mesenteric)

cecal, anterior/posterior

Internal Iliac (Hypogastric)

sacral (lateral sacral)

hemorrhoidal, middle

Often lymph nodes whose configurations have been obliterated by tumor are described by the

pathologist as tumor nodules in pericolic fat. These are not to be confused with Peyer's patches

which are areas of lymphoid tissue in the mucosa.

221
Malignant and Benign Tumors

The usual histologic type of intestinal malignancy is adenocarcinoma. Squamous cell carcinoma

arises in the anus; cloacogenic transitional cell carcinoma arises at the anorectal junction. Tumors

arising on the right side of the colon tend to be cauliflower-type lesions; those on the left encircling

or "napkin-ring" type.

Carcinoids are the most common appendicial tumors. They rarely metastasize. There is a

difference of opinion among pathologists as to the criteria for determining their malignancy.

There are some premalignant conditions of which you should be aware. Adenomatous polyps are

small reddish lesions, frequently on a stalk, which are important because of the possibility of their

becoming malignant. Villous adenomas are soft, spongy, sessile lesions which arise from the bowel

wall and have an even higher likelihood of becoming malignant. Familial polyposis, a hereditary

polypoid disease, has a marked tendency to undergo malignant change. Ulcerative colitis may also

be a precursor of malignancy. You may be required to include some of these diagnoses in your

registry, or, at least, record these conditions if they are mentioned in the history of a patient with

malignant disease of the colon.

Figure 37. LYMPHATIC DRAINAGE OF THE COLON AND RECTUM

222
The distribution of malignant tumors in the large intestine is as follows:

Percent of all Colorectal

Subsite Cancers*

Appendix I

Cecum 16

Ascending colon 9

Transverse colon incl. 13

flexures

Descending colon 5

Sigmoid 25

Rectosigmoid 10

Rectum 18

Colon, NOS 3

100

*Special SEER tabulation update: Cancer Incidence, 1988. Surveillance, Epidemiology, and End

Results Program.

223
224
Q41

The large intestine is about feet long and is composed of three major parts:

1.

2.

3.

Q42

The colon is usually subdivided into five major segments:

1.

2.

3.

4.

5.

225
Answer: Q41

The large intestine is about five feet long and is composed of the following parts:

1. Colon

2. Rectum

3. Anus

Answer: Q42

The five major segments of the colon are:

1. Cecum

2. Ascending colon

3. Transverse colon

4. Descending colon

5. Sigmoid colon

226
Q43

The ileocolic nodes are regional nodes for which one of the following sites?

[ ] 1) Transverse colon

[ ] 2) Splenic flexure

[ ] 3) Ascending colon

[ ] 4) Rectum

Q44

Match the site on the left with the appropriate regional nodes on the right:

1) Ascending colon a. Right colic

2) Descending colon b. Inferior hemorrhoidal

3) Sigmoid colon c. Left colic

4) Rectum d. Inferior mesenteric

227
Answer: Q43

3. The ileocolic lymph nodes are regional for the ascending colon.

Answer: Q44

a 1) Ascending colon Right colic

c,d 2) Descending colon Left colic, inferior mesenteric

d 3) Sigmoid colon Inferior mesenteric

b,d 4) Rectum Inferior hemorrhoidal, inferior mesenteric

228
Liver

The liver is the largest internal organ of the body, weighing three to four pounds (1.4-1.8 kg.).

It lies immediately under the diaphragm in the right upper abdomen. Its visceral surface is molded

over the stomach, duodenum, gallbladder, hepatic flexure of the colon, right kidney, and right

suprarenal gland. It is divided into right and left lobes. The right lobe has three parts called the right

lobe proper, the caudate lobe, and the quadrate lobe. The small bile ducts within the liver

(intrahepatic ducts) join to form two larger ducts which emerge from the under surface of the liver

at the porta hepatis as the right and left hepatic ducts.

The liver is one of the most vital organs in the body and plays a crucial role in the digestion and

absorption of food. It breaks down protein, stores glycogen, iron, and vitamins, maintains the

composition of the blood, and secretes products of detoxification. It continuously produces bile which

is important in the digestion of fat and protein. The liver assists in keeping the amount of glucose

(sugar) in the blood at a normal level. The liver manufactures plasma proteins. It destroys worn-out

erythrocytes and foreign materials (phagocytosis). It produces heparin, an anticoagulant. It removes

nitrogen from amino acids and converts it into urea. The urea then enters the blood stream and is

carried to the kidneys where it is concentrated in urine and eliminated from the body.

The liver secretes certain bile salts which aid in digestion. These substances pass through the bile

ducts and may be stored in the gallbladder. With the stimulation of eating, these chemicals then pass

through the cystic duct and the common bile duct to enter the duodenum at the ampulla of Vater.

All of these ducts and the gallbladder are referred to as the "extra-hepatic biliary system."

The lymphatic drainage from the liver is to hilar nodes, hepatic and periportal nodes below the

diaphragm, and to cardiac, pericardial, posterior mediastinai, and aortic nodes above the diaphragm.

Lymphatic vessels reach all parts of the organ.

Malignant and Benign Tumors

Malignant tumors of the liver are of glandular origin, i.e., adenocarcinomas. Benign liver tumors

are of current interest because of a suggested association with oral contraceptive use. Primary liver

tumors are rare, but may be classified as follows:

• Hepatocellular carcinoma (hepatoma, liver cell carcinoma) arises in the parenchymal cells of

the liver. It is the predominant type of primary malignant liver tumor and is associated with

pre-existing cirrhosis of the liver.

• Cholangiocarcinoma (bile duct carcinoma) arises in the intrahepatic bile ducts. Consequently,

you may find cholangiocarcinomas of the liver as well as of the extrahepatic bile ducts.

• Hemangioma is a benign tumor which arises in the blood vessels of the liver; it is the most

common benign liver tumor.

• Adenomas may arise in either the liver cells or the bile ducts of the liver.

229
Metastatic tumors involving the liver are much more common than primary liver tumors. Both

venous and arterial blood may transport tumor cells to the liver. Section E, The Cardiovascular

System, describes the transport of blood to the liver more fully.

Extrahepatic bile ducts. The right and left hepatic ducts emerging from the liver immediately join

to form one common hepatic duct. The common hepatic duct merges with the cystic duct from the

gallbladder to form the common bile duct. At a point seven to ten cm. below the pylorus the

common bile duct enters the duodenum at the ampulla of Vater.

Figure 38. BILIARY SYSTEM

D Jl.al_

LI

230
Q45

The most common primary tumor of the liver is or . The

most common malignancy found in the liver is usually a tumor.

231
Answer: Q45

The most common primary tumor of the liver is hepatocarcinoma or hepatoma. The most

common malignancy found in the liver is usually a metastatic tumor.

232
Gallbladder

The gallbladder is a pear-shaped sac 7 to 10 cm. long and about 2.5 cm. wide. It lies on the

undersurface of the right lobe of the liver. The wall of the gallbladder is composed of three layers:

a mucosa, a muscular layer, and an outer covering of peritoneum called the serosa which coats the

gallbladder except where it is in immediate contact with the liver. The mucous lining is arranged in

folds called rugae which are similar in structure and function to those of the stomach. The

gallbladder stores and regulates the flow of bile manufactured by the liver. The bile enters the

gallbladder via the hepatic and cystic ducts. The cystic duct from the gallbladder unites with the

hepatic duct to form the common bile duct. During the digestive process the gallbladder ejects

concentrated bile into the duodenum by way of the common bile duct. The duodenum receives a

mixture of bile and pancreatic juice.

Lymph nodes for the gallbladder and extrahepatic bile ducts accompany the cystic and hepatic

arteries to the celiac axis region. Nodes are located in relation to the common bile duct

(pericholedochal), hilus of liver (hilar), the duodenum (periduodenal), liver (periportal), pancreas

(peripancreatic), and cystic duct. A node of the anterior border of the foramen of Winslow _ may

be identified specifically.

Adenocarcinoma is the most common tumor of gallbladder or bile duct origin. Those arising in

bile ducts may be called cholangiocarcinomas.

lforamen of Winslow--an epiploic (omental) foramen, an opening in the omentum.

233
234
Q46

The function of the gallbladder is to and

Q47

The histologic type of the malignant tumors of bile duct origin, whether intrahepatic or

extrahepatic, is called

235
Answer: 046

The function of the gallbladder is to store and regulate bile.

Answer: Q47

The histologic type of malignant tumors of bile duct origin, whether intrahepatic or

extrahepatic, is called cholangiocarcinoma.

236
Pancreas

The pancreas is a gland shaped somewhat like a fish. It is located behind the stomach with its

head situated in the C-shaped curve of the duodenum, its body extending horizontally across the

posterior abdominal wall and its tail touching the spleen. The pancreas is both an exocrine and

endocrine gland. Its exocrine functions are in manufacturing and secreting pancreatic juice which

empties into the duodenum via the main pancreatic duct (duct of Wirsung). This juice helps to break

down all types of food. For example, it contains lipase which helps in the digestion of fats, and it

makes amylase which helps in the digestion of sugars and starches. Its endocrine functions involve

certain cells (beta) of the islets of Langerhans scattered all over the gland, which secrete insulin, a

hormone that plays a major role in carbohydrate metabolism. When these cells begin to lose their

ability to produce insulin, the disease known as diabetes mellitus results. Other cells (alpha) of the

pancreas secrete glucagon, another hormone involved in carbohydrate metabolism.

The blood supply is derived from the splenic, superior mesenteric, and hepatic arteries. The veins

accompany the arteries and drain into the portal vein by way of the splenic and superior mesenteric

tributaries.

Peripancreatic lymph nodes may be located superior, inferior, anterior or posterior to the organ,

and the drainage will differ depending on whether it is from the head or body and tail of the

pancreas. The lymph nodes for the pancreas are the:

Splenic: pancreaticolienal (body and tail)

Hepatic: infrapyloric/subpyloric (head)

pancreaticoduodenal

Superior mesenteric

Celiac axis (head)

Lateral aortic/retroperitoneal

Malignant and Benign Tumors

Adenocarcinomas make up the majority of all malignant tumors of the pancreas. Two-thirds are

located in the head of the pancreas. Usually these tumors spread to adjacent organs or have

metastasized by the time the diagnosis is made. Islet cell tumors may arise from the cells of the islets

of Langerhans, and may be further subdivided as insulinomas, glucagonomas, or gastrinomas on the

basis of their hormonal activity. These tumors may be malignant.

237
238
Q48

The pancreas plays an important role in because it secretes

found in pancreatic juices.

Q49

The three anatomic subdivisions of the pancreas are the

, and

Q50

The duct and the duct carry digestive juices to the intestine emptying

into the by way of the

239
Answer: Q48

.The pancreas plays an important role in digestion because it secretes digestive enzymes

found in pancreatic juices. Beta cells produce insulin (hormone), and alpha cells produce

glucagon (hormone) into the blood stream. Both are involved in carbohydrate metabolism

and assist in controlling glucose levels. Diabetes occurs when beta cells malfunction.

Answer: Q49

The three anatomic subdivisions of the pancreas are the head, body, and tail.

Answer: Q50

The hepatic duct and the cystic duct carry digestive juices to the intestine emptying into

the duodenum by way of the common bile duct.
SECTION H

THE URINARY SYSTEM

241
Figure 39. PRINCIPAL PARTS OF THE URINARY SYSTEM

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242
SECTION H

THE URINARY SYSTEM

The urinary system in both males and females consists of two kidneys, two ureters, a urinary

bladder, and a urethra. It is part of the excretory system of the body which also includes the

respiratory, integumentary, and digestive systems.

Kidney

Each kidney is located lateral to the spinal column in the lumbar region behind the abdominal

cavity. Each is, therefore, retroperitoneal, or in back of the peritoneal cavity. Each is embedded in

a mass of fatty tissue which is surrounded by a fibrous covering called the renal fascia or Gerota's

fascia. The renal pelvis represents extensions of the ureter and the kidney parenchyma 1 at the hilus

which is located on the inner, or medial side of each kidney. The structures of the kidney

parenchyma and kidney pelvis are quite different:

• The kidney parenchyma is the glandular part of the organ where the filtration of

blood takes place and urine is produced. The outer connective tissue layer is

called the cortex; the inner structure is called the medulla. The medulla consists

of renal (medullary) pyramids which are separated from one another by extensions

of the cortex into the medulla called renal columns.

• The renal pelvis and calyces2 collect the urine which is then transported by the

ureters from the kidney to the urinary bladder for storage.

Figure 40. KIDNEY

Cortex

P.renchy-- __ _''duL]L"

.

!1

lparenchyma--the functional working elements of an organ.

2calyces--(plural of calyx--cuplike organs or cavities.

243
The microscopic structure of the renal pelvis is similar to that found in parts of the gastrointestinal

tract as well as the bladder and ureter and is as follows:

• MUCOSA

The EPITHELIAL LAYER contains no blood vessels or lymphatics.

The BASEMENT MEMBRANE is a sheet of extracellular material that functions as a

filtration barrier and a boundary which helps to generate and maintain tissue structure.

• LAMINA PROPRIA, composed of areolar connective tissue, contains blood vessels, nerves,

and, in some regions, glands. Once tumor has broken through the basement membrane into

the lamina propria, it can spread by way of the lymphatics and blood vessels to the other parts

of the body.

The urinary sites have NO MUSCULARIS MUCOSAE, and therefore, the lamina propria and

the submucosa tend to merge; these terms will be used interchangeably.

• The SUBMUCOSA is a thick layer of either dense or areolar connective tissue. It contains

blood vessels, lymphatic vessels, nerves, and, in some regions, glands.

• The MUSCULARIS PROPRIA is composed of two layers of smooth muscle tissue; it

constitutes the wall of the organ.

• The SEROSA, the outermost layer covering, is a serous membrane, part of the visceral

peritoneum. There is no serosa on the renal pelvis or ureters. Where there is no serosa, the

connective tissue of surrounding structures merges with the connective tissue of the organ and

is called ADVENTITIA.

244
Q1

The urinary system consists of two , two ,

a urinary , and a

Q2

The kidneys are located in back of the peritoneal cavity or retroperitoneally, specifically, lateral

to the in the region behind

the abdominal cavity.

Q3

The glandular (working) part of the kidney is called the , while the

part of the kidney that collects the urine which is then transported by way of the ureter to the urinary

bladder is called the

245
Answer: Q1

The urinary system consists of two kidneys, two ureters, urinary bladder, and a urethra.

Answer: Q2

The kidneys are located in back of the peritoneal cavity or retroperitoneally, specifically,

lateral to the spinal column in the lumbar region behind the abdominal cavity.

Answer: Q3

The glandular (working) part of the kidney is called the parenchyma, while the part of the

kidney that collects the urine which is then transported by way of the ureter to the urinary

bladder is called the renal pelvis.

246
The Structural and Functional Unit of the Kidney

The structural and functional unit of the kidney is called a nephron. Each kidney has hundreds

of thousands of nephrons, each of which is composed of a glomerulus (a knot of coiled capillaries 1

arising from the renal artery) and a renal tubule:

• The glomerulus and a surrounding Bowman's capsule are called the renal corpuscle. The

renal corpuscles are located in the cortex of the kidney.

• The renal tubule begins in the glomerular capsule and has three different designations

along its course: the proximal convoluted tubule, the descending loop of Henle, and the

distal convoluted tubule (the end of the nephron). The proximal and the distal convoluted

tubules are located in the cortex of the kidney; the loop of Henle is located in the medulla.

The proximal tubules form the double-walled cup known as Bowman's capsule. The distal

tubules of several nephrons empty into a common collecting tubule that transports urine

back into the renal pyramids of the medulla and then into a minor calyx of the renal pelvis.

lcapillary--a minute blood vessel.

247
Figure 41. A NEPHRON

_ Otomes_JLus_;_x|msL convoluted tubule

Collectlnl tubuLes_ i_._-_- _ Loop ot Hente

DI;.tnL

convoluted

tubule

248
The function of the kidney is to remove metabolic waste products from the blood and to maintain

the electrolyte 1 balance. This is accomplished by the production of urine.

The formation of urine and the regulation of the internal environment of the body by the kidneys

are a composite of four processes:

• Filtration of the blood through the capillaries of the glomerulus into Bowman's capsule

• Selective reabsorption by the renal tubules of materials required to maintain the internal

environment of the body, i.e., the fluid and electrolyte balance

• Secretion of certain substances produced in the distal and collecting tubules causing

potassium, hydrogen ions, and other substances to be taken from the blood and added to

the tubular filtrate

• Maintenance of acid-base balance (pH 2 7.4) by regulating the amount of acid or base

which the kidneys eliminate in the urine.

The Production of Urine

The aorta brings waste-filled blood from the heart to the kidneys by way of the renal arteries. Here

in the kidneys the waste products of metabolism and toxic substances are eliminated. Blood enters

the glomerulus through the afferent arteriole which divides into capillaries. These will later unite to

form the efferent arteriole that drains blood from the glomerulus. As the blood passes through the

glomerulus, water, glucose, salts, and nitrogenous wastes are filtered into Bowman's capsule which

is the beginning of the renal tubule. The contents of the distal portion of the tubule pass to branches

of the collecting tubule which empties into the calyces of the renal pelvis. These contents are then

transported through the ureters from the renal pelvis to the bladder. Certain substances required to

maintain fluid and electrolyte balance are reabsorbed by the peritubular capillaries 3 (e.g., sodium,

glucose, water) and returned to the blood. Secretions produced in the distal and collecting tubules

cause other substances to be added to the tubular filtrate from the blood (e.g., potassium, hydrogen

ions, and ammonia).

Some abnormal constituents found in the urine are albumin, blood, calculi, melanin, and malignant

cells.

Through the capillaries of the glomeruli, approximately 120 milliliters (ml) of water and salts are

filtered from the blood each minute. Most of the water is reabsorbed as are other essential

substances unless their concentration in the body happens to be too high. The urine passes out

through the collecting tubules at a rate of approximately 1.0 milliliter per minute, so that a healthy

person will excrete about 1 to 1 and 1/2 liters per day.

Xelectrolytes--mainly, ions such as sodium, potassium, ammonium chloride, bicarbonate,

phosphate, and sulfate. Levels vary with diet and other factors.

2pH--refers to the hydrogen ion concentration expressing both acidity and alkalinity on a scale whose

values run from 0 to 14 with 7 representing neutrality, numbers less than 7 increasing acidity, and

numbers greater than 7 increasing alkalinity.

3peritubular capillaries--capillary beds that surround the renal tubules.

249
250
Q4

Why is blood circulated through the kidneys?

a.

b.

Q5

What is the structural and functional unit of the kidney?

Q6

Through which parts of the kidney are water and salts filtered?

Q7

Give the names of the major structures involved in the urinary process from the point at which

blood enters the capillaries in the cortex of the kidney until it enters the calyces of the renal pelvis.

1. 2.

31 4.

251
Answer: Q4

The blood is circulated through the kidneys:

a. To excrete waste products of metabolism and toxic substances from the body.

b. To help maintain the fluid and electrolyte balance.

Answer: Q5

The nephron is the structural and functional unit of the kidney.

Answer: Q6

Water and salts are filtered through the capillaries of the glomeruli.

Answer: Q7

The major structures involved in the urinary process from the point at which blood enters

the capillaries in the cortex of the kidney until it enters the calyces of the renal pelvis are:

1. Glomerulus

2. Bowman's capsule

3. Renal tubule

4. Collecting tubule

252
Regional Lymph Nodes

The lymphatics of the kidney and renal pelvis drain to retroperitoneal nodes along the abdominal

aorta and vena cava (paracaval), primarily to those near the origin of the renal arteries. Perirenai

nodes are those at the renal hilus.

Malignant Tumors

Tumors which arise in the kidney parenchyma or the renal pelvis usually can be distinguished by

the histologic type:

Malignant tumors of the k/dney parenchyma:

• Adenocarcinoma makes up 80 per cent of renal tumors. It may also be called hypernephroma,

renal cell carcinoma, and Grawitz's tumor.

• Wilms' tumor or nephroblastoma is the most common abdominal malignancy in children. It is

almost exclusively a disease of children under six years of age. It is a mixed tumor histologically

made up of embryonal tissue, probably of nephrogenic origin. It is highly malignant but often

is successfully treated.

Malignant tumors of the renalpelvis:

• Transitional cell carcinoma is the most common tumor of the renal pelvis.

• Squamous cell carcinoma is rare.

Tumors of the renal pelvis comprise 15-18 percent of the renal malignancies.

253
254
Q8

The regional lymph node drainage for the kidney parenchyma is to:

1.

2.

3.

The regional lymph node drainage for the renal pelvis is to:

1.

2.

3.

Q9

Indicate whether the following tumors would most likely arise in the kidney parenchyma (use

symbol k) or in the renal pelvis (use symbol r):

1. Transitional cell carcinoma

2. Wilms' tumor

3. Adenocarcinoma

4. Squamous cell carcinoma

Q10

What is the major kidney tumor occurring in childhood?

Qll

What is the most common type of kidney cancer?

255
Answer: Q8

The regional lymph node drainage for the kidney parenchyma is to:

1. Renal hilar lymph nodes

2. Paracaval lymph nodes

3. Para-aortic or retroperitoneal lymph nodes

The regional lymph node drainage for the renal pelvis is to:

1. Renal hilar lymph nodes

2. Paracaval lymph nodes

3. Para-aortic or retroperitoneal lymph nodes

Answer: Q9

The following tumors would most likely arise in the kidney parenchyma (indicated by k)

or the renal pelvis (indicated by r):

r 1. Transitional cell carcinoma

k 2. Wilms' tumor

k 3. Adenocarcinoma

r 4. Squamous cell carcinoma

Answer: Q10

The major kidney tumor occurring in childhood is Wilms' tumor.

Answer: Qll

The most common type of kidney cancer is adenocarcinoma. It may also be called a renal

cell carcinoma, hypernephroma, or Grawitz's tumor.

256
Ureters

Each kidney is connected to the urinary bladder by a ureter. These muscular tubes are about 26

to 28 cm in length, beginning at the renal pelvis. They transport urine from the kidney to the bladder.

The microscopic structure of the ureter is similar to that of the renal pelvis consisting of a mucosa

of epithelium and lamina propria, a submucosa, a muscularis propria, and an outer adventitia of

fibroelastic connective tissue.

Regional Lymph Nodes

The regional lymph node drainage for the ureters is to the:

Periureteral

Renal hilar

Common iliac

Internal iliac (hypogastric)

External iliac

Paracaval

Malignant Tumors

Primary cancer of the ureter is rare. When cancer does occur, it is usually transitional cell

carcinoma, resembling cancer of the renal pelvis; it often presents as an ureteral obstruction.

257
258
Q12

What is the tube which carries urine from the kidney to the bladder?

Q13

What are the tissue layers of the renal pelvis excluding the basement membrane?

1. }

) Mucosa

2.

3.

4.

5.

259
Answer: Q12

The tube which carries urine from the kidney to the bladder is the ureter.

Answer: Q13

The tissue layers of the renal pelvis are:

1. Epithelium } Mucosa

2. Lamina propria }

3. Submucosa

4. Muscularis propria (or two layers of smooth muscle)

5. Adventitia

260
Urinary Bladder

The urinary bladder is a hollow muscular organ which serves as a reservoir for urine. It lies in the

pelvis behind the pubic bone. The adult urinary bladder has a capacity of 300-350 milliliters.

Three openings mark off a triangular area called the trigone at the base of the bladder. These are

the orifices of the two ureters and the urethra. The trigone is smooth even when the bladder is

empty; the remainder of the bladder wall is in folds allowing for expansion when the bladder is full.

The superior surface of the bladder may be referred to as the dome; other subsites are the lateral,

anterior, and posterior walls. The trigone may also be referred to as the floor or base.

In the female, the bladder is located in front of and below the uterus being separated from the

anterior part of the uterus by a fold of peritoneum called the uterovesical pouch. Posteriorly, it is

connected to the cervix and upper vagina by a thick layer of connective tissue.

In the male, the inferior surface of the bladder which is not covered by peritoneum is in proximity

to the upper rectum and is separated from it by the rectovesical fascia which contains the seminal

vesicles and vas deferens. The prostate lies just below the bladder and surrounds the proximal part

of the urethra as it emerges from the urinary bladder.

Figure 42. URINARY BLADDER

Ureterm_

Yertex

261
URINARY BLADDER, RENAL PELVIS AND URETERS

PRIMARY MUCOSA MUSCULARIS I SEROSA

SITE PROPRIA '

, , [

B

Epithelium A Lamina Propria/

S Submucosa

E

Urinary Bladder Yes • Yes Yes Yes, on superior

(C67.__) Ivl surface

E

Renal pelvis Yes M Yes Yes No

(C65.9) B

Ureter(s) Yes A Yes Yes No

(C66.9) N

E

I I I I I I I

The bladder wall has the same three tissue layers as the renal pelvis and ureter:

The EPITHELIAL LAYER (mucosa) contains no blood vessels or lymphatics.

The BASEMENT MEMBRANE is a sheet of extracellular material that functions as a

filtration barrier and a boundary which helps to generate and maintain tissue structure.

• LAMINA PROPRIA, composed of areolar connective tissue, contains blood vessels,

nerves, and, in some regions, glands. Once tumor has broken through the basement

membrane into the lamina propria, it can spread by way of the lymphatics and blood vessels

to the other parts of the body.

The urinary sites have NO MUSCULARIS MUCOSAE, and therefore, the lamina propria and

the submucosa tend to merge; these terms will be used interchangeably.

° The SUBMUCOSA is a thick layer of connective tissue. It contains blood vessels,

lymphatic vessels, nerves, and in some regions, glands.

° MUSCULARIS PROPRIA consists of three layers of smooth muscle which provide the

ability to expand and contract.

• The superior and posterior aspects of the bladder have a serosal covering (peritoneum)

which is not found interiorly.

262
Regional Lymph Nodes

The regional lymph nodes draining the bladder are:

Perivesical

Internal iliac (hypogastric) including obturator

External iliac

Sacral (lateral, presacral, promontory (Gerota's)

263
Malignant Tumors

Bladder cancer isthe most frequent malignancy of the urinary tract, and it is more common in men

than in women. Most bladder tumors are papillary in appearance and will often occur and recur in

multiple sites within the bladder. The lateral and posterior walls are involved with tumor more

frequently than is the trigone. There is a high frequency of bladder cancer in heavy smokers.

• Transitional cell carcinoma is the most common bladder cancer accounting for 90-95 percent

of bladder tumors. The grading, as well as the staging, of these tumors is of particular

significance in prognosis, there being a high level of correlation between grade (differentiation)

and stage (invasiveness).

There are different grading systems. Using Broders '1 Classification, bladder tumors may be

diagnosed as carcinoma Grades I - IV. In other classifications, Broders' Grade I tumor is called

a papilloma, with further subdivision into carcinoma Grades I - III.

Foci of squamous cell carcinoma and adenocarcinoma may be found in association with

transitional cell carcinoma, especially in high-grade tumors.

° Squamous cell carcinoma occurring in a pure form is rare, less than 10 percent of all bladder

carcinomas.

° Adenocarcinoma of the bladder is rarely found in pure form and is almost impossible to

distinguish from prostatic carcinoma with extension to the bladder.

• Leiomyosarcoma is a rare tumor arising in the smooth muscle of the bladder.

1Broders, Albert C.--a pathologist who formulated a four-grade classification of malignancy

based on the degree of cellular dedifferentiation.

264
Q14

What is the term for the muscular sac which serves as a reservoir for urine?

Q15

What is the trigone area of the organ referred to in Q14 above?

Q16

Which of the following lymph nodes are regional for the bladder?

i"7 a. Supraclavicular

1 I b. External iliac

['-] c. Inguinal

1-'1 d. Obturator

[_] e. Aortic (para-, peri-, lateral) (retroperitoneal)

Q17

What are the layers of the bladder wall (interior to exterior)?

1. of (a) and (b)

2.

3.

4.

265
Answer: Q14

The urinary bladder is a reservoir for urine.

Answer: Q15

You might have said: The trigone area of the bladder is a triangular area at the base of

the bladder marked off by orifices of the two ureters and urethra.

Answer: Q16

Regional nodes for the bladder are:

b. External iliac

d. Obturator

Answer: Q17

The layers of the bladder wall (interior to exterior) are:

1. Mucosa of (a) epithelium and (b) lamina propria

2. Submucosa

3. Muscularis propria or musculature (three layers of smooth muscle)

4. Serosa (superior surface only)

266
Urethra

The urethra is a membranous tube which conveys urine from the urinary bladder to the exterior

of the body.

At the proximal end is a circular smooth muscle which surrounds the bladder neck and is known

as the internal sphincter. It is controlled by the autonomic nervous system. The external sphincter of

the urethra is a circular striated muscle which is under voluntary control. In the female, the external

sphincter is located in the vulva; in the male it is in the glans penis.

The urethra differs in men and women:

The female urethra is a part of only the excretory system and is approximately 2.5 - 3.0 cm long.

The male urethra is a part of both the excretory system and the reproductive system. It has three

regions:

• The prostatic urethra which passes through the prostate gland is approximately 2.5 cm long.

• The membranous urethra which comprises the external muscular section is approximately

1.3 em long.

• The penile (spongy or cavernous) urethra which passes through the penis is approximately

9.0 - 15.0 cm long.

Regional LYmph Nodes

The regional lymph nodes for the urethra are:

Common iliac

Internal iliac (hypogastric) including obturator

External iliac

Inguinal (superficial or deep)

Presacral

Malignant tumors are rare and are almost always transitional cell carcinomas.

267
Q18

The is a membranous tube which conveys urine from the urinary

bladder to the exterior of the body.

Q19

Match the terms on the left with the descriptions on the right.

1. Bowman's a. Tubules leading from Bowman's capsule to the

capsule collecting tubules

2. Renal tubules b. Tube carrying urine from the bladder to the

outside of the body

3. Glomerulus c. Muscular sac which serves as a reservoir for

urine

4. Urethra d. Tubes carrying urine from the kidney to the

urinary bladder

5. Ureters e. Collection of capillaries through which blood is

filtered

6. Bladder f. Structure in the kidney which receives the

filtered materials directly from the glomerulus

7. Nephron g. The structural and functional unit of the kidney

268
Q2o

The renal pelvis is:

--'l a. a muscular sac which serves as a reservoir for urine.

F] b. the central urine-collecting structure of the kidney from which urine is delivered

to the bladder via the ureters

[-"] c. a structure which receives the filtered materials directly from the glomerulus.

["'] d. the outer layer of the kidney.

269
Answer: Q18

The urethra is a membranous tube which conveys urine from the urinary bladder to the

exterior of the body.

Answer: Q19

f 1. Bowman's Structure in the kidney which receives the

capsule filtered materials directly from the glomerulus

a 2. Renal tubules Tubules leading from Bowman's capsule to the

collecting tubules

e 3. Glomerulus Collection of capillaries through which blood is

filtered

b 4. Urethra Tube carrying urine from the bladder to the

outside of the body

d 5. Ureters Tubes carrying urine from the kidney to the

urinary bladder

c 6. Bladder Muscular sac which serves as a reservoir for

urine

g 7. Nephron The structural and functional unit of the kidney

Answer: Q20

The renal pelvis is:

b. The central urine-collecting structure of the kidney from which urine is delivered

to the bladder via the ureters.

270
SECTION I

THE REPRODUCTIVE SYSTEM

271
Figure 44. FEMALE PELVIS (frontal view)

n£undlb_Lum

/

Serosa /

/

MYomet r I um /"

Endomet r I uss

pus ( boOy ot uterus )

Cervix

Xntern_t and externa_

Va8 os o_ cervix

Vut

272
SECTION I

THE REPRODUCTIVE SYSTEM

Female Reproductive System

The female reproductive system is made up of the uterus and two ovaries, two fallopian tubes

(uterine tubes or oviducts), a vagina, and a vulva (pudendum or external genitalia). Two breasts (or

mammary glands) are considered to be accessory organs of the female reproductive system and will

be discussed in this section.

Uterus

The uterus is a hollow, pear-shaped, muscular organ located in the pelvic cavity between the

bladder and the rectum. The uterus plays a role in three important functions: menstruation,

pregnancy, and parturition. It is composed of two parts, an upper portion called the corpus (or body),

and a lower, narrow part called the cervix. The fundus is that portion of the corpus which rounds into

a bulging prominence at about the level at which the fallopian tubes enter the corpus.

Midway between the uterus and the rectum is a region in the abdominal cavity known as the cul

de sac. It is important that you remember this term because it will be examined for the presence of

cancer.

Figure 45. FEMALE PELVIS (sagittal view)

Fs L]Lop|_n t

V_,Itna

273
CORPUS UTERI

I I _ '

PRIMARY] ENDOMETRIUM (mucosa) ] MYOMETRIUM ] SEROSA

SITE , , (3 muscle layers) [ (Perimetrium)

Columnar B Stroma

Epithelium A (Lamina Propria)

S

E

Corpus Uteri Yes Yes Yes Yes

(C54.__) M

E

M

I I I I

The wall of the uterine corpus is composed of the following microscopic layers:

• The EPITHELIAL LAYER contains no blood vessels or lymphatics.

The BASEMENT MEMBRANE is a sheet of extracellular material that functions

as a filtration barrier and boundary which helps to generate and maintain tissue

structure.

The LAMINA PROPRIA, composed of areolar connective tissue, contains blood

vessels, nerves, and, in some regions, glands. Once tumor has broken through the

basement membrane into the lamina propria, it can spread by way of the lymphatics

and blood vessels to other parts of the body.

• There is NO MUSCULARIS MUCOSAE OR SUBMUCOSA in the endometrium.

• The MYOMETRIUM, the thick middle layer, is composed of three layers of

smooth muscle fibers: longitudinal, transverse, and oblique, that extend in all

directions and give great strength to the uterus. It contains an abundance of blood

vessels, lymphatics, and nerves.

The uterine cervix is composed of:

• A MUCOSA of columnar glandular epithelium in the upper portion of the cervical

canal (endocervix) which is continuous with that of the corpus. It becomes

stratified squamous epithelium at the lower end of the canal extending onto the lip

of the cervix (ectocervix or exocervix).

• A LAMINA PROPRIA (stroma) of dense connective tissue which contains a few

smooth muscle fibers and the cervical glands.

274
Q1

The female reproductive organs are:

1.

2.

3.

4.

5.

Q2

The uterus is located in the cavity between the and

the

Q3

The uterus is composed of two parts, an upper portion called the and a

lower, narrow portion called the

Q4

The portion of the body of the uterus which rounds into a bulging prominence at about the level

at which the fallopian tubes enter is called the

Q5

The three tissue layers of the body of the uterus are:

1.

2.

3.

275
Answer: Q1

The female reproductive organs are:

1. The uterus

2. Two ovaries

3. Two fallopian tubes (uterine tubes or oviducts)

4. A vagina

5. A vulva

Answer: Q2

The uterus is located in the pelvic cavity between the bladder and the rectum.

Answer: Q3

The uterus is composed of two parts, an upper portion called the body (or corpus) and a

lower, narrow portion called the cervix.

Answer: Q4

The portion of the body of the uterus which rounds into a bulging prominence at about

the level at which the fallopian tubes enter is called the fundus.

Answer: Q5

The three tissue layers of the body of the uterus are:

1. Endometrium (mucosa)

2. Myometrium

3. Serosa (Perimetrium)

276
The uterus has thick walls and a small, flat, triangular-shaped cavity. Its apex is directed downward

and forms the internal os which opens into the cervical canal. The cervical canal narrows at its lower

end and forms the external os opening into the vagina. The mucosa of the vaginal wall is contiguous

with the mucosa of the cervix. A circular recess around the cervix at its junction with the vagina is

called the fornix. It is divided into four fornices or parts: anterior, posterior, and two lateral. The

fallopian tubes join the uterine cavity at the upper, outer angles. A generous blood supply is received

by the uterus from the uterine arteries which are branches of the internal iliac arteries. Eight

ligaments which hold the uterus in place but allow considerable movement are two broad ligaments,

two uterosacral ligaments, the posterior ligament, the anterior ligament, and two round ligaments.

Parametrium, connective tissue which surrounds the uterus, separates the cervix from the bladder

and extends between the two serosal layers of the broad ligaments as well as to and over the pelvic

walls.

Regional Lymph Nodes

The regional lymph nodes for both the corpus and the cervix uteri are:

Pelvic Nodes:

Paracervical

Parametrial

Common iliac

Internal iliac (hypogastric, including obturator)

External iliac

Sacral (lateral, presacral, promontory (Gerota's), uterosacral)

Aortic (para-, peri-, lateral)--regional for corpus uteri only

The major lymphatic trunk is the utero-ovarian (infundibulo-pelvic), which drains into the iliac and

sacral nodes.

Malignant Tumors

The histologic types of cancer arising in the uterus are:

• Adenocarcinoma arising in the glandular epithelium of the endometrium and of the

upper two-thirds of the cervical canal

• Leiomyosarcoma arising in the smooth muscle of the myometrium

• Adenosquamous carcinoma arising at the squamous columnar junction

• Squamous cell carcinoma arising in the lower one-third of the cervical canal and the

lip of the cervix, and often extending into the vagina. The majority of the

neoplasms arising in the cervix will arise in the lower one-third. These will be

chiefly in situ, i.e., there will be no stromal invasion. Lesions with stromal invasion

of 3 mm or less may be described as micro-invasive.

° Endometrial stromal sarcoma

277
• Choriocarcinoma, a highly malignant tumor composed of chorionic (placental) type

tissue

• Muellerian mixed tumor (mixed mesenchymal or mesodermal sarcoma), a relatively

large group of sarcomas with no single histologic pattern

° Carcinosarcoma, a tumor of the endometrium which is composed of carcinomatous

elements as well as stroma with characteristics of sarcoma.

278
Q6

For each of the sites below, list four lymph node groups that drain these sites.

Corpus:

Cervix

279
Answer: Q6

For corpus uteri you might have said:

Common iliac

Internal iliac or hypogastric or obturator

External iliac

Parametrial

Paracervical

Aortic (para-, peri-, lateral)

Sacral

For cervix uteri you might have said:

Common iliac

Internal iliac or hypogastric or obturator

External iliac

Sacral

Paracervical

Parametrial

280
Ovaries

The ovaries, female gonads1, are the shape and size of large almonds and are located one on

either side of the uterus, below and behind the fallopian tubes. Each ovary lies between the folds

of the broad ligament and is attached to its posterior surface by the mesovarian ligament. The

ovarian ligament anchors it to the uterus. The distal portion of the fallopian tube curves about the

ovary so that a fimbriated cup hangs over each ovary but is not actually attached to it. The ovary is

an example of a gland whose duct is detached from it.

Microscopically, the ovary consists of a layer of germinal epithelial cells and a layer of connective

tissue in which structures known as graafian follicles are embedded. When a graafian follicle matures

(usually one per month alternating between right and left ovaries), it expels an ovum. This process

is called ovulation. After ovulation, the wall of the follicle is transformed into an endocrine gland,

the corpus luteum, which secretes progesterone and some estradiol. The corpus luteum lasts only

about 12-14 days if the ovum is not fertilized; it then deteriorates into a small fibrous cicatrix.2

When the ovum has been fertilized, it travels to the uterus and becomes embedded in endometrial

tissue. The developing trophoblast3produces hormones (chorionic gonadotrophins) which stimulate

the corpus luteum to increase in size and to prolong its production of progesterone which furthers

the developing of the endometrium and the anchoring and nurturing of the embryo. Near the end

of pregnancy, the corpus luteum shrinks and over a period of months undergoes the same

degenerative changes as when the ovum is not fertilized.

The development and activities of the graafian follicle and of the corpus luteum are triggered by

hormones secreted by the pituitary gland. However, as indicated above, the ovary itself has a

hormonal function. During the maturation of the graafian follicle, certain ceils (thecal and

granulosal) surrounding or sheathing the developing ovum produce estrogenic hormones, mainly

estradiol and estrone. These cells are replaced by the luteai cells after ovulation. The normal cyclical

process of menstruation, with development and degeneration of endometrial cells, is governed by

these hormonal activities of the pituitary and the ovaries.

Regional Lymph Nodes

Regional lymph node metastasis from the ovary is infrequent, but when it occurs it is primarily to

the para-aortic nodes. However, any of the following may be considered regional lymph nodes

draining the ovaries:

Pelvic lymph nodes:

Common iliac

Internal iliac (hypogastric, including obturator)

External iliac

Lateral sacral

Aortic (para-, peri-, lateral)

Inguinal (rare)

1gonads--organs which produce sex cells--ovaries and testes.

2cicatrix--scar resulting from formation and contraction of fibrous tissue.

3trophoblast--the ectodermal layer covering and attaching the embryo to the uterine wall and

supplying nutrition for it.

281
Fallopian tubes

The fallopian tubes, also called oviducts and uterine tubes, are attached to the uterus at its upper,

outer angles. They lie between the folds of the broad Ligaments and extend upward and outward

toward the pelvic sidewalls and then curve downward and backward.

The walls of the tubes are composed of the same three tissue layers as the uterine corpus.

• A ciliated mucous lining of epithelial tissue. (The cilia propel the ovum from the

ovary to the uterus.)

• Smooth muscle

• Serosa (or external peritoneal covering)

At the distal end, each tube expands into a funnel-like portion (the infundibulum) which resembles

a fringe or is "fimbriated." Here the mucous lining of the tubes is directly continuous with the

peritoneum. The fallopian tubes serve as ducts for the ova produced by the ovaries. Fertilization

(union of a spermatozoon and an ovum) normally occurs in the fallopian tubes. Tumors of the

fallopian tubes are extremely rare.

Regional Lymph Nodes

The regional lymph nodes for the fallopian tubes are:

Pelvic lymph nodes

Common iliac

Internal lilac (hypogastric, including obturator)

External iliac

Lateral sacral

Aortic (para-, peri-, lateral)

Inguinal

282
Q7

Match the sites on the left with the descriptions on the right.

1. Uterus a. Ducts through which ova travel into the uterus

2. Fallopian tubes b. Pear-shaped muscular organ in the pelvic cavity in

which the embryo develops after fertilization

3. Ovaries c. Organs which produce ova and hormones associated

with female reproduction and secondary sex

characteristics

283
Answer: Q7

b 1. Uterus Pear-shaped muscular organ in the pelvic cavity in which

the embryo develops after fertilization

a 2. Fallopian tubes Ducts through which ova travel into the uterus

c 3. Ovaries Organs which produce ova and hormones associated

with female reproduction and secondary sex

characteristics

284
Malignant Tumors

Common histologic types of ovarian tumors are as follow:

• Cystadenocarcinoma is a malignant tumor growing within a cyst, the walls of which

are lined with columnar epithelial cells. This glandular epithelium may be seroussecreting or mucinous-secreting giving rise to:

1. Serous cystadenocarcinorna, a cystic cavity which is lined with ciliated

epithelial cells and contains serous fluid. It is the most common malignant

tumor of the ovary.

2. Mucinous cystadenocarcinoma, a cystic cavity which is lined with ciliated

epithelial cells and contains mucin. These mucinous cystadenocarcinomas

sometimes rupture and spill their contents into the peritoneal cavity. This

spillage can cause a clinical condition called pseudomyxoma peritonei in

which tumor is implanted on all serosal surfaces and the abdominal contents

are matted together.

• Endometrioid carcinoma is an ovarian tumor of epithelial origin that microscopically

resembles a tumor originating in the endometrium.

• Dysgerminoma is a relatively uncommon tumor of germ cell origin, the counterpart

of seminoma of the testis.

• Teratocarcinoma or malignant teratoma is a tumor of germ cell origin composed of

embryonic tissue which is differentiated into bone, hair, teeth, cartilage, and skin.

All these types of tissues may be found in the tumor. A benign tumor with these

characteristics is called a dermoid.

• Granulosa cell and theca cell tumors arise from cells of the early ovarian

mesenchyme in the ovarian stroma which surrounds the developing ovum. They are

sometimes called feminizing or estrogen-producing tumors.

• Krukenberg tumor is a metastatic tumor of the ovary, usually from a primary in the

stomach or other gastrointestinal site, with a marked ovarian tissue proliferation.

Less common tumors of the ovary are: Brenner tumors, arrhenoblastoma (masculinizing

tumor), fibrosarcoma, and mesonephric tumors.

Ovarian tumors are frequently bilateral. They spread by implantation to the peritoneum,

omentum, and serosai surfaces. They may also arise as independent primaries with no evidence of

intraperitoneal spread.

285
Q8

Name the three openings of the uterus:

1.

2.

3.

Q9

The walls of the fallopian tubes are composed of the same three tissue layers as the uterus except

that the mucosa is to propel the ovum.

Q10

What is the purpose of the fallopian tubes?

Qll

The regional lymph nodes which drain the fallopian tubes and the ovaries are:

1.

2.

"_.

4.

5.

Q12

In relation to the uterus, the ovaries are located

286
Q13

The fimbriae of the fallopian tubes cup over the ovaries but are not actually attached to them.

This is an example of a gland whose is detached.

287
Answer: 08

In naming the three openings of the uterus, you might have said the openings of two

fallopian tubes (oviducts or uterine tubes) and the opening into the vagina (or the external

OS).

Answer: Q9

The walls of the fallopian tubes are composed of the same three tissue layers as the uterus

except that the mucosa is ciliated to propel the ovum.

Answer: Q10

You might have said the fallopian tubes serve as ducts to carry the ova produced by the

ovaries to the uterus.

Answer: Qll

The regional lymph nodes draining the fallopian tubes and the ovaries are:

Common iliac

Internal lilac or hypogastric or obturator

External iliac

Lateral sacral

Aortic (para-, peri-, lateral)

Inguinal (rare)

Answer: Q12

The ovaries are located on either side of the uterus below and behind the fallopian tubes.

Answer: Q13

The fimbriae of the fallopian tubes cup over the ovaries but are not actually attached to

them. This is an example of a gland whose duct is detached.

288
Vagina

The vagina is situated posterior to the bladder and anterior to the rectum. It extends upward and

backward from the vaginal orifice to the uterus. The vagina is a collapsible tube, capable of great

distension, composed mostly of smooth muscle lined with a mucous membrane of stratified squamous

epithelium and connective tissue (stroma) arranged in rugaek It is about 3 inches (7.5 cm) in length.

A fold of mucous membrane, the hymen, forms a border around its external opening in the virginal

state. The functions of the vagina include: 1) receiving semen from the male; 2) serving as the lower

part of the birth canal; and 3) acting as the excretory duct for uterine secretions and the menstrual

flow.

The region between the vaginal orifice and the anus is called the perineum.

Vulva

The external female genitalia (or vulva) consist of the following structures:

• The mons pubis (mons veneris) is a skin-covered pad of fat over the symphysis

pubis (pubic bone).

• Labia majora (large lips) are covered with pigmented skin and hair on the outer

surface, smooth and free from hair on the inner surface, and composed mainly of

fat and glands.

• Labia minora (small lips) are Iocated within the labia majora and are covered with

a modified skin. (These labia come together anteriorly in the midline, and the area

between them is called the vestibule of the vagina.)

• The clitoris, a small organ composed of erectile tissue located just behind the upper

junction of the labia minora, corresponds in structure to the corpora cavernosa and

glans of the penis in the male. The prepuce or foreskin covers the clitoris as it

does the glans penis in the male.

• The urinary (urethral) meatus, the small opening of the urethra located between

the clitoris and the vaginal orifice.

• The vaginal orifice, the opening into the vagina, located posterior to the urinary

meatus.

• Bartholin's glands (greater vestibular glands), two bean-shaped glands, one on either

side of the vaginal orifice. Each gland opens by means of a single, long duct into

the space between the hymen and the labia minora and corresponds to the

bulbourethral glands in the male. They secrete a lubricating fluid.

• Skene's glands (lesser vestibular glands) open into the vestibule of the vagina near

the urinary meatus through two small ducts. They are a group of tiny mucous

glands.

lrugae--ridges, wrinkles, or folds of mucous membrane.

289
Regional Lymph Nodes

The regional lymph nodes draining the vagina are:

Upper two-thirds of vagina:

Pelvic lymph nodes:

Common iliac

Internal iliac (hypogastric, including obturator)

External iliac

Sacral promontory

Lower one-third of vagina and vulva:

Superficial Inguinal or Femoral (unilateral or bilateral)

Deep inguinal: Rosenmuller's or Cloquet's node (vulva only)

Malignant Tumors

The most common histologic type of malignant neoplasm found in the vulva and vagina is

squamous cell carcinoma. The usual spread of disease from the vagina is to the cervix, vulva, rectum,

and bladder. For tumors arising in the vulva, the usual spread of disease is to the vagina, urethral

orifice, and perineum.

290
Q14

The vagina is situated between the , which is posterior to it, and the

, which is anterior to it.

Q15

The vagina is a collapsible tube, the walls of which are composed of

lined with

Q16

The female externaI genitalia are called the . Match each of its parts

(on the left) with the descriptions on the right.

1. Mons pubis (mons veneris) a. A small organ composed of

erectile tissue

2. Labia majora b. The external opening of the vagina

3. Labia minora c. A skin-covered pad of fat over the

pubic bone

4. Clitoris d. Tiny mucous glands opening into

the vestibule near the urinary

meatus

5. Urinary meatus e. Covered with pigmented skin on

outer surface and composed

mainly of fat and glands

291
6. Vaginal orifice f. Glands that secrete a lubricating

fluid into the space between the

hymen and the labia minora

7. Bartholin's glands g. The small opening of the urethra

located between the clitoris and

the vaginal orifice

8. Skene's glands h. Located within the labia majora

and covered with modified skin.

Q17

Match the neoplasms on the left with the descriptions on the right:

1. Cystadenocarcinoma a. A metastatic ovarian tumor, usually a

primary of the gastrointestinal tract,

especially of the stomach

2. Dysgerminoma b. Malignant tumor derived from more

than one type of germ cell and

containing several tissue types

3. Krukenberg tumor c. An epithelial tumor that

microscopically resembles a tumor of

endometrial origin

4. Teratocarcinoma d. A tumor derived from the germ cells

of the ovary comparable to seminoma

of the testis in the male

292
5. Endometrioid carcinoma e. An adenocarcinoma growing within a

cyst, serous or mucinous

Q18

The most common histologic type of malignant tumor found in the vulva and vagina is

For both sites, lymph node drainage is to the and

nodes.

293
Answer: Q14

The vagina is situated between the rectum which is posterior to it, and the bladder which

is anterior to it.

Answer: O15

The vagina is a collapsible tube, the walls of which are composed of smooth muscle lined

with mucous membrane.

Answer: Q16

The female external genitalia are called the vulva. Match each of its parts (on the left)

with the descriptions on the right.

c 1. Mons pubis (mons veneris) A skin-covered pad of fat over the

pubic bone

e 2. Labia majora Covered with pigmented skin on the

outer surface and composed mainly of

fat and glands

h 3. Labia minora Located within the labia majora and

covered with modified skin.

a 4. Clitoris A small organ composed of erectile

tissue

g 5. Urinary meatus The small opening of the urethra

located between the clitoris and the

vaginal orifice

b 6. Vaginal orifice The external opening of the vagina

f 7. Bartholin's glands Glands that secrete a lubricating fluid

into the space between the hymen and

the labia minora

d 8. Skene's glands Tiny mucous glands opening into the

vestibule near the urinary meatus

Answer: Q17

Match the neoplasms on the left with the descriptions on the right:

e 1. Cystadenocarcinoma An adenocarcinotna growing within a cyst,

serous or mucinous.

d 2. Dysgerminoma A tumor derived from the germ cells of the

ovary comparable to seminoma of the testis in

the male

294
a 3. Krukenberg tumor A metastatic ovarian tumor, usually a primary of

the gastrointestinal tract, especially of the

stomach.

b 4. Teratocarcinoma Malignant tumor derived from more than one

type of germ cell and containing several tissue

types

c 5. Endometrioid carcinoma An epithelial tumor that microscopically

resembles a tumor of endometrial origin

Answer: Q18

The most common histologic type of malignant tumor found in the vulva and vagina is

squamous cell carcinoma.

For both sites, lymph node drainage is to the external and internal iliac nodes.

295
296
Breast

The breasts, or mammary glands, are modified sweat glands and, in some of the earlier

classification systems, were grouped with the inte[gumentary system. The breasts lie on top of the

chest wall immediately over the pectoral muscles*, pectoralis major and peetoralis minor, and are

attached to the pectoralis major by a layer of connective tissue, the pectoral fascia. On the lower

lateral aspect of the chest wall, the breasts are in contact with the serratus anterior muscles 2.

Each breast consists of many separate glands that are connected by individual ducts (lactiferous

ducts) to the nipple. These glands constitute the lobes of the breast, 15 to 20 lobes (glands) for each

breast. Each lobe is composed of many lobules which are formed from minute ducts and contain

secreting cells (alveoli). The lobes are separated from each other by dense connective tissue and are

surrounded by quantities of adipose tissue (fat). Suspensory ligaments (Cooper's ligaments) run from

the corium of the skin through the breast to the fascia overlying the chest wall.

Located in the center of each breast is a nipple bordered by a circular pigmented area of skin

called the areola. The lactiferous ducts from the lobes of the breast converge in the nipple. During

pregnancy, hormonal changes in the body stimulate the production of milk in the lobes (mammary

glands); the ducts transport the milk to the nipple.

Figure 46. BREAST (sagittal view)

_ H_roo la

¢/. !_ ,Z '

Pectoratls minor "

muHc L_ ms.Jo r

1pectoral muscles--The function of the pectoralis major muscle is to adduct, flex, and rotate the

humerus inward. The pectoralis minor lies between the pectoralis major and serves to depress

the tip of the shoulder and help rotate the scapula downward and forward.

2serratus anterior muscles--These muscles draw the scapula forward and rotate it to raise the tip

of the shoulder.

297
298
Q19

The breasts overlie the muscles.

Q20

Each breast consists of multiple glandular which are further subdivided into

formed from minute ducts surrounded by alveoli.

Q21

The circular area bordering each nipple is called the

299
Answer: Q19

The breasts overlie the pectoral muscles.

Answer: Q20

Each breast consists of multiple glandular lobes which are further subdivided into lobules

formed from minute ducts surrounded by alveoli.

Answer: Q21

The circular area bordering each nipple is called the areola.

3OO
The female breast is classified according to the following subsites in ICD-O:

• Nipple/areola C50.0

• Central portion (subareolar, C50.1

retroareolar)

• Upper-inner quadrant (UIQ) C50.2

• Lower-inner quadrant (LIQ) C50.3

• Upper-outer quadrant (UOQ) C50.4

• Lower-outer quadrant (LOQ) C50.5

• Axillary tail C50.6

• Inner/outer lower upper breast, midline (250.8

You will sometimes find the location described in terms of hours on the clock; it is important to • /

note that this designation will be different for the mrfer and outer quadrants of the right and left

breast.

Figure 47. QUADRANTS OF THE BREAST

, 12 12

, ;.I' :

UOQ.J..UtO 'Ii ulo,.:_,uo¢

)---,o _.---3 / _9---(,O_---:

LATERAl LOQ'_i_LIQ / \ LIQ "'V/LOQ LATERAL

_EOIA_

t RIGHT LEFT

One shortcoming of our present classification system is that midline tumors, tumors at 3, 6, 9, and

12 o'clock, are grouped in a single category (C50.8) in ICD-0, and thus lose their identification. Since

a substantial number of tumors arise in these locations, we may be obscuring useful information by

including all of them in code C50.8. Medial lesions, for instance, have a poorer prognosis because of

their potential for metastasis to the internal mammary nodes.

301
A tumor specified as "subareolar" is coded to the central portion of the breast (C50.1) indicating

that the tumor is located directly under the nipple.

Extending outward from the nipple and areola and covering the entire surface of the breast is a

layer of skin. Skin changes are significant in the clinical evaluation of breast cancer and indicate

involvement of parenchymal tissue as well as invasion of the skin itself. Changes such as dimpling,

tethering, and nipple retraction are presumed to be due to tension on Cooper's ligaments and not

to actual skin involvement; adherence, attachment, fixation, induration, and,thickening are usuall),due

to extension of tumor to the skin or subcutaneous tissue. Edema, peau d orange, 1 en cuirasse _, and

ulceration clinically indicate extensive skin involvement.

The blood supply to the breast is from both the internal thoracic (subclavian) and the lateral

thoracic (axillary) arteries. The veins form both superficial and deep plexuses and correspond in

general to the arterial pattern.

Regional Lymph Nodes

The lymph nodes of the breast may be divided into the following categories:

Axillary lymph nodes (ipsilaterai)

Low axiUary(Level I): area adjacent to the tail of the breast

Mid axillary (Level II): central, interpectoral (Rotter's node)

High axillary (Level III): apex of the axilla including those designated as

subclavicular, infraclavicular, and apical nodes

Internal mammary (parasternal) lymph nodes (ipsilateral): in the intercostal spaces along

the edge of the sternum in the endothoracic fascia

Nodules of cancer cells found in the axillary fat which are not specifically identified as lymph nodes

are considered to be nodes which have lost their architectural configuration or to be intransit

metastases in the lymphatics.

Contralateral or bilateral involvement of any of the above lymph nodes is considered distant lymph

node metastasis.

All other lymph node metastases are coded as distant metastases, including any supraclavicular,

scalene, and cervical lymph nodes.

lpeau d'orange--a dimpled skin condition resembling the skin of an orange.

2en cuirasse--an inflammatory process in which skin involvement resembles armor plate.

302
Q22

One of the first and most frequent areas of nodal metastasis in breast cancer patients is the

lymph nodes.

Q23

Match the axillary lymph node levels on the left with the descriptions on the right.

1. Low a. Area next to the tail of the breast

2. Mid b. Apex of the axilla

3. High c. Area under the pectoralis minor muscles

Q24

What are the most frequently involved distant lymph nodes for breast cancer?

303
Answer: Q22

One of the first and most frequent areas of nodal metastasis in breast cancer patients isthe

axilla_ lymph nodes.

Answer: Q23

a 1. Low Area adjacent to the tail of the breast

c 2. Mid Area under the pectoralis minor muscles

b 3. High Apex of the axilla

Answer: Q24

The most frequently involved distant lymph nodes for breast cancer are the supraclavicular

(transverse cervical) lymph nodes.

3O4
Malignant Tumors

Ninety percent of all breast cancers arise from the glandular epithelial lining of the ducts. Thus, most

tumors are intraductal in origin. The epithelium is supported by a basement membrane and an

incomplete layer of myoepithelial cells. Invasion takes place when the tumor penetrates the basement

membrane of the duct and grows into the supporting stroma. The histologic types of tumors generally

described are:

• lntraductal (adeno)carcinoma, is a noninfiltrating or in situ lesion.

• Ductal (duct cell) (adeno)carcinoma is a general term denoting an infiltrating tumor

of ductal origin.

• Medullary (adeno)carcinoma is a well-differentiated tumor of epithelial origin which

will often have evidence of lymphoid infiltration in the stroma.

• Mucinous (adeno) carcinoma is a mucin-producing tumor which may have a

gelatinous or colloid (glue-like) appearance when sufficient amounts of mucin are

present.

• Lobular (adeno) carcinoma arises in the lobules of the breast as the name implies.

It is most often diagnosed in situ but will eventually invade the parenchyma.

Multiple foci are frequently found including foci in both breasts.

• Inflammatory carcinoma is a clinical term used to describe a condition in which

there is diffuse involvement of the breast, particularly of the skin, causing

widespread erythema, edema, and discoloration. It is generally inoperable and has

a poor prognosis.

• Scirrhous (adeno) carcinoma is a tumor of ductal epithelial origin in which fibrous

connective tissue has formed giving it a hard consistency.

• Paget's disease presents as a weeping eczematoid lesion of the nipple and areola.

It occurs as the result of nipple invasion from an underlying ductal carcinoma. The

presence of Paget's disease does not alter the staging of the original tumor.

° Cystosarcoma phyllodes, also known as cellular intracanalicular fibroma, is usually

a benign disease contrary to the inclusion of "sarcoma" in the name of this tumor.

It is one of the rare stromal tumors of the breast and, although it may become very

large, cystic, and hemorrhagic, it only infrequently becomes invasive.

305
306
REVIEW TEST

Match the descriptions on the left with the organs on the right:

1. Gonads in the female a. Perineum

2. Muscular layer of the uterus b. Cul de sac

3. Fringe bordering opening of the c. Myometrium

fallopian tube

4. Area between the vagina and anus d. Ovaries

5. External genitalia of female e. Fallopian tubes

6. Ducts through which the ova travel f. Female genitalia

into the uterus

7. Region of abdominal cavity midway g. Vulva

between the rectum and uterus

h. Fimbria

307
ANSWERS TO REVIEW TEST

d 1. Gonads in the female Ovaries

c 2. Muscular layer of the uterus Myometrium

h 3. Fringe bordering opening of the Fimbria

fallopian tube

a 4. Area between the vagina and anus Perineum

g 5. External genitalia of female Vulva

e 6. Ducts through which the ova travel Fallopian tubes

into the uterus

b 7. Region of abdominal cavity Cul de sac

midway between the rectum and

uterus

308
Male Reproductive System

The male reproductive system, like that of the female, consists of those organs whose function is

to produce a new individual, i.e., to accomplish reproduction. This system consists of a pair of testes

and a network of excretory ducts (epididymis, ductus deferens (vas deferens), and ejaculatory ducts),

seminal vesicles, the prostate, the bulbourethral glands, and the penis.

Scrotum

The scrotum is a skin-covered pouch of muscle and fascia suspended on the outside of the body.

It is one of the supporting structures of the male reproductive system. The scrotum is divided

internally into two (left and right) sacs by a septum (partition) so that each sac contains a testis,

epididymis, and the lower part of the spermatic cord.

Testes

The testes are two small ovoid glands, male gonads, which lie in the scrotum. These glands are not

developed within the scrotal sac, but descend from the abdominal cavity during fetal development.

A thick fibrous capsule (tunica albuginea) encases each testis, extensions of which (septa) partition

the interior into lobules. Each lobule contains tiny coiled seminiferous tubules and many interstitial

(Leydig) cells which lie between the seminiferous cells. The interstitial cells are glandular cells that

produce the hormone testosterone.

The primary functions of the testes are:

• Production of male reproductive cells by the seminiferous tubes (spermatozoa or

sperm)

• Secretion of hormones, mainly testosterone, by the interstitial cells of Leydig.

Testosterone is an androgen secreted by the Leydig cells of the testicle. Testosterone is

responsible for the development of male secondary sex characteristics and genital growth; it also

influences the retention of nitrogen, potassium, phosphorous, and calcium, required for building

protoplasm. Androgens also have important growth-regulating functions.

Regional nodes for the testis are found on page 322.

309
310
Q25

The male gonads consist of a pair of enclosed in a sac called the

lying outside of the body cavity.

Q26

A major hormone secreted by the interstitial cells of the testes is It is

responsible for the development of the male sex characteristics.

311
Answer: Q25

The male gonads consist of a pair of testes enclosed in a sac called the scrotum lying

outside of the body cavity.

Answer: Q26

A major hormone secreted by the interstitial cells of the testes is testosterone. It is

responsible for the development of the male sex characteristics.

Figure 48. MALE PELVIS (sagittal view)

312
The internal structure of the testis is composed of seminiferous tubules. The seminiferous tubules

are narrow, coiled tubules located within the lobules of the testis and composed of parenchymal

tissue. Thus, these tubules perform the essential, active work of the organ, that is, production of the

sperm cells by two types of cells: 1) the spermatogenic cells and 2) the Sertoli cells which support

and protect the developing sperm cells and may even contribute to their nourishment. The Sertoli

cells are resistant to heat, radiation, and other agents that prove toxic to germ cells.

Epididymis. Each epididymis consists of a single coiled tube or duct encased in a fibrous covering.

It is about 20 feet long with a very small diameter and lies along the top and side of the testis. The

sperm cells are temporarily stored in the epididymis after leaving the testis.

Vas deferens. The vas deferens (seminal duct or ductus deferens) is really an extension of the

epididymis. It carries sperm from the epididymis to the urethra. The vas deferens passes from the

scrotal sac through the opening of the pelvic body wall called the inguinal canal and into the pelvic

cavity. There it extends over the top and down the posterior surface of the bladder where it joins

the duct from the seminal vesicle on each side to form the ejaculatory ducts. These short tubes, the

ejaculatory ducts, pass through the prostate gland and terminate in the prostatic portion of the

urethra.

The aggregate of vas deferens and associated blood vessels, lymphatics, and nerves is bound within

a connective tissue sheath called the spermatic cord.

Figure 49. TESTIS (sagittal view)

$permat|c cord_

Sesint.fero_ ___--¥_a _eferens

tubules

_Epldldys|6

313
314
Q29

Match the structures on the left with its function on the right.

1. Epididymis a. Narrow tubes which carry sperm from the

epididymis to the urethra

2. Vas deferens b. Narrow, coiled tubules in the testes which

produce sperm

3. Seminiferous tubules c. Tube located on top of each testis which

carries and stores sperm before they enter

the vas deferens

Q28

The are the parenchymal (essential) tissue of the

testes because they produce the sperm.

315
Answer: Q27

c 1. Epididymis Tube located on top of each testis which

carries and stores sperm before they enter

the vas deferens

a 2. Vas deferens Narrow tubes which carry sperm from the

epididymis to the urethra

b 3. Seminiferous tubules Narrow, coiled tubules in the testes which

produce sperm

Answer: Q28

The seminiferous tubules are the parenchymal (essential) tissue of the testes because they

produce the sperm.

316
Seminal Vesicles

The seminal vesicles are two glands located on the posterior surface of the urinary bladder

between the bladder and the rectum. They secrete a substance that nourishes the sperm cells.

Approximately 30 percent of the semen is composed of the secretion produced by the seminal

vesicles.

Prostate Gland

The prostate gland is located on the inferior surface of the urinary bladder encompassing the

prostatic portion of the urethra. It lies behind the symphysis pubis (to which it is connected by the

puboprostatic ligament), above the urogenital diaphragm (pelvic floor), and in front of the rectum.

It is separated from the rectum by Denonvilliers' fascia1. The adult prostate weighs about 20 grams

and is typically divided into three lobes: the right and left lateral lobes and the middle lobe. These

lobes consist of alveoli lined with columnar epithelium encased in a thin capsule of connective tissue

and embedded in a thick fibromuscular stroma. The prostate secretes an alkaline substance which

constitutes the largest part (60 percent) of the seminal fluid. This establishes a suitable pH

environment for sperm reaching the vagina and protects the ejaculated semen from mechanical

damage. The seminal fluid is drained from the navel by a system of branching ducts which open into

the prostatic portion of the urethra.

Acid phosphatase is present in the prostatic secretions. Patients with prostatic carcinoma which

is still confined within the prostatic capsule usually have a normal serum acid phosphatase level.

However, elevated serum levels are seen in patients with carcinoma of the prostate that has extended

beyond the prostatic capsule. Acid phosphatase determination is used diagnostically to help

determine the spread of the disease. See page 116 of Book 5 for normal values.

Figure 50. PROSTATE GLAND (sagittai view)

._ 1

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( C o_'pe r's )

_L &rid

1Denovilliers' fascia--a portion of the rectovesical fascia between the rectum and prostate gland•

317
Figure 51. PROSTATE GLAND (frontal view)

Vm8 deferenB

se.l..t .e.lcte . ":'-, /I/

Rlaht Lateral lobe Left teteral lobe

Prost,st ic _[uc t 8 dr_ /,__ _

Membranous urethra " \ ...... ,_..

E.iacuL& tory orlLf tces

Relationship of Prostatic Hypertrophy, Hyperplasia, and Prostatic Cancer

Hypertrophy means an increase in size of the prostate due to the increase in the size of the

individual cells. In contrast, hyperplasia means an increase in the size of the prostate due to an

increase in the number of its cells.

Benign prostatic hypertrophy (enlargement of the prostate) is very common in elderly men. Its

exact etiology is not known, although there is some evidence to show that part of it is hormonally

mandated. Benign prostatic hypertrophy increases with age as does prostatic cancer; and both require

testosterone to grow and divide. In general, prostatic cancer originates in the periphery of the

prostate where benign prostatic hypertrophy occurs. That is why it is possible for the physician to

palpate these tumors via the rectum. A clinical diagnosis of benign prostatic hypertrophy may be

made when a man has symptoms of prostatic disease. Then a TUR is done, and only then may a

diagnosis of cancer be made based on the increase in the number of cells, hyperplasia.

Bulbourethral (Cowper's) Glands

The Cowper's glands are located below the prostate on either side of the membranous urethra.

They resemble peas in both size and shape. A duct about 2.5 cm long connects each of them with

the urethra. Cowper's glands, like the prostate, secrete an alkaline, mucous fluid which makes up

about 5 percent of the semen. These glands are also supplied with muscular tissue which aids in

expulsion of sperm during ejaculation.

318
Q29

Match the structures on the left with the descriptions on the right

1. Prostate a. Glands which nourish sperm cells by their

secretions

2. Bulbourethral b. Gland which secretes an alkaline substance (60

percent of seminal fluid) providing protective

environment for sperm

3. Seminal vesicles c. Glands which aid in ejaculation because of their

muscular tissue

319
Answer: Q29

b 1. Prostate Gland which secretes an alkaline substance

(60 percent of seminal fluid) providing

protective environment for sperm

e 2. Bulbourethral Glands which aid in ejaculation because of

their muscular tissue

a 3. Seminal vesicles Glands which nourish sperm cells by their

secretions

320
Penis

The penis consists of erectile and connective tissue sheathed in skin. There are three distinct

bands of the erectile tissue within the penis: The two corpora cavemosa and the single corpus

spongiosum. At the distal end is the glans penis over which there is a double fold of skin called the

prepuce or foreskin. The penis contains the penile (spongy or cavernous) segment of the urethra

which is the terminal duct for both the urinary and the reproductive tracts in the male.

The penile blood supply is from the internal iliac and femoral arteries by way of the pudendal

arteries. Blood drains to the internal iliac veins. During erection, the blood vessels of the penis

undergo a change; the arteries become dilated and the veins constricted.

The penis serves two purposes:

• An excretory organ for liquid wastes

• The male copulatory organ

321
Regional Lymph Nodes

The regional lymph node drainage for the prostate is:

Periprostatic

Internal iliac: (hypogastric, including obturator)

External iliac

Sacral (lateral, presacral, promontory (Gerota's))

The regional lymph node drainage for the testis is:

Paracaval

A_rtic (para-, peri-, lateral)

External iliac (intrapelvic)

The regional lymph node drainage for the penis is:

External iliac

Internal iliac (hypogastric)

Superficial inguinal (femoral)

Deep inguinal: Rosenmuller's or Cioquet's node

Figure 52. LYMPHATIC DRAINAGE OF THE PROSTATE AND TESTES

322
Malignant Tumors

The most common malignant neoplasms which occur in the male reproductive systems are as

follows:

• Adenocarcinoma of the prostate gland, diagnosed primarily in men over 65 years

of age.

° Testicular tumors occurring primarily in young men. The classification of testicular

tumors is highly controversial and complicated by the frequent occurrence of tumors

of mixed cell types. Tumors arising in the germinal epithelium (germ cell types)

account for 97 percent of testicular tumors. The most frequent histologic types are

as follows:

Seminoma is the most common testicular tumor. It also has the best

prognosis as it is slow to spread. Foci of the more malignant types of germ

cell tumors, embryonal carcinoma and choriocarcinoma, may be found in the

seminoma. Then the prognosis is similar to the more malignant tumor

rather than to the pure seminoma. Variants of seminoma are the anaplastic

type of seminoma and the spermatocytic seminoma, both of which are rare.

Teratocarcinoma or malignant teratoma is the second most common

testicular tumor. Teratomas are tumors of germ cell origin composed of

embryonic tissue which is differentiated into bone, hair, teeth, cartilage, and

skin. All these types of tissues may be found in the tumor.

Embryonal carcinoma is a more infiltrative type of testicular tumor and

consequently has a poorer prognosis. It arises from the primitive or

multipotentiai cells of the germinal epithelium and occurs in a variety of

cellular patterns.

Choriocarcinoma (chorioepithelioma) is a rare tumor in its pure form

although loci of choriocarcinoma may be found in any of the other germinal

tumors. It is highly malignant and metastasizes rapidly. It is derived from

primitive cells differentiating as trophoblastic cells 1. High levels of

gonadotropin hormone may be found in the urine with the tumor.

Nongerminal tumors of the testes are extremely rare. Tumors arising in the gonadal stroma

include: interstitial cell (Leydig cell) tumors and Sertoli cell tumors. These tumors are seldom

malignant.

ltrophoblastic cells--pertaining to the layer of extraembryonic ectodermal tissue which covers the

embryo.

323
324
Q30

Male hormonesare produced primarily in the

Q31

Which of the following are regional nodes for the prostate? (Check as appropriate.)

1. Aortic (para-, peri-, lateral)

2. Internal iliac (hypogastric)

3. Sacral

4. External iliac

5. Periprostatic

Q32

Which of the following are regional nodes for the testes?

1. Portal

2. Aortic (para-, peri-, lateral)

3. External iliac

4. Inguinal

5. Internal iliac (hypogastric)

325
Answer: Q30

Male hormones are produced primarily in the testes (or in the interstitial cells of Leydig

of the testes).

Answer: Q31

The regional nodes for the prostate are:

2 Internal iliac (hypogastric)

3 Sacral

4 External iliac

5 Periprostatic

Answer: Q31

The regional nodes for the testes are:

2 Aortic (para-, peri-, lateral)

3 External iliac

326
SECTION J

THE ENDOCRINE SYSTEM

327
Figure 53. ENDOCRINE GLANDS

328
SECTION J

THE ENDOCRINE SYSTEM

The endocrine system is comprised of ductless glands which manufacture and release specific

organic secretions called hormones directly into the bloodstream to be carded to various parts of the

body where they perform their particular functions. The individual glands are located in widely

separated parts of the body and form a system only from a functional point of view. In contrast, the

exocrine glands, such as the tear, digestive, and sweat glands release their secretions into ducts

leading to the body cavities or outside the body as appropriate. (You may wish to review the

pancreas, ovary, and testis which are also part of the endocrine system.)

The islets of Langerhans of the pancreas are part of the endocrine system and have already been

described under the digestive system. The endocrine functions of the ovaries and testes were

described under the reproductive system. The remaining endocrine glands and their distinct functions

as well as their interesting relationships with each other are described below.

Pituitary Gland (Hypophysis)

The pituitary gland (hypophysis) is controlled by the hypothalamus of the brain and links the

nervous system to the endocrine system. Located at the base of the brain behind the eyes in the sella

turcica of the sphenoid bone, the pituitary is only the size of a pea. It is referred to as the master

gland since it controls all secretions of hormones within the body. The pituitary gland has two lobes,

the anterior lobe (the adenohypophysis) and the posterior lobe of the neurohypophysis). Each lobe

has definite functions.

The anterior lobe is responsible for producing at least the following hormones:

• Adrenocorticotrophic hormone: ACTH controls the development and secretory

activityof the adrenal cortex for secretion of the glucocorticoids (primarily cortisol).

• Thyrotrophic (thyroid-stimulating) hormone: TSH stimulates the growth and

development of the thyroid gland and stimulates it to secrete thyroxin and triiodothyronine (together called thyroid hormone).

• Follicle-stimulating hormone: FSH stimulates the development of ovarian follicles

which secrete estrogen in the female. In the male, FSH stimulates the development

of the seminiferous tubules and promotes spermatogenesis.

• Male gonadotrophic hormone (interstitial cell-stimulating hormone): ICSH

stimulates the development of the interstitial cells (cells of Leydig) of the testes and

the secretion of testosterone.

• Female luteinizing hormone: LH stimulates the secretion of progesterone by the

corpus luteum in the ovaries.

• Growth or somatotrophic hormone: GH or STH accelerates growth of bone,

muscle, kidney, liver, and adipose tissues.

329
• Prolactin (luteotrophic hormone): LTH is concerned with initialization and

maintenance of lactation in the mammary glands. LH stimulates the ovary to

release the developed ovum and prepares the uterus for implantation of a fertilized

ovum. It also stimulates formation of the corpus luteum in the ovary, which

secretes progesterone and readies the mammary glands for milk secretion.

• Melanocyte-stimulating hormones: MSH and ACTH are thought to produce

increased pigmentation of the skin.

The function of the posterior lobe of the pituitary is to produce the following:

• Oxytocin (pitoein) which stimulates the uterine muscles to contract during childbirth

and causes the secretion of milk in lactating breasts.

• Antidiuretic hormone (vasopressin) (ADH) which has several effects on the body:

It has an antidiuretic effect stimulating the reabsorption of water by the

kidney tubules.

It is thought to have a pressor effect increasing blood pressure by

constriction of the arterioles.

It also is believed to have an effect on the smooth muscle of the intestinal

tract.

Tumors

Tumors of the pituitary are almost always benign; malignant tumors are rare. These benign tumors

may produce hormonal changes in the body or may simulate the symptoms of a brain tumor.

• Adenomas, representing about three-fourths of the pituitary tumors, are of three

main types: acidophilic (eosinophilic), basophilic, and chromophobe.

• Craniopharyngioma (Rathke's pouch tumor) arises along the craniopharyngeal duct

and is benign.

330
Thyroid Gland

The thyroid gland consists of two lateral lobes united by a strip of glandular tissue called the

isthmus. It is covered by two capsules: an inner capsule of fibroelastic tissue and an outer capsule

continuous with and part of the deep cervical fascia. The thyroid is located on either side of the

trachea just below the thyroid cartilage. The unit structure of the thyroid gland is the follicle. A

thin, continuous basal membrane surrounds each follicle. Between the follicles are capillaries,

fibroblasts, and small bundles of collagenous fibers. This gland produces the hormones thyroxin and

tri-iodothyronine which are necessary to maintain a normal level of metabolism in all body cells.

These hormones are synthesized in the thyroid gland from iodine. Another hormone produced by

the thyroid gland is thyrocalcitonin which aids in maintaining the proper level of calcium in the blood.

In summary, the main physiological actions of this gland are to assist in regulating the metabolic rate

in concert with growth and tissue regulation.

Lymphatic drainage is to cervical and mediastinal nodes:

Delphian node

Anterior cervical: prelaryngeal, pretracheal, laterotracheal (recurrent

laryngeal nerve chain)

Internal jugular: jugulodigastric and jugulo-omohyoid

Tracheoesophageal

Mediastinal, upper anterior and posterior (tracheoesophageal)

Retropharyngeal

Tumors

Malignant tumors of the thyroid are primarily of two main types:

• Papillaly adenocarcinoma is the most common thyroid cancer. It is generally well

differentiated and characterized by well-defined papillary fronds. Spread is usually

via the lymphatics to the cervical lymph nodes. Prognosis is good following excision

of the involved lobe(s). Lymph node dissection may be deferred until there is

clinical evidence of nodal involvement.

• Follictdar adenocaminoma is the second most common type of thyroid malignancy.

It has well-developed follicles resembling normal thyroid tissue. Dissemination is

usually via the blood stream to distant sites.

Mixed papillary and follicular carcinoma is common. It behaves like papillary carcinoma.

• Medullary calvinoma with amyloid stroma is a rare tumor.

• Anaplastic carcinoma is also rare; it occurs predominantly in older patients.

The most common bcnign tumor of thc thyroid is the adenoma of which there are several types,

such as: papillary, tk)llicular, colloid, fetal, and Hurthlc cell_ These benign tumors are not generally

included in the cancer registry unless they are of special interest to the medical staff.

331
ParathyroidGland

There are four parathyroidglandslocatedimmediatelybehindthe thyroidglandbeneathitsouter

capsule. There is, however, little correlation between the functions of the thyroid and the

parathyroids. Although eachparathyroidis only about the sizeof a grain of rice, its function is

essentialto life.

The chief cells of the parathyroid secrete a hormone, parathormone, which maintains the normal

phosphorous and calcium levels in the body. Parathormone controls the excretion of phosphorus in

the kidney and also mobilizes calcium and phosphorus in bone. It also increases the absorption of

calcium from the intestinal tract when necessary.

An excess of parathormone may cause Recklinghausen's disease of the bone (osteitis fibrosa

cystica). Excessive parathormone draws calcium from the bone and raises this level in the blood.

Pathological fractures may result.

Tumors of the parathyroid are extremely rare; most are benign adenomas.

Pineal Gland

The pineal gland (epiphysis) is located in the brain attached to the roof of the third ventricle

(epithalamus). It secretes the hormone melatonin, which contributes to the process of skin

pigmentation, and is thought to secrete serotonin and adrenoglomerulotropin. Although its true

functions remain a mystery, it is also believed to serve as a "biological clock."

Tumors of the pineal gland are called pinealomas and are usually benign. Since these tumors are

located in the brain, you may be requested to include them in the registry together with benign brain

tumors.

Figure 54. THYROID AND Figure 55. PINEAL GLAND

PARATHYROID GLANDS

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332
Adrenal (Suprarenal) Glands

There are two adrenal (suprarenal) glands, about the size of the last digit of the little finger, each

paired with and located on top of a kidney and behind the peritoneum. Each adrenal gland consists

of two parts, an inner medulla and an outer cortex.

• The adrenal medulla secretes hormones called catecholamines, i.e., epinephrine and

norepinephrine. These are hormones produced by stress and were once referred

to only as adrenalin.

Epinephrine (adrenalin) increases heart rate and cardiac activity, dilates the

bronchial tubes, and stimulates the production of glucose from glycogen.

Norepinephrine (acetylcholine) constricts blood vessels and raises blood

pressure.

• The adrenal cortex secretes hormones called steroids. Some of the more important

ones are:

Aldosterone, a mineralocorticoid, promotes sodium retention and potassium

loss in the urine and vice versa as needed to balance the body fluids.

Cortisol increases the ability of the cells to make new sugars out of fats and

proteins. (Cortisone is a hormone similar to cortisol but is produced

synthetically.)

Androgens, estrogens, andprogestin (male and female hormones) are secreted

by the adrenal cortex in small amounts. They promote normal development

of bones and reproductive organs.

Tumors

Adrenal tumors may be divided into those arising from the cortical cells and those from the

medullary cells of the glands.

• Neuroblastoma, which arises in the medulla, is the most common malignant tumor

of the adrenal gland. It is found most frequently in children and young adults and

is, in fact, one of the most common childhood tumors. Neuroblastomas can also

arise from neural tissue elsewhere in the body.

• Pheochromocytoma and ganglioneuroma are benign, rarely malignant, tumors of the

adrenal medulla.

• Adrenal conical adenocarcinoma arises in the adrenal cortex. Its benign counterpart

is the cortical adenoma.

333
Thymus Gland

The thymus gland is located behind the sternum in the mediastinum. It is large in childhood, but

shrinks in adults. Its structure is lymphoepithelial. It is a source of lymphoeytes. T lymphocytes

mature in the thymus and are involved in cell-mediated immunity, that is, the cells themselves mediate

the immune effect. The thymus is also included in the section on the Lymphatic System.

Tumors of the thymus, thymomas, are rare and most often benign. As a lymphoid organ, the

thymus may be primarily or secondarily involved in lymphomas of the mediastinum.

The condition of myasthenia gravis, which is characterized by muscular weakness and fatigue, may

be associated with tumors of the thymus.

Other Hormone Producers

The stomach wall secretes a hormone called gastrin which stimulates the blood vessels and

secretions of the stomach glands.

The upper part of the small intestine secretes a hormone called secretin which stimulates the

pancreas and causes the gallbladder to contract.

The placenta produces chorionic gonadotropic hormones which help to maintain pregnancy.

Figure 56. ADRENAL GLAND Figure 57. THYMUS GLAND

". ".....-._.-" ; .'.".._ . '_'.'.. ".a. ( ....... /

"_ _,......... ' _" "_:'_" I__'. .

'_i_':::_ _....... % :"::';: ) _!_i_' '_" "': "/

...._;........... , .,.._.. t,_..- _-_-_;I,/

,...:._. ........ ,7:::._i.. _.' ._ ,, ,,.-

t .................. _....... _ ................... _ ' _;,--., "_._-'_,,, ...:. .,.:........ ,., .... -.-- _q_-"

: " .-' _; , !:.. - : .,'" " ."i _'

334
Q1

Match the terms on the left with the descriptions on the right.

1. Hormones a. An endocrine gland which lies at the base of the brain; the

pituitary

.. 2. Hypophysis b. Ductless glands which secrete substances into the bloodstream

3. Exocrine glands c. A narrow strip of tissue connecting two parts

4. Isthmus d. Organic secretions originating in a ductless gland and conveyed

to another part of the body by the bloodstream

5. Endocrine glands e. Glands which secrete substances through ducts in the body

surfaces or into body cavities

6. Steroids f. Hormones produced by the adrenal cortex, such as aldosterone,

cortisol, and androgens

335
Q2

Match the hormone on the left with the appropriate endocrine gland on the right. The same

gland may be selected more than once.

1. FSH (follicle-stimulating a. Pancreas

hormone)

m 2. Androgens b. Pituitary

3. Cortisol c. Ovaries

m 4. Insulin d. Adrenals (medulla)

5. Thyroxin e. Testes

6. Parathormone f. Adrenals (cortex)

7. Epinephrine g. Thyroid

8. Estrogen h. Parathyroid

9. Steroids

Q3

The endocrine system consists of glandulartissue which secretes

directly into the blood stream from its (type) glands.

336
Q4

Match the endocrine glands on the left with their locations in the body on the right:

1. Ovaries (paired) a. In the mediastinum

2. Testes (paired) b. On top of each kidney

3. Adrenals (paired) c. In the middle brain

4. Parathyroids d. At the base of the brain

5. Thyroid e. Behind the stomach

6. Pancreas f. On the dorsal aspect of the

thyroid

7. Pineal g. In the lower abdominal region of

the female

8. Thymus h. On either side of the trachea just

below the thyroid cartilage

9. Pituitary i. Suspended by the spermatic cord

and surrounded by the scrotal sac

Q5

Match the tumor on the left with the typical gland of origin on the right. The same gland may

be selected more than once.

1. Neuroblastoma a. Pituitary gland

2. Papillary adenocarcinoma b. Thyroid gland

3. Craniopharyngioma c. Adrenal gland

4. Follicular adenocarcinoma

337
Answer: Q1

d 1. Hormones Organic secretions originating in a ductless gland and conveyed

to another part of the body by the bloodstream

a 2. Hypophysis An endocrine gland which lies at the base of the

brain; the pituitary

e 3. Exocrine glands Glands which secrete substances through ducts to the body

surface or into body cavities

c 4. Isthmus A narrow strip of tissue connecting two parts

b 5. Endocrine glands Ductless glands which secrete substances into the

bloodstream

f 6. Steroids Hormones produced by the adrenal cortex, such as aldosterone,

cortisol, and androgens

Answer: Q2

b 1. FSH (follicle-stimulating Pituitary

hormone)

e/f 2. Androgens Testes, adrenals (cortex)

f 3. Cortisol Adrenals (cortex)

a 4. Insulin Pancreas

g 5. Thyroxin Thyroid

h 6. Parathormone Parathyroid

d 7. Epinephrine (adrenalin) Adrenals (medulla)

c/f 8. Estrogen Ovaries, adrenals (cortex)

f/e 9. Steroids Adrenals (cortex), testes

338
Answer: Q3

The endocrine system consists of glandular tissue which secretes hormones directly into the

blood stream from its ductless glands.

Answer: Q4

g 1. Ovaries (paired) In the lower abdominal region of

the female

i 2. Testes (paired) Suspended by the spermatic cord

and surrounded by the scrotal sac

b 3. Adrenals (paired) On top of each kidney

f 4. Parathyroids On the dorsal aspect of the

thyroid

h 5. Thyroid On either side of the trachea

just below the thyroid cartilage

e 6. Pancreas Behind the stomach

, c 7. Pineal In the middle brain

a 8. Thymus In the mediastinum

d 9. Pituitary At the base of the brain

Answer: Q5

c I. Neuroblastoma Adrenal gland

,b 2. Papillary adenocarcinoma Thyroid gland

a 3. Craniopharyngioma Pituitary gland

b 4. Follicular adenocarcinoma Thyroid gland

339
340
SECTION K

THE SKELETAL SYSTEM

341
Figure 58. AXIAL SKELETON

SkuLl.

342
SECTION K

THE SKELETAL SYSTEM

The skeletal system is composed of bones and cartilage. Most of the bones and much of the

cartilage form joints which are held together by ligaments of tough, fibrous connective tissue. Joints

can be classified as immovable (synarthrosis), slightly movable (amphiarthrosis), and freely movable

(diarthrosis).

There are a total of 206 bones in the adult human body. Eighty of these bones form the upright

axis of the body, the axial skeleton, which is the basic framework of the body. It includes the skull,

vertebral column, and the bones (ribs) which encase the thorax. The other 126 bones comprise the

appendicular skeleton which is made up of bones that are attached or appended to the axial skeleton:

the upper and lower extremities (arms and legs) including the shoulder and pelvic girdles (clavicle,

scapula, and hip bones). The main bones that compose the skeletal system can be located in Figures

58 and 67.

This complex skeletal system has a variety of functions.

• It provides a supporting framework for the body.

• It affords protection for the vital organs: heart, lungs, brain, spinal cord, as well as

sensory organs, and soft tissues.

• It provides a leverage system for muscle action with the bones providing

attachments for the muscles, ligaments,1 tendons,2 and fascia.3

• It serves as a storehouse (within the bone) for minerals, and supplies calcium and

phosphorus to the blood.

• It contains bone marrow which produces millions of red blood cells and thousands

of white cells (hemopoiesis).

lligament--a fibrous band of connective tissue that connects bones to bones serving to support and

strengthen joints.

Ztendon--a fibrous cord of connective tissue by which a muscle is attached to bone.

3fascia--a fibrous sheet of connective tissue covering and separating muscles.

343
344
Q1

The skeletal system is composed of and

which may be held together by at their joints.

Q2

Five functions of the skeletal system are:

1.

2.

3.

4.

5.

Q3

The 206 bones of the skeleton may be grouped into two skeletal divisions:

1. (the basic framework of the body).

2. (the appendage of this

framework).

345
Answer: Q1

The skeletal system is composed of bones and cartilage which may be held together by

ligaments at their joints.

Answer: Q2

You might have said:

1. It provides a supporting framework for the body.

2. It protects the vital organs.

3. It provides leverage for muscle action.

4. It serves as a storehouse for minerals and supplies calcium and phosphorus to

the blood.

5. The bone marrow produces blood cells.

Answer: Q3

The 206 bones of the skeleton may be grouped into two skeletal divisions:

1. Axial skeleton (the basic framework of the body).

2. Appendicular skeleton (the appendage of this framework).

346
Bone/Cartilaginous Tissue

Bone, or osseous tissue, is a form of dense connective tissue in which the intercellular substance,

or matrix, is infiltrated with calcium salts. It differs from cartilage in that bone is a vascular tissue

permeated with canaliculi. The canaliculi are tiny canals that connect the lacunae (in which bone

cells lie) with each other and serve as a transport system (Haversian system) between the blood

capillaries and the bone cells. Tissue fluid in the canaliculi diffuses oxygen and nutrient material from

the blood to the bone cells and carries their waste material back to the circulatory system. Thus the

bone cells (osteocytes) may remain alive although surrounded by calcified intercellular substance

(bone matrix). No bone cell is more than 0.1 mm from a blood capillary.

In contrast, cartilage is nonvascular connective tissue. Its cells (chondrocytes) are nourished by

means of blood vessels in the outer layer ofperichondrium which covers the surface of the cartilage.

There are three types of cartilage:

• Hyaline cartilage, the most abundant, may become calcified and replaced by bone.

However, much of it remains uncalcified as part of the ears, nose, larynx, trachea,

and larger bronchi, and as a covering of the articulating 1 bones in freely moving

joints where it has a cushioning effect.

• Elastic cartilage is rare; it occurs primarily in the external ear and in the epiglottis.

• Fibrocartilage (fibrous cartilage) is found in the areas where tendons insert into

bone.

Figure 59. OSSEOUS TISSUE Figure 60. HYALINE CARTILAGE

: _." " "...- ...'.::...i• • • .... " . . . . _" _-" : ". 'u_z_A.

•.:''." " • _- ."_:: _ ...'._._ " . ".'. ',

Chondrocyte8

larticulation--the place of union or junction between two or more bones.

347
348
Q4

One characteristic which distinguishes bone from cartilage is that bone is while

cartilage is

Q5

Bone cells are called

06

Cartilage cells are called

Q7

Match the types of cartilage on the left with the descriptions on the right:

1. Hyaline a. Rare, occurring only in external ear and epiglottis

2. Elastic b. Occurs in areas of insertion of tendons into bone

3. Fibrous c. Most abundant, may become calcified and be replaced by

bone or remain unealcified as a covering of articulating

bones.

349
Answer: Q4

One characteristic which distinguishes bone from cartilage is that bone is vascular while

cartilage is nonvascular.

Answer: Q5

Bone cells are called osteocytes.

Answer: Q6

Cartilage cells are called chondrocytes.

Answer: Q7

c 1. Hyaline Most abundant, may become calcified and be replaced by bone

or remain uncalcified as a covering of articulating bones.

a 2. Elastic Rare, occurring only in external ear and epiglottis.

b 3. Fibrous Occurs in areas of insertion of tendons into bone

350
Classification of Bones

Bones may be classified by shape as follows:

• Long bones are found in the arms and legs. Examples: humerus, radius, ulna,

phalanges, femur, tibia and fibula.

• Short bones are short and cuboid or irregular in shape. The three dimensions

(length, width, and depth) are all about the same. Examples: wrist and ankle bones

(carpal and tarsal).

• Flat bones are protection for the soft body parts. Examples: ribs, sternum,

scapulae, and bones of the pelvis and skull (e.g., temporal, frontal).

• Irregular bones are similar in structure to flat bones, but because of their peculiar

shape they are included in their own classification. Examples: vertebrae, sacrum,

ethmoid, sphenoid, and ear bones of the skull.

• Round bones are small, fiat round sesamoid bones, so named because of their

resemblance to sesame seeds. Because the number of these bones varies greatly

with the individual, only a few are reflected in the total bone count. The function

of round bones is to eliminate or reduce friction. Example: The patella or kneecap

is the largest sesamoid bone of the body and is embedded in the tendon of the

quadriceps femoris muscle at each knee.

Figure 61. CLASSIFICATION OF BONES

351
352
Q8

The purpose of the sesamoid bones is to

Q9

Match the following bones with the appropriate descriptions of their shapes.

1. Femur a. Short

2. Temporal b. Flat

3. Sacrum c. Irregular

4. Carpal d. Round (sesamoid)

5. Patella e. Long

Q10

The consists of both flat and irregular bones.

353
Answer: Q8

The purpose of the sesamoid bones is to eliminate (or reduce) friction.

Answer: Q9

e 1. Femur Long

b 2. Temporal Flat

c 3. Sacrum Irregular

a 4. Carpal Short

d 5. Patella Round (sesamoid)

Answer: Q10

The skull consists of both flat and irregular bones.

354
Figure 62. HAVERSIAN SYSTEM OF THE BONE

ADULT FEMUR

1. Diaphysis (main shaft) 6. Blood vessel (from marrow)

2. Metaphysis (shaft end) 7. Inter-Haversian lamellae

3. Epiphysis (has separate 8. Osteocyte within lacunae

center of bone growth) enlarged to show canaliculi)

4. Compact bone 9. Central canal of Haversian system

5. Medullary cavity (with 10. Periosteum

trabecular, cancellous

spongy bone, and marrow)

355
Structure of Bone

Each long bone of the body is made up of several parts (Figure 62). The main shaft is called

the diaphysis. It provides strong support without undue weight, and consists mainly of compact

bone, 1 although the innermost portion is composed of cancellous2, or spongy, bone. At the ends

of a bone are structures known as epiphyses which are bulbous in shape, allowing ample space for

muscle attachments near joints.

• Short bones consist of a core of cancellous bone encased in a thin layer of compact bone.

• Flat bones are made up of a layer of cancellous bone containing red marrow between two

plates of compact bone.

• Irregular bones are similar in structure to short bones in that they are composed of a thin

layer of compact bone forming a casing over cancellous bone.

• Round (or sesamoid) bones are made of dense fibrous tissue, cartilage, and bone in varying

proportions. They are found embedded in tendons in close relation to articulating surfaces

where they modify pressure and reduce friction.

The outside of the bone is covered by a fibrous membrane, the periosteum. Blood vessels,

lymphatic vessels, and nerves are present in the periosteum and enter the Haversian 3 canals of

the compact bone to become vessels of the Haversian system permeating the entire bone.

The Haversian system is a series of small canals containing blood vessels which bring oxygen

and nutrients to the bone and remove waste products such as carbon dioxide.

Bone Marrow

In the adult there are two types of bone marrow: yellow and red. In the center of the

diaphysis there is a large space called the medullary cavity which is filled with yellow or fatty bone

marrow. Red marrow fills the cancellous spaces in the upper (proximal) epiphyses of the

humerus and femur, the iliac crest, body of the vertebra, bones of the skull (diploe), ribs, sternum,

clavicle, and scapula. Red bone marrow is the source of red cells and granular leukocytes as well

as platelets and monocytes. Marrow is changed from red to yellow by the replacement of myeloid

cells by fat cells, a process which begins soon after birth.

Special lymphocytes, B cells, are formed in the bone marrow. Mature B cells are responsible

for the manufacture of antibodies which circulate in blood or other body fluids and respond to

antigens found on the surface of viruses and bacteria, thus preventing the spread of infection.

1compact bone--continuous dense, hard structure in which spaces can only be distinguished with

the aid of a microscope

2cancellous bone--spongy or lattice-like structure surrounding intercommunicating spaces filled

with bone marrow.

3Haversian--the canal or system named after Clopton Havers (1650-1702) an English anatomist,

who first described the structure of osseous tissue.

356
Qll

Name each of the five numbered parts of the gross structure of the long bone in Figure 62:

1.

2.

3.

4.

5.

Q12

The outer covering of the bone is known as the

Q13

Periosteum contains vessels, vessels, and which enter the

compact bone to become vessels of the system.

Q14

Bone marrow is found in the of long bones and in spaces

of bones.

357
Answer: Qll

The numbered parts of the gross structure of the long bone listed in Figure 62 are:

1. Diaphysis

2. Metaphysis

3. Epiphysis

4. Compact bone

5. Medullary cavity

7. Cancellous (spongy) bone

Answer: Q12

The outer covering of the bone is known as the periosteum.

Answer: Q13

Periosteum contains blood vessels, lymph vessels, and nerves which enter the compact

bone to become vessels of the Haversian system.

Answer: Q14

Bone marrow is found in the medullary _ of long bones and in spaces of cancellous

bones.

358
AXIAL SKELETON

There are a total of eighty bones in the axial skeleton. It is composed of the skull (29 bones), the

thorax (25 bones) and the vertebral column (26 bones).

Bones of the Skull. The skull is the skeleton of the face and head. These bones protect the brain

and related structures. The skull is composed of 29 bones, 8 forming the cranium, 14 forming the

bones of the face, 6 forming the small bones in the middle ear, and 1 hyoid bone.

Cranial bones. The cranial bones are the frontal, occipital, sphenoid, ethmoid, 2 temporal, and

2 parietal bones. They are joined together by suturae 1 and are immovable.

• The frontal bone is located at the front of the skull. It contains the frontal sinuses and forms

the upper rim of the orbit.

• The occipital bone makes up the framework of the lower, posterior part of the skull.

• The sphenoid bone houses the pituitary gland in a depression in its upper surface, the sella

turcica, and forms a part of the roof of the nose with its undersurface. It contains the

sphenoidal sinuses.

• The ethmoid bone is a light, spongy bone located at the base of the cranium, between the

orbits, and at the roof of the nose. It contains the ethmoid air cells (sinuses).

• The temporal bones (2 bones) form part of the sides and part of the base of the skull.

• The parietal bones (2 bones) form the roof and upper part of the sides of the cranium.

Figure 63. CRANIAL BONES

Ptrtet.l . '_ '_ /Llbcr tm_t

o==lpl,.t ', : :i.

lsuturae--fibrous joints in which the apposed bony surfaces are so closely united by a very thin

layer of fibrous connective tissue that no movement can occur.

359
Facial bones. The facial bones are the paired zygomatic, lacrimal, nasal, maxillae, palatine,

conchae, and the unpaired vomer and mandible. All the facial bones except the mandible are joined

together by suturae so that they are immovable.

• The zygomatic/malar bones form the cheek bones and part of the orbit.

• The lacrimal bones are the smallest and most fragile bones of the face. The tear ducts pass

through them in the lacrimal canal.

• The nasal bones support the bridge of the nose.

• The maxillae compose the massive upper jaw bones. Joined by a sutura in the median plane,

they contain the maxillary sinuses. A condition known as cleft palate results when the two

bones do not grow together normally before birth.

• The vomer is a thin, fiat bone which forms the lower portion of the nasal septum.

° The mandible is the lower jaw bone. It is movable for chewing and speaking purposes.

• The palatine bone forms part of the wall and floor of the nasal cavity and part of the roof of

the mouth.

° The conchae (turbinates) are thin bony plates with curved margins which form the lower part

of the lateral wall of the nasal cavity.

Bones of the ear. A chain of three small bones extend across the middle ear on each side: the

malleus, the incus, and the stapes. These bones transmit sound waves from the eardrum membrane

to the fluid of the inner ear.

Figure 64. FACIAL BONES

/"

,:/.°t°.- bo...

i f_"

"3 .t/2

'" I " ". , I

Y

360
Bones of the Thorax. There are 25 bones in the thorax: the sternum, and I2 pairs of ribs.

• Sternum (breast bone) is a flat bone extending down the middle of the chest. It articulates

on the sides with the clavicle and ribs.

° Ribs. There are 12 pairs of ribs.

The first 7 pairs of ribs articulate with the sternum by cartilaginous attachments. These are called

the true ribs.

The last 5 pairs of ribs are called false ribs because they do not join the sternum directly. Instead,

the first 3 (the 8th, 9th, and 10th) have cartilage which converges before the sternum is reached. The

last two are floating ribs which end in the midchest; they are not attached to the sternum at all.

All the ribs are attached to the vertebral column dorsally and form a cage-like structure enclosing

and protecting the heart, lungs, and other thoracic structures.

Vertebral column. The vertebral column is made up of 26 bones.

• Cervical vertebrae (7 bones) constitute the skeleton of the neck.

• Thoracic vertebrae (12 bones) are situated between the cervical and lumbar vertebrae.

They are attached to the 12 pair of ribs and form part of the posterior wall of the thorax.

• Lumbar vertebrae (5 bones) are situated between the thoracic vertebrae and the sacrum.

° The sacrum is formed by 5 vertebrae fused into a triangular-shaped bone in the adult.

• The coccyx (tailbone) is formed by four fused vertebrae.

361
Figure 65. BONES OF THE THORAX Figure 66. VERTEBRAL COLUMN

(frontal view) (sagittal view)

362
Q15

Name the cranial bones:

1.

2.

3.

4.

5.

6.

Q16

Name six facial bones:

1.

2.

3.

4.

5.

6.

363
Q17

Match the bones on the left with the descriptions on the right.

1. Occipital a. Bones which form part of the sides and

part of the base of the skull

2. Hyoid b. Houses the pituitary gland and

sphenoid sinuses

3. Lacrimal c. Framework of lower, posterior part of

the skull

4. Temporal d. The tear ducts pass through them

5. Sphenoid e. Bone of attachment for muscles which

move the tongue

364
Answer: Q15

The cranial bones are:

1. Frontal

2. Occipital

3. Sphenoid

4. Ethmoid

5. Temporal (2 bones)

6. Parietal (2 bones)

Answer: Q16

You might have mentioned any 6 of the following facial bones:

1. Zygomatic

2. Lacrimal

6. Maxillae

4. Nasal

5. Palatine

6. Vomer

7. Mandible

8. Conchae

Answer: Q17

c 1. Occipital Framework of lower, posterior part of the

skull

e 2. Hyoid Bone of attachment for muscles which

move the tongue

d 3. Lacrimal The tear ducts pass through them

a 4. Temporal Bones which form part of the sides and

part of the base of the skull

b 5. Sphenoid Houses the pituitary gland and sphenoid

sinuses

365
Figure 67. APPENDICULAR SKELETON

366
APPENDICULAR SKELETON

The appendicular skeleton is composed of 126 bones.

Upper extremity (32 bones on each side):

• Clavicle: collar bone connects the sternum to the scapula

• Scapula: shoulder blade lies on the upper part of the back

• Humerus: upper arm bone articulates with the scapula at the upper end and with

the ulna and radius at its lower end

• Ulna: medial lower arm bone

• Radius: lateral lower arm bone

• Carpals: wrist bones in 2 rows of 4 bones (total of 8 bones on each hand)

• Metacarpals: bones which form the bony structure of the palm of the hand (total

of 5 bones on each hand)

• Phalanges: bones which form the fingers. Each finger, except the thumb, has 3

phalanges; the thumb has only 2 (total of 14 bones on each hand).

Lower extremity (31 bones on each side)

• Hip bones: ilium, ischium, and pubis form the lateral and anterior walls of the

pelvis

• Femur: thigh bone articulates with the tibia at the distal end

• Patella: kneecap

• Tibia (shin bone): The larger of the two lower leg bones articulates with the femur

at upper end and with the fibula at both upper and lower ends.

• Tarsals: ankle bones, the highest of which articulates with the tibia and fibula (total

of 7 bones on each foot)

• Metatarsals: bones which form the bony structure of the foot (total of 5 bones on

each foot)

• Phalanges (toe bones): Each toe, except the big toe, has 3 phalanges; the big toe

has only 2 (total of 14 bones on each foot).

367
Malignant Tumors

Bone is derived from three cell lines each of which can produce tumors: osteogenic, chondrogenic,

and collagenic 1. Bone also houses the marrow which contains hematopoietic precursors of

myelogenic tumors. All are derived from mesoderm. Only malignant tumors are discussed here.

• Osteogenic Sarcoma (osteosarcoma) is the second most common bone malignancy

after myeloma. It occurs mainly in males between the ages of 10 and 20 years. It

grows rapidly in the long bones of the extremities and metastasizes quickly via the

blood stream to the lungs. It may perforate the periosteum and invade the

surrounding soft tissues.

• Periosteal Sarcoma is a rare, slow-growing malignancy. It arises from periosteal

fibrous tissue. The posterior aspect of the distal femur is the most common site.

• Giant Cell Tumor, Malignant (malignant osteoclastoma) is a tumor which arises

from the connective tissue of the medullary cavity. The malignant type expands

rapidly.

• Chondrosarcoma is a tumor arising from the chondrogenic line. There are two

distinct types of this tumor: peripheral, which develops on the surface of the bone,

and central, which develops in the interior. The peripheral chondrosarcoma tends

to affect fiat bones such as ilium, sacrum, or scapula. The central chondrosarcoma

occurs most often in the femur, tibia, or humerus.

• Ewing's Sarcoma is a highly malignant sarcoma usually occurring in males under 25

years of age. It ismulticentric, originates from the reticulum cell, and usually begins

in the metaphysis or wide part at the extremity of a long bone.

Closely associated with bone tumors are the following soft tissue tumors:

• Fibrosarcoma and Angiosarcoma: Malignant tumors which come from the

connective tissue line. Fibrosarcoma, affecting mainly young adults, causes local

bone destruction, particularly of the long bones. Angiosarcoma is a rare tumor

arising primarily from capillary endothelial cells (vascular tissue within the bone).

Tumors of myelogenic (bone marrow) origin, other than the myeloproliferative disorders, are

malignant, for example:

• Multiple Myeloma: A systemic disease found most often between ages 40 to 60

years. It originates in the reticular stem cell in the marrow spaces of the bone and

is characterized by overproduction of plasma cells by the marrow. It is the most

common bone tumor.

Bone is a common metastatic site for malignant cancer cells which are usually transported by way

of the blood stream. The primary sites from which metastases to bone most often occur are breast,

prostate, lung, colon, stomach, and urinary bladder.

lcollagenic--containing fibrous connective tissue.

368
Q18

Match the descriptions on the left with the terms on the right.

1. A bone which connects the sternum to the scapula a. Carpals

2. The 8 bones of the wrist b. Patella

3. The 5 bones which form the bony structure of the hand c. Hip

4. The kneecap d. Clavicle

5. The smaller of the 2 lower leg bones e. Tarsals

6. The ankle bones f. Metacarpals

7. The ilium, ischium, and pubis g. Femur

8. The bones of the toes h. Humerus

9. The shoulder blade i. Fibula

10. The lateral lower arm j. Scapula

11. The bone which articulates with the tibia at the

distal end k. Phalanges

12. The bones which form the fingers I. Tibia

13. The bones which form the long structure of the foot m. Metatarsals

14. The shin bone n. Radius

15. The upper arm bone o. Ulna

16. The medial lower arm bone p. Long

Q19

Primary malignancies elsewhere in the body frequently metastasize to the bone via the

369
Q20

Sites from which metastases to bone most frequently occur are:

1.

2.

3.

4.

5.

6.

370
Q21

Match each of the tumors on the left with its description on the right.

1. Angiosarcoma a. A tumor composed of both osteogenic and

chondrogenic elements

2. Giant cell tumor b. A rare, slow-growing malignancy arising

from fibrous tissue of the periosteum

3. Osteosarcoma c. A malignant tumor arising in the vascular

tissue within the bone

4. Periosteal sarcoma d. A common bone tumor, second only to

myeloma, which occurs mainly in males

5. Osteochondrosarcoma e. A bone tumor which arises from

connective tissue of the medullary cavity

6. Multiple myeloma f. A highly malignant, multicentric sarcoma

originating from the reticulum cell

7. Ewing's sarcoma g. A systemic disease originating in the

reticular stem cell in the marrow spaces of

the bone

371
Q22

Match the description on the left with 0n¢ of the terms on the right.

1. Outer membrane covering bone tissue a. Epiphysis

2. Flexible, connective tissue found in the b. Diarthrosis

ribs, nasal septum, external ear, joints, c. Fascia

and respiratory tubes of an adult d. Cartilage

. 3. Skull bones: parietal, occipital, frontal, e. Diaphysis

ethmoid, sphenoid, and temporal bones f. Osteocyte

4. Shaft of the long bone g. Tendon

5. Bones found in sternum, pelvis, and ribs; h. Ligament

6. Bone cell i. Haversian system

j. Cranial bones

k. Flat bones

I. Conchae

m. Periosteum

n. Joints

o. Fossa

p. Sulcus

372
Answer: Q18

d 1. A bone which connects the sternum to the scapula Clavicle

a 2. The 8 bones of the wrist Carpals

f 3. The 5 bones which form the bony structure of the hand MOa:arlxdS

b 4. The kneecap Patella

i 5. The smaller of the 2 lower leg bones Fibula

e 6. The ankle bones Tarsals

c 7. The ilium, ischium, and pubis Hip

k 8. The bones of the toes Phalanges

j 9. The shoulder blade Scapula

n 10. The lateral lower arm Radius

g 11. The bone which articulates with the tibia at the distal end Femur

k 12. The bones which form the fingers Phalanges

m 13. The bones which form the long structure of the foot Metatarsals

1 14. The shin bone Tibia

h 15. The upper arm bone Humerus

o 16. The medial lower arm bone Ulna

Answer: Q19

Primary malignancies elsewhere in the body frequently metastasize to the bone via the

blood stream.

Answer: Q20

Sites from which metastases most frequently occur are:

1. Breast

2. Prostate

3. Lung

4. Colon

5. Stomach

6. Urinary bladder

373
Answer: Q21

c 1. Angiosarcoma A malignant tumor arising in the vascular tissue

within the bone

e 2. Giant cell tumor A bone tumor which arises from connective

tissue of the medullary cavity

d 3. Osteosarcoma A common bone tumor, second only to

myeloma, which occurs mainly in males

b 4. Periosteal sarcoma A rare, slow-growing malignancy arising from

fibrous tissue of the periosteum

a 5. Osteochondrosarcoma A tumor composed of both osteogenic and

chondrogenic elements

g 6. Multiple myeloma A systemic disease originating in the reticular

stem cell in the marrow spaces of the bone

f 7. Ewing'ssarcoma A highly malignant, multicentric sarcoma

originating from the reticulum cell

Answer: Q22

m 1. Outer membrane covering bone tissue Periosteum

d 2. Flexible, connective tissue found in the Cartilage

ribs, nasal septum, external ear, joints,

and respiratory tubes of an adult

i 3. Skull bones: parietal, occipital, frontal, Cranial bones

ethmoid, sphenoid, and temporal

bones

e 4. Shaft of the long bone Diaphysis

k 5. Bones found in sternum, pelvis, and Flat bones

ribs; protect soft parts

f 6. Bone cell Osteocyte

374
SECTION L

THE MUSCULAR SYSTEM

375
Figure 68. MUSCLE TYPES

376
SECTION L

THE MUSCULAR SYSTEM

The muscular system is composed of specialized cells called muscle fibers. Their predominant

function is contractibility. Muscles, where attached to bones or internal organs and blood vessels, are

responsible for movement. Internal movement involves the contraction and relaxation of muscles

which are a part of the viscera; external movement is accomplished by the contraction and relaxation

of muscles which are attached to bones.

Muscle Types

In the body are found three types of muscle: skeletal, smooth, and cardiac.

• Skeletal muscle, attached to bones, is responsible for skeletal movements. The

peripheral portion of the central nervous system (CNS) controls the skeletal

muscles. Thus, these muscles are under conscious, or voluntary, control. The basic

unit is the muscle fiber with many nuclei. These muscle fibers are striated (having

transverse streaks) and each acts independently of neighboring muscle fibers.

• Smooth muscle, found in the walls of the hollow internal organs such as blood

vessels, the gastrointestinal tract, bladder, and uterus, is under control of the

autonomic nervous system. Smooth muscle cannot be controlled consciously and

thus acts involuntarily. The nonstriated (smooth) muscle cell is spindle-shaped and

has one central nucleus. Smooth muscle contracts slowly and rhythmically.

• Cardiac muscle, found in the walls of the heart, is also under _ontrol of the

autonomic nervous system. The cardiac muscle cell has one central nucleus, like

smooth muscle, but it also is striated, like skeletal muscle. The cardiac muscle cell

is rectangular in shape. The contraction of cardiac muscle is involuntary, strong,

and rhythmical.

Muscle tissue receives a rich supply of blood which is carried by the arteries into the very

substance of the muscle. Most of the arterioles run parallel with muscle fibers and branch off into

capillaries at right angles into the fibers.

Muscle tumors tend to spread by way of the blood stream rather than to the lymphatics. Lymph

node metastasis does not often occur.

Smooth and cardiac muscle are discussed in more detail with respect to their appropriate systems.

This section explains mainly the skeletal muscular system.

377
Figure 69. HISTOLOGICAL COMPARISONS OF MUSCLE TYPES

SKELETAL MUSCLE

CARDIAC MUSCLE

of the heart Dlo ClLr d I um

SMOOTH MUSCLE :"::: :'". .... ' 4"

__ Lumen of__

small intestine ','_'

;|OjLI MUSCUl ar i_ proprla "_'"

Ctrcut_r [_yer

Lon_Alud |hal tayer

378
Q1

Name the three types of muscle found in the body:

1.

2.

3.

Q2

The two types of muscle that act without voluntary control are and

muscle.

Q3

muscle is under voluntary control.

Q4

Which muscle types are described as striated and which is described as nonstriated muscle?

Q5

The and muscle cells have one nucleus, while the muscle cell

has many nuclei.

379
Answer: Q1

The three types of muscle found in the body are:

1. Skeletal muscle

2. Smooth muscle

3. Cardiac muscle

Answer: Q2

The two types of muscle that act without voluntary control are smooth and cardiac muscle.

Answer: Q3

Skeletal muscle is under voluntary control.

Answer: Q4

Skeletal and cardiac muscle are described as striated while smooth muscle is described as

nonstriated muscle.

Answer: Q5

The smooth and cardiac muscle cells have one nucleus, while the skeletal muscle cell has

many nuclei.

380
Tendons, Fascia, and Ligaments

Each muscle merges into a tendon, a tough nonelastic fibrous band of connective tissue which

attaches to the fibrous covering of bone (the periosteum), so that the action of the muscle will be

transferred to the bone, causing movement of the joint. Perhaps the most well-known is the Achilles

tendon, where the posterior muscles of the calf of the leg merge and attach to the calcaneus (heel)

bone of the foot.

Fascia is a fibrous sheet of connective tissue which covers and separates muscles. It also encloses

the viscera, glands, blood vessels, and nerves. Some fasciae are located superficially under the skin

while other fasciae associated with muscles lie deeper within the body.

Ligaments are fibrous bands of connective tissue which anchor bones together thereby

strengthening and supporting the joints. Ligaments also serve to hold organs in place.

381
382
Q6

["] True ['-'1 False 1. Muscles have a rich blood supply, therefore, malignant

tumors of muscle often invade blood vessels by virtue

of their proximity.

True 1-1 False 2. The periosteum is the outer covering of the bone.

i"'] True F] False 3. The fascia is a tough fibrous band of connective tissue

which attaches to the fibrous covering of the bone.

F] True _ False 4. The force of a muscle contraction is transferred to the

bone by way of the tendon.

True ["7 False 5. Fasciae are associated only with skeletal muscles.

Q7

Match the descriptions on the left with one of the terms on the right.

1. A fibrous cord of connective tissue a. Epiphysis

binding muscle to bone

2. A fibrous sheet of connective tissue b. Diarthrosis

covering and separating muscle

3. Connective tissue binding bones to bones c. Fascia

d. Cartilage

e. Ligament

f. Osteocyte

g. Tendon

383
Answer: Q6

1. True Malignant tumors of muscles often invade blood vessels.

2. True The periosteum is the outer covering of the bone.

3. False Tendons, not fasciae, attach to the fibrous covering of bones.

4. True The force of a muscle contraction is transferred to the bone by

way of the tendon.

5. False Fasciae are associated with all muscles as well as the viscera,

glands, blood vessels, and nerves.

Answer: Q7

g 1. A fibrous cord of connective tissue binding Tendon

muscle to bone

c 2. A fibrous sheet of connective tissue Fascia

covering and separating muscle

e 3. Connective tissue binding bones to bones Ligament

384
Skeletal Muscles

Some of the skeletal muscles are shown in Figure 68. An extensive list of skeletal muscles is

found in your medical dictionary under "muscle." Dorland's dictionary also contains five plates which

show most of the more than 600 muscles of the body. Two prominent groups of muscles which have

been given characteristic names are the hamstrings (lower extremity) and the biceps (upper

extremity).

The five functional characteristics of muscle tissue are:

• Irritability: ability to respond to a stimulus

• Conductivity: ability to transmit impulses

• Extensibility: ability to stretch

• Elasticity: ability to resume former length when the stretching force is removed

• Contractibility: ability to shorten

The three general functions of skeletal muscle are:

• Movement: sometimes locomotion and sometimes movement within a given area

• Heat production: developed by muscle contraction

• Posture: alignment of body parts.

Posture is maintained by a continual pull of muscles on bones in a direction

opposite to the pull of gravity, i.e., by the continual partial contraction of muscles,

known as muscle tone. Therefore, posture is indirectly dependent on many other

factors, such as a normal nervous system and health in general.

The names given to muscles describe one or more of the following features of muscle: action,

direction of fibers, location, number of divisions, shape, and points of attachment to bone. Muscles

may be classified into groups according to the action or movement performed.

• Flexors decrease the angle in a joint.

• Extensors increase the angle in a joint and also return a body part to neutral

position after flexion.

• Abductors move a body part away from the midline.

• Adductors move a body part towards the midline.

• Rotators cause a body part to pivot on its axis.

• Levators/elevators raise a body part.

385
• Supinators turn the palm upward or forward.

• Pronators turn the palm downward or backward.

• Sphincters reduce the size of an opening.

• Tensors make a body part more rigid.

Malignant Tumors

Malignant tumors of muscle tissue are known as sarcomas. Refer to The International

Classification of Diseases for Oncology, Second Edition, (8890-8920), p. 37, for a list of myomatous

(muscle) tumors.

All sarcomas usually present as firm masses in the subcutaneous tissue or deep within or between

muscles. However, there are many different varieties of malignant soft tissue tumors:

• Leiomyosarcoma is a tumor of smooth muscle.

• Rhabdomyosarcoma is a tumor of striated muscle.

• Angiomyosarcoma is a tumor composed of blood vessels and muscular tissue.

Malignant tumors closely associated with muscle tissue:

• Synovial sarcoma is a tumor arising in the tendon sheaths, bursa, and joints.

• Fibrosarcoma is a tumor of fibrous tissue which may arise in association with

striated muscle or fascia.

386
Q8

What are the three general functions of the skeletal muscle?

1.

2.

3.

Q9

How is the posture of the body maintained?

Q10

What are the functional characteristics of muscle tissue?

1.

2.

3.

4.

5.

387
Answer: Q8

The three general functions of skeletal muscle are:

1. Movement

2. Heat production

3. Posture

Answer: Q9

Posture is maintained by continual partial contraction of the muscles.

Answer: Q10

1. Irritability

2. Conductivity

3. Extensibility

4. Elasticity

5. Contractibility

388
Qll

Match the muscle groups on the left with the descriptions on the right.

1. Supinators a. Decrease the angle in a joint

2. Sphincters b. Move a body part away from the midline

3. Abductors c. Lower a body part

4. Flexors d. Turn the palm upward or forward

5. Depressors e. Reduce the size of an opening

Q12

Match each description on the left with one of the terms on the right.

1. Heart muscle, involuntary and a. Fasciae

striated

2. Fibrous sheets of connective b. Visceral muscle

tissue which cover the muscles

3. The hamstring muscles and the c. Leiomyosarcoma

biceps muscles

4. A malignant tumor of smooth d. Striation

muscle

5. A characteristic of skeletal muscle e. Tendons

6. Connective tissue binding muscle f. Rhabdomyosarcoma

to bone

7. Involuntary, visceral muscle g. Cardiac muscle

h. Ligaments

i. Skeletal muscle

j. Angiomyosarcoma

k. Smooth muscle

389
Answer: Q11

Match the muscle groups on the left with the descriptions on the right.

d 1. Supinators turn the palm upward or forward

e 2. Sphincters reduce the size of an opening

b 3. Abductors move a body part away from the midline

a 4. Flexors decrease the angle in a joint

c 5. Depressors lower a body part

Answer: Q12

Match each description on the left with one of the terms on the right.

g 1. Heart muscle, involuntary and Cardiac muscle

striated

a 2. Fibrous sheets of connective Fasciae

tissue which cover the muscles

i 3. The hamstring muscles and the Skeletal muscle

biceps muscles

c 4. A malignant tumor of smooth Leiomyosarcoma

muscle

d 5. A characteristic of skeletal muscle Striation

e 6. Connective tissue binding muscle Tendons

to bone

39O
SECTION M

THE NERVOUS SYSTEM

391
392
SECTION M

THE NERVOUS SYSTEM

The nervous system provides the integration and control of body processes. It is customarily

divided into: 1) the central nervous system which consists of the brain and spinal cord and their

coverings which are called meninges and 2) the peripheral nervous system which consists of the

nerves that connect the brain and spinal cord to the tissues and organs of the body.

Nervous Tissue

Nervous tissue is composed of three types of cells:

• Neuron

The nerve cell (neuron) is the basic structural and functional unit of the nervous

system. Each neuron consists of a cell body which contains a large nucleus

surrounded by cytoplasm and processes called dendrites and axons. These processes

are peculiar to neurons and are responsible for the conduction and transmission of

neural information. Dendrites carry impulses toward the cell body; a single axon

conducts impulses away from the cell body. Axons (nerve fibers) in the peripheral

nervous system may be covered by a myelin sheath and by neurilemma, which is a

membranous sheath that covers the axon directly or covers the myelin sheath when

it is present. Not only does the myelin sheath increase the speed of nerve impulse

conduction, but it insulates and maintains the axon; the neurilemma assists in the

regeneration of injured axons. Nerve tissue of the brain and spinal cord has no

neurilemma, and, thus, it does not regenerate. Instead, the central nervous system

contains neuroglial cells, called oligodendrocytes, which form a myelin covering for

the brain and spinal cord.

• Neuroglia (glial cells)

The neuroglial cells of the nervous system provide the connective tissue which binds

together the neurons in the central nervous system giving support and protection.

They consist of astrocytes, oligodendrites, ependymal cells, and microglial cells.

Most central nervous system (CNS) tumors arise in the neurogliai cells.

• Schwann cells

The Schwann cells form a sheath (neurilemma) covering the axons of peripheral

nerve fibers.

The processes of the neurons (nerve fibers) may serve sensory or motor functions. Sensory nerve

fibers carry messages of sensation and feeling from the tissues and organs to the brain and spinal cord.

Motor nerve fibers carry messages pertaining to movement from the brain and spinal cord t__qotissues

and organs.

393
Figure 70. NERVE CELL (neuron)

394
Q1

The central nervous system is made up of the and the

Q2

The nerves outside the central nervous system comprise the nervous system.

Q3

Match each nerve on the left with its function on the right.

1. Motor nerves a. Carry messages to the brain from the

tissues and organs

2. Sensory nerves b. Carry messages from the brain to the

tissues and organs

Q4

A neurilemma is found only on nerves of the nervous system.

What is the significance of the neurilemma?

Q5

Name the parts of the nerve cell:

1.

2.

3.

4.

5.

395
Answer: Q1

The central nervous system is made up of the brain and the spinal cord.

Answer: Q2

The nerves outside the central nervous system comprise the peripheral nervous system.

Answer: Q3

b 1. Motor nerves Carry messages from the brain to the

tissues and organs

a 2. Sensory nerves Carry messages from the tissues and

organs to the brain

Answer: Q4

A neurilemma is found only on nerves of the peripheral nervous system.

The neurilemma promotes peripheraI nerve fiber regeneration.

Answer: Q5

The names of the parts of the nerve cell are as follows:

1. Dendrites

2. Cell body

3. Axons

4. Myelin sheath

5. Neurilemma

396
CENTRAL NERVOUS SYSTEM

The central nervous system (CNS) consists of the brain (encephalon), spinal cord, and meninges.

Brain

The brain lies within the cranial cavity of the skull. It may be described in terms of three main

subdivisions: forebrain, midbrain, and hindbrain.

Forebrain

The forebrain consists of the cerebrum (telencephalon) and the diencephalon.

• The cerebrum is the largest part of the human brain, and controls, for example,

voluntary muscular activity, speech, thought, memory, vision, taste, and hearing. It is

made up of two cerebral hemispheres. The folds on the surface of the brain are known

as convolutions. The cerebral hemispheres enclose the lateral ventricles (canals in the

interior of the brain filled with cerebrospinal fluid). The two hemispheres are

connected by the corpus callosum. Each hemisphere consists of:

1. The cerebral cortex forms the outer layer. It contains the cell bodies of neurons

often called the "gray matter" of the brain. (The inner "white matter" is made

up of myelinated nerve fibers.)

2. The basal ganglia lie deep within the hemispheres and are responsible for

voluntary muscle movement. Basal ganglia are masses of gray matter.

3. Olfactory bulbs (rhinocephalon) lie on the ventral surface of each cerebral

hemisphere and are associated with the sense of smell (cranial nerve I).

The cerebrum is divided into lobes designated as frontal, temporal, parietal and

occipital (see Figure 71).

° The diencephalon or thalamencephalon connects the cerebral hemispheres with the

midbrain and forms the walls of the third ventricle.

1. The thalamus is an important relay center for sensory fibers on their way to the

cerebral cortex; crude sensation and pain may be registered here.

2. The hypothalamus contains the centers for the autonomic nervous system

controlling sleep, water balance, temperature regulation, and secretions from the

pituitary gland.

3. The epithalamus contains the pineal body (gland).

397
Figure 71. CEREBRUM

CEREBRUM

C_ere_et rum

rsrtebrat

disc

Auto.omlc Front o£ body

ill"lilii

Figure 72. SPINAL CORD

398
Midbrain (mesencephalon)

The midbrain receives impulses from the eye and ear. It serves as a center for v&ual and auditory

reflexes. It also connects the forebrain to the hindbrain. Cranial nerves III and IV stem from the midbrain.

Hindbrain (rhombencephalon)

The hindbrain consists of the pons, the cerebellum, and the medulla oblongata. It surrounds the

fourth ventricle.

• Thepons (pons- bridge) bridges the cerebrum and cerebellum. It contains nerve fibers

which link the cerebral cortex with the medulla oblongata and the spinal cord.

The nuclei of the cranial nerves V, VI, VII, and VIII are situated in the pons.

• The medulla oblongata controls breathing and heartbeat. It consists of neurons which

form the nuclei of the cranial nerves IX, X, XI, and XII.

• The cerebellum has centers which are concerned with balance and equilibrium. The

function of the cerebellum is coordinating groups of muscles to work together smoothly.

Spinal Cord

The spinal cord lies in the vertebral canal of the spinal column and extends from the medulla

oblongata to the lumbar vertebrae. There are 3I pairs of spinal nerves, both motor and sensory. The spinal

cord also serves as a reflex center.

In certain areas of the spinal cord the anterior rami (branches) of the spinal nerves combine to form

networks of nerve fibers called plexuses. These are the cervical (first 4 cervical spinal nerves) branchial (last

4 cervical and first thoracic spinal nerve), lumbar (first 4 lumbar nerves), sacral (fourth and fifth lumbar and

first sacral nerve), pudendal (third and fourth sacral nerves), and coccygeal (fifth sacral and coccygeal nerve)

plexuses.

Meninges

The meninges are comprised of three membranes which surround the brain and spinal cord. The dura

mater is a thick, tough membrane lining the skull. The pia mater is the thin innermost layer which is in

contact with the brain. The arachnoid mater lies between the two; it is a thin covering and contains the

blood vessels.

Cerebrospinal Fluid (CSF)

Cerebrospinal fluid is found in each ventricle and is formed by filtration out of the blood in networks

of capillaries known as choroid plexuses. 1

lchoroid plexus--vascular fringelike folds in the pia mater of the cerebral ventricles.

399
400
PERIPHERAL NERVOUS SYSTEM

The peripheral nervous system (PNS) consists of nerves and ganglia outside the brain and spinal cord.

It (PNS) serves to interconnect all other tissues with the central nervous system.

Peripheral nerves are connected to the spinal cord by two roots: the anterior, ventral, or motor root

and the posterior, dorsal, or sensory root.

Peripheral nervous system innervates all voluntary muscles and transmits the sensory impulses from

the whole body. It is largely under conscious (cerebral) control.

Thus, injury or disease of peripheral nerves usually results in both sensory and motor loss. Because

of the regenerative ability of the neurilemma, however, eventual recovery is possible if the nerve is largely

intact or the ends of the divided nerve are placed close together.

Autonomic Nervous System

The autonomic nervous system is a subdivision of the peripheral nervous system and carries impulses

from the brain and spinal cord to body organs. It controls and regulates largely by involuntary action of the

glands, heart, and smooth muscle tissues (e.g., smooth muscle in the intestines and blood vessel walls).

Autonomic nerves arise at different levels of the central nervous system. The autonomic nerves arising

from the spinal cord comprise the sympathetic (thoracolumbar) and parasympathetic (craniosacral) nervous

system.

Spinal Nerves

There are 31 pairs of spinal nerves: 9 pairs of cervical nerves, 12 pairs of thoracic nerves, 5 pairs of

lumbar nerves, 5 pairs of sacral nerves, and 1 pair of coccygeal nerves. All spinal nerves carry impulses

between the spinal cord and the abdomen, chest, and extremities.

401
Figure 74 CRANIAL NERVES

402
Cranial Nerves

The Cranial nerves carry impulses to or from the brain.

Cranial Nerves Motor Function Sensory_Function

I Olfactory None Smell

II Optic None Sight

III Oculomotor All eye muscles except the

superior oblique and the

external rectus; also

innervates the iris and ciliary

body

IV Trochlear Superior oblique muscle

Eye movement

V Trigeminal Muscles of mastication Sensations from eye, face,

sinuses, and teeth

VI Abducens External rectus muscle

Eye movement

VII Facial Facial muscles, submaxillary Tactile and taste sensations

and sublingual salivary glands from the anterior 2/3's of

tongue and soft palate

VIII Acoustic: None

(2 branches)

Cochlear Hearing

Vestibular Equilibrium/balance

IX Glossopharyngeal Pharyngeal muscles and Tactile and taste sensations

parotid gland from the posterior 1/3 of

tongue, tonsils, pharynx, and

carotid sinuses

X Vagus Pharynx, larynx, heart, lungs, Sensations to the heart, lungs,

bronchi, and digestive tract bronchi, trachea, pharynx,

digestive system, and external

ear

XI Spinal Accessory Sternomastoid, trapezius, and

constrictor muscles of

pharynx, larynx, and soft

palate

XII Hypoglossal Strap muscles of neck and

tongue muscles

4O3
Malignant Tumors

Gliomas are tumors of the neuroglia which comprise the non-nervous, supporting tissue of the brain

derived chiefly from ectoderm. The most frequently occurring types are:

• Astrocytoma arises from glial cells known as astro- (star-shaped) cytes (cells). Glial cells

(neuroglia), which may be either protoplasmic or fibrous, provide the connective tissue

which binds together the neurons of the central nervous system. This tumor generally

occurs in the cerebrum of adults and the cerebellum of children and is the most

common type of glioma.

• Glioblastoma (multiforme) is derived from embryonal astrocytes and is sometimes called

Grade IV astrocytoma. It is the most malignant of all brain tumors and occurs most

frequently in adults arising in the cerebral hemispheres.

• Oligodendroglioma arises from glial cells known as oligo- (small, few) dendro-

(branching) glia. These supporting cells are located as satellites about the nerve cells,

between nerve fibers, and along blood vessels. These tumors occur more commonly in

the cerebral hemispheres of adults.

• Medulloblastoma is composed of undifferentiated neuroepithelial cells. It is one of the

most frequent gliomas of childhood and tends to occur at the midline of the cerebellum;

in young adults it is found more often in the lateral lobes of the cerebellum. These

tumors have a proclivity for intercranial or intraspinal metastases.

• Ependymoma arises from the ependymal cells which line the ventricles of the brain and

the central canal of the spinal cord. It is found most often in the fourth ventricle

occurring in children and young adults.

Nerve Sheath Tumors

• Neurilemmoma (neurinoma, schwannoma) arises from the neur- (nerve) (e)ilemma

(covering) which is the thin membrane covering the peripheral nerves, also called the

sheath of Schwann. These tumors are usually benign, but may occasionally occur in a

malignant form. In the cranial cavity, they frequently arise at the root of the VIIIth

nerve (cerebellopontine angle) and are called acoustic neuromas.

• Neurofibrosarcoma is composed of interlacing bundles of anaplastic spindle-shaped cells

which resemble those of nerve sheaths.

Neuroepitheliomatous Neoplasms

• Neuroblastoma is derived from embryonic nerve tissue (neuroblasts) arising primarily

in the autonomic nervous system and adrenal medulla, but not in the brain or spinal

cord.

• Meningiomas arise in the meninges, the membranes that envelop the brain and spinal

cord: the dura mater, pia mater, and arachnoid. These are slow growing tumors and

are most always benign. They are rare in children.

,,04
Benign Tumors

Benign tumors of the brain, while not invasive, do consume space and press upon vital tissues. These

tumors are, thereby, potentially lethal, although they do allow for more prolonged survival than do malignant

brain tumors. Consequently, cancer registries generally collect information on benign brain tumors as well

as malignant brain tumors.

Some benign tumors are collected because they arise in the cranial vault, although they are not central

nervous system (CNS) tumors.

• Hemangioblastoma is a hemangioma of the brain derived from blood vessel-forming

cells (angioblasts).

• Craniopharyngioma is a tumor arising from embryonic cells of the craniopharyngeal

canal (Rathke's pouch) and involving the pituitary gland. The tumor usually occurs in

children.

• Chromophobe Adenoma is a benign tumor of the anterior pituitary gland. It is

associated with hypopituitarism and occurs mainly in adults.

405
406
Q6

Match each term on the left with one of the descriptions on the right.

1. Astrocytoma a. Tumor of the membranes surrounding the brain and spinal

cord

2. Neuroglia b. The most common malignant brain tumor

3. Medulloblastoma c. The most malignant of all brain tumors

m 4. Meningioma d. Non-nervous tissue which supports the nerve cells

5. Glioblastoma e. Tumor of the brain which is most common in the

cerebellum of children.

Q7

Which of the following are nerves of the autonomic nervous system?

1"-7 a. Sympathetic nerves

!"-] b. Spinal nerves

!"7 c. Cranial nerves

407
Answer: Q6

Match each term on the left with one of the descriptions on the right.

b 1. Astrocytoma The most common malignant brain tumor

d 2. Neuroglia Non-nervous tissue which supports the nerve cells

e 3. Medulloblastoma Tumor of the brain which is most common in the

cerebellum of children.

a 4. Meningioma Tumor of the membranes surrounding the brain

and spinal cord

c 5. Glioblastoma The most malignant of all brain tumors

Answer: Q7

The sympathetic nerves are nerves of the autonomic nervous system.

408
SECTION N

SENSORY ORGANS

409
410
SECTION N

SENSORY ORGANS

There are five major senses of the body: vision, taste, smell, hearing, and touch. The body,

however, has literally millions of sensory organs (or receptors), each associated with one or more

nerves whose function is to convert the energy of a stimulus into a sensation or reflex. Receptors

detect changes in our external and internal environment and initiate the responses necessary for

adjusting the body to these changes. It is the dendrite portion of the sensory neuron which serves

as the receptor of a sense organ.

Receptors may be classified according to their locations as follows:

Exteroceptors are surface receptors. They are located in the skin, mucosa, eye, and ear.

Visceroceptors (interoceptors) are located in the walls of the blood vessels in the stomach,

intestines, and various other organs.

Proprioceptors are located in muscles, tendons, joints, and the internal ear.

In this section, we will not cover all the body senses. Rather, the discussion will be restricted to

four of the major senses: vision, taste, smell, and hearing.

411
412
Q1

What are the five major senses of the body?

1.

2.

3.

4.

5.

Q2

Match the receptors on the left with a location on the right.

Receptors Location

1. Exteroceptors a. Located in the walls of blood vessels in the stomach,

intestines, and other organs

2. Proprioceptors h. Located in the skin, mucosa, eye, and ear

3. Visceroceptors c. Located in the muscles, tendons, joints, and the

internal ear

413
Answer: Q1

The five major senses of the body are:

1. Vision

2. Hearing

3. Taste

4. Smell

5. Touch

Answer: Q2

b 1. Exteroceptors Located in the skin, mucosa, eye, and ear

c 2. Proprioceptors Located in the muscles, tendons, joints,

and the internal ear

a 3. Visceroceptors Located in the walls of blood vessels in the

stomach, intestines, and other organs

414
The Sense of Vision (Eye)

The eye is set in a bony socket, the orbit. The visible portion of the eye is covered by a thin

transparent membrane called the coniunctiva 1.

The eyeball is not a solid sphere. It contains a large interior cavity that is divided into two parts,

the anterior and posterior cavities. The anterior cavity, in turn, has two subdivisions known as the

anterior chamber and the posterior chamber. Most of the eyeball (Figure 76) is recessed in the orbit,

protected by the walls of this bony cavity. The wall of the eyeball is composed of three layers; from

the outside to the inside, they are the sclera, the choroid, and the retina.

. The sclera, composed of tough fibrous tissue, is the protective and supportive layer of the

eye. The anterior portion of the sclera, called the cornea, lies over the colored part of the

eye (iris) and the pupil. The cornea is transparent and allows passage of light.

o The middle or choroid layer (the pigmented vascular coat) of the eye contains a great many

blood vessels. The iris, the colored muscular ring, controls the size of the pupil and the

amount of light entering the eye. The anterior portion is modified to form the ciliary body,

the main part of which is ciliary muscle. Its function is the adjustment of the lens of the

eye for vision at different distances. The crystalline lens is suspended from the inner

surface of the ciliary body by circular ligaments called the suspensory ligaments. The

function of the lens is to bend light rays in order to focus an image on the retina.

° The retina is the innermost layer of the eye. It is composed of two sections: the outer is

pigmented and attached to the choroid layer, and the inner is composed of nervous tissue.

The retina is the light sensitive layer.

Figure 75. EYE

Pog ter Lot chamber

................ v,,,-,,.,,, boa,

Eye muscle Choro i.d

lconjunctiva--mucous membrane covering the anterior portion of the eyeball, and lining the

eyelids.

415
416
Q3

What are the three layers which compose the wall of the eyeball?

1.

2.

3.

Q4

The retina is composed of tissue.

417
Answer: Q3

The three layers which compose the wall of the eyeball are:

1. Sclera

2. Choroid

3. Retina

Answer: Q4

The retina is composed mainly of nervous tissue.

418
The accessory structures of the eye include the eyebrow, eyelashes, and eyelid. The eyebrow and

eyelashes serve a protective function. The eyelid is lined with mucous membrane (called conjunctiva)

which continues over the surface of the eyeball. The corner where the upper and lower eyelids join

is called the canthus, the medial canthus being on the innerside, the internal (temporal) canthus being

on the outer side. The lacrimal apparatus consists of four structures: the lacrimal glands, lacrimal

ducts, lacrimal sac, and nasolacrimal duct. These structures perform the functions of secreting and

draining tears on the surface of the eyeball (Figures 76 and 77).

Figure 76. EYEBALL (sagittal view) Figure 77. EYEBALL (frontal view)

°.

Canthllt _. * i/ed[¢lL (n¢iCL) T,!spore][

c6nthua cant bus

- , LacrJLelat ILnnds

"_";:'_'_-)"'_ ":_" i_xcretory ductl

L_c rlm_t Ila.C '_ "

anti

LagrLmaL ducte

Co nJ uric t I va

Na soLae r I ran J_'_J]

Figure 78. LACRIMAL APPARATUS

419
420
Q5

The eyeball is/is not a solid sphere. It is divided into two large

Q6

The corner where the upper and lower eyelids meet is called the

Q7

The apparatus performs the function of secreting tears.

421
Answer: Q5

The eyeball/s not a solid sphere. It is divided into two large cavities.

Answer: Q6

The corner where the upper and lower eyelids meet is called the canthus.

Answer: Q7

The lacrimal apparatus performs the function of secreting tears.

422
Regional Lymph Nodes

Much of the eye does not have true lymphatics, i.e., cornea, sclera, uveal tract, lens, retina, and

orbit. The conjunctiva and the eyelid are drained by the submandibular, preauricular and infraauricular (parotid) and cervical lymph nodes.

Malignant Tumors

• Malignant melanoma is the most common intraocular tumor.

• Retinoblastoma, a tumor arising from the retinal germ cells, is the most common

intraocular neoplasm in children.

• Epidermoid carcinoma may arise from conjunctiva.

Figure 79. LYMPHATIC DRAINAGE OF THE HEAD (sensory organs)

423
424
Q8

Name the lymph nodes which drain each of the following areas of the eye:

1. Cornea, sclera, and lens:

2. Eyelid: , , and

Q9

The most common malignancy of the eye is

Q10

The most common eye malignancy in children is

425
Answer: Q8

Name the lymph nodes which drain each of the following areas of the eye:

1. Cornea, sclera, and lens: no true lymphatics

2. Eyelid: submandibular, preauricular (parotid), and cervical.

Answer: Q9

The most common malignancy of the eye is malignant melanoma.

Answer: Q10

The most common eye malignancy in children is retinoblastoma.

426
The Sense of Taste (Gustatory Sense Organ)

Receptors for the sense of taste are known as taste buds. These are located on the tongue, palate,

pharynx, and epiglottis. They are most numerous on the tongue. Different taste receptors are

stimulated by different kinds of substances. There are separate taste buds for sweet, sour, bitter, and

salt substances (see Figure 80). All other qualities of experienced taste are a result of the fusion of

two or more of the four primary tastes and as a result of the stimulation of the olfactory receptors.

Therefore, the numerous tastes recognized are not taste alone but taste plus odors.

The four kinds of taste buds or corpuscles are not evenly distributed over the tongue. Most of

those sensitive to bitter are located at the back of the tongue, those sensitive to sweet at the tip, and

those sensitive to salt and sour along the sides and tip. (Refer to the Digestive System for the

anatomy of the tongue.)

Regional Lymph Nodes

The regional lymph nodes are submandibular (submaxillary), submental and internal jugular (upper

and lower deep cervical): jugulodigastric and jugulo-omohyoid.

Malignant Tumors

Malignant lesions are more common on the anterior two-thirds than on the posterior one-third

of the tongue. Squamous cell carcinomas constitute 90 percent of all malignant tumors of the tongue.

The other 10 percent are made up primarily of lymphoepitheliomas and lymphosarcomas.

Lymphosarcomas will arise in the lymphoid tissue (lingual tonsil) found at the base of the tongue.

427
Figure 80. TONGUE: Areas of taste

!

UvuLa

!

428
Qll

Receptors for the sense of taste called are most

numerous in the

Q12

Separate receptors sense the tastes of , , , and

; but all other qualities of taste are a result of a fusion of two or more primary

tastes and the stimulation of the

429
Answer: Qll

Receptors for the sense of taste called taste buds are most numerous in the tongue.

Answer: Q12

Separate receptors sense the taste of sweet, sour, bitter, and salt, but all other qualities of

taste are a result of a fusion of two or more primary tastes and the stimulation of the

olfactory receptors.

_0
The Sense of Smell (Olfactory Sensory Organs)

The receptors for the sense of smell lie in the mucosa of the upper part of the nasal cavity. These

receptors respond to chemical stimuli. Their location explains the necessity for sniffing or draining

air forcibly into the nose in order to smell delicate odors. The olfactory sensory organs consist of hair

cells which are extremely sensitive to stimulation by even very slight odors. However, they are also

easily fatigued. This explains why odors that are at first very noticeable are not sensed at all after

a short time.

The term "nasal fossa" is the name for the entire nasal chamber. This chamber is divided

physiologically into:

• A lower or respiratory portion of the nasal fossa

• An upper or olfactory portion of the nasal fossa. The term "nasal cavity" most properly

belongs to this upper portion of the nasal fossa.

Regional Lymph Nodes

The regional lymph nodes are the submental, submandibular (submaxillary), and internal jugular

(upper and lower deep cervical) nodes: jugulodigastric and jugulo-omohyoid, and the

retropharyngeal.

Figure 81. NOSE: Olfactory receptors

]. IactorY

nerve ( bu].b )

431
Malignant Tumors

Tumors of the nasal fossa are rare. The most common type is squamous cell (epidermoid)

carcinoma. Other types which occur less frequently are:

• Adenocarcinoma

• Adenoid cystic

• Melanoma

• Lymphoma

A malignant tumor known as esthesioneuroblastoma or esthesioneuroepithelioma, which arises in

the olfactory nerve, will be found occasionally in the nasal cavities.

432
Q13

The nasal fossa is divided into a lower or portion and an upper or

portion.

Q14

The receptors for the sense of smell lie in the mucosa of the part of

the cavity.

Q15

The most common type of tumor in the nasal cavities is

433
Answer: Q13

The nasal fossa is divided into a lower or respiratory portion and an upper or olfactory

portion.

Answer: Q14

The receptors for the sense of smell lie in the mucosa of the upper part of the nasal cavity.

Answer: Q15

The most common type of tumor in the nasal cavities is squamous cell carcinoma.

434
The Sense of Hearing (Ear)

The organ for hearing (see Figure 82) consists of three main parts: the external ear, the middle

ear, and the inner ear.

• The external ear is made up of the pinna (or auricle) and the auditory canal. The pinna

(pinna-wing) is made up of cartilage covered by skin. It collects the sound which is

transmitted through the external auditory canal, leading to the tympanic membrane (or

eardrum).

• The middle ear lies in a cavity in the temporal bone and is separated from the external ear

by the tympanic membrane which transmits sounds to the internal ear. The middle ear is

connected with the nasopharynx by the Eustachian tube. The function of the Eustachian

tube is to equalize pressure on the eardrum. It opens when yawning or swallowing takes

place.

• The inner ear is comprised of membranous tissue contained within a bony structure. The

bony labyrinth has three divisions: the vestibule and two extensions of the vestibule called

the cochlea and the semicircular canals. The cochlea is a spiral canal containing a receptor

for hearing called th_ Organ of Corti. It has hair cells which pick up impulses transmitted

from the inner ear.

The semicircular canals form the organ of balance. The superior, posterior, and lateral

semicircular canals each connect by an ampulla (jug) to the utricle (a small sac), from which impulses

travel to the brain by the vestibular branch of the VIIIth cranial nerve.

Figure 82. EAR: Coronal section

[ / Te,,,por,,1, bone

.,>);

 xte,-..l e.," t!i, /"l' dte ..r/ l.-,,*"

V / co¢ ht oa .,

_(_'_YIlIth crenl&L nerve

,, .z Euste_chtan tube

435
Regional Lymph Nodes

The lymphatics of the external and middle ear drain to parotid (preauricular) lymph nodes. The

middle ear lymphatics, in addition, drain to retropharyngeal nodes. Lymphatics from both parts of

the ear go directly or indirectly to the internal jugular (upper and lower deep cervical) nodes. The

inner ear has no lymphatics.

Benign Tumors

Acoustic neuroma, a benign tumor of the auditory nerve, is the most common tumor of the ear.

436
Q16

Match the parts of the ear on the left with the descriptions on the right.

1. External ear a. Contains the receptors for hearing

2. Middle ear b. Made up of the auricle and the

auditory canal

3. Inner ear c. Contains the opening from the

Eustachian tube

437
Answer: Q16

b 1. External ear Made up of the auricle and the

auditory canal

c 2. Middle ear Contains the opening from the

Eustachian tube

a 3. Inner ear Contains the receptors for hearing

438
APPENDIX A

HISTOLOGIC TYPE/PRIMARY SITE

439
440
APPENDIX A: HISTOLOGIC TYPE/PRIMARY SITE

HISTOLOGIC TYPE PRIMARY SITE

Squamous cell carcinoma Oral and nasal cavities

Pharynx and larynx

Trachea, bronchus, and lung

Esophagus

Cervix, vagina, and vulva

Anus and penis

Skin

Adenocarcinoma Stomach

Small intestine

Colon and rectum

Pancreas and gallbladder

Endometrium and endocervix

Breast

Prostate

Transitional cell carcinoma Bladder and urethra

Renal pelvis and ureters

Hepatoma Liver

Liver cell carcinoma

Cholangiocarcinoma Bile ducts (intrahepatic and extrahepatic)

Hypernephroma Kidney parenchyma

Renal cell carcinoma

Wilms' Tumor

Seminoma Testis

Dysgerminoma Ovary

Cystadenocarcinoma

Granulosa/theca cell carcinoma

Liposarcoma Adipose soft tissue

Fibrosarcoma Fibrous soft tissue

Leiomyosarcoma Smooth muscle, muscularis of organ walls

Rhabdomyosarcoma Striated muscle, skeletal muscle

Mesothelial sarcoma Pleura and peritoneum

Osteogenic sarcoma Bone

Ewing's sarcoma

Chondrosarcoma Cartilage

Lymphosarcoma Lymph nodes and other aggregates of

Malignant lymphoma lymphoid tissue

Hodgkin's disease

Reticulum cell sarcoma

Lymphangiosarcoma Lymph vessels

Hemangiosarcoma Blood vessels

441
HISTOLOGIC TYPE PRIMARY SITE

Leukemias Bone marrow

Multiple myeloma

Astrocytoma Brain

Glioblastoma multiforme

Medulloblastoma

Melanoma Skin

Eye

442
APPENDIX B

RULES FOR DETERMINING MULTIPLE PRIMARIES FOR LYMPHATIC AND

HEMATOPOIETIC DISEASES

443
444
APPENDIX B

RULES FOR DETERMINING MULTIPLE PRIMARIES FOR LYMPHATIC AND

HEMATOPOIETIC DISEASES

The table on pages 446-468 is to be used to help determine multiple primaries of the lymphatic and

hematopoietic diseases. Because of the rarity of subacute leukemias and aleukemias, they have been

excluded from this table. Similarly, malignant myeloproliferative and immunoproliferative diseases,

except Waldenstrom's macroglobulinemia, are not included.

RULES:

1. No topography (site) is to be considered in determining multiple primaries of lymphatic and

hematopoietie diseases.

2. The interval between diagnoses is NOT to enter into the decision.

Example: A lymphocytic lymphoma (M-9670/3) diagnosed in March, 1987 and an unspecified

non-Hodgkin's lymphoma (M-9590/3) diagnosed in April, 1988 would be considered one primary,

a lymphocytic iymphoma diagnosed in March, 1987 (the earlier diagnosis).

To use this table locate the first diagnosis in the left column of the table, then locate the second

diagnosis in the other columns. If the second primary appears in the middle column, the diagnoses

are usually considered two separate primaries. If the second diagnosis appears in the right hand

column, then the two diagnoses are usually considered one primary. Select the disease men- tioned

in the first column unless there is an indication in the right hand column to do otherwise. If the

pathology report specifically states differently, use the pathology report. Consult your medical advisor

or pathologist if questions remain.

For example,

1) a. first diagnosis: small cleaved cell, diffuse lymphoma

b. second diagnosis: Hodgkin's disease, mixed cellularity

This case would be considered two primaries.

2) a. first diagnosis: small cleaved cell, diffuse lymphoma

b. second diagnosis: acute lymphocytic leukemia

This case would be considered one primary.

445
DETERMINATION OF SUBSEQUENT PRIMARIES OF

LYMPHATIC (NODAL AND EXTRANODAL) AND HEMATOPOIETIC DISEASES

First Primary Presumably a Second Presumably NOT a

Primary Subsequent Primary

_onl_, One Primal)

Hodgkin's disease Non-Hodgkin's lymphoma Hodgkin's disease 1

(9650-9667) (9591-9595, 9670-9686, (9650-9667)

9690-9698, 9702-9714)

Malignant lymphoma, NOS

Burkitt's lymphoma (9687) (9590)

Mycosis fungoides or

Sezary's disease (9700-9701)

Malignant histiocytosis or

Letterer-Siwe's disease

(9720, 9722)

True histiocytic lymphoma

(9723)

Plasmacytoma or multiple

myeloma (9731, 9732)

Mast cell tumor

(9740-9741)

Waldenstrom's

macroglobulinemia (9761)

Any leukemia (9800-9941)

1Code to the term with the higher histology code.

446
DETERMINATION OF SUBSEQUENT PRIMARIES OF

LYMPItATIC (NODAL AND EXTRANODAL) AND HEMATOPOIETIC DISEASES

First Primary Presumably a Second Presumably NOT a

Subsequent Primary Subsequent Primary

(only One Primary)

Malignant lymphoma, NOS 1 Burkitt's lymphoma (9687) Non-Hodgkin's

(9590) lymphoma 2 (9590-9595,

Mycosis fungoides or 9670-9686, 9690-9698,

Sezary's disease (9700, 9702-9714)

9701)

Hodgkin's disease 2

Malignant histiocytosis or (9650-9667)

Letterer-Siwe's disease

(9720, 9722) True histiocytic lymphoma

(9723)

Mast cell tumor (9740,

9741) Plasmacytoma 2 or

multiple myeloma (9731,

Acute leukemia, NOS 9732)

(9801)

Leukemia, NOS (9800)

Non-lymphocytic leukemias

(9840-9842, 9860-9910) Chronic leukemia, NOS

(9803)

Myeloid sarcoma (9930)

Lymphoid or lymphocytic

Acute panmyelosis (9931) leukemia (9820-9827)

Acute rnyelofibrosis (9932) Plasma cell leukemia

(9830)

Hairy cell leukemia (9940)

Lymphosarcoma cell

Leukemic leukemia (9850)

reticuloendotheliosis (9941)

Waldenstrom's

macroglobulinemia (9761)

1If the diagnosis includes "can't rule out leukemia" or "consistent with chronic lymphocytic

leukemia," and a bone marrow or peripheral blood study within two months confirms the chronic

lymphocytic leukemia diagnosis; then code only to chronic lymphocytic leukemia (9823/3). If not

confirmed as chronic lymphocytic leukemia, then code as the lymphoma.

2presumably this is the correct diagnosis. Code the case to this histology.

447
DETERMINATION OF SUBSEQUENT PRIMARIES OF

LYMPHATIC (NODAL AND EXTRANODAL) AND HEMATOPOIETIC DISEASES

First Primary Presumably a Second Presumably NOT a

Subsequent Primary Subsequent Primary

(only One Primary)

Non-Hodgkin's Hodgkin's disease Non-Hodgkin's lymphoma z

lymphoma 1 (9591-9595, (9650-9667) (9590-9595, 9670-9686,

9670-9686, 9690-9698, 9711- 9690-9698, 9702-9714)

9714) Burkitt's lymphoma (9687)

Plasmacytoma 3 or

Mycosis fungoides or multiple myeloma (9731,

Sezary's disease (9700, 9732)

9701)

True histiocytic lymphoma

Malignant histiocytosis or (9723)

Letterer-Siwe's disease

(9720, 9722) Leukemia, NOS (9800)

Mast cell tumor Chronic leukemia, NOS

(9740-9741) (9803)

Acute leukemia, NOS Lymphoid or lymphocytic

(9801) leukemia (9820-9827)

Non-lymphocytic leukemias Plasma cell leukemia

(9840-9842, 9860-9910) (9830)

Myeloid sarcoma (9930) Lymphosarcoma cell

leukemia (9850)

Acute panmyelosis (9931)

Waldenstrom's

Acute myelofibrosis (9932) macroglobulinemia (9761)

Hairy cell leukemia (9940)

Leukemic

reticuloendotheliosis (9941)

1If the diagnosis includes "can't rule out leukemia" or "consistent with chronic lymphocytic

leukemia," and a bone marrow or peripheral blood study within two months confirms the chronic

lymphocytic leukemia diagnosis; then code only to chronic lymphocytic leukemia (9823/3). If not

confirmed as chronic lymphocytic leukemia, then code as the lymphoma.

2Code to the term with the higher histology code.

3presumably this is the correct diagnosis. Code the case to this histology.

448
DETERMINATION OF SUBSEQUENT PRIMARIES OF

LYMPHATIC (NODAL AND EXTRANODAL) AND HEMATOPOIETIC DISEASES

First Primary Presumably a Second Presumably NOT a

Subsequent Primary Subsequent Primary

(only One Primary)

Burkitt's lymphoma (9687) Specific non-Hodgkin's Malignant lymphoma, NOS

lymphoma (9593-9594, (9590-9591, 9595)

9670-9686, 9690-9698,

9702-9714) Lymphosarcoma (9592)

Hodgkin's disease Burkitt's lymphoma (9687)

(9650-9667)

Burkitt's leukemia

Mycosis fungoides or (9826)

Sezary's disease (9700,

9701) Lymphoid or lymphocytic

leukemia (9820-9822, 9824-

Malignant histiocytosis or 9825, 9827)

Letterer-Siwe's disease

(9720, 9722)

Plasmacytoma or multiple

myeloma (9731, 9732)

True histiocytic lymphoma

(9723)

Mast cell tumor (9740,

9741)

Waldenstrom's

macroglobulinemia (9761)

Leukemia, NOS (9800)

Acute leukemia, NOS

(9801)

Chronic leukemia, NOS

(9803)

Chronic lymphocytic

leukemia (9823)

Non-lymphocytic leukemias

(9840-9842, 9860-9910)

449
DETERMINATION OF SUBSEQUENT PRIMARIES OF

LYMPHATIC (NODAL AND EXTRANODAL) AND HEMATOPOIETIC DISEASES

First Primary Presumably a Second Presumably NOT a

Subsequent Primary Subsequent Primary

(only One Primal)

Burkitt's lymphoma (9687) Plasma cell leukemia

(cont'd) (9830)

Lymphosarcoma cell

leukemia (9850)

Myeloid sarcoma (9930)

Acute panmyelosis (9931)

Acute myelofibrosis (9932)

Hairy cell leukemia (9940)

Leukemic

reticuloendotheliosis (9941)

450
DETERMINATION OF SUBSEQUENT PRIMARIES OF

LYMPHATIC (NODAL AND EXTRANODAL) AND HEMATOPOIETIC DISEASES

First Primary Presumably a Second Presumably NOT a

Subsequent Primary Subsequent Primary

(only One Primary)

Cutaneous and peripheral Specific non-Hodgkin's Malignant lymphoma, NOS

T-cell lymphomas lymphoma (9593-9594, (9590-9591, 9595)

(9700-9709) 9670-9687, 9690-9698, 9711-

9714) Lymphosarcoma (9592)

Hodgkin's disease Cutaneous and peripheral

(9650-9667) T-cell lymphomas

(9700-9709)

Malignant histiocytosis or

Letterer-Siwe's disease Leukemia, NOS (9800)

(9720, 9722)

Acute leukemia, NOS

True histiocytic lymphoma (9801)

(9723)

Chronic leukemia, NOS

Plasmacytoma or multiple (9803)

myeloma (9731, 9732)

Lymphoid or lymphocytic

Mast cell tumor (9740, leukemia unless specifically

9741) identified as B-cell

(9820-9827)

Waldenstrom's

macroglobulinemia (9761)

Lymphoid or lymphocytic

leukemia specified as B-cell

(9820-9827)

Plasma ceil leukemia

(9830)

Non-lymphocytic leukemia

(9840-9842, 9860-9910)

Lymphosarcoma cell

leukemia (9850)

Myeloid sarcoma (9930)

Acute panmyelosis (9931)

Acute myelofibrosis (9932)

451
DETERMINATION OF SUBSEQUENT PRIMARIES OF

LYMPHATIC (NODAL AND EXTRANODAL) AND HEMATOPOIETIC DISEASES

First Primary Presumably a Second Presumably NOT a

Subsequent Primary Subsequent Primary

(only One Primary)

Cutaneous and peripheral Hairy cell leukemia (9940)

T-cell lymphomas

(9700-9709) (cont'd) Leukemic

reticuloendotheliosis (9941)

452
DETERMINATION OF SUBSEQUENT PRIMARIES OF

LYMPHATIC (NODAL AND EXTRANODAL) AND HEMATOPOIETIC DISEASES

First Primary Presumably a Second Presumably NOT a

Subsequent Primary Subsequent Primary

(only One Primary)

Malignant histiocytosis or Specific non-Hodgkin's Non-Hodgkin's lymphoma,

Letterer-Siwe's disease lymphoma (9592-9594, NOS (9590-9591, 9595)

(9720, 9722, 9723) 9670-9686, 9690-9698,

9702-9714) Malignant histiocytosis or

Letterer-Siwe's disease

Hodgkin's disease (9720, 9722, 9723)

(9650-9667)

Hairy cell leukemia (9940)

Burkitt's lymphoma (9687)

Leukemic

Mycosis fungoides or reticuloendotheliosis (9941)

Sezary's disease (9700,

9701)

Plasmacytoma or multiple

myeloma (9731, 9732)

Mast cell tumor (9740,

9741)

Waldenstrom's

macroglobulinemia (9761)

Leukemia except hairy cell

and leukemic

reticuloendotheliosis

(9800-9932)

453
DETERMINATION OF SUBSEQUENT PRIMARIES OF

LYMPHATIC(NODAL AND EXTRANODAL) AND HEMATOPOIETIC DISEASES

First Primary Presumably a Second Presumably NOT a

Subsequent Primary Subsequent Primary

(only One Primary)

Plasmacytoma or multiple Non-Hodgkin's lymphoma Malignant lymphoma, NOS

myeloma (9731, 9732) except immunoblastic or (9590, 9591, 9595)

large-cell lymphoma

(9592-9594, 9670, Immunoblastic or large cell

9672-9677, 9683, 9685-9686, lymphoma 1 (9671,

9690-9697, 9702-9713) 9680-9682, 9684, 9698,

9714)

Hodgkin's disease

(9650-9667) Plasmacytoma or multiple

myeloma (9731, 9732)

Burkitt's lymphoma (9687)

Waldenstrom's

Mycosis fungoides or macroglobulinemia (9761)

Sezary's disease (9700,

9701) Plasma cell leukemia

(9830)

Malignant histiocytosis or

Letterer-Siwe's disease

(9720, 9722)

True histiocytic lymphoma

(9723)

Mast cell tumor (9740,

9741)

Leukemia except plasma

cell (9800-9827, 9840-9941)

Occasionally multiple myeloma develops an immunoblastic or large cell lymphoma phase. This

is to be considered one primary, multiple myeloma. Consult your medical advisor or pathologist

if questions remain.

454
DETERMINATION OF SUBSEQUENT PRIMARIES OF

LYMPHATIC (NODAL AND EXTRANODAL) AND HEMATOPOIETIC DISEASES

First Primary Presumably a Second Presumably NOT a

Subsequent Primary Subsequent Primary

(only One Primary)

Mast cell tumor (9740, Non-Hodgkin's lymphoma Mast cell' tumor (9740,

9741) (9590-9595, 9670-9687, 9741)

9690-9698, 9702-9714)

Leukemia, NOS (9800)

Hodgkin's disease

(9650-9667) Acute leukemia, NOS

(9801)

Mycosis fungoides or

Sezary's disease (9700, Chronic leukemia, NOS

9701) (9803)

Malignant histiocytosis or Monocytic leukemia

Letterer-Siwe's disease (9890-9894)

(9720, 9722)

Mast cell leukemia (9900)

True histiocytic lymphoma

(9723)

Plasmacytoma or multiple

myeloma (9731, 9732)

Waldenstrom's

macroglobulinemia (9761)

Chronic lymphocytic

leukemia (9823)

Plasma cell leukemia

(9830)

Non-lymphocytic leukemias

(9840-9842, 9860-9880,

9910)

Lymphosarcoma cell

leukemia (9850)

Myeloid sarcoma (9930)

Acute panmyelosis (9931)

455
DETERMINATION OF SUBSEQUENT PRIMARIES OF

LYMPHATIC(NODAL AND EXTRANODAL) AND HEMATOPOIETIC DISEASES

First Primary Presumably a Second Presumably NOT a

Subsequent Primary Subsequent Primary

(only One Primary)

Mast cell tumor (9740, Acute myelofibrosis (9932)

9741) (cont'd)

Hairy cell Leukemia (9940)

Leukemic

reticuloendotheliosis

9941)

456
DETERMINATION OF SUBSEQUENT PRIMARIES OF

LYMPHATIC (NODAL AND EXTRANODAL) AND HEMATOPOIETIC DISEASES

First Primary Presumably a Second Presumably NOT a

Subsequent Primary Subsequent Primary

(only One Primary)

Waldenstrom's Non-Hodgkin's lymphoma Malignant lymphoma, NOS

macroglobulinemia (9761) except immunoblastic or (9590, 9591, 9595)

large cell lymphoma

(9593-9594, 9673-9677, Lymphosarcoma (9592)

9683, 9685-9686, 9690-9697,

9702-9713) Immunoblastic or large cell

lymphoma (9671,

Hodgkin's disease 9680-9682, 9684, 9698,

(9650-9667) 9714)

Burkitt's lymphoma (9687) Malignant lymphoma,

lymphocytic (9670, 9672)

Mycosis fungoides or

Sezary's disease (9700, Plasmacytoma or multiple

9701) myeloma (9731, 9732)

Malignant histiocytosis or Waldenstrom's

Letterer-Siwe's disease macroglobulinemia (9761)

(9720, 9722)

Plasma cell leukemia

True histiocytic lymphoma (9830)

(9723)

Mast cell tumor (9740,

9741)

Leukemia except plasma

cell (9800-9827, 9840-9941)

457
DETERMINATION OF SUBSEQUENT PRIMARIES OF

LYMPHATIC (NODAL AND EXTRANODAL) AND HEMATOPOIETIC DISEASES

First Primary Presumably a Second Presumably NOT a

Subsequent Primary Subsequent Primary

(only One Primary)

Leukemia, NOS (9800) Non-Hodgkin's Any leukemia 2 (9800-9941)

lymphoma 1 (9590-9595,

9670-9687, 9690-9698, Sezary's disease 3 (9701)

9702-9714)

Hodgkin's disease

(9650-9667)

Mycosis fungoides (9700)

Malignant histiocytosis or

Letterer-Siwe's disease

(9720, 9722)

True histiocytic lymphoma

(9723)

Plasmacytoma or multiple

myeloma (9731, 9732)

Mast cell tumor (9740,

9741)

Waldenstrom's

macroglobulinemia (9761)

1If the diagnosis includes "can't rule out leukemia" or "consistent with chronic lymphocytic

leukemia," and a bone marrow or peripheral blood study within two months confirms the chronic

lymphocytic leukemia diagnosis; then code only to chronic lymphocytic leukemia (9823/3). If not

confirmed as chronic lymphocytic leukemia, then code as the lymphoma.

2Note: Leukemia, NOS (9800) should be upgraded to a more specific leukemia diagnosis

(higher number) when it is found but not considered a second primary.

3presumably this is the correct diagnosis. Code the case to this histology.

458
DETERMINATION OF SUBSEQUENT PRIMARIES OF

LYMPHATIC (NODAL AND EXTRANODAL) AND HEMATOPOIETIC DISEASES

First Primary Presumably a Second Presumably NOT a

Subsequent Primary Subsequent Primary

(only One Primary)

Acute leukemia, NOS Non-Hodgkin's lymphoma Any leukemia 1 (9800-9941)

(9801) (9590-9595, 9670-9687,

9690-9698, 9702-9714) Sezary's disease 2 (9701)

Hodgkin's disease

(9650-9667)

Mycosis fungoides (9700)

Malignant histiocytosis

Letterer-Siwe's disease

(9720, 9722)

True histiocytic lymphoma

(9723)

Plasmacytoma or multiple

myeloma (9731, 9732)

Mast cell tumor (9740,

9741)

Waldenstrom's

macroglobulinemia (9761)

1Note: Acute leukemia, NOS (9801) should be upgraded to a more specific type of acute

leukemia (higher number) when it is found, but not considered a second primary.

2presumably this is the correct diagnosis. Code the case to this histology.

459
DETERMINATION OF SUBSEQUENT PRIMARIES OF

LYMPHATIC (NODAL AND EXTRANODAL) AND HEMATOPOIETIC DISEASES

First Primary Presumably a Second Presumably NOT a

Subsequent Primary Subsequent Primary

(only One Primary)

Chronic leukemia, NOS Hodgkin's disease Non-Hodgkin's

(9803) (9650-9667) lymphoma 1 (9590-9595,

9670-9686, 9690-9698,

Malignant histiocytosis or 9702-9714)

Letterer-Siwe's disease

(9720, 9722) Burkitt's lymphoma (9687)

Mast cell tumor (9740, Mycosis fungoides or

9741) Sezary's disease (9700,

9701)

True histiocytic lymphoma

(9723)

Plasmacytoma or multiple

myeloma (9731, 9732)

Waldenstrom's

macroglobulinemia (9761)

Any leukemia 2 (9800-9941)

1If the diagnosis includes "can't rule out leukemia" or "consistent with chronic lymphocytic

leukemia," and a bone marrow or peripheral blood study within two months confirms the chronic

lymphocytic leukemia diagnosis; then code only to chronic lymphocytic leukemia (9823/3). If not

confirmed as chronic lymphocytic leukemia, then code as the lymphoma.

2Note: Chronic leukemia, NOS (9803) should be upgraded to a more specific type of chronic

leukemia (higher number) when it is found, but not considered a second primary.

460
DETERMINATION OF SUBSEQUENT PRIMARIES OF

LYMPHATIC (NODAL AND EXTRANODAL) AND HEMATOPOIETIC DISEASES

First Primary Presumably a Second Presumably NOT a

Subsequent Primary Subsequent Primary

(only One Primary)

Lymphocytic leukemia Hodgkin's disease Non-Hodgkin's

(9820-9827) (9650-9667) lymphoma 2 (9592-9595,

9670-9687, 9690-9698,

Malignant histiocytosis or 9702-9714)

Letterer-Siwe's disease

(9720, 9722) Malignant lymphoma,

NOS 2 (9590-9591)

Plasmacytoma or multiple

myeloma (9731, 9732) Mycosis fungoides or

Sezary's disease 3 (9700,

Mast cell tumor (9740, 9701)

9741)

True histiocytic lymphoma

Waldenstrom's (9723)

macroglobulinemia (9761)

Leukemia, NOS (9800)

Non-lymphocytic

leukemias 1 (9840-9842, Acute leukemia, NOS

9860-9910) (9801)

Myeloid sarcoma 1 (9930) Chronic leukemia, NOS

(9803)

Acute panmyelosis 1

(9931) Lymphocytic leukemia 3

(9820-9827)

Acute myelofibrosis 1

(9932)

1If any of these diagnoses are made within 4 months of lymphocytic leukemia, NOS (9820) or

acute lymphocytic leukemia (982I), one of the two diagnoses probably is wrong. The case should

be reviewed.

2If the diagnosis includes "can't rule out leukemia" or "consistent with chronic lymphocytic

leukemia," and a bone marrow or peripheral blood study within two months confirms the chronic

lymphocytic leukemia diagnosis; then code only to chronic lymphocytic leukemia (9823). If not

confirmed as chronic lymphocytic leukemia, then code as the lymphoma.

3Note: Lymphocytic leukemia, NOS (9820) should be upgraded to a more specific diagnosis

that is not considered a second primary.

461
DETERMINATION OF SUBSEQUENT PRIMARIES OF

LYMPHATIC (NODAL AND EXTRANODAL) AND HEMATOPOIETIC DISEASES

First Primary Presumably a Second Presumably NOT a

Subsequent Primary Subsequent Primary

(only One Primary)

Lymphocytic leukemia Plasma cell leukemia 1

(9820-9827) (cont'd) (9830)

Lymphosarcoma cell

leukemia 1 (9850)

Hairy cell leukemia 1 (9940)

Leukemic

reticuloendotheliosis _

(9941)

1Note: Lymphocytic leukemia, NOS (9820) should be upgraded to a more specific diagnosis

that is not considered a second primary.

462
DETERMINATION OF SUBSEQUENT PRIMARIES OF

LYMPHATIC (NODAL AND EXTRANODAL) AND HEMATOPOIETIC DISEASES

First Primary Presumably a Second Presumably NOT a

Subsequent Primary Subsequent Primary

(only One Primary)

Plasma cell leukemia Non-Hodgkin's lyrnphoma Plasmacytoma or multiple

(9830) (9590-9595, 9670-9686, myeloma (9731, 9732)

9690-9698, 9702-9714)

Waldenstrom's

Hodgkin's disease macroglobulinemia (9761)

(9650-9667)

Leukemia, NOS (9800)

Burkitt's lymphoma (9687)

Acute leukemia, NOS

Mycosis fungoides or (9801)

Sezary's disease (9700,

9701) Chronic leukemia, NOS

(9803)

Malignant histiocytosis or

Letterer-Siwe's disease Lymphocytic leukemia

(9720, 9722) (9820-9827)

True histiocytic lymphoma Plasma cell leukemia

(9723) (9830)

Mast cell tumor (9740, Lymphosarcoma cell

9741) leukemia (9850)

Non-lymphocytic leukemia Hairy cell leukemia (9940)

(9840-9842, 9860-9910)

Leukemic

Myeloid sarcoma (9930) reticuloendotheliosis (9941)

Acute panmyelosis (9931)

Acute myelofibrosis (9932)

463
DETERMINATION OF SUBSEQUENT PRIMARIES OF

LYMPHATIC(NODAL AND EXTRANODAL) AND HEMATOPOIETIC DISEASES

First Primary Presumably a Second Presumably NOT a

Subsequent Primary Subsequent Primary

(only One Primary)

Lymphosarcoma cell Hodgkin's disease (9650- Non-Hodgkin's lymphoma

leukemia (9850) 9667) (9590-9595, 9670-9687,

9690-9698, 9702-9714)

Mycosis fungoides or

Sezary's disease (9700, True histiocytic lymphoma

9701) (9723)

Malignant histiocytosis or Plasmacytoma or multiple

Letterer-Siwe's disease myeloma (9731-9732)

(9720, 9722)

Waldenstrom's

Mast cell tumor (9740, macroglobulinemia (9761)

9741)

Leukemia, NOS (9800)

Non-lymphocytic leukemia

(9840-9842, 9860-9941) Acute leukemia, NOS

(9801)

Chronic leukemia, NOS

(9803)

Lymphocytic leukemia

(9820-9827)

Plasma cell leukemia

(9830)

Lymphosarcoma cell

leukemia (9850)

464
DETERMINATION OF SUBSEQUENT PRIMARIES OF

LYMPHATIC (NODAL AND EXTRANODAL) AND HEMATOPOIETIC DISEASES

First Primary Presumably a Second Presumably NOT a

Subsequent Primary Subsequent Primary

(only One Primary)

Non-lymphocytic leukemias Non-Hodgkin's lymphoma Leukemia, NOS (9800)

(9840-9842, 9860-9894, (9590-9595, 9670-9686,

9910-9932) 9690-9698, 9702-9714) Acute leukemia, NOS

(9801)

Hodgkin's disease

(9650-9667) Chronic leukemia, NOS

(9803)

Burkitt's lymphoma (9687)

Non-lymphocytic

Mycosis fungoides or leukemia 1 (9840-9842,

Sezary's disease (9700, 9860-9894, 9910-9932)

9701)

Malignant histiocytosis or

Letterer-Siwe's disease

(9720, 9722)

True histiocytic lymphoma

(9723)

Piasmacytoma or multiple

myeloma (9731, 9732)

Mast cell tumor (9740,

9741)

Waldenstrom's

macroglobulinemia (9761)

Lymphocytic leukemia

(9820-9827)

Plasma cell leukemia

(9830)

Lymphosarcoma cell

leukemia (9850)

1Code to the term with the higher histology code.

465
DETERMINATION OF SUBSEQUENT PRIMARIES OF

LYMPHATIC(NODAL AND EXTRANODAL) AND HEMATOPOIETIC DISEASES

First Primary Presumably a Second Presumably NOT a

Subsequent Primary Subsequent Primary

(only One Primary)

Non-lymphocytic leukemias Mast cell leukemia (9900)

(9840-9842, 9860-9894,

9910-9932) (cont'd) Hairy cell leukemia (9940)

Leukemic

reticuloendotheliosis (9941)

466
DETERMINATION OF SUBSEQUENT PRIMARIES OF

LYMPHATIC (NODAL AND EXTRANODAL) AND HEMATOPOIETIC DISEASES

First Primary Presumably a Second Presumably NOT a

Subsequent Primary Subsequent Primary

(only One Primary)

Mast cell leukemia (9900) Non-Hodgkin's lymphoma Mast cell tumor (9740,

(9590-9595, 9670-9686, 9741)

9690-9698, 9702-9714)

Leukemia, NOS (9800)

Hodgkin's disease

(9650-9667) Acute leukemia, NOS

(9801)

Burkitt's lymphoma (9687)

Chronic leukemia, NOS

Mycosis fungoides or (9803)

Sezary's disease (9700,

9701) Mast cell leukemia (9900)

Malignant histiocytosis or

Letterer-Siwe's disease

(9720, 9722)

True histiocytic iymphoma

(9723)

Plasmacytoma or multiple

myeloma (9731, 9732)

Waldenstrom's

macroglobulinemia (9761)

Any other leukemia

(9820-9894, 9910-9941)

467
DETERMINATION OF SUBSEQUENT PRIMARIES OF

LYMPHATIC (NODAL AND EXTRANODAL) AND HEMATOPOIETIC DISEASES

First Primary Presumably a Second Presumably NOT a

Subsequent Primary Subsequent Primary

(only One Primary)

Hairy cell leukemia or Non-Hodgkin's lymphoma Malignant histiocytosis or

leukemic (9590-9595, 9670-9686, Letterer-Siwe's (9720, 9722)

reticuloendotheliosis (9940, 9690-9698, 9702-9714)

9941) Lymphocytic leukemia,

Hodgkin's disease NOS (9820)

(9650-9667)

Hairy cell leukemia or

Burkitt's lymphoma (9687) leukemic

reticuloendotheliosis (9940,

Mycosis fungoides or 9941)

Sezary's disease (9700,

9701)

True histiocytic lymphoma

(9723)

Plasmacytoma or multiple

myeloma (9731, 9732)

Mast cell tumor (9740,

9741)

Waldenstrom's

macroglobulinemia (9761)

Any non-lymphocytic

leukemia (9800-9804,

9830-9932)

Lymphocytic leukemia

(9821-9827)

468
APPENDIX C

OTHER ICD-O-2 CODES TO BE CONSIDERED ONE PRIMARY SITE

WHEN DETERMINING MULTIPLE PRIMARIES

469
470
APPENDIX C

OTHER ICD-O-2 CODES TO BE CONSIDERED ONE PRIMARY SITE

WHEN DETERMINING MULTIPLE PRIMARIES

ICD-O-2 Codes Site Groupings

C01 Base of tongue

C02 Other and unspecified parts of tongue

C05 Palate

C06 Other and unspecified parts of tongue

C07 Parotid gland

C08 Other and unspecified salivary glands

C09 Tonsil

C10 Oropharynx

C12 Pyriform sinus

C13 Hypopharynx

C23 Gallbladder

C24 Other and unspecified parts of biliary tract

C30 Nasal cavity and middle ear

C31 Accessory sinuses

C33 Trachea

C34 Bronchus and lung

C37 Thymus

C38.0 Heart

C38.1-.3 Mediastinum

C38.8 Overlapping lesion of heart, mediastinum, and pleura

C38.4 Pleura

C51 Vulva

C52 Vagina

C57.7 Other specified female genital organs

C57.8-.9 Unspecified female genital organs

C56 Ovary

C57.0 Fallopian tube

C57.1 Broad ligament

C57.2 Round ligament

C57.3 Parametrium

C57.4 Uterine adnexa

471
OTHER ICD-O-2 CODES TO BE CONSIDERED ONE PRIMARY SITE

WHEN DETERMINING MULTIPLE PRIMARIES (Cont.)

ICD-O-2 Codes Site Groupin[_s

C60 Penis

C63 Other and unspecified male genital organs

C64 Kidney

C65 Renal pelvis

C66 Ureter

C68 Other and unspecified urinary organs

C74 Adrenal gland

C75 Other endocrine glands and related structures

472
SELECTED BIBLIOGRAPHY

473
474
SELECTED BIBLIOGRAPHY

Ackerman, L.V.; Del Regato, J.A.; and Spjut, H.J. Ackerman and Del Regato's Cancer:

Diagnosis, Treatment, and Prognosis. 6th ed. St. Louis: Mosby, 1985.

Ackerman, L. V. and Rosai, J. Ackerman's Surgical Patholo_. 7th ed. St. Louis: Mosby, 1989.

Basmajian, J. V. PrimaryAnatomy. 8th ed. Baltimore: Williams and Wilkins, 1982.

Beahrs, O. H.; Henson, D.E.; Hutter, R.V.P; and Kennedy, B.J., eds. Manual for Staging of

Cancer. 4th ed. American Joint Committee on Cancer. Philadelphia: Lippincott, 1992.

Chaffee, E. E. and Greisheimer, E. M. Basic Physiology and Anatomy. 3rd ed. Philadelphia:

Lippincott, 1974.

Clark, W. H., Jr.; From, L.; Goldman, L. I.; and Mastrangelo, M.J. "Human Malignant

Melanoma." New York: Grune & Stratton, Inc., 1979.

Crouch, J. E. Functional Human Anatomy. 4th ed. Philadelphia: Lea and Febiger, 1985.

DeVita, V. T., Jr.; Hellman, S.; and Rosenberg, S. A. Cancer: Principles and Practice of

Oncology. Philadelphia: Lippincott, 1992.

Grant, J.C.B.; Agur, A.M.R.; and Ming, J.L., eds. Grant's Atlas of Anatomy. 9th ed. Baltimore:

Williams and Wilkins, 1991.

Gray, H. and Williams, P.L., eds. Gray's Anatomy. 37th ed. New York: Churchill Livingstone,

1989.

Haagensen, C. D. et al. The Lymphatics in Cancer. Philadelphia: W.B. Saunders, 1972.

Haskell, C. M. and Berek, J.S. Cancer Treatment. 3rd ed. Philadelphia: Saunders, 1990.

Hermanek, P. and Sobin, L.H. TNM Classification of Malignant Tumours. 4th ed. New York:

Springer-Verlag, 1976.

Holleb, A.L.; Fink, D.J.; and Murphy, G.P., eds. American Cancer Society Textbook of Clinical

Oncology. 1st ed. Rochester, New York: American Cancer Society, 1991.

Holland, J. F. and Frei, E., III, eds. Cancer Medicine. 2nd ed. Philadelphia: Lea & Febiger,

1982.

International Classification of Diseases for Oncology, Second Edition. World Health

Organization: Geneva, 1990

Netter, F.H. Atlas of Human Anatomy. Summit, N.J.: CIBA-GEIGY Corp., 1989.

Pansky, B. Review of Gross Anatomy: Text and Illustrations. 5th ed. New York: Macmillan,

1984.

475
SELECTED BIBLIOGRAPHY (cont'd)

Paul, L.W. and Juhl, J.H. Paul and Juhrs Essentials of Roentgen Interpretation. 4th ed.

Hagerstown, MD: Harper and Row, 1981.

Rappaport, H. Tumors of the Hematopoietic System. Atlas of Tumor Pathology, Section III,

Fascicle 8. Washington D.C.: Armed Forces Institute of Pathology, 1966.

Robbins, S. L. and Cotran, R. S. Pathologic Basis of Disease. 4th ed. Philadelphia: Saunders,

1989.

Schlossberg, L. and Zuidema, G.D. The Johns Hopkins Atlas of Human Functional Anatomy.

3rd ed. Baltimore: The Johns Hopkins University Press, 1986.

Spence, A.P. Basic Human Anatomy. Menlo Park, California: The Benjamin/Cummings

Publishing Company, Inc., 1982.

Spiessl, B.; Beahrs, O.H.; Hermanek, P.; Hutter, R.V.P., Scheilie, O.; Sobin, L.H.; and Wagner,

H., eds. TNM Atlas. 3rd ed. New York: Springer-Verlag, 1992.

Taylor, G. W. and Nathanson, I.T. Lymph Node Metastases. London: Oxford University Press,

1942. Ann Arbor: University Microfilms.

476
INDEX

477
478
INDEX

Abdomen (abdominal), 12, 13, 85, 112, 208, 209, 219, 220, 229, 237, 243, 245, 246, 253, 273, 307,

309, 401

Aortic (para-, peri-) lymph nodes, 81, 84, 229

Ascites, 112, 114

Cavity, 10, 12, 57, 112, 203, 208, 212, 215, 243, 245, 246, 273, 307, 309, 401

Gastric lymph nodes, 81, 84

Hepatic lymph nodes, 81

Iliac (common, external, internal, hypogastric) lymph nodes, 65, 66, 81, 84

Lymphatic drainage from, 71, 81

Mesenteric (inferior, superior) lymph nodes, 62, 65, 66, 71, 81

Parietal lymph nodes, 77, 81, 83, 84

Pelvic cavity, 10, 12

Pelvic lymph nodes, 12, 65, 71, 80, 81, 84

Sacral lymph nodes, 65, 66, 81, 84

Splenic lymph nodes, 81, 84

Tumors of, 253

Viscera, 81, 210

Visceral lymph nodes, 77, 81, 83, 84

Abdominopelvic cavity, 10, 13

Abducens nerve (VI), 399, 403

Abductor muscle, 385, 389

Achilles tendon, 381

Acid phosphatase, 317

Acid-base balance (pH), 249, 317

Acidophilic (eosinophilic) tumors, 330

Acoustic (cochlear, vestibular nerve (VIII)), 399, 402-404, 435, 436

Tumor (neuroma, neurilemmoma) of, 404, 436

Acral lentiginous melanoma, 40, 43, 45

ACTH (see Adrenocorticotrophic hormone), 329

Adamantinoma (odontogenic tumor), 178

Adductor muscle, 385

Adenoacanthoma (adenosquamous carcinoma), 157

Adenocarcinoma, 36, 135, 157, 160, 177, 185, 211, 214, 215, 218, 222, 229, 233, 237, 253,

255, 256, 264, 277, 285, 292, 293, 294, 323, 331,333, 339, 432, 441

Adrenal cortical, 333

Cystadenocarcinoma, 285, 292-294

Ductal, 305

Follicular, 331,337, 339

Grawitz's tumor, 253

Hypernephroma, 253

Intraductal, 305

Krukenberg metastatic, 211,285, 292, 295

Lobular, 305

Medullary, 305

Mucinous, 305

Papillary, 331, 337, 339

479
Adenocarcinoma (continued)

Primary site for, 441

Renal cell carcinoma, 253

Scirrhous, 305

Serous, 285, 293, 294

Squamous, 277, 432

Adenohypophysis (anterior lobe, pituitary gland), 329

Adenoid (see Pharyngeal tonsil), 68, 193, 201, 202

Adenoid cystic carcinoma, 135, 185, 432

Adenoma, 35, 185, 211,222, 229, 330-333, 405

Acidophilic (eosinophilic), 330

Basophilic, 330

Bronchial (carcinoid, cylindroid), 157

Chromophobe, 330, 405

Colloid, 331

Cortical, 333

Fetal, 331

Follicular, 331

Hurthle cell, 331

Liver, 229

Papillary, 331

Parathyroid, 332

Pituitary, 330, 405

Pleomorphic, 185

Villous, 222

Adenomatous polyp, 222

Adenosquamous carcinoma (adenoacanthoma), 157, 277

ADH (antidiuretic hormone), 330

Adipose (fat) tissue, 289, 297, 302, 329, 441

Histologic type of cancer, 441

Adrenal (suprarenal) gland, 229, 328, 333-339

Adrenalin (epinephrine), 333, 336, 338

Cortex, 329, 333, 335, 336, 338

Cortisol, 333

Epinephrine (Adrenalin), 333

Location of, 333

Lymphatic drainage from, 81

Medulla, 333, 336, 338

Norepinephrine, 333

Tumors of, 333, 404

Adrenal cortical adenocarcinoma, 333

Adrenalin (see Epinephrine), 333

Adrenocorticotrophic hormone (ACTH), 329

Adventitia, 205, 208, 244, 257, 260

Aldosterone, 333, 335, 338

Aleukemic (subleukemic), 124

Alimentary canal (see also Digestive system), 165, 168

Allergens, 68

480
Alveolar, 297, 299, 300, 317

Alveoli, 157

Breast, 297, 299, 300

Bronchiolar (alveolar) carcinoma, 157

Lung, 154, 157, 161, 162

Process (mucosa covering mandible, maxilla), 178

Prostate, 317

Ridge (mucosa covering mandible, maxilla), 177

Sacs, 152, 154

Tumors of, 157

Ameloblastoma, 178

Ammonia, 249

Ampulla of Vater, 81, 215, 229, 230

Amylase, 237

Anal verge, 219

Anaplastic neoplasm (carcinoma, seminoma, spindle cell), 323, 331, 404

Anatomic divisions (quadrants, regions, cavities), 14

Anatomical position, 9, 15

Androgens, 309, 333, 335, 336, 338

Angiosarcoma, 368, 371, 375

Ankle (tarsals), 351, 367, 369, 373

Anorectal junction, 219, 222

Anterior (ventral) plane, 12

Anterior ligament, 277

Antibodies (gamma globulins) (see also Immunity), 54, 62, 67, 356

Antidiuretic hormone (ADH), 330

Antigens, 68, 356

Antrum of Highmore (maxillary sinus), 135, 138

Anus, 85, 165, 167, 168, 219, 222, 226, 289, 307, 308, 441

Histologic type of cancer, 441

Lymphatic drainage from, 85, 87

Tumors of, 222

Aorta (ascending, great), 81, 103, 105, 110, 154, 161, 162, 205

Appendices epiploica, 220

Appendicular bones (see also Bone), 366, 367, 369, 373

Classification of, 367

Appendix, 89, 94, 165, 219

Tumors of, 94, 222, 223

Arachnoid mater, 399, 404

Areola (breast), 297, 299-301, 305

Argentaffinoma (carcinoid tumor), 215, 218, 222

Arm (humerus, radius, ulna) bones, 343, 351, 367, 369, 373

Arm and armpit, and/or lymphatic drainage from, 9, 39, 46, 65, 66, 85, 87, 88, 158

Arrhenoblastoma (masculinizing tumor), 285

Arteries (see also Vessels), 71, 81, 99, 102, 103, 111, 114, 115, 154, 249, 302, 321

Aorta, 81, 83, 84, 103, 105, 110, 249

Arterioles, 111, 114

481
Arteries (see also Vessels) (continued)

Axillary, 302

Bronchial, 154

Carotid (external, internal), 135, 139, 169, 193

Celiac, 81, 83, 84, 205, 210

Coronary (left, right), 103

Femoral, 321

Gastric, 81

Hepatic, 81,237

Iliac (internal, left, right), 81, 83, 84, 277, 321

Mesenteric (inferior, superior), 71, 81, 83, 84, 221, 237

Pudendal, 321

Pulmonary (deoxygenated blood) trunk, 103, 105, 110, 111, 153-156

Renal, 249

Splenic branch, 81, 237

Subclavian, 302

Thoracic (internal, lateral subclavian), 302

Thyroid (inferior, superior), 144

Uterine, 277

Arterioles (see also Arteries), 111, 114, 249, 330

Articulating bones, 347, 349, 350

Articulation, 173

Aryepiglottic fold (see also Hypopharynx), 195, 201, 202

Arytenoid cartilage, 143, 144, 147, 148, 195

Ascending colon, 12, 166, 219, 220, 223, 226-228

Ascites (abdominal), 112, 114

Astrocytoma, 404, 407, 408, 442

Primary site for, 442

Atelectasis, 158

Atrioventricular orifice, node, and/or function, 103

Atrium (atria, heart), 103, 105, 110

Auditory (eustachian) tubes, 46, 139

Auditory canal and nerve, 404

Acoustic neuroma, 404, 436

Autonomic nervous system, 267, 377, 397, 401, 404, 407, 408

Urethra control by, 267

Axial skeleton, 342, 343, 346, 359

Classification of, 359

Axilla, 49, 62, 65, 66

Axillary and/or axillary lymph node, 46, 50, 65, 85, 87, 88, 302-304

Axon (nerve fiber), 393-396

B-Cells, 54, 356

B-K mole syndrome, 39

Back (posterior) of body, and/or lymphatic drainage from, 85

Bartholin's gland (greater vestibular), 289, 292, 294

Basal cell carcinoma, 36

Basal cell layer of the epidermis, 22, 23, 25, 36, 39-41, 43, 45

Basal ganglia, 397

482
Basement membrane (basal lamina), 22, 41, 244, 262, 274, 276, 305, 331

Bladder wall, 262

Corpus uteri, 274-276

Renal pelvis, 244, 259, 262

Ureter, 262

Basophilic tumors, 330

Basosquamous cell carcinoma, 36

Belly (anterior, ventral), 12

Bi- (bilateral), 9

Bicep muscle, 385, 390

Bifurcation, 81, 203

Bile (see Ducts, Gallbladder), 165, 215, 229, 230, 233, 236, 240

Tumors of, 229, 233, 235, 236, 441

Bile duct carcinoma (intrahepatic, extrahepatic), 441

Histologic type of cancer, 441

Biliary system, 229, 230

Birthmarks (see also Nevus), 35

Bladder (see also Urinary system), 242-246, 261, 262, 264-268, 441

Dome, 261

Fundus, 261

Histologic type of cancer, 441

Location of, 10, 261

Lymphatic drainage, 263, 265, 266

Metastases, 368, 374

Muscle wall, 261,262, 264-266

Neck (internal sphincter), 267

Orifices, 261

Serosai covering (peritoneum), 261, 262

Sphincter (internal and external), 261, 267

Structure of, 262

Tissue layers, 262, 265, 266

Trigone (orifices), 261, 264, 265

Tumors of, 264, 441

Ureter, 242-246, 249, 257, 260-262, 266, 268-270

Urethra, 243, 261,266-268, 270

Urine, formation and transportation of, 247, 249

Vertex, 261

Wall (lateral and posterior), 261, 262, 264-266

Blood (see also Cardiovascular system), 73, 103, 105, 114, 115, 125, 131, 134, 135, 139,

144, 157, 161,162, 166, 193, 210, 211, 215, 219-221, 237, 244, 247, 249, 251,

252, 262, 268, 270, 274, 313, 329, 331, 335, 336, 338, 343, 345, 346, 356

Abnormal (leukemia), 123, 126

Anemia, 115

Arterial, 110-112, 114, 230

B-cell, 54

Blast form (immature, unspecified), 123, 124

Capillaries, 249, 251, 252, 268, 270, 347

Cell production, 343, 345, 346, 368

483
Blood (see also Cardiovascular system) (continued)

Cells, 54, 61, 62, 67-70, 90-92, 115, 117-119, 121-128, 131

Circulation of, 249, 251, 252, 277

Clot (coagulation), 115, 119, 121, 122

Composition of, 63, 115, 229

Counts (RBC, WBC), 115, 119, 123, 124

Deoxygenated blood (see also Venous system), 105, 109-111, 154

Differential, 119

Embolus (clot), 119, 122

Erythrocyte (RBC), 67, 115, 117, 118, 127, 229

Erythropoiesis, 115

Fibrinogen, 115

Filtration through kidney, 243, 247, 249, 252, 268-270

Flow through body and/or heart, 100, 102, 105

Functions of, 99, 101, 102, 113, 114, 119, 121, 122

Granulocyte, 119, 123, 124

Hematocrit, 115, 117, 118

Hemoglobin, 115, 117, 118, 124

Histologic type of cancer, 441

Leukocyte (WBC), 62, 115, 118, 119, 122-124, 126, 127, 356

Life cycle, 115

Lymphoblast, 123, 124

Lymphocyte, 53, 54, 62, 67, 68

Metastasis, blood-borne, 112, 331, 368, 369, 373

Monoblast, 123, 124

Monocyte, 67

Myeloblast, 123, 124

Myeloproliferative disorders (see also Bone marrow), 127

Nutriments, 249, 343, 345, 346

Oxygenated blood, 105, 107-111, 154

Peripheral (circulating) blood, 123

Plasma (plasmacyte), 54, 62, 63, 67, 115, 118, 124, 229

Platelets (thrombocytes), 115, 118, 119, 356

Polycythemia vera, 115, 127, 128

Portal circulation, 100, 112-114, 210, 221, 237

Pressure (diastolic, systolic), 105, 111

Protein, 115, 119, 229

Prothrombin, 119

Reabsorption, 249

Secretion of antibodies into, 356

Secretion of hormones into, 329, 331, 333, 335, 336, 338, 339

Serum, 115

T-cell, 54, 68-70, 90

Thrombocyte (platelet), 115, 118, 119

Thrombus (clot, embolus), 119, 122

Tumors of, 368

Values (normal), 124

Vascular papillae, 31

484
Blood (see also cardiovascular system) (continued)

Venous (deoxygenated), 111-114, 135, 144, 169, 205, 210, 230

Vessels (see also Venous system), 23, 27, 31, 53, 65, 66, 71-73, 99, 101-103, 105,

109-111, 113, 114, 119, 154, 157, 205, 229, 244, 249, 262, 274, 313, 321, 347,

356-358, 377, 381, 383, 384, 386, 441

Volume, 115, 118

Blood vessels, 399, 401, 404, 411, 441

Arachnoid mater containing, 399, 404

Autonomic nervous system, 401

Muscle (smooth) of, 401

Tumors of, 404

Visceroceptors (interoceptors), 411,413, 414

Blue nevus, 39

Body cavities, 10, 15, 17

Body temperature (homeostasis), 21, 31, 99, 102

Bone marrow, 115, 119, 123, 124, 343, 346, 356-358, 368

B-cell, 356

Erythropoiesis, 115

Leukemia diagnosis, 123, 124, 126

Leukocyte (granular, polymorphonuclear) production in, 115, 119

Platelet production in, 119

Polycythemia vera, 115, 127, 128

Tumors of, 125, 126, 368, 371, 375, 442

Bone tissue (osseous, vascular tissue), 242, 261, 289, 291, 294, 329, 332, 334, 343, 346,

347, 349-369, 371-373, 375, 381, 441

Articulating bones, 347, 349, 350

Bone marrow, histologic type of cancer, 442

Cancellous (spongy), 355, 356, 358

Cell (osteocyte), 347, 350, 355, 372, 375

Classification (long, short, flat, irregular, round), 351, 352, 354

Compact, 356

Development (growth), 329, 333

Diaphysis (long bone), 356-358, 372, 375

Flat (pelvis, ribs, sternum, skull), 351, 353

Functions of, 343, 359

Haversian system, 347, 355, 356, 358

Histologie type of cancer, 441

Irregular (ear, vertebra), 347, 351

Long (arm, leg), 351, 356-358, 368

Marrow (red and yellow), 343, 346, 355-358, 368, 371, 375, 442

Matrix, 347

Medullary cavity, 355, 356, 358, 368

Metaphysis, 355, 368

Metastases, 368, 370

Mineral stabilization, 343

Muscle attachment to, 377, 381, 383

Number of bones in body, 343, 345, 346, 351, 359-361, 367

Nutriments (calcium, oxygen, phosphorus), 309, 332, 343, 345-347

485
Bone tissue (osseous, vascular tissue) (continued)

Pelvis (ilium, ischium, pubis, hip bones), 242, 261, 272, 312, 343, 351, 366, 375

Periosteum, 355, 356, 358, 368, 381, 383

Phalange (finger, toe), 367, 373

Pubic, 261, 289, 291, 294

Radius (lower arm), 367

Recklinghausen's disease, 332

Rib, 343, 356, 361,372, 375

Round (sesamoid, kneecap), 351, 353, 354, 356

Sacrum, 351, 353, 354, 361

Scapula (shoulder), 369

Sesamoid, 351,353, 354, 356

Short (ankle, wrist), 351

Skeletal system, 341, 343, 345-347, 349-352, 354-369, 371-373, 375

Sphenoid (cranial, paranasal bone), 329

Sternum, 351, 356, 361, 367, 369, 373, 375

Structure of bone, 351, 356-358

Suturae, 359, 360

Tibia (shin bone), 351

Tumors of, 368, 371, 375

Ulna (lower arm), 367

Bone tissue, Appendicular (appendages - - extremities), 343, 345, 346, 366, 367, 369

Cancellous (spongy), 355, 356, 358

Carpal (wrist bone), 351, 353, 354, 366, 367, 369, 373

Clavicle (collar bone), 343, 356, 361, 366, 367, 369, 373

Femur (thigh), 351,353-356, 366, 367, 369, 373

Fibula (leg), 343, 351, 367, 369, 373

Hip, 343, 367, 369, 373

Humerus (upper arm), 351, 356, 366-369, 373

Marrow (red and yellow), 343, 346, 355-357, 368, 371, 375

Metatarsal (foot), 366, 367, 369, 373

Patella (kneecap), 351, 354, 366, 367, 369, 373

Pelvis (ilium, ischium, pubis, hip bones), 351, 366, 367

Phalange (finger, toe), 351,366, 367, 369, 373

Radius (lower arm), 343, 351,366, 367, 369, 373

Rib, 343, 351, 356, 361, 372, 375

Sacrum, 351, 353, 354, 361, 368

Scapula (shoulder), 343, 366, 367

Sternum, 334, 351, 356, 361,366, 367, 369, 373

Tarsal (ankle), 351,366, 367

Tibia (shin bone), 351, 366-369, 373

Ulna (lower arm), 351,366, 367, 369, 373

Bone tissue, Axial (axis), Skull (diploe), 342, 343, 351, 354, 356, 359, 363-365, 372

Cranial (ethmoid, frontal, occipital parietal, sphenoid), 343, 351, 354, 359,

363-365, 372

Ear (middle, incus, malleus, stapes) bones, 351, 360

Facial, 360

Frontal (skull), 351

486
Bone tissue, Axial (axis), Skull (diploe) (continued)

Hyoid, 359, 364, 365

Rib, 343

Temporal (skull), 343, 351, 354, 359, 363-365, 372

Bone tissue, Axial (axis), Thorax, 342, 343, 359, 362

Manubrium, 362

Ribs, 361, 362, 372, 373

Sternum, 361,362, 373

Bone tissue, Axial (axis), Vertebral column, 343, 359, 361,362

Cervical, thoracic, lumbar, sacrum, coccyx, 342, 361, 368

Bone, metastasis to, 211, 368

Bowel (see Intestine), 221, 222

Bowen's disease, 36-38

Bowman's capsule, 249, 252, 268, 270

Brain (CNS, encephalon), 12, I3, 329, 368, 397, 399, 400, 442

Cerebellum, 399

Cerebral cortex, 397, 399

Brain (CNS, encephalon) (continued)

Cerebral hemispheres, 397

Cerebrospinal fluid (CSF), 399

Cerebrum (frontal, parietal, occipital, temporal lobe), 397, 398

Diencephalon (thalamencephalon), 397

Epithalamus (third ventricle)_ 332, 397

Forebrain (prosencephalon), 397

Fourth ventricle (hindbrain), 399

Hindbrain (rhombencephalon), 399

Histologic type of cancer, 442

Hypothalamus, 329, 397

Medulla oblongata (hindbrain), 399

Meninges (dura mater, pia mater, arachnoid mater), 10, 397, 400, 404

Metastases, 31,211, 370, 404

Midbrain (mesencephalon), 397, 399

Nervous system (control of sense and movement), 31, 393-401, 404, 407, 408

Neurons (gray matter), 393, 394, 397, 399, 404

Pineal (epiphysis) gland, 332, 337, 339, 397

Pons (hindbrain), 399

Proscencephalon (forebrain), 397

Rhombencephalon (hindbrain), 399

Thalamus, 397

Breast (mammary gland), 273, 297, 299-305, 44I

Areola, 297, 300-302, 305

Axillary tail, 301-303

Blood supply for, 302

Clinical evaluation of tumors, 302

Cooper's ligament., 297, 302

Duct (lactiferous), 297

Gland (lobe) of, 297, 300

487
Breast (mammary gland) (continued)

Histologic type of cancer, 441

Ligament, 297, 302

Lymphatic drainage from, 77, 85, 302-304

Metastatic sites, 301-304

Muscle (pectoral) of, 297

Nipple, 297, 299-302

Parenchymal, 302

Quadrant, 13, 301

Skin (dimpling, tethering, retraction, peau d'orange), 302

Spread of cancer, 302, 305

Subsites, 301

Tumors of, 302, 305

Brenner tumor, 285

Broad ligament, 277, 281, 282

Broders' classification of bladder tumors, 264

Bronchial adenoma (carcinoid, cylindroid), 157

Bronchioles (see also Bronchi, Lung), 154, 157, 161, 162

Tumors of, 157

Bronchogenic carcinoma, 157, 159, 160

Bronchus (bronchi), 149, 153, 155, 156, 333, 347, 403, 441

Cranial nerve (motor, sensory) functions, 403

Extrapulmonary, 149

Histologic type of cancer, 441

Intrapulmonary, 149

Lobar (secondary), 149, 152

Lumen, 157

Lymphatic drainage from, 77

Main stem (primary, left, right), 149, 152

Sensations from, 403

Tube, 333

Tumors of, 157-160

Buccal cavity (see also Cheek and Mouth), 193, 199, 200

Anatomic limits, 181

Buccal gutter, 178

Buccal mucosa (cheek), 65, 66, 74, 181, 183, 184, 189, 191

Buccal sulcus (gingival) (see also Palate), 178

Glands (minor salivary), 177, 185

Lymphatic drainage from, 65, 66, 74, 189

Bulbourethral (Cowper's) gland, (See Reproductive system, male 289, 309, 318-320

Bursa Fabricius, 54

Calcium levels, 332

Cancellous (spongy), 355, 356, 358, 359

Cancer (see Tumor), 62, 68, 71-73, 76, 145, 158, 159, 178, 205, 211

Canthus, lymph node drainage from, 46

Capillaries, 31, 53, 56, 57, 63, 66, 99, 102, 105, 111, 112, 114, 115, 154, 249, 251, 252, 268,

270, 331, 377

Blood, 63, 66, 99, 102, 111, 112, 114, 115

488
Capillaries (continued)

Bowman's capsule, 252

Dermal, 31

Fascia, 377

Glomeruli, 249, 252

Intestinal, 215

Lymphatic, 53, 56, 57, 63

Pulmonary, 105, 154

Renal peritubular, 249

Renal, Bowman's capsule, 249, 251, 252, 268, 270

Thyroid gland, 331

Carbohydrate metabolism, 215, 237

Carbon dioxide exchange, 102, 105, 111, 114, 115, 117, 118, 131, 134, 154, 161, 162

Carcinoid tumor (argentaffinoma), 157, 215, 218, 222

Carcinoma (see also Tumor or specific histologic type), 253, 264, 285, 293, 295, 305, 323,

441

Adenoid cystic, 432

Anaplastic, 323, 331

Cystadenocarcinoma, 441

Embryonal, 323

Endometrioid, 285, 293, 295

Epidermoid, 423, 425

Inflammatory, 305

Liposarcoma, 441

Medullary, 305, 331

Spread of, 71-73

Squamous, 253, 264, 277, 290, 295, 427

Transitional cell, 253

Cardi(o), 9

Cardia, 209, 214

Cardiac (heart rate) stimulant, 333

Cardiac (heart) muscle, 377, 380, 389, 390

Cardioesophageal junction (cardiac orifice), 203, 211

Cardiovascular system, 249

Aorta, 249

Carina (see also Carinal lymph node), 149, 157

Carinal (see Tracheobronchial), 77

Carpal (wrist) bone, 351,353, 354, 367, 369, 373

Cartilage (nonvascular tissue), 147-149, 285, 323, 343, 346, 347, 349, 350, 356, 361, 372,

375, 383, 441

Arytenoid, 143, 148, 195

Attachment to bone, 343, 346, 383

C-shaped rings (trachea), 149

Cell (chondrocyte), 347, 349, 350

Corniculate, 143, 148

Cricoid (signet-ring), 143, 148, 195, 203

Cuneiform, 143, 148

Elastic, 347, 349, 350

489
Cartilage (nonvascular tissue) (continued)

Epiglottis (see also Larynx), 143, 148, 161, 162

Fibrous, 347, 349, 350, 356

Histologic type of cancer, 441

Hyaline, 347, 349, 350

Laryngeal, 143

Perichondrium, 347

Thyroid (Adam's apple), 143, 148, 195

Catecholamine (hormone), 333

Caudal, 12

Cavities of the body, 15, 17, 243, 245, 246, 329, 401, 441

Abdominal, 243, 245, 246, 273, 307-309, 401

Abdominopelvic, 13

Anterior and posterior (eye orbit), 415, 423

Cranial, 13, 397, 404

Dorsal, 13

Eye orbit (anterior and posterior), 415, 423

Nasal, 431-434, 441

Oral, 441

Pelvic, 272, 273, 275, 276, 283, 284, 313

Peritoneal, 243, 245, 246, 285

Pleural, 13

Thoracic, 13

Uterine, 277

Ventral, 13

Vertebral, 13

Cecum (large intestine), 166, 219, 223, 226

Ileocecal orifice (valve), 219

Lymphatic drainage from, 222

Tumors of, 223

Cell type (see also Blood, Lymphatic system), 23, 25, 31, 36, 38, 244, 262, 329, 393, 404

Angioblast, 405

Atypical (abnormal), 123-126

B-cells, 54, 356

Blastic (immature, unspecified), 123, 124

Blood, 343, 345, 346

Bone (osteocyte), 347, 349, 350

Chondrocytes, 347, 349, 350

Ciliated epithelial, 285

Columnar epithelial, 285, 317

Duct, 305

Embryo (see also Germ cell), 281,283, 285

Embryonic (see also Germ cell), 404

Endometrial, 281

Epithelial tissue, 244, 262, 281, 292, 295, 305

Germ cell (embryonic, germinal), 285, 292, 294, 313, 323, 404, 405, 423

Giant cell, 368, 371,375

Glial cells (neuroglia), 404

490
Cell type (see also Blood, Lymphatic system) (continued)

Granulosa, 281,285

Histiocyte (see also Reticulum cell), 61

Immature (see also Blastic), 123, 126

Interstitial, 309, 311, 312, 323, 326, 329

Leydig (interstitial (glandular) cell), 309, 323, 326, 329

Luteal, 281

Lymphocyte development and production, 53, 54, 62, 68, 119, 124

Macrophage, 68

Mature (differentiated, specialized), 123, 124

Melanin-producing, 36-38

Mixed, 36

Myoepithelial, 305

Nerve, 393-395, 404

Neuroepithelial, 404

Neuroglia (glial cells), 393

Oat, 157, 160, 161

Osteocyte (see Bone cell), 393, 404

Parathyroid, 332

Phagocyte, 68

Plasma, 54, 62, 67, 368

Reed-Sternberg, 90, 92

Reserve (bronchial epithelium), 157

Reticuloendothelial (histiocytes), 61, 67

Reticulum cell, 368, 371, 375

Secreting (alveoli, mucinous, serous), 297

Sertoli, 313, 323

Small cell, 157

Sperm cell, 313, 317, 319, 320

Spindle cell (anaplastic), 404

Stem, 123, 124

T-cells, 54, 68-70

Theca, 281

Trophoblast (trophoblastic), 323

Undifferentiated, 123, 157, 160, 161

Cellular intracanalicular fibroma, 305

Cellular metabolism (homeostasis), 102

Balance, Hydrogen-ion concentration (pH), 99

Body temperature, 21, 31, 99

Cellular respiration (see also Metabolism), 99, 102, 131

Central nervous system (CNS), 377, 393-401, 404, 407, 408

Cephalic (cephalo-, cranial) plane, 12

Cerebellum (hindbrain), 399, 404, 407, 408

Tumors of, 404, 407, 408

Cerebral cortex, 397, 399

Cerebrospinal fluid (CSF), 397, 399

Cerebrum (forebrain, telencephalon), 397, 399

Basal ganglia (cerebral nuclei), 397

491
Cerebrum (forebrain, telencephalon) (continued)

Cerebral cortex, 397

Hemispheres, 397, 404

Lateral ventricles, 397

Tumors of, 404

Cervical (see also Lymph nodes), 62, 65, 66, 74, 75

Cervical lymph nodes,

Parotid (infra-auricular, preauricular), 49, 50

Submandibular (submaxillary), 46, 49, 50

Supraclavicular (transverse cervical), 46, 49, 50

Cervix uteri, 273-277, 279, 280, 441

Cervical canal (endocervix), 274, 275, 277

Composition of, 273, 274

Ectocervix (lip), 274, 277

Endocervix (canal), 274, 277, 441

Fornices (parts), 277

Histologic type of cancer, 441

Lip of cervix (ectocervix), 274

Lymphatic drainage, 277

Submucosa (stroma), 277

Tumors of, 277

CF-'S(cerebrospinal fluid), 397

Cheek (see also Buccal cavity), 46, 169, 181, 183-185

Lymphatic drainage from, 65, 66, 74, 189

Chest and chest wall (see also Thorax), 49, 50, 77, 79, 80, 85, 157

Chin, lymphaticdrainage from, 46, 65, 66

Choana, 135, 139

Cholangiocarcinoma, 229, 233, 236, 441

Primary site for, 441

Chondrocyte, 347, 350

Chonclrogenic (chondrosarcoma, osteochondrosarcoma) tumor, 368, 371, 375, 441

Primary site for, 441

Chorionic gonadotrophic hormone, 329

Choroid (middle layer of eye), 415, 417, 418

Choroid plexus, 399

Chromophobe tumors, 330, 405

Chyle, 57

Chyme (see also Stomach), 209, 211, 215

Cicatrix (fibrous), 281

Cilia, 149, 161, 162

Cisterna chyli, 57, 221

Clark's classification, 44, 45

Clavicle (collar bone), 14, 343, 356, 361, 367, 369, 373

Cleft palate, 360

Clitoris (see also Reproductive system, female), 289, 291, 292, 294

Cloacogenic transitional cell carcinoma, 222

Clot (coagulation), 122

Coccyx (tailbone), 361

492
Colloid adenoma, 331

Colon, 165, 168, 219, 220, 223, 225, 226, 229, 441

Anus, 165, 167, 168, 219, 222, 226

Appendix, 165, 219

Ascending, 12, 166, 219, 220, 223, 226-228

Cecum, 166, 219, 220, 223, 226

Cul-de-sac, 219

Descending, 166, 219, 220, 223, 226, 228

Hepatic flexure, 219, 229

Histologic type of cancer, 441

Lymphatic drainage from, 65, 66, 81, 222

Rectosigmoid, 219

Rectum, 10, 12, 165, 166, 168, 219, 220, 222, 226-228

Sigmoid (pelvic), 10, 166, 219, 220, 223, 226-228

Splenic flexure, 219, 227

Tissue layers (see also Digestive system), 166-168, 220

Transverse, 166, 219, 220, 223, 226, 227

Tumor nodules in mesenteric fat, 221

Tumors of, 166, 222, 223

Columnar epithelium cell, 274, 285, 317

Commissure (anterior, posterior),

Larynx, 134

Lip, 170, 172, 189

Compact bone, 355-358

Compound nevus, 35

Conch a (turbinate, inferior, middle superior, facial bone), 365

Connective tissue (see also Tendon, Cartilage, Fascia), 381,393

Areolar, 274

Connective tissue, dermis, subserosa, 27, 35, 36, 61, 166, 170, 205, 208, 210, 381, 383, 384,

389, 390

Constrictor muscle (cranial nerves, motor, sensory), 403

Cooper's ligament, 297, 302

Cord, 313

Spermatic, 309, 313

Spinal, 393

Corium, dermis (see Integumentary system), 26

Cornea (eye), 415, 418, 423, 425

Corniculate cartilage, 148

Coronal (frontal) plane, 10

Corpora cavernosa, 289, 321

Corpus luteum (see also Ovary), 281, 330

Corpus uteri, 272, 273, 275-277, 279, 280

Lymphatic drainage from, 81, 277

Mucosa, 274

Submucosa (stroma), 273

Tumors of, 277

Wall, composition of, 273

Cortical adenoma, 333

493
Cortisol, 329, 333, 336, 338

Cortisone, 333

Cowper's (bulbourethral) gland, 289, 309, 318-320

Cranial (superior) (see also Cephalic), 10, 12

Cranial bone (see also Cavities of the body), 329, 343, 351, 354, 359, 363-365, 372, 401

Ethmoid bone, 359, 363-365, 372, 375

Frontal bone, 351,359, 372, 375

Nerve, 399, 401, 435

Occipital bone, 359, 363-365, 372, 375

Parietal bone, 359, 363-365, 372, 375

Sphenoid bone, 329, 359, 363-365, 372, 375

Temporal bone, 351,353, 354, 359, 363-365, 372, 375

Craniopharyngioma (Rathke's pouch tumor), 330, 337, 405

Cricoid cartilage (signet-ring), 143, 144, 148, 149, 195, 203

Cuboid (short bones), 351

Cul de sac (see also Reproductive system, female), 273, 307, 308

Cuneiform cartilage, 148

Cylindroid tumors, 157

Cystadenocarcinoma (mucinous, serous), 285, 441

Primary site for, 441

Cystic duct, 229, 230, 233, 240

Cystosarcoma phyllodes, 305

Dendrite, 393, 395, 396

Denonvilliers' fascia, 317

Deoxygenated blood (see also Venous system), 105, 109-111, 154

Depressor muscle, 389

Dermal-epidermal junction (see also Nevus), 35, 39

Dermatofibroma, 35

Dermatofibrosarcoma (protuberans), 36-38

Dermis, connective tissue, corium (see Integumentary system), 21-23, 25-27, 31, 33-38, 40,

41, 44, 45

Dermoid tumor, 285

Descending colon, 166, 219, 220, 223, 226-228

Di Guglielmo's disease, 124

Diagnostic workup for cancer, 71-73

Diaphragm, 67, 77, 79, 80, 103, 108, 153, 158, 203, 208, 209, 214, 229

Diaphysis (long bone), 356-358

Diastolic blood pressure, 105

Diencephalon (thalamencephalon), 397

Different histologies, 445

Multiple primaries and, 445

Digestive system, 12, 243, 403

Alimentary canal (see Intestine), 165, 168

Circular, longitudinal and/or oblique muscle, 205, 210, 220

Cranial nerves, motor, sensory, 403

Digestion, 166, 215, 218-220, 229, 237, 240

Gastrointestinal tract (GI, alimentary canal), 165-169, 215, 220

494
Digestive system (continued

Mucosa, 166-172, 177-181, 183-185, 189, 191, 192, 205, 208, 210, 211,220, 221,

233

Muscularis mucosae, 166, 168, 169, 181, 184, 205, 210, 220

Muscularis propria, 166, 168, 205, 208, 210, 214, 220

Serosa (visceral peritoneum), 166, 168, 205, 208, 210, 214, 215, 219, 220, 233

Submucosa, 166, 168, 169, 181, 205, 208, 210, 214, 220

Subserosa (see Connective tissue and Fat), 177

Surface epithelium, 166, 168, 205, 220

Tissue layers of wall of GI tract, 166-168, 207, 208, 212, 214, 220

Tumor spread by depth of penetration, 166

Wall of intestine (structure), 166

Dimpling of breast, 302

Directional planes of the body, 9, 10, 12

Distal, 12, 14-16

Dorsal (posterior) plane, 12, 15, 17

Ductal (duct cell, adeno) carcinoma, 305

Ducts (see also Endocrine system and Digestive system), 273, 276, 281, 288, 289, 297, 305,

309, 313, 317, 318, 329, 330

Bile, 165, 215, 229, 230, 233, 235, 236

Breast, 305

Carcinoma of bile ducts, 235, 236

Cisterna chyli, 221

Common bile duct, 215, 229, 230, 233, 240

Craniopharyngeal, 330

Cystic, 229, 230, 233, 240

Ductus deferens (vas deferens), 309, 313

Ejaculatory, 309, 313

Endocrine (ductless), 281, 329, 335, 338, 339

Epididymis, 309, 313

Excretory, 289, 309, 317

Exocrine, 329

Extrahepatic bile, 229, 230, 235, 236, 441

Fallopian tube (oviduct), 273, 275-277, 281-284, 286-288, 307

Glandular, 318

Hepatic (left, right), 229, 230, 233, 240

Intrahepatic (see also Bile), 229, 235, 236, 441

Lactiferous, 297

Lymphatic, 57-60

Origin of breast cancer in, 305

Pancreatic (duct of Wirsung), 215, 237

Parotid (Stensen's), 185

Penile, 321

Porta hepatis, 229

Salts (bile), 229

Sebaceous gland, 31

Seminal, 313

Stensen's (parotid), 185

495
Ducts (see also Endocrine system and Digestive system) (continued)

Submandibular (Wharton's), 185

Sweat gland, 31

Tear (lacrimal), 329, 419

Thoracic, 57, 60, 221

Tumors of, 305, 329

Wharton's (submandibular), 185

Wirsung (pancreatic), 237

Ductus deferens (vas deferens), 309, 313, 315, 3t.6

Duodenum (see also Intestine, small), 209, 211,214, 215, 218, 229, 230, 233, 237, 240

Lymphatic drainage from, 81

Tumors of, 215

Dura mater, 399, 404

Dysgerminoma, 285, 292, 294, 441

Primary site for, 441

Ear (external auditory), 39, 185, 347, 349-351,359, 360, 372, 375, 413, 414, 435, 436, 438

Bone (incus, malleus, stapes), 351, 359, 360, 372, 375

Canal, 31, 33, 34, 46, 435, 438

Connective tissue, 372

Drum membrane, 34

Eustachian (auditory) tube, 46, 139, 435, 438

Exteroceptor (receptor), 411,413, 414

Lymphatic drainage from, 46, 74, 436

Melanoma of, 39, 43

Proprioceptor (receptor), 411, 413, 414

Topography code (skin of), 39

Tumors of, 436

Tympanic cavity and/or membrane, 31, 74, 435

Ectocervix (lip), 274

Ectoderm, 27

Eczematoid lesion (Paget's disease), 305

Edema, 62, 158

Ejaculatory duct (see Reproductive system, male), 309, 313, 317

Elbow (epitrochlear lymph nodes), 65, 66, 85

Electrolyte balance, 249, 252

Eleidin, 22

Elevator (levator) muscle, 385

Embolus (thromboembolus), 119, 122

Embryo (see also Germ cell), 281, 283-285, 323

Tumor of, 285, 323

En cuirasse of breast, 302

Endo-, 15, 16

Endocardium (see also Heart), 104

Endocervix (see Cervix uteri), 274

Endocrine gland, 68-70

Endocrine system (see also specific glands), 327-329, 331-339

Endometrial stromal sarcoma, 277

Endometrioid carcinoma, 285

496
Endometrium, 274-277, 281, 285, 441

Histologic type of cancer, 441

Structure of, 274

Tumors of, 277, 278, 285

Eosinophilic tumors, 330

Ependymoma, 404

Epi-, 15, 16

Epicardium (surface covering) (see also Heart), 104, 108

Epigastric region, 14

Epiglottis, 143, 148, 161, 162, 194, 195

Aryepiglottic fold, 144, 195, 201, 202

Base, 173, 194

Glossoepiglottic fold, 194

Lingual (anterior surface), 194, 201,202

Pharyngoepiglottic fold, 194, 195

Epinephrine (Adrenalin), 333, 336, 338

Epiphysis (bone), 356-358

Epithalamus, 397

Epithelial tissue, 27, 36, 68, 161, 162, 274, 281, 282, 285, 292, 295, 305, 334

Bronchial, 157

Ciliated, 282

Columnar, 274, 285

Ductal, 305

Fallopian tubes, 282

Glandular, 274, 277, 285, 305

Lymphoepithelial, 334

Mucin-producing (ciliated columnar), 149

Myoepithelial, 305

Neuroepithelial, 404

Ovary, 281

Squamous, 219

Stratified squamous, 274, 289

Surface epithelium, 166, 168, 205, 220

Tumors, 285, 292, 295

Uterus, 274, 277

Erythroleukemia (Di Guglielmo's disease), 124

Esophagus (see also Digestive system), 12, 154, 157, 161, 162, 165, 166, 168, 195, 203,

205, 207-210

Adventitia, 205, 208

Blood supply to, 205

Histologic type of cancer, 441

Lymphatic drainage from (lower, mid, upper), 77, 81, 205

Peristaltic motion of, 203

Regions and/or segments, 203, 205, 207, 208

Tissue layers of (see also Digestive system), 207, 208

Tumors of, 205

Esthesioneuroblastoma (esthesioneuroepithelioma), 135, 432

Esthesioneuroepithelioma, 432

497
Estradiol, 281

Estrogen-producing cancer, 285

Estrogens, 281,329, 333

Estrone, 281

Ethmoid (cranial) bone, 135, 138, 359, 363, 365, 375

Ethmoid sinus, 135, 138

Eustachian (auditory) tube (see also Ear), 46, 139, 435

Ewing's sarcoma, 368, 371, 375, 441

Primary site for, 441

Exocervix, 274

Exocrine gland, 329, 335, 338

Expiration (exhaling), 131

Extensor muscle, 385

External auditory canal, 435

External rectus muscle (cranial nerves, motor, sensory), 403

External, 13

Respiration, 131

Exteroceptor (receptor), 411, 413, 414

Extra-, 15, 16

Extrahepatic biliary system, 229, 230, 235, 236

Extralymphatic sites (see Lymphoma), 94

Extranodal (extralymphatic) lymphoid tumors, 89, 94

Extremities (lower, upper), lymph nodes of, 85

Axillary, 46, 85, 87

Epitrochlear, 46, 85, 87

Femoral (superficial inguinal), 46, 85, 87

Inguinal (femoral, superficial), 46, 85, 87

Popliteal, 46, 85, 87, 88

Eye (see also Sense organs), 411,413, 415, 417-419, 421-423, 425, 442

Accessory structures, 419, 421,422

Canthus, 419, 422

Choroid, 415, 417, 418

Cranial nerves, motor, sensory, 403

Exteroceptor (receptor), 411, 413

Eyeball, 415, 417, 418, 421, 422

Histologic type of cancer, 442

Lymphatic drainage, 46, 74, 423, 425, 426

Melanoma of, 39, 43, 423

Proprioceptor (receptor), 413

Retina, 415, 417, 418

Sclera, 415, 417, 418

Tumors of, 423, 425, 426, 442

Eyeball, 419, 421, 422

Composition of, 419

Face and/or lymphatic drainage from, 39, 46, 65, 66, 158

Facial, 360, 363, 365

Bone (facial), 360, 363, 365

Conchae, 360, 363, 365

498
Facial (continued)

Lacrimal, 360, 363, 365

Mandible, 360, 363, 365

Maxilla, 360, 365

Muscle (cranial nerves, motor, sensory), 403

Nasal, 360, 363, 365

Nerve (VII), 399, 402, 403

Palatine, 360, 363, 365

Sensations from, 403

Zygomatic/malar, 360, 363, 365

Fallopian tube (uterine tube, oviduct), 273, 275-277, 281, 282

Composition of, 282

Fimbria, 281, 282, 287, 288, 307

Oviduct (uterine tube), 282, 288

Structure of, 288

Walls of, 288

Familial polyposis, 222

Fascia, 243, 261,331, 381,383, 384, 386, 389, 390

Denonvilliers', 317

Endothoracic, 302

Gerota's (renal), 243

Pectoral, 297

Rectovesical, 261

Fat (adipose tissue), 243, 289, 291, 294, 297, 302, 441

Pericolic (mesenteric) and/or tumor nodules in, 221

Fat, digestion of, 57, 211,215, 229, 237

Feet, acral lentiginous melanoma of, 40, 43, 45

Skin of, 23

Female reproductive system (see also specific organs), 273, 275, 277, 279-295, 297,

299-305, 307, 308, 329

Feminizing (estrogen-producing) tumor, 285

Femur (thigh), 351,353-356, 367-369, 373

Fertilization, 282, 283

Fetal adenoma, 331

Fibrinogen, 115

Fibrosarcoma, 36-38, 285, 368, 371,375, 386, 441

Primary site for, 441

Fibrous tissue (see also Ligament, Tendon), 104, 143, 147-149, 281, 305, 309, 313, 404

Fibroxanthoma, 35

Fibula (leg), 351, 367, 369, 373

Filtration functions of kidney, 243, 247-249, 251, 252, 268, 269

Fimbria(e), 281, 287, 288, 307, 308

Flat bones, 351, 353, 354, 356, 361,368, 375

Flexor muscle, 385, 389

Floor of mouth,

Lymphatic drainage from, 74

Fluid balance (see also Urine formation), 249, 333

Follicle-stimulating hormone (FSH), 336, 338

499
Follicular adenocarcinoma, 331, 337

Forearm, lymphatic drainage of, 46, 85, 87, 88

Forebrain, 397, 399

Basal ganglia, 397

Cerebral cortex, 397

Cerebral hemisphere, 397

Cerebrum (telencephalon), 397

Diencephalon, 397

Epithalamus, 397

Hypothalamus, 397

Olfactory bulbs (rhinencephalon), 397

Thalamus, 397

Forehead (bone) and/or lymphatic drainage from, 46, 135

Frontal (cranial bone), 343, 354, 359, 365

Frontal,

Cranial bone, 135, 138, 351, 359, 363-365, 372, 375

Lobe of cerebrum, 397

Paranasal sinus, 135, 138

Plane, coronal, 12

Gallbladder, 10, 165, 215, 229, 233, 235, 334, 441

Bile, 215, 229, 230, 233, 236

Ducts, 229, 230, 233, 236, 240

Function of, 236

Histologic type of cancer, 441

Tissue layers, 233

Tumors of, 233

Gamma globulin (antibodies), 54, 62, 67

Ganglia, thoracolumbar, sympathetic, and basal, 397, 401

Ganglioneuroma, 333

Gastrin hormone, 334

Gastrinoma, 237

Gastrointestinal tract (see Anus, Colon, Digestive system, Esophagus, Intestine, Mouth,

Pharynx, Rectum, Stomach), 165, 166, 168, 169, 215, 220

Genitourinary organs (see also Urinary and Reproductive system), 36

Germ cell tumor, 285, 292, 294, 295, 323, 423

Gerota's (renal) fascia, 243

Giant cell tumor, 368

Giant hairy nevus, 39

Gland (see also specific gland), 273, 274, 281,288, 289, 297, 299, 302-305, 309, 313, 319,

328-339, 405

Accessory, skin, 27

Adrenal (suprarenal), 14, 81, 329, 333-339

Bartholin's (greater vestibular), 289, 292, 294

Breast, 273, 297, 299-305

Bulbourethral (Cowper's gland), 289, 309, 318-320

Ceruminous, 27, 29-31, 33-35

500
Gland (see also specific gland) icontinued)

Cervical, 274

Ductless, 281, 329, 335, 336, 338, 339

Endocrine, 281, 328, 329, 335, 336, 338, 339

Exocrine, 329

Female gonads, 281, 307, 308

Hypophysis, 338

Male gonads, 309, 311, 312

Mammary, 27, 273, 297, 299-305, 330

Master, 329

Mucous, 157, 159, 160, 185, 205, 210, 289, 291, 294

Ostia of gland, 177, 183, 184, 188

Ovarian (graafian follicle), 281, 329, 336

Ovoid, 309

Pancreas, 337

Parathyroid, 328, 332, 336, 337

Parotid, 74, 185, 189, 403

Pineal, 328, 332, 337, 339, 397

Pituitary, 281, 329, 330, 335, 337, 339, 397, 405

Prostate, 309, 313, 317-320, 323

Pyloric, 211

Salivary, 139, 165, 169, 177, 185, 187-189

Sebaceous, 27, 29-31, 33, 34, 36

Seminal vesicles, 309, 313, 317, 319, 320

Skene's, 289, 292, 294

Stomach, 334

Sweat (sudoriferous), 27, 29-31, 33, 34, 36, 115, 297, 329

Testes, 336

Thymus, 53, 54, 56, 67-70, 77, 334, 337, 339

Thyroid, 68, 74, 77, 328, 329, 331, 337-339

Tumors of, 331

Glans penis, 289, 321

Glial cells (Neuroglia), 393, 404

Glioblastoma (multiforme), 404, 407, 408, 442

Primary site for, 442

Gliomas, 404

Glomerulus (glomeruli) capsule, 249, 251, 252, 268-270

Capillaries, 249, 252

Glossoepiglottic fold and/or sulcus, 194

Glossopalatine fold (anterior tonsillar pillar), 194, 201, 202

Glossopharyngeal nerve (IX), 399, 402, 403

Glottic region (see also Larynx), 145, 148, 161, 162

Cartilage (Thyroid, Arytenoid), 144

Commissures, 144

True vocal cords, 143-145, 148, 161, 162

Glucagon and/or glucagonoma, 237

Glucocorticoids, 329

Glucose, 211, 214, 229, 249

501
Glycogen, 229

Gonadotrophic hormone (ICSH), 329

Chorionic, 329

Male, 329

Gonad (see Ovary and Testis)

Graafian follicle (see Ovary), 281

Granuloma (see also Hodgkin's disease), 90

Granulosa (theca) cell tumor, 441

Primary site for, 441

Grawitz's tumor, 253, 256

Groin and/or lymphatic drainage from, 65, 66, 85

Growth hormone (GH), 329

Gum (gingiva) (see also Mouth), 165, 169, 178-180, 183, 184, 191

Alveolar process and ridge, 179, 180, 189

Lymphatic drainage from, 189, 191, 192

Process (mandible, palatine), 178, 181, 183, 184

Tumors of, 169

Gustatory (Taste) sense organ, 427

Hair (see also Integumentary system), 23, 27, 31,285, 323

Hamstring muscle, 385, 390

Hand, 31, 46, 85

Lymphatic drainage of, 85

Skin of, 22, 23, 40, 43, 45

Hard palate (see Palate)

Haustra (sac), 220

Haversian system of the bone, 347, 355, 356, 358

Head and neck, 12, 50

Anterior deep cervical nodes, 74

Axillary nodes for neck, 46

Cervical lymph nodes, 46, 62, 65, 66, 74-76, 135, 139, 145, 189, 192, 193, 203, 205

Facial lymph nodes, 74, 189, 191, 192

Internal (upper deep) jugular lymph nodes, 71, 74-76, 135, 139, 145, 189, 191-193

Laterotracheal lymph nodes, 74

Lymphatic drainage from, 46, 189, 191, 192

Mastoid (postauricular) lymph nodes, 74

Occipital lymph nodes, 74

Parotid (infra-auricular, preauricular) lymph nodes, 74, 189

Prelaryngeal lymph nodes, 74

Pretracheal (prelaryngeal) lymph nodes, 74

Recurrent laryngeal lymph nodes, 74

Regional lymph nodes, 46

Retropharyngeal nodes, 135, 189, 191-193

Spinal accessory (posterior cervical) lymph nodes, 74-76

Sublingual lymph nodes, 189

Submandibular (submaxillary) lymph nodes, 74, 75, 135, 139, 189, 191-193

Submental lymph nodes, 65, 66, 74, 135, 139, 189

Supraclavicular (transverse cervical) lymph nodes, 74, 76, 189, 192

Hearing (sense of), 403

502
Heart (see also Cardiovascular system)

Aorta, 249

Apex, 103, 107, 108

Atria (left, right), 103, 105, 107, 108

Atrioventricular orifice, node, and/or function, 103

Blood supply to, 103

Blood, 99-103, 105, 107-115, 117-119, 121, 122, 124-128, 135, 154

Chambers, 103, 104, 107, 108

Circuit (pulmonary, systemic), 99, 101-103, 105

Circulation, 99, 100, 103, 105, 112-114

Clot, 115, 119, 121, 122

Endocardium, 104

Epicardium, 104, 108

Failure, 112

Flow through, 100, 105

Motor function of, 333, 403

Myocardium (muscle), 99, 103, 104, 377, 399, 401

Orifices (see also Valves), 103

Pericardial fluid, 104

Pericardium (outer surface, parietal peritoneum, sac), 77, 103, 104, 107, 108, 157

Portal system, Venous system, 99-105, 107-112, 114, 115, 119

Pulmonary circuit, 111

Pulmonary trunk, 105

Pump, as a, 99, 103, 105, 107, 108

Sensations from, 403

Sinoatrial node, 103

Valve, semilunar (aortic, pulmonary), 103, 105, 110

Valves, mitral (bicuspid), tricuspid, 103, 105, 110

Ventricle (left, right), 103, 105, 107, 108, 110

Heel, lymphatic drainage of skin, 46, 85

Hemangioblastoma, 405

Hemangioma, 35, 229

Hemangiosarcoma (primary site for), 441

Hematopoiesis, 62, 66, 68

Henle, descending loop of, 247

Hepatic flexure, 219, 229

Hepatocellular carcinoma, 229, 232

Hepatoma, 229, 232

Primary site for, 441

Hiatus, 203, 208

Hilus (lung), 153, 156, 157

Hindbrain (rhombencephalon), 397, 399

Cerebellum, 399

Cerebrum, 398

Medulla oblongata, 399

Pons, 399

Hip, and/or lymphatic drainage from, 39, 46

Histiocyte (see also Cells, reticuloendothelial), 61, 67

503
Histologic type of cancer, 439-441

Histologic type/Primary site, 439-441

Hodgkin's disease, 90-92, 211, 445

Lymphocytic depletion (LD), 90, 92

Lymphocytic predominance (LP), 90, 92

Mixed cellularity (MC), 90, 92

Nodular sclerosis (NS), 90, 92

Primary site for, 441

Reed-Sternberg cells, 90, 92

Stomach, 211

Unclassified (NOS), 90

Homeostasis (see also Cardiovascular system), 99, 102

Horizontal (transverse) plane, 10

Hormone, 281, 329, 330, 332-336, 338, 339

ADH (see antidiuretic), 330

Adrenalin, 333

Adrenocorticotrophic (ACTH), 329

Aldosterone, 333, 338

Androgen, 333, 336, 338

Antidiuretic (vasopressin) (ADH), 330

Catecholamine, 333

Cell-stimulating (interstitial), 329

Chorionic gonadotrophin, 281, 334

Cortisol, 333, 336, 338

Epinephrine, 333, 336

Estradiol, 281

Estrogen, 281, 329, 333, 336

Estrone, 281

Female luteinizing (LH), 329

Gastrin, 334

Gonadotrophic, male, interstitial cell-stimulating (ICSH), 329

Growth or somatrophic (GH or STH), 329

Insulin, 336, 338

Melanocyte-stimulating (MSH and ACTH), 330

Melatonin, 332

Norepinephrine, 333

Ovarian produced, 281

Oxytocin (pitocin), 330

Parathormone, 332, 336, 338

Progesterone, 281

Progestin (progesterone), 281, 333

Prolactin (luteotrophic) LTH, 330

Secretin, 334

Steroids, 333, 336

Testosterone, 309, 312, 318

Thyrocalcitonin, 331

Thyrotrophic (thyroid-stimulating) TSH, 329

Thyroxin, 329, 331,336, 338

504
Hormone (continued)

Tri-iodothyronine, 329, 331

Humerus (upper arm), 351, 356, 367-369, 373

Tumors of, 368

Hurthle cell adenoma, 331

Hutchinson's freckle, 40, 43, 45

Hydrogen-ion concentration (pH), 99, 102, 249

Hymen, 289, 292, 294

Hyoid bone, 359, 364, 365

Hyper-, 15, 16

Hypernephroma, 253, 256, 441

Histologic type of cancer, 441

Hyperplasia and Hypertrophy (prostate), 318

Hypo-, 15, 16

Hypochondriac region, 14

Hypogastric region, 14

Hypoglossal nerve (XII), 399, 402

Hypopharynx (laryngopharynx), 139, 142, 143, 161, 162, 193, 195, 197-200, 203

Anatomical limits, 195

Aryepiglottic fold, 195, 201, 202

Functions of, 195, 199, 200

Tumors of, 198

Hypophysis, (see Pitituary gland) 329

Hypothalamus, 329, 397

ICD-O (International Classification of Diseases for Oncology), 39, 170, 194, 301, 302, 386

ICSH (see Interstitial cell-stimulating hormone), 329

Ileocecal valve, 215, 219

Ileum (small intestine), 68, 215, 218, 219

Extranodal lymphoma, 94, 96

Lymphatic drainage from, 81

Tumors of, 215

Iliac crest (see Inguinal)

Immunity, lymphatic defense in, 54, 68, 334

Immunotherapy, 68

In situ carcinoma (noninfiltrating intraductal), 305

Incidence (SEER Tabulation), 223

Inferior (caudal) plane, 12, 14

Inflammatory carcinoma, 305

Inguinal (iliac) regions, 14, 65, 66

Inspiration (inhaling), 131

Insulin secretion, 237, 336, 338

Insulinoma, 237

Integumentary system (skin), 21,243, 297, 442

Accessory organs (appendages), tumors of, 27, 33, 34

Adenocarcinoma of, 36

Basal cell layer (stratum basale), 39

Basement membrane (basal lamina), 22, 41

Ceruminous glands, 27, 30, 31, 33-35

505
Integumentary system (skin) (continued)

Clear-cell layer (stratum lucidum), 22

Cornified-cell layer (horny) (stratum corneum), 22

Dermis (connective tissue, corium), 21-23, 25, 26, 31, 33-38, 40, 41, 44, 45

Epidermis (epithelium), 21, 23, 25-27, 31, 36, 40, 41, 43

Epithelial tissue (see also Epidermis), 27, 36

Glands, glandular epithelium, 21, 23, 27, 29-31, 33-35

Granular-cell layer (stratum granulosum), 22

Hair, 23, 27, 31

Histologic type of cancer, 441, 442

Intraepidermal (in-situ), 41, 44, 45

Lymphatic drainage from, 46, 47, 49, 50, 57

Malignant melanoma, 36-41, 43-45

Nails, 27, 31, 39, 43, 45

Papillary (stratum papillare), 23, 33, 41, 44

Papillary-reticular dermal interface, 41, 44, 45

Perianal skin, 219

Pigmentation (melanin), 21, 26, 332

Prickle-cell layer (stratum spinosum), 22

Reticular (stratum reticulare), 23, 33, 34, 41, 44, 45

Sebaceous glands, 21, 23, 27, 30, 31, 33-36

Subcutaneous tissue, 23, 41, 44, 45

Sweat (sudoriferous) glands, 21, 23, 27, 30, 31, 33-36

Topography code for, 39

Tumors of, 35-37, 40, 94, 442

Inter-, 15, 16

Internal, 13

Organs, 10

Respiration (see also Metabolism), 131, 161, 162

International Classification of Diseases for Oncology (ICD-O), 301, 302, 386

Interstitial (tissue) fluid, 57, 63, 66

Interstitial cell-stimulating hormone, 309, 311, 312

Intestine (see also Digestive system), 10, 12, 69, 70, 165, 166, 168, 209, 211, 215, 217-220,

225, 226, 239, 240, 332, 377, 441

Alimentary canal (GI tract), 165, 166, 168

Appendix, 94

Blood supply to, 221

Functions of, 217-219

Gastrointestinal tract, 166, 168, 220

Hepatic flexure, 219, 229

Histologic type of cancer, 441

Hormone secretions by, 332, 334

Ileocecal valve, 215, 219

Large (see also Anus, Colon, Rectum), 10, 65, 66, 81, 85, 215, 219-221, 223, 225,

226

Lymphatic drainage from, 65, 66, 81, 221, 222

Mesentery, 62, 65, 66

Muscle, smooth, 377

506
Intestine (see also Digestive system) (continued)

Peristaltic motion, 215

Peyer's patches, 53, 56, 68-70, 215, 221

Portal system, vein, 100, 112-114, 221

Rectum, 81

Small (see also Duodenum, IIeum, Jejunum), 10, 12, 53, 57, 65, 66, 68, 94, 96, 165,

166, 168, 209, 215, 217-220

Splenic flexure, 81,219, 227

Tissue layers of (see also Digestive system), 166-168

Tumors of, 94, 96, 166, 215, 217, 218, 221-223

Villi, 215, 220

Wall of (structure), 166

Intra-, 15, 16

Intracanalicular fibroma (cellular), 305

Intradermal nevus, 35, 39

Intraductal (adeno) carcinoma, 305

Intraepidermal (in-situ, squamous cell) carcinoma, 36-38

Involuntary muscle, 377, 389, 390

Iron, 229

Irregular bones, 347, 351, 356, 359, 360

Structure of, 351, 356

Ischium (see Pelvis)

Islet cell tumor, 237

Islets of Langerhans, 237, 329

Isthmus (thyroid), 331

Jejunum (small intestine), 215, 218, 334

Lymphatic drainage from, 81

Joint, 343, 381

Amphiarthrosis (slightly movable), 343

Connective tissue, 381, 385, 389, 390

Diarthrosis (freely movable), 343

Proprioceptor (receptor), 411, 413, 414

Synarthrosis (immovable), 343

Jugular vein (external, internal, see also Lymph node), 57, 71, 135, 139, 144, 169, 193

Junctional nevus, 35, 39

Juxta-, 15, 16

Kaposi's (multiple idiopathic hemorrhagic) sarcoma, 36-38

Keratin (keras), 22, 31

Kidney (see also Urinary system), 10, 14, 115, 229, 242-247, 249, 252, 253, 255-257,

260-263, 265, 266, 268, 270, 329, 330, 332, 333, 336, 441

Afferent, efferent, 249

Arterioles (afferent, efferent), 249

Bowman's capsule, 249, 252, 268, 270

Calyx (calyces), 243, 247, 249

Capillaries, 249, 251, 252

Capsule (renal), 247, 249, 252, 270

Cortex, 243, 247, 251, 252

Electrolyte balance, 249, 252

507
Kidney (see also Urinary system) (continued)

Excretion of waste products, 115, 229, 243, 247, 249, 251, 252, 268, 269

Fascia (Gerota's), 243

Filtration, 243, 244, 248, 249, 251, 252, 268, 269

Function of, 243, 251, 252

Glomerulus (glomeruli) capsule, 249, 251, 252, 268-270

Histologic type of cancer, 441

Location of, 243

Loop of Henle (tubule, convoluted, distal), 2.,47,249

Lymphatic drainage from, 81,255-257

Medulla, 243

Nephron, 247, 248, 252, 268, 270

Parenchyma, 243, 246, 253, 255, 256

Parenchyma, histologic type of cancer, 441

Parenchyma, Tumors of, 253, 255, 256

Reabsorption, 249

Regional, 263

Renal corpuscle, 247

Renal pelvis, 242-244, 246, 247, 249, 251, 253, 255

Renal pelvis, tumors of, 253

Secretions, 249

Structure of, 243, 244

Tissue layers, 243, 244, 259-262

Tubule, distal, 249

Tubule, Peritubular capillaries, 249

Tumors of, 256

Urine, production of, 249

Waste products, 249, 251, 252

Knee, popliteal lymph nodes, 85

Krukenberg (metastatic) tumor, 211,285

Labia majora (large lips), 289, 291,294

Labia minora (small lips), 289, 291,292, 294

Labial mucosa, 170, 172, 181

Lacrimal apparatus, 360, 419

Accessory structures (eyebrows, lashes, lids), 419, 421,422

Bone (facial), 360, 365

Canthus, 419, 421, 422

Duct, 419

Gland, 419

Sac, 419

Lactation, 330

Lacteals (see also Lymphatic system), 57

Lactiferous duct, 297

Lacunae, 347, 355

Lamina propria (see also Digestive system), 166, 168, 169, 178, 205, 210, 215, 220, 244,

257, 260, 262, 265, 266, 274

Bladder wall, 262, 265, 266

Corpus uteri, 274

5O8
Lamina propria (see also Digestive system) (continued)

Renal pelvis, 244, 260

Ureter, 257

Large cell (undifferentiated carcinoma), 157

Laryngopharynx (see Hypopharynx)

Larynx (see also Respiratory system), 131, 134, 139, 144, 161, 162, 193, 195, 199, 200, 441

Arytenoid (see Cartilage), 148

Blood supply to, 144

Cartilage, 143, 147, 149, 162

Composition of, 143

Cricoid cartilage (see Cartilage), 148

Epiglottis (see Cartilage), 148

Histologic type of cancer, 441

Lymphatic drainage from, 144

Motor functions of, 403

Subsites of, 143, 144, 147, 148

Thyroid cartilage (see Cartilage), 148

Tumors of, 145

Vocal cords (false, true), 143, 147, 148, 158, 161, 162

Lateral plane, 9, 12, 14-16

Leg (fibula, tibia) bones, 351, 367, 369, 373, 381

Leg and/or lymphatic drainage from, 46, 85

Leiomyoma, 211

Leiomyosarcoma, 205, 211,215, 218, 264, 277, 386, 389, 390, 441

Primary site for, 441

Lentigo maligna melanoma (Hutchinson's freckle), 40, 43, 45

Leukemia (leukocytosis), 123-128, 445-461, 463-468

Acute, 124, 126

Aleukemic (subleukemic), 124

Blastic (undifferentiated), 123, 124

Chronic, 124, 126

Classification of, 126

Clinical manifestations, 123, 124, 126

Di Guglielmo's disease (erythroleukemia), 124

Diagnosis of, 124

Granulocytic, 123, 126

Leukopenia, 124

Lymphatic (lymphocytic), 123, 126

Monocytic, 123, 126

Multiple primaries and, 446-461, 463-468

Myelocytic (myelogenous), 123

Plasma cell, 124

Primary site for, 442

Stem cell (undifferentiated), 123, 124

Subacute (aleukemic), 124, 126

Subleukemic (aleukemic), 124

5O9
Leukocyte (WBC),

Agranular, 119

B-Cells, 54

Development (leukopoiesis) of, 123, 124

Differentiated (mature, specialized), 123

Granulocyte (granular, polymorphonuclear), 119, 123, 124

Immature (blast) unspecialized, 123, 126

Lymphoblast, 123, 124

Lymphocyte, 53, 54, 61, 62, 67, 68, 119, 123, 124

Metamyelocyte, 123, 124

Monoblast, 123, 124

Monocyte (phagocyte), 67, 119, 123, 124

Mononuclear, 119

Myeloblast, 123, 124

Myelocyte, 123, 124

Proliferation of, 126

Prolymphocyte, 123, 124

Promonocyte, 123, 124

Promyelocyte, 123, 124

Stem cell, 123, 124

T-cell, 54, 68-70

White cell differential, 119

Leukocythemia (see Blood)

Leukocytosis, 124

Leukopenia, 124

Levators/elevator muscle, 385

Leydig (interstitial) cell, 309, 312, 326, 329

LH (luteinizing hormone), 329

Ligaments (anterior, posterior, round), 143, 277, 281, 282, 297, 302, 381, 383, 384

Broad, 277, 281, 282

Circular, 277

Cooper's (suspensory), 297, 302

Mesovarian, 281

Ovarian (mesovarian), 281

Suspensory, 297, 302

Uterosacral, 277

Lingual tonsil, 68, 94, 173, 174, 193, 201, 202

Lingula (lung), 153

Linitis plastica, 211

Lip, 165, 167-169, 171, 179, 180, 184, 185

Commissure (mouth corners), 170-172, 189

Definitions (American Joint Committee on Cancer), 170

Labial mucosa (mucous membrane), 170, 172, 181

Lymphatic drainage from, 46, 74, 189, 191, 192

Skin of (topography code), 39

Tumors of, 170-172, 174, 181

Vermilion border, 39, 170, 172

Lipase, 211, 237

510
Liposarcoma (primary site for), 441

Liver, 10, 54, 112, 114, 115, 165, 210, 219, 229, 329, 441

Arterial blood, 112, 230

Blood supply to, 112

Cell carcinoma, 229, 441

Histologic type of cancer, 441

Lobes (caudate, quadrate, right), 229, 233

Lymphatic drainage from, 77, 229

Phagocytosis of erythrocytes in, 229

Portal system veins, 112, 210, 221, 237

Sinusoids, 112

Tumor and/or metastatic to, 43, 45, 112, 211, 229-232

Lobular (adeno) carcinoma, 305

Location reference terms, 9, 12-16

Long bones, 351, 368, 375

Structure of, 356-358

Tumors of, 368

Loop of Henle, 247

Lower extremity bones, 367

LTH (luteotrophic) hormone, 330

Lumbar region (lower back), 14, 57, 243, 245, 246

Lymphatic drainage from, 85

Lung (see also Respiratory system, Bronchus), 13, 99, 101-103, 108, 110, 111, 115, 117,

118, 131, 134, 135, 138, 149, 152-156, 159-161, 193, 403

Alveolar sac, 154

Alveoli (see also Alveolar), 154, 157

Apex, 153

Bronchioles, 154, 157, 161,162

Clinical manifestations (diagnosis of carcinoma), 158

Cranial nerves to, 399, 403

Excretion of waste products, 115

Hilus, 153, 156, 157

Histologic type of cancer, 441

Intrapulmonary bronchi, 149

Lingula, 153

Lobes (lower, middle, upper), 153, 155, 156, 161, 162

Lumen of the bronchus, 157

Lymphatic drainage from, 77, 157

Mesothelium (see also Pleura), 157

Metastasis to, 157, 211

Motor functions of, 403

Mucosa (bronchial, epithelial), 157

Pleura (mesothelium, parietal, visceral), 10, 13, 153, 156, 157, 160-162

Pleural cavity and/or interpleural space, 153, 159, 162

Pleural effusion, 158

Respiratory, 131

Sensations from, 403

Tumors of, 157, 441

511
Luteal cell, 281

Luteinizing hormone (LH), 330

Luteotrophic hormone, 330

Lymph (see also Lymphatic system), 77

Lymph nodes, 12, 46, 71, 81,135, 139, 145, 154, 158, 159, 189, 191, 205, 253, 255-257,

259, 263, 265-267, 281, 282, 288, 301-304, 331, 423, 441

Abdominal (see also Abdomen), 12

Abdominal pelvic lymph nodes (see also Abdomen), 81

Accessible, 62, 71-73

Anterior deep cervical, 74

Aortic (para-, peri-, lateral), 81, 84, 229, 255, 256, 277, 281, 282, 288, 290, 322

Auricular (pre- and infra-auricular), 423, 425, 426

Axillary, 46, 49, 50, 62, 65, 66, 85, 87, 88, 302-304

Bladder, 263, 265, 266

Breast, 302

Buccal, 46, 65, 66, 74, 191, 192

Buccinator, 46, 74, 189, 191, 192

Capsule, 61

Carinal (see Tracheobronchial), 77

Caval (paracaval, lateral) node, 256, 322

Cecal (cecum), 215, 221-222

Celiac, 81, 210, 237

Cervical (anterior deep, para, upper cervical), 331

Cervical (see also Head and Neck), 62, 65, 66, 74-76, 135, 139, 145, 189, 192, 193,

205, 423

Cervix uteri, 277, 280

Chains, groups of, 71

Cloquet's, 290

Colic (colon, left, middle, right), 221, 227-228

Composition of, 63

Contralateral, 302

Corpus of uterus, 277, 280

Cystic, 215

Delphian, 331

Diaphragmatic, 77, 79, 80

Distant, 71, 81, 189, 191, 192

Epicolic, 221-222

Epiploic.(Foramen of Winslow), 210, 233

Epitrochlear, 46, 49, 50, 65, 66, 85, 87, 88

Extremities (lower, upper), 46, 49, 50, 85, 87, 88

Facial (buccinator, infra-orbital, maxillary, submandibular), 46, 189, 191, 192, 439

Fallopian tubes, 282, 286, 288

Femoral (superficial inguinal), 46, 49, 50, 85, 87, 88

Functions of, 62, 66

Gastric (inferior, left, right, superior), 81, 84, 205, 214

Head and neck (see also Head and neck for specific nodes), 46, 49, 50, 73, 74,

189

Hemorrhoidal (middle, inferior, superior), 221, 227-228

512
Lymph nodes (continued)

Hepatic, 81,229

Hilar (see also Tracheobronchial), 77, 160, 229, 256

Histologic type of cancer, 441

Hypogastric (see also Mac), 65, 66, 81, 277, 281, 282, 288, 290, 322

Ileocolic, 227, 228

Iliac (common, external, hypogastric, internal), 65, 66, 81, 84, 263, 265, 267, 277,

282, 288, 290, 322

Inaccessible, 71-73

Infra-auricular (see also Facial), 46, 74, 189, 191, 192, 423

Infra-orbital (see also Facial), 46, 74, 189, 191, 192

Inguinal (deep, superficial), 46, 49, 50, 65, 66, 85, 87, 88, 267, 281,282, 288, 290,

322, 325

Intercostal, 65, 66, 77, 79, 80

Internal (upper and lower deep) jugular, 331

Jugular (internal, upper and lower deep cervical), 71, 74-76, 135, 139, 145, 189,

191-193, 331,427, 431,436

Jugulo-omohyoid (see Jugular), 139, 427

Jugulodigastric (see Jugular), 139, 331,427

Kidney, 257, 259

Laryngeal (prelaryngeal, pretracheal, laterotracheal), 331

Laterotracheal (anterior deep cervical, recurrent laryngeal), 74

Lingual, 74

Lymphatic drainage from, 57, 58, 71, 74, 85, 87, 189, 205, 222, 229, 277, 288, 423

Mammary (internal, parasternal) (see also Gland), 46, 77, 79, 80, 301-304

Mastoid (postauricular), 46, 74

Maxillary (see also Submandibular), 46

Mediastinal (anterior, posterior), 68, 77, 79, 80, 154, 158, 160, 205, 229, 331

Mesenteric (inferior, superior), 62, 65, 66, 71, 81, 84, 221,227, 228, 233

Metastasis, 62, 145, 281

Nasal fossa, 135

Nodules in pericolic fat, 221

Obstruction, 62

Obturator, 265-267, 281

Occipital, 46, 74

Ovary, 281, 286, 288

Para-aortic, 81, 256, 277, 280-281

Paracervical, 277, 280

Parametrial, 277, 280

Parietal, 77, 79-81, 83, 84

Parotid (infra-auricular, preauricular), 49, 50, 74, 189, 436

Pelvic, 81

Penis, 322

Periaortic (aortic), 84, 229

Peribronchial, 154

Pericardial, 229

Periprostatic, 322

Peritracheal (see Tracheobronchial), 77

513
Lymph nodes (continued)

Perivesical, 263

Phagocytosis, 62

Popliteal, 46, 49, 50, 85, 87, 88

Postauricular (see also Mastoid), 46, 74

Preauricular, 46, 74, 423, 426

Prelaryngeal (see also Cervical), 46, 145

Pretracheal (prelaryngeal), 74

Prostate, 322, 325

Recurrent laryngeal nerve chain, 74

Regional, 71, 74, 77, 81, 145, 154, 189, 211,212, 214, 227, 228

Retroperitoneal (NOS), 81, 84, 282

Retropharyngeal, 74, 135, 189, 191-193, 331, 436

Rosenmuller's, 290

Sacral, 65, 66, 81, 84, 263, 277, 280-281,282, 288, 290, 322

Sigmoidal (colon), 221

Skin, 46, 47, 49, 50, 74, 85

Spinal Accessory (posterior cervical), 46, 75, 76

Splenic, splenic hilar, 81, 84, 214

Structure of, 61

Sublingual (lingual), 74, 189

Submandibular (submaxillary), 46, 49, 50, 74-76, 135, 139, 189, 191, 192, 423, 426,

431

Submental, 46, 65, 66, 74, 135, 139, 189, 427

Supraclavicular (transverse cervical), 74, 76, 189, 192, 304

Testes, 322

Thorax (see also Chest wall), 50, 77, 79, 80

Tracheobronchial (carinal, hilar, peritracheal), 77, 79, 80

Transverse cervical (see also Supraclavicular), 49, 50, 74-76, 189, 192, 304

Tumors of, 89, 91, 92, 94

Ureter (periureteral), 257

Urethra (pelvic, NOS), 267

Uterus, 277

Vagina, 290

Visceral, 77, 79-81, 83, 84

Vulva, 290

Lymphangiography, 71, 73

Lymphangioma (lymphangiosarcoma), 35, 89

Lymphangiosarcoma, histologic type of cancer, 441

Lymphatic (collecting) system, 205, 210, 215, 221

Capillary network, 53

Drainage (see also specific organs), 46, 49, 57, 58, 71, 74, 85, 87, 189, 193, 205,

221, 222, 229

Ducts (right, lymphatic, thoracic), 57, 59, 60, 221

Function of, 57, 62, 65-67

Interstitial (tissue) fluid, 57, 63, 66

Lacteals, 57

Lymph node (see specific Lymph node), 46, 49, 50

514
Lymphatic (collecting) system (continued)

Lymphocytes (B-cells, T-cells), 53, 54, 61, 62, 67, 68

Metastasis (distant, regional node), 211

Organs and lymphoid tissue, 55, 56, 61, 62, 67, 68, 71, 89, 91, 92, 119, 193

Retrograde flow of, 57, 62, 157

Trunk (main), 57, 59, 60

Tumor (extranodal, nodal) of, (see also Lymphoma), 71, 89, 91, 92, 94, 211

Valves (semilunar), 57

Vessels (veins), 53, 57, 59-61, 63, 71, 89

Lymphatic drainage from, 253, 255-257, 263, 331

Bladder, 263

Cecum, 221

Colon (ascending, sigmoid, transverse), 222

Ear, 436

Kidney, 255, 256

Liver, 77, 229

Ovary, 81

Rectum, 222

Renal pelvis, 255, 256

Small intestine, 215

Thymus, 334

Ureter, 257

Uterus, 81

Vagina, 81

Vessels (veins), 244, 262

Lymphatic vessels,

Functions of, 57, 63

Internal jugular vein, 57

Structure of, 57, 59, 60

Subclavian vein, 53, 56, 57

Tumors of, 89

Lymphocytes (hematopoiesis), 334

B-cells, 54, 356

T-cells, 54, 68-70, 334

Lymphoepithelioma, 139, 427

Lymphoid (lymphatic) tissue, 55, 56, 61, 62, 67, 68, 119, 141, 142, 161, 162, 173, 174, 193,

215, 221

Tumors of, 71, 89, 91, 92, 94, 174, 195, 211, 215, 218, 221

Lymphoid tissue and organs (see also Lymphatic System), 334

Lymphoma (malignant), 432

Lymphoma, 54, 135, 139, 218, 441, 445-447, 449-461, 463-468

Base of tongue (lingual tonsil), (see Waideyer's ring), 94

Differentiation, 96

Extralymphatic (nodal), 94-96

Extranodal, 94, 211

Hodgkin's disease, 91, 92, 445

Multiple primaries and, 445-447, 449, 450, 452-461, 463-468

Mycosis fungoides, 36-38, 94

515
Lymphoma (continued)

Nasopharynx (pharyngeal tonsil), (see Waldeyer's ring), 94, 139

Non-Hodgkin's, 92, 95, 96

Oropharynx (palatine tonsil), (see Waldeyer's ring), 94

Primary site for, 441

Skin (see Extralymphatic), 94

Small intestine (ileum) and appendix, (see Extralymphatic), 94, 96, 215, 218

Stomach (see Extralymphatic), 94, 96, 211

Lymphopoiesis (hematopoiesis), 66

Lymphosarcoma, 174, 427, 441

Primary site for, 441

Macrophage, 68

Male reproductive system (see also specific organs), 309, 311, 312, 315-322, 325, 326

Mammary gland (see also Breast), 273, 297, 301, 302, 330

Mandible (facial bone), 177, 178, 185, 360, 365

Marrow, bone (see bone marrow), 343, 346, 355-358, 368

Masculinizing (arrhenoblastoma) tumor, 285

Mastication, muscles of, 403

Maxilla (upper jawbone), 14, 135, 178, 360, 365

Maxillary (see also Submandibular), 46, 49, 50, 74, 181, 183, 184

Maxillary sinus (antrum of Highmore), 135, 138

Medial (median, midsagittal) plane, 9, 10, 12, 14-16, 153

Mediastinum, 10, 103, 108, 153, 157, 161, 162, 203

Nodes, enlarged, 158

Medulla (see also Adrenal gland, Bone, Brain, Kidney), 243, 247, 331, 333

Medulla oblongata, 399

Medullary (adeno) carcinoma, 305

Medullary bone cavity, 355, 356, 358, 368

Medullary carcinoma, 331

Medulloblastoma, 404, 442

Primary site for, 442

Megakaryocyte (large cell), 119

Melanocytes (melanin), pigment cells, 23, 26, 35, 36, 39, 40, 330

Melanoma (malignant), 36, 38, 40, 45, 135, 423, 425, 426, 432

Acral lentiginous, 40, 43, 45

Amelanotic (nonpigmented), 36

B-K moles (familial), 39

Clark's Classification, 41, 44, 45

Classification (histologic type), 39, 40, 43

Depth of invasion (level, thickness), 40, 41, 44

Eye, 39, 43

Lentigo maligna (Hutchinson's freckle), 40, 43, 45

Nodular, 40, 43, 45

Primary site for, 442

Radial (superficial spreading), 40, 43, 45

Subungual, 39, 40, 43

Superficial spreading, 40, 43, 45

Unclassified, 40

516
Melatonin hormone, 332

Membrane, 10, 143, 243, 244, 257, 259, 262, 404

Basement (basal lamina), 22, 41, 244, 259, 262

Bladder, 262, 265, 266

Conjunctiva of eye, 415, 419

Frenulum of tongue, 173, 177

Gland (minor salivary) in, 185

Labial mucosa, 170, 172

Mucous, 135, 138, 139, 142, 143, 147-149, 161, 162, 166, 169, 170, 173, 176, 178,

185, 193, 200, 233, 289, 294

Nerve (neurilemmona), 404

Peritoneum, 81, 83, 84, 166, 210, 220, 233

Renal pelvis, 244, 262

Serous (pleura), 10

Tumors of, 404

Ureter, 243, 257, 262

Urethral, 243

Meninges (dura mater, pia mater, arachnoid mater), 10, 393, 397, 399, 400, 404

Tumors of, 404

Meningioma, 404

Menstruation, 273, 281

Mesenteric fat (pericolic), 221

Mesentery (peritoneum), 65, 66

Mesonephric tumor, 285

Mesothelial sarcoma, 441

Primary site for, 441

Mesothelioma, 157

Mesothelium,

Parietal, 153

Visceral, 153

Mesovarian ligament, 281

Metabolism,

Carbohydrate, 215, 237

Cellular (see also Cardiovascular system), 99, 102, 131

Nutrient exchange (see also Carbon dioxide, Oxygen), 57, 63, 102, 105, 111, 114,

115, 117, 118

Respiration, 131

.Transported via blood and interstitial fluid, 99, 102, 115, 117, 118

Metacarpals (hand), 367, 369, 373

Metaphysis (long bone), 355, 368

Metastases, 62, 71,230, 302, 368, 370

Blood-borne, 71, 112, 230, 368, 370

Carcinoma, 71

Corpus uteri, 274

Cul de sac, 273, 307, 308

Direct, 62, 154, 157

Distant nodes, 71

Liver, 112, 230-232

517
Metastases (continued)

Lymph node, 62, 71, 94

Regional nodes, 71, 211

Retrograde flow, 62, 157

Sarcoma, 71

Metastasis, blood-borne, 71,211,230

Metatarsal (foot), 367, 373

Midbrain (mesencephalon), 336, 397-399

Midline, 10

Midsagittal (median) plane, 10, 12

Mineralocorticoid (aldosterone), 333

Mons pubis (mons veneris), 289, 291, 294

Motor nerve fibers, 393, 395, 396, 399

Mouth (see also Buccal cavity (cheek), 165, 168-170

Alveolar process covering, 179

Buccal (cheek), 178, 181

Composition of floor of mouth, 177

Floor of, 169, 173, 177-180, 184, 189

Glands located in, 169, 177, 184, 185

Lymphatic drainage from, 189

Oral cavity, 139

Palate (hard, soft), 139

Retromolar trigone, 177, 178

Roof (see also Palate), 169, 181, 184

Salivary gland, 139

Teeth, 165, 169, 178, 183, 184, 203

Tumors of, 169, 170, 174-178, 181

MSH (see Melanocyte stimulating hormone), 330

Mucin-producing (ciliated columnar) epithelium, 149

Mucinous (adeno) carcinoma, 305

Mucinous cystadenocarcinoma, 285

Mucoepidermoid carcinoma, 185

Mucoperiosteum (mucous membrane, periosteum of gums), 178, 181

Mucosa (see also Digestive system), 166-168, 183, 184, 205, 214, 221, 244, 257, 259, 260,

262, 274, 275, 282, 285, 286, 288, 411, 413, 414, 431, 434

Alveolar process covering, 177-180

Bladder, 262, 265, 266

Bronchial, 157

Buccal (cheek), 169, 170, 178, 181, 183, 184, 189, 191, 192

Ciliated, 149, 282, 285, 286, 288

Corpus uteri, 274

Epithelial (esophageal, surface epithelium), 166, 168, 205, 208, 210, 220

Fallopian tube, 282, 286, 288

Floor of mouth, 177, 180, 185

Gastrointestinal, 166-169, 205, 208, 210, 211, 214, 220, 221, 233

Gingival (gum), 178-181

Labial, 170, 172, 181

Muscularis mucosae (see Digestive system), 166, 168, 169, 184, 205, 210, 220

518
Mucosa (see Digestive system) (continued)

Nasal, 135, 431, 433, 434

Oral cavity, 169, 170, 173, 183, 184

Pharyngeal, 193

Renal pelvis, 244, 259, 260, 262

Ureter, 257, 262

Uterus, 274-276

Muellerian mixed tumor, 278

Multiple myeloma, 442

Primary site for, 442

Multiple primaries, 445-447, 449-461,463-467, 471, 472

Date of diagnosis and, 445

Histology and, 445-447, 449-461, 463-468

Rules for determining, 445-447, 449-461, 463-468, 471, 472

Single lesion and, 445

Muscle (see also Muscular system), 205, 244, 260, 262, 264, 266, 267, 274, 294, 297, 329,

375-378, 380, 384-387, 390, 441

Abductor, 385, 388-390

Adductors, 385

Arrector, 31

Attachment to bone, 377, 381, 383-385

Buccinator, 181

Cardiac (heart), 99, 103, 104, 376-378, 380, 389, 390, 403

Characteristics (functional), 385, 387, 388

Comparisons of types of, 378

Composition of, 377

Conductivity, 385, 388

Constrictor (cranial nerves, motor, sensory), 403

Contractibility, 385, 388

Elasticity, 385, 388

Extensibility, 385, 388

Extensors, 385

External rectus (cranial nerves, motor, sensory), 403, 415

Eye (cranial nerves, motor, sensory), 399, 403, 415

Facial (cranial nerves, motor, sensory), 399, 403

Fascia, 381,383, 384

Fiber, 377

Flexor, 385, 389

Functions (heat production, movement, posture), 385, 388, 389

Histologic type of cancer, 441

Hypoglossus, 177

Involuntary, 377, 389, 390

Irritability, 388

Laryngeal (cranial nerves, motor, sensory), 403

Levators/elevators, 385

Ligaments, 381,383, 384

Longitudinal (taenia coli), 210, 220, 274

Lung (cranial nerves, motor, sensory), 403

519
Muscle (see also Muscular system) (continued)

Mixed, 205

Muscle types, 376-380

Mylohyoid, 177

Oblique (external, internal), 274

Palatine, 181, 183, 184

Pectoralis (major and minor), 297

Pharyngeal (cranial nerves, motor, sensory), 142, 193, 200, 403

Pronators, 386

Rotator, 385

Serratus, 297

Sinoatrial node, atrioventricular junction, 103

Skeletal (striated), 377, 378, 380, 385, 388

Smooth (involuntary), 149, 205, 211, 244, 260, 262, 264, 266, 267, 274, 277, 282,

289, 294, 376-378, 380, 389, 390, 441

Soft palate (cranial nerves, motor, sensory), 403

Sphincters, 386, 389

Sternomastoid (cranial nerves, motor, sensory), 403

Striated, 170, 173, 176, 205, 267, 376, 389, 390

Supinator, 386, 389

Tendons, 381, 383, 384

Tensors, 386

Tongue, 173-175

Transverse, 274

Trapezius (cranial nerves, motor, sensory), 403

Tumors of, 174, 386

Voluntary, 377, 379-380

Muscular system

Histologic type of cancer, 441

Skeletal (striated), 441

Voluntary, 397

Muscularis mucosae (see also Digestive system, Tissue), 166, 168, 169, 181, 184, 205, 210,

220, 244, 262

Muscularis propria (circular longitudinal layer), 166, 168, 205, 208, 210, 214, 220, 244, 262

Bladder, 262, 266

Renal pelvis, 244, 260

Ureter, 257

Myasthenia gravis, 68, 334

Mycosis fungoides, 37, 38, 94

Myelin sheath, 393

Myelogenic, 368

Myeloma (plasma cell), 124, 368

Myeloproliferative disorder (see also Bone marrow), 368

Myocardium (see also Heart muscle), 104

Myometrium, 274, 276, 277, 307, 308

Structure of, 274

Nails (see also Integumentary system), 27, 31, 43, 45

Subungual melanoma, 39, 40, 43

520
Nares (see Nose)

Nasal bone (facial), 360, 365

Nasal cavity, tumors of, and/or lymphatic drainage, 74, 135, 137-139, 181, 184

Nasal fossa, 431-434

Lymphatic drainage, 431

Tumors of, 432

Nasolabial sulcus, 39

Nasopharynx, 135, 141, 142, 181, 184, 193

Blood supply to, 139

Function of, 193, 199

Location of, 131, 134, 139, 193, 199, 200

Lymphatic drainage from, 139

Pharyngeal (adenoid) tonsil in, 68, 94, 139, 142, 161, 162, 193, 201, 202

Tumor of, 139

Neck, and/or lymph nodes, 39, 57, 62, 65, 66, 73, 75, 76, 158, 189, 191, 192

Lymphatic drainage from, 46, 74

Neck, strap muscle (cranial nerves, motor, sensory), 403

Nephron, 247, 252, 268, 270

Major structure, 247, 249

Nerve (afferent, efferent), 13, 153, 155-157, 205, 210

Heart action, regulation by, 103

Olfactory, 135, 432

Peripheral, 13

Phrenic, 158

Recurrent laryngeal, 158

Tumor (olfactory), 135

Nerve fiber (white matter), 397

Nervous system (nerve sheath), 267, 377, 391,393-401, 403, 404, 407, 408

Autonomic, 267, 377, 401

Central nervous system, 393-400, 407, 408

Cranial, 404

Meninges, 393

Motor function, 393, 403

Parasympathetic, 401

Peripheral, 393, 401

Sensory function, 403

Spinal, 393, 397, 399, 401

Sympathetic, 401,407, 408

Tumors of, 404

Nervous system, Cranial, 399, 402, 403, 435

Abducens nerve (VI), 399, 402, 403

Acoustic (VIII), cochlear, vestibular, 399, 402, 403, 435

Facial (VII), 399, 402, 403

Glossopharyngeal (IX), 399, 402, 403

Hypoglossal nerve (XII), 399, 402, 403

Oculomotor (III), 399, 403

Spinal accessory (XI), 399, 402, 403

Trigeminal (V), 399, 402, 403

521
Nervous system, Cranial (continued)

Trochlear (IV), 399, 402, 403

Vagus (X), 399, 402, 403

Neural crest, 35

Neurilemmoma (neurinoma, schwannoma), 404

Neuroblastoma, 333, 337, 404

Neuroepitheliomatous neoplasms, 404

Neurofibrosarcoma, 404

Neuroglia (glial cells), 393, 404, 407, 408

Neurohypophysis (posterior lobe, pituitary gland), 329

Neuroma, 404

Neurons (gray matter), 393, 394, 399, 404

Nevus (mole, nevi), 35, 39

Blue, 39

Compound, 35

Dermal-epidermal junction, 35, 39

Giant hairy (pigmented), 35, 39

Intradermal, 35, 39

Junctional, 35, 39

Neural crest origin, 35

Nonpigmented, 35

Pigmented (see also Melanoma), 35

Nipple (breast), 297, 300-302, 305

Nodal lymphoid tumor, 94

Nodular melanoma, 40, 43, 45

Non-Hodgkin's lymphoma, 92, 93

BNLI--British National Lymphoma Investigation, 93

Cell type predominance, 95, 96

Diagnostic schemes, 93

Diffuse, 93

Dorfman classification, 93

Extralymphatic, 89

Extranodal, 89

Kiel classification, 93

Lukes-Collins classification, 93

Multiple primaries, rules for determining, 94

Rappaport classification, 93

World Health Organization, 93

Norepinephrine hormone, 333

Nose (see also Respiratory system), 131, 133-135, 161, 162, 431

Blood supply to, 135

Cavity (nasal), 135, 137-139, 181, 184, 193, 199, 200, 431-434

Choana, 135, 139

Conchae (turbinates), 135

Functions of, 135, 137, 138

Lymphatic drainage from, 46, 74, 135, 139, 431

Membranes (mucous), 135

Nares (nostril), 39

522
Nose (see also Respiratory system) (continued)

Nasolabial sulcus, 39

Nostrils (see Nares), 135

Tumors of, 135, 137, 138

Nutrients, 347, 356

Oat cell carcinoma, 157, 160, 161

Occipital (cranial) bone, 359, 363, 365, 375

Occipital lobe of cerebrum, 397

Oculomotor nerve (III), 399, 403

Olfactory (sense organ), 397, 431-434

Olfactory nerve (I), 399, 403, 432

Oligodendroglioma, 404

Optic nerve (II), 399, 403

Oral cavity (see also Buccal mucosa), 139, 169, 173, 181, 183, 184

Alveolar ridge, process, 177-181

Anterior wall, 169, 170, 179, 180, 194

Blood supply to, 169

Buccal gutter, 178

Histologic type of cancer, 441

ICD-O codes for, 194

Lymphatic drainage from, 74, 139, 189, 192

Mandible, 177, 178, 185

Membranes, 169, 170, 173, 176, 178, 185

Mucosa, 183, 184

Pterygopalatine arch (palatoglossal), 178

Retromolar trigone, 177, 178, 184

Tonsillar fossae, pillar, 177, 181, 194

Tumors of, 169, 170, 174-178, 181, 184

Uvula, 194

Organs and lymphoid tissue,

Lingual tonsil, 173, 174, 193, 201, 202

Palatine (faucial) tonsil, 193, 194, 201, 202

Pharyngeal (adenoid) tonsil, 139, 142, 161, 162, 193, 201, 202

Orifices, atrioventricular, 103

Oropharynx (see also Digestive system), 139, 142, 193, 201

Anatomical limits (anterior, lateral, posterior walls), 194

Functions of, 194, 199, 200

Glossopalatine fold (anterior tonsillar pillar), 194, 201, 202

Palatine (faucial) tonsil in, 68, 94, 193, 202

Tonsillar fossae, pillar, 194, 201, 202

Tumors of, 94, 195, 197, 198

Osteitis fibrosa cystica, 332

Osteochondrosarcoma, 371, 375

Osteocytes, 347, 350, 355, 372, 375

Lacunae, 347

Osteogenic sarcoma, 368, 371, 375, 441

Primary site for, 441

Ostium (ostia) (see also Salivary gland), 177, 183, 184

523
Ovary (female gonad), 273, 281,285, 329, 333, 339

Endocrine gland (corpus luteum), 281,329

Estrogenic hormones of, 281, 285, 329, 333

Graafian follicles, 281

Histologic type of cancer, 441

Krukenberg (metastatic tumor), 211, 285

Ligaments holding, 281

Location of, 281

Lymphatic drainage from, 81, 281

Mesenchyme, 285

Ovulation, 281

Spread of disease from, 285

Structure of, 281

Tumors of, 285, 292, 294, 295, 441

Oviduct (uterine tube), 273, 276, 282, 288

Ovum (see also Ovary), 281

Graafian follicle, 281

Oxidation of fats, carbohydrates, 21

Oxygen exchange, 53, 57, 63, 65, 66, 99, 102, 105, 107-111, 114, 115, 117, 118, 131, 133,

134, 161

Oxygenated blood, 53, 63, 66, 105, 107-111, 154

Oxytocin (pitocin), 330

Paget's disease, 305

Palate, 183-185

Gingival buccal sulcus, 178

Hard, 178, 181, 183, 184, 189

ICD-O codes for, 194

Lymphatic drainage from, 189, 191, 192

Palatine process, 181

Soft, 139, 169, 181, 183, 184, 189, 193, 194, 199, 200

Palatine (faucial) tonsil (see also Tonsil), 68, 94, 193, 194, 201,202, 365

Palatine bones and/or process, 135, 181, 183, 184

Palpation of lymph nodes, 71, 73

Pancreas (body, tail), 10, 12, 112, 114, 165, 237, 329, 334, 336-339, 441

Histologic type of cancer, 441

Islets of Langerhans, 329

Lymphatic drainage from, 81

Portal system veins, 112, 114, 237

Secretions, 215, 237, 239, 240

Tumors of, 237

Papillae, 173, 179, 180

Circumvallate, 173, 176

Vascular, 31

Papillary adenocarcinoma, 331, 337, 339

Para-, 9, 15, 17

Parametrium (connective tissue surrounding uterus), 277

Paranasal sinus, frontal, maxillary, sphenoid, 135, 137-139, 161

Lymphatic drainage from, 135

524
Paranasal sinus, frontal, maxillary, sphenoid (continued)

Tumors of, 135, 137, 138

Parathormone, 332, 336, 338

Parathyroid gland, 332, 337

Parenchyma,

Tumors of, 253, 256

Parietal, 13, 77, 79-81, 83, 84, 104, 108, 359, 363, 365, 375

Bone (cranial), 359, 363, 365, 375

Diaphragmatic lymph nodes, 77, 79, 80

Heart layers, 104, 108

Intercostal lymph nodes, 77, 79, 80

Lobe of cerebrum, 397

Mammary (internal) lymph nodes, 77, 79, 80

Pleura, 13, 153, 156, 160-162

Parotid gland (salivary gland), 185, 188

Lymphatic drainage from, 74, 189

Stensen's duct (parotid), 185

Tumors of, 185, 188

Patella (kneecap), 351, 354, 367, 369, 373

Peau d'orange, 302

Pectoral (major and minor) (see Muscle), 297, 300

Pelvic cavity (including walls and girdles), 10, 13, 14, 219, 261, 273, 275-277, 282-284, 313,

317, 343, 351

Lymphatic drainage from, 81

Pelvis (ilium, ischium, pubis, hip bones) (see Female pelvis), 242, 261, 272, 312, 343, 351,

366, 367, 375

Penile (spongy or cavernous) urethra, 267

Penis (see also Reproductive system, male), 267, 321, 322, 441

Basal and Squamous carcinoma, 36

Blood supply to, 321

Corpora cavernosa, 321

Corpus spongiosum, 321

Foreskin (prepuce), 321

Glans penis, 267, 321

Histologic type of cancer, 441

ICD-O code, skin of, 39

Lymphatic drainage from, 85, 322

Prepuce (foreskin), 321

Tumors of, 323, 441

Peri- (around), 15, 17

Pericardial fluid, 104

Pericardium (see Heart), 103, 104, 108

Pericolic fat, 221

Perimetrium (serosa of corpus uteri and bladder), 274, 276

Perineum, 85, 289, 290, 307, 308

Periosteal sarcoma, 368, 371, 375

Periosteum (mucoperiosteum), 178, 181, 355, 356, 358, 368, 384

Tumors (periosteal sarcoma) of, 368

525
Peripheral nervous system, 393, 396, 401, 404

Sheath of Schwann, 393, 404

Peripheral, 13, 123

Circulating blood, 123

Nervous system, 13

Peristaltic motion, 203, 215, 220

Peritoneal reflection (see also Rectosigmoid), 219, 220

Peritoneum (mesentery), lymphatic drainage from, 10, 83, 84, 233

Visceral, 166, 210, 220

Peritoneum (uterovesical pouch), 244, 261, 262, 282, 285, 441

Histologic type of cancer, 441

Peyer's patches, 53, 56, 68-70

pH (acid-base balance), 249, 317

Sperm environment, 317

Phagocytosis, 62, 67, 229

Phalange (finger and toe), 351, 367, 369, 373

Pharyngeal (hypopharyngeal, oropharyngeal) wall, 68, 194, 195

Pharyngeal tonsil (adenoid), 68, 94, 139, 142, 161, 162, 193, 201, 202

Pharyngoepiglottic fold, 194, 195

Pharynx (throat) (see also Hypopharynx, Nasopharynx, Oropharynx), 68, 161, 162, 165,

168, 169, 181, 184, 194, 195, 197-200, 203, 208, 441

Blood supply to, 139, 193

Composition of, 139, 141, 142, 193, 199, 200

Histologic type of cancer, 441

Lymphatic drainage from, 74, 139, 193

Motor functions of, 403

Muscle functions of, 403

Oral cavity and/or ICD-O codes for, 194

Palatine (faucial) tonsil (see Tonsil), 193, 201,202

Pharyngeal recess (Rosenmuller's fossa), 139

Pharyngeal tonsil (adenoid) (see Tonsil), 193, 201, 202

Structure of, 139, 193

Tumors of, 195, 197, 198, 201

Wall, 68, 139, 194, 195

Pheochromocytoma, 333

Phosphorous levels, 332

Pia mater, 399, 404

Pigment cell (melanin, melanocytes), 21, 23, 26, 35, 36, 39, 40

Pineal gland (epiphysis), 332

Location of, 332

Tumors of, 332

Pinealoma, 332

Pitocin (see Oxytocin), 330

Pituitary gland (Hypophysis), 281,329, 330, 397

Function of, 329, 330

Hormones secreted by, 281, 329

Lobe of, Anterior (adenohypophysis), 329

Lobe of, Posterior (neurohypophysis), 329, 330

526
Pituitary gland (Hypophysis) (continued)

Location of, 328, 329

Tumors of, 330

Placenta, 278, 334

Hormones secreted by, 334

Planes of the body, 9, 10

Plasma (plasmacyte), 54, 62, 63, 67, 115, 118, 124, 229

Plasma cell myeloma, 124

Plasmacytoma, 124

Platelets (see Blood, thrombocytes), 115, 118, 119

Pleomorphic adenomas, 185

Pleura (parietal, visceral), 13, 104, 108, 153, 156, 157, 160-162, 441

Histologic type of cancer, 441

Lymphatic drainage from, 77

Serous membrane, 10, 104, 108

Pleural cavity (left, right) and/or interpleural space, 10, 153, 158-162

Pleural effusion, 158

Pneumonitis, 158

Polycythemia, (primary, rubra vera, secondary, vera), 115, 127, 128

Porta hepatis, 229

Portal system (see also Intestine, Pancreas, Spleen, Stomach, Venous system), 100,

112-114, 210, 221,237

Circulation, 100, 112, 113

Positional terms, 9, 12, 14-17

Head (cephalo), 9

Postcricoid area, 195, 201,202

Posterior (dorsal) plane, 9, 10, 12, 15, 17

Posterior (laryngeal) surface, 144

Posterior ligament, 277

Posture, 385, 387, 388

Potassium, 249, 333

Pre-, 15, 17

Prefixes for medical terms, 9, 14

Prepuce (foreskin), 289

Primary site, 445

Multiple primaries and, 445, 471, 472

Process (mandible, palatine), 178-181, 183, 184

Proct(o)-, 9

Progesterone, 281

Progestin, 333

Prolactin (LTH), 330

Pronator muscle, 386

Proprioceptor, 411,413, 414

Prostate, 261,267, 309, 313, 317, 318, 441

Capsule, 317

Histologic type of cancer, 441

Lymphatic drainage from, 81,322

Tumors of, 317, 323

527
Prostate (continued)

Urethra (prostatic), 313, 316, 318

Prostatic hyperplasia and prostatic hypertrophy, 318

Protein, blood and/or water soluble, 115, 119, 211, 215, 229

Prothrombin (see also Blood), 119

Proximal, 12, 15, 17

Pseudomyxoma peritonei, 285

Pterygopalatine arch (palatoglossal), 178

Pubic (pelvis) bone, 261

Puboprostatic ligament, 317

Pudendum (see also Vulva), 273

Pulmonary (circulatory)circuit, 99, 102, 103, 105, 108, 110, 111

Pylorus (pyloric antrum, sphincter), 209, 211, 214, 230

Pyriform sinus (see also Hypopharynx), 195, 201, 202

Quadrants (divisions, quarters), abdominal, 13

Quadriceps femoris muscle, 351

Radial (superficial spreading melanoma), 40, 43, 45

Radius (lower arm), 351, 367, 369, 373

Rappaport classification for non-Hodgkin's lymphoma, 93

Rathke's pouch tumor, 330, 405

Receptor (see Sense organs), 411

Recklinghausen's disease, 332

Rectosigmoid colon and/or junction, 219

Rectum, 9, 10, 12, 165, 168, 219, 220, 226, 261,290, 441

Histologic type of cancer, 441

Lymphatic drainage from, 81, 222, 227, 228

Metastatic site for, 290

Tissue layers (see also Digestive system), 166

Reed-Sternberg cell, 90, 92

Relative positions, directional terms, 9, 10, 12

Renal cell carcinoma, 253, 256, 441

Primary site for, 441

Renal pelvis, 244

Histologic type of cancer, 441

Structure of, 244

Reproductive organs, 10

Reproductive system (female), 261, 267, 272, 273, 275-277, 279-295, 297, 299-305, 307,

308, 329

Breast, 297, 299-305

Corpus uteri, 274-277, 279, 280

External genitalia (pudendum), 273, 289, 291, 294, 308

Fallopian tube, 275, 276, 282-288, 307

Ovary (female gonad), 273, 275, 276, 281, 284, 285, 288, 329

Tumors of, 277, 281, 282, 285, 290, 304, 305

Uterus, 261, 273, 275-277, 279, 280, 284, 288

Vagina, 261, 275, 289, 290

Vulva, 267, 275, 293, 294, 308

528
Reproductive system (male), 267, 289, 309, 311-313, 315-322, 325, 326, 329

Bulbourethral gland, 289, 309, 318

Excretory ducts (epididymis, ductus deferens, ejaculatory), 309, 313, 315, 316

Functions of, 309

Hormone secretion, 309

Penis, 267, 289, 309, 321, 322

Prostate gland, 309, 317, 318, 320, 323

Scrotum, 309, 312

Seminal vesicle, 309, 313, 317, 319, 320

Testis, 309, 313, 315, 316, 322, 326, 329

Tumors of, 323, 325

Respiratory system (see also Nose, Paranasal sinuses, Nasopharynx, Larynx), 243

Bronchioles, 154, 157, 161, 162

Bronchus (lungs), 149, 152, 153, 155-157

Cellular, 131

External (inhaling, exhaling), 131, 161, 162

Function of, 131

Internal, 131, 135, 161, 162

Reticuloendothelial cell (see also Cell type), 61, 67

Reticulum cell (stem sarcoma), 368, 371,375

Primary site for, 441

Retina (eye), 415, 417, 418, 423

Retinoblastoma, 423

Retraction of the nipple, 302

Retro-, 15, 17

Retrograde flow (see also Lymphatic system), 57, 62, 157

Retromolar trigone (mandible), 177, 178

Rhabdomyosarcoma, 386, 389, 441

Primary site for, 441

Rib, 13, 131, 157, 343, 351, 356, 372, 375

Connective tissue, 372, 375

False, 361

Floating, 361

True, 361

Rotator muscle, 385

Round bones, 351,353, 354, 356

Round ligament, 277

Rugae (see also Stomach), 210, 289

Gallbladder, 233

Sacrum, 351,353, 354, 361, 368

Lymphatic drainage from, 65, 66

Tumors of, 368

Sagittal plane, 10, 12

Salivary gland (see also Parotid, Sublingual, Submandibular), 165, 185, 187

Function of, 185

Lymphatic drainage from, 189

Mixed type tumors, 185, 188

Ostia (ostium), 177, 183, 184

529
Salivary gland (see also Parotid, Sublingual, Submandibular) (continued)

Saliva secretion from, 169, 185

Tumors of, 139, 177, 185, 187, 188

Salts, 249, 251, 252, 347

Sarcoma (see also non-Hodgkin's lymphoma), 90, 368, 371, 386, 441

Angiomyosarcoma, 386

Angiosarcoma, 368, 371, 375

Blood-borne metastasis, 71-73, 230, 368

Chondrosarcoma (osteochondrosarcoma), 368, 441

Ewing's sarcoma, 368, 371, 375, 441

Fibrosarcoma, 368, 386, 441

Giant cell (malignant osteoclastoma), 368, 371, 375

Hemangiosarcoma, 441

Leiomyosarcoma, 386, 389, 390, 441

Liposarcoma, 441

Lymphangiosarcoma, 441

Lymphosarcoma, 441

Mesothelial sarcoma, 441

Multiple Myeloma, 368, 371

Osteochondrosarcoma, 371,375

Osteogenic, 368, 375, 441

Osteosarcoma, 371

Periosteal, 368, 371, 375

Reticulum cell, 441

Rhabdomyosarcoma, 386, 441

Skin, 36, 38

Synovial, 386

Scalp, and/or lymphatic drainage from, 39, 46, 74

Scapula (upper back), lymphatic drainage from, 85

Schwann cell, 393

Schwannoma, 404

Scirrhous (adeno) carcinoma, 305

Sclera (eye), 415, 417, 418, 425, 426

Cornea, 415

Iris, 415

Pupil, 415

Scrotum (see also Reproductive system, male), 309, 311

ICD-O codes, skin of, 39

Lymphatic drainage from, 46, 85, 87, 88

Malignancies, skin of, 36

Sac, 309, 339

Spermatic cord, 309, 339

Sebaceous gland (see also Integumentary system), 21, 23, 27, 30, 31, 33, 34

Adenocarcinoma, 36

Secretin, 334

SEER incidence tabulation, 223

Sella turcica, 359

Seminal fluid, 317, 319, 320

530
Seminal vesicle, duct and tubule, 309, 313, 317, 319

Seminoma, 323, 441

Primary site for, 441

Sense organs (receptors), 409, 410, 413-415, 417-419, 421-423, 425-438

Classification of, 411

Exteroceptors, 411, 413, 414

Gustatory (taste), 410, 413, 414, 427, 429, 430

Olfactory (smell), 397, 403, 410, 413, 414

Proprioceptors, 411, 413, 414

Tactile (touch), 403, 410, 413, 414

Visceroceptors, 411, 413, 414

Sensory nerve fibers, 393-397, 399, 401, 403

Functions of, 403

Serosa (see also Digestive system), 166, 168, 205, 208, 210, 214, 215, 219, 220, 233, 244,

261, 262, 274, 276, 277, 282, 285

Bladder covering, 244, 261, 262

Bladder, 266

Fallopian tube, 282

Uterine, 276, 277

Serous cystadenocarcinoma, 285

Serratus muscle (see also Muscle), 297

Sertoli cell tumors, 323

Serum acid phosphatase, 317

Sesamoid bone, 351,353, 354, 356

Sheath of Schwann, 393

Short bones (cuboid, irregular), 351, 356, 367, 369, 373

Shoulder, and/or lymphatic drainage from, 39, 46, 85

Sigmoid colon (pelvic), 10, 166, 219, 220, 223, 226-228

Sinoatrial node, atrioventricular junction, 103

Sinuses, 62

Ethmoid, 138, 359

Frontal, 138, 359

Lymph (sinus) marginal, medullary channels, 62

Lymphatic drainage from, 135

Maxillary (antrum of Highmore), 135, 138

Nasal, Paranasal (accessory), 135, 137-139, 161

Pyriform, 195, 201, 202

Sensations from, 403

Sphenoid, 135, 138, 359

Tumors of, 135, 138

Sinusoids, 112

Skeletal (voluntary, striated) muscles, 377, 378, 380, 383, 385-390

Function of, 385, 387

Skeletal system (see also Bone, Cartilage, Connective tissue), 341-343, 345-347, 349-351, 354-369,

371-373, 375, 377, 378, 380, 383, 386-389

Skene's gland, 289, 292

Skin (see also Integumentary system), 285, 289, 291, 294

Pigmentation (melanin), 330

531
Skull (diploe), 351, 354, 356, 359, 360, 363-365, 397

Base, 193

Cranium, 359

Ear (small bones of middle), 359

Face, 359, 360

Hyoid, 359, 363, 364

Smooth (involuntary) muscle, 330, 377, 378, 380, 386, 389, 390, 441

Histologic type of cancer, 441

Soft palate, 139, 169, 181, 183, 184, 193, 194, 199, 200, 403

Somatotrophic hormone, 329

Spermatic cord, 309, 313, 337, 339

Spermatogenesis, 313, 329

Sphenoid (cranial, paranasal bone), 329

Sphenoid sinus (paranasal), 135, 138

Sphincter muscle, 386, 389

Spinal accessory nerve (XI), 399, 402, 403

Spinal column, 10, 13, 243, 246, 377, 399

Autonomic nervous system, 377

Nerve, 404

Spinal cord, 399, 404

Spleen (see also Lymphatic system), 10, 67, 69, 70, 112, 114, 115, 219, 237

Lymphatic drainage from, 81

Lymphoma (nodal) in, 94

Phagocytosis, 229

Portal system veins, 112, 114, 210, 221, 237

Tumors of, 94

Splenic flexure, 219, 227

Spread of cancer (see Metastasis)

Squamous cell (epidermoid) carcinoma, 36-38, 135, 138, 139, 145, 157, 160, 169, 170, 174,

177, 178, 181, 184, 185, 195, 198, 205, 211, 222, 253, 255, 256, 264, 277,

290, 295, 423, 427, 432, 434

Primary site for, 441

Renal pelvis, 253

Squamous columnar junction, 277

Stem cells, 123, 124

Stensen's duct (parotid), 185

Sternomastoid (cranial nerves, motor, sensory), 403

Sternum (breast bone), 334, 351,356, 361, 367, 369, 373, 375

Steroids, 333, 335

Aldosterone, 333

Androgens, 333

Cortisol, 333

Estrogen, 281, 333

Progestin (progesterone), 281, 333

STH (see Somatrophic hormone), 329

Stomach (see also Digestive system), 10, 12, 112, 114, 165, 168, 193, 203, 208, 212, 219,

229, 233, 237, 285, 334, 441

Blood supply to, 210

532
Stomach (see also Digestive system) (continued)

Cardia (body, corpus), 209, 214

Cardioesophageal junction (cardiac orifice), 203, 211

Chyme (fluid content), 209, 211, 215

Corpus (body), 209, 214

Curvature (greater, lesser), 67, 210

Functions, 209, 211,213, 214

Fundus (fornix), 209, 214

Gastrin, 334

Histologic type of cancer, 441

Hormone secretions, 334

Krukenberg metastatic tumor, 211, 285, 292, 295

Linitis plastica, 211

Lymphatic drainage from, 81, 210, 212, 214

Lymphoma (extralymphatic, extranodal), 94, 96, 211

Omentum (greater, gastrocolic, lesser, gastrohepatic), 210

Portal system veins, 112, 114, 210

Pylorus (pyloric antrum, sphincter), 209, 211, 214, 215, 230

Rugae, 210

Secretions, 209-211, 214

Tissue layers (see also Digestive system), 166-168, 210, 212, 214

Tumors of, 211, 213, 214, 285, 441

Strap muscles of neck, 403

Stratified, 274, 289

Striated muscle (see Muscle, skeletal), 441

Histologic type of cancer, 441

Stroma, 274, 277, 278, 285, 289, 305, 317, 323, 331

Sub- (under), 9, 15, 17

Subclavian vein (see also Venous system), 53, 56, 57, 63

Subcutaneous tissue, 23, 41, 44, 45

Subglottis (see also Larynx), 144, 148

Cartilage (Cricoid), 144

Subleukemic (aleukemic), 124

Sublingual (salivary) glands, 185, 188, 189

Ostia of, 177, 184

Submandibular (submaxillary) salivary gland, 185, 188

Lymph node, 46, 49, 50, 75, 76, 191, 192

Lymphatic drainage from, 74, 189

Ostia of, 177, 183

Submucosa (gastrointestinal), 166, 168, 169, 181, 205, 208, 210, 214, 220, 244, 257, 260,

262, 266

Bladder (wall), 262, 266

Renal pelvis, 244, 260

Ureter, 257

Subserosa (see Connective tissue and Fat)

Sudoriferous (sweat) gland, 27, 30, 31, 115

Adenocarcinoma, 36

Excretion of waste products, 33, 34, 115

533
Sulcus,

Buccal, 178

Nasolabial, 39

Superficial spreading (radial) melanoma, 40, 43, 45

Superficial, 12, 15, 17

Superior (cephalic, cranial) plane, 12, 14-17

Supinator muscle, 386, 389

Supra- (above), 9, 14, 15, 17

Supraclavicular (transverse cervical), 74, 76

Supraglottis (see also Larynx), 144, 148, 161

Aryepiglottic folds, 144

Arytenoid (see Cartilage), 144

Posterior laryngeal surface of epiglottis, 144

Tumors of, 145

Ventricular bands (false cords), 144, 148

Suprarenal (adrenal) gland, 14, 333, 334

Surface epithelium (see also Digestive system), 166, 168, 205, 210, 220

Suturae, 359, 360

Sweat gland (see Sudoriferous), 36

Synovial sarcoma, 386

Systemic circulation, 99, 102, 103, 105, 110

Systolic blood pressure, 105

T-cell54, ,68-70334 ,

Tactile(sensations oftouchsee , alsoSenseorgans)4,03,410,413,414

Taeniacoli,220

Tarsal(ankle)351 , ,356,367,369,373

Taste(sensationofs,seealsoSenseorgans)4,03,410,413,414

Receptors(buds),410,413,414,427-430

Teeth(incisors)165,,169,178,183,184 203,403

Mastication169, ,403

Odontogenitumor c ,178

Sensations from, 403

Telencephalon (see Forebrain), 397

Temple, lymphatic drainage from, 46

Temporal (cranial) bone, 343, 351, 354, 359, 363-365, 372

Temporal lobe of cerebrum, 397

Tendon, 381, 383, 384

Achilles, 381

Proprioceptors (receptor), 411,413, 414

Tensor muscle, 385, 386

Teratocarcinoma, 292, 295, 323

Testis (male gonad), 261, 309, 311-313, 329, 441

Endocrine gland, 329

Functions of, 308, 309

Histologic type of cancer, 441

Hormones secreted by, 309, 311

Inguinal canal, 313

Lymphatic drainage from, 81, 322

534
Testis (male gonad) (continued)

Seminal fluid, 317, 319, 320

Seminal vesicles, 309, 317, 319, 320

Seminiferous tubule duct and gland, 309, 329

Spermatazoa (sperm), productior, "_f, 329

Spermatic cord, 313, 337

Tumors of, 323, 441

Vas deferens, 261, 313, 315, 316

Testosterone, 309, 329

Tethering of breast, 302

Thalamus, 397

Theca ceil, 285

Tumor, 285

Thigh, lymph nodes located in, 85, 87, 88

Thorax (chest), 77, 79, 80, 131, 153, 155, 156, 161, 162, 189, 191, 192, 334, 343, 356, 359,

361, 362, 369, 375

Cavity (thoracic), 10, 13, 68, 77, 79, 80, 134, 203, 207, 208

Cisterna chyli, 57

Duct (thoracic), 57, 60, 221

Lymphatic drainage from, 49, 50, 77, 79, 80

Mediastinal (anterior, posterior), 205, 229

Parietal nodes, 77, 79, 80

Skin of lower chest wall, 189, 1(,1, 192

Sternum, ribs, 334, 343, 356, 361, 367, 369, 373, 375

Vertebra (thoracic), 203

Vertebrae (see also Vertebral column), 399

Visceral nodes, 77, 79, 80

Thrombocyte (see Blood and/or Platelets), 115, 118, 119

Thrombocytopenia, 124

Thrombus (thromboembolus), 119, 122

Thymoma, 334

Thymus (see also Lymphatic system), 53, 54, 56, 67-70, 334, 337, 339

Location of, 68

Lymphatic drainage from, 77

Tumors of, 334

Thyrocalcitonin, 331

Thyroid gland, 68, 329, 331, 332, 336-339

Adrenal cortical adenocarcinoma, 333

Arteries, 144

Cartilage (Adam's apple), 148, 195

Ganglioneuroma, 333

Hormone secretion from, 329

Lymphatic drainage from, 74, 331

Pheochromocytoma, 333

Squamous cell (epidermoid) carcinoma, 264

Thymomas, 334

Tumors of, 331

Thyrotrophic (thyroid-stimulating) hormone (TSH), 329

535
Tibia (shin bone), 351, 369

Tumors of, 368

Tissue, 53, 56, 59, 60, 62, 69, 94, 243, 244, 253, 257, 259-262, 285, 313, 329, 331

Adipose (fat), 329

Ciliated, 282, 285, 288

Connective, 61, 166, 170, 205, 208, 210, 243, 244, 257, 261, 262, 277, 289, 313,

321, 347, 368, 381, 383, 384, 389, 390, 393, 441

Embryonal, 253

Embryonic, 285, 323

Endometrial, 275

Epithelial, 68, 244, 257, 260, 262, 274, 285, 288, 295

Erectile, 321

Fluid (interstitial fluid), 63, 66

Glandular (isthmus), 331,336

Layers of the GI tract, 166-168, 207, 208, 212, 220

Lymphatic drainage from, 85

Lymphoid, 53, 55, 56, 61, 62, 67, 68, 71, 89, 91, 92

Myometrium, 276

Parenchyma, 243, 245, 246, 253, 255, 256

Renal pelvis, 244, 259, 262

Transplant and rejected tissue, 68

Tumors of, 441

Ureter, 257, 262

Urinary bladder, 262

Toe, finger (see Phalange)

Tongue (apex, dorsal, lateral, ventral surface), 165, 169, 175, 176, 179, 180, 184, 189,

427-430

Anterior two-thirds, 74, 173-176, 189

Base (vallecula), 173-176, 193, 194, 201,202

Circumvallate papillae, 173, 176, 179, 180

Frenulum, 173, 177

Functions, 173, 403

ICD-O code for, 194

Lingual tonsil at base of tongue, 68, 94, 173, 174, 193, 427

Lymphatic drainage from, 74, 189, 191, 192

Midline, 173

Muscle motor, sensory function, 403

Posterior one-third, 427

Salivary glands (minor), 177, 185

Sensations (taste), 403

Sensations from, 427

Tumors of, 94, 174, 175, 427

Ventral surface of, 173

Tonsil (see also Lymphatic system), 53, 56, 69

Extralymphatic lymphoma of, 94

Fossa, 194

Glossopalatine fold, 194, 201, 202

Lingual, 94, 173, 174, 193, 201, 202, 427

536
Tonsil (see also Lymphatic system) (continued)

Location of, 68

Palatine (faucial), 68, 94, 193, 194, 201,202

Pharyngeal (adenoid), 68, 94, 139, 142, 161, 162, 193, 201

Pharyngoepiglottic fold (posterior tonsillar pillar), 194, 195

Pillars (anterior, posterior), 177, 181, 194, 201, 202

Sensations of, 403

Tumors of, 181, 427

Waldeyer's ring, 68-70, 94

Topography code (ICD-O) of skin, 39

Touch (see Sense organs, tactile)

Trachea (windpipe), 12, 131, 134, 143, 151, 152, 154, 157, 161, 162, 203, 331, 337, 339,

403, 441

Cartilage (tracheal), 149

Histologic type of cancer, 441

Lymphatic drainage from, 77

Sensations from, 403

Transitional cell carcinoma, 222, 253, 255-257, 264, 267, 441

Primary sites for, 441

Transplant and rejected tissue (see also Tissue), 68

Transverse (horizontal) plane, 10

Transverse colon (see also Colon), 166, 219, 220, 223, 226, 227

Trapezius muscle, motor, sensory function, 403

Tri-iodothyronine, 329, 331

Trigeminal nerve (V), 399, 402, 403

Trochlear nerve (IV), 399, 403

Trophoblast (trophoblastic), 323

Trunk of body (lower, upper), 12

Lymphatic drainage from, 77, 80

Topography code for skin of, 39

TSH (see Thyrotrophic hormone), 329

Tubules, 247, 249, 268, 270

Collection, 247, 268, 270

Convoluted and distal, 247

Renal, 247, 268, 270

Tumor (see also specific histologic type), 244, 253, 255-257, 262, 264, 267, 285, 292, 294,

323, 330, 441

Adenocarcinoma, 253, 255, 256, 264, 277, 331

Adenoma, 330

Astrocytoma, 404

Basophilic, 330

Benign, 89, 91, 92

Bladder, 264

Blood-borne metastasis, 230

Blood-forming organs, 125, 126

Buccal mucosa, 181

Carcinoid, 157, 215, 218, 222

Chondrosarcoma, 441

537
Tumor (see also specific histologic type) (continued)

Choriocarcinoma, 278

Craniopharyngioma, 330, 337

Cylindroid, 157

Diagnostic workup for, 71-73

Ependymoma, 404

Esophagus, 205

Esthesioneuroblastoma, 432

Eyelid, 39

Fibrosarcoma, 441

Ganglioneuroma, 333

Germ cell, 285, 292, 294, 323

Giant cell, 368

Glioblastoma, 404

Glottic region (larynx), 145

Grading bladder tumors, 264

Grawitz's, 256

Gum (gingiva), 178

In-situ (intraepidermal), 36

Intestinal, 215, 217, 218, 222, 223

Kidney, 253

Krukenberg, 285, 292, 295

Larynx, 441

Leiomyosarcoma, 264, 277

Leydig (interstitial) cell, 323

Lip, 39

Liver, 211, 229, 231, 232

Lung, 157, 158

Lymphatic metastasis, 211

Lymphatic spread, 72, 73, 94

Lymphoid tissue, 94, 174, 195, 221

Lymphoma, 432

Malignant, 253

Medulloblastoma, 404

Melanoma, 432

Meningiomas, 404

Metastatic process (spread), 157, 229, 230

Multifocal, 36-38

Nasopharynx, 139

Neurilemmoma, 404

Neuroblastoma, 333, 337, 404

Neurofibrosareoma, 404

Nose, 135, 137, 138

Oligodendroglioma, 404

Oral cavity, 169, 170, 174, 177, 183, 184

Osteogenic, 368

Ovarian, 285

Papillary adenocarcinoma 331

538
Tumor (see also specific histologic type) (continued)

Paranasal sinus, 135, 137, 138

Penetration (measure of spread), 40, 166

Periosteal sarcoma, 368

Pharynx, 195, 197, 198, 441

Pheochromocytoma, 333

Pinealomas, 332

Pituitary, 330

Premalignant, 35, 222

Rathke's pouch, 330

Renal pelvis, 253

Retinoblastoma, 423

Salivary glands, 177, 185, 187, 188

Sarcoma, 386

Sertoli, 323

Skin, 35-40, 43

Squamous cell (epidermoid) carcinoma, 253, 255, 256, 264, 427, 432, 441

Staging bladder tumors, 264

Stomach, 211, 213, 214, 441

Thymic, 68

Thyroid, 331

Tongue, 174-176, 427

Transitional cell carcinoma, 256

Urethra, 267

Uterus, 277

Vascular (Kaposi's), 36

Wilms', 253, 255, 256

Tunica albuginea, 309

Turbinate (concha), 135

Tympanic cavity, membrane, and/or lymphatic drainage from, 31, 74

Ulceration, 302

Ulcerative colitis, 222

Ulna (lower arm), 351,367, 369, 373

Umbilical region (navel), 14

Underarm lymph nodes, 85

Underside (ventral), 12

Undifferentiated (large cell) carcinoma, 157, 160, 161

Upper extremity, 367

Urea, 229

Ureter, 10, 242-246, 249, 257, 260-262, 266, 268-270, 289, 441

Histologic type of cancer, 441

Lymphatic drainage of, 257

Obstruction, 257

Orifices, 261, 266

Structure of, 257

Tumors of, 257

Urethra (female, male), 242, 243, 246, 261, 266-268, 270, 289

Histologic type of cancer, 441

539
Urethra (female, male) (continued)

Location of, 267

Meatus, 289

Membranes, 267, 268

Orifices, 261, 266

Penile, 267

Prostatic, 267

Sphincter (internal, external), 267

Tumors of, 267

Urinary system (female, male), 241-249, 251-253, 255-257, 259-263, 265-270

Bladder, 242, 243, 261-263, 265, 266

Excretory system, 243

Kidney, 242-245, 247, 249, 251,253, 256, 257, 259, 260

Metastases, 290

Renal pelvis, 242

Tumors of, 253

Ureter, 242-246, 249, 257, 260-262, 266, 268-270

Urethra, 242, 243, 246, 261,266-268, 270, 289, 290, 292, 294, 313, 315-318, 321

Urethral meatus, 289, 291, 294

Urine (see also Ureter and Urethra), 243, 249, 252

Acid-base balance (pH), 249

Excretion of water, 249, 252

Formation and production of, 243

Uterine tube (see Fallopian tube), 282

Uterosacral ligament, 277

Uterovesical pouch (peritoneum), 244, 261, 282

Uterus (see also Reproductive system, female), 261, 272-277, 281, 308, 377

Apex, 277

Arteries, 277

Blood supply to, 277

Cervix uteri, 273-277

Composition of, 274

Corpus uteri, 273-277

Cul de sac, 273, 307, 308

Endometrium, 275, 276

Epithelial tissue, 274

Fallopian tube (uterine tube and oviduct), 275-277, 282-284, 286-288, 307, 308

Fimbria(e), 308

Fundus, 273, 276

Ligaments holding, 277

Location of, 273

Lymphatic drainage of, 81, 277

Myometrium, 274-277, 307, 308

Os (internal and external), 277, 286-288

Ovaries, 273, 275, 276, 281, 283, 284, 307, 308

Parametrium, 277

Serosa, 276

Structure of, 273

540
Uterus (see also Reproductive system, female) (continued)

Tumors of, 277

Walls of, 277

Uvula, 194

Vagina, 81, 261,273, 276, 277, 288, 289, 441

Composition of, 289, 291, 294

Function of, 289

Histologic type of cancer, 441

Lymphatic drainage from, 290

Os (internal and external), 277, 286-288

Tumors of, 277, 290, 293, 295

Upper, 261

Vestibule, 289

Vagus nerve (X), 399, 402, 403

Vallate papillae, 173, 176

Vallecula (tongue base), 173, 194

Valve (see also Heart),

Ileal, 215, 219

Lymphatic, 57

Vas deferens (ductus deferens), 261,313, 315, 316

Vascular papillae, 31

Vasopressin, 330

Vena eava (inferior, superior), 105, 110, 112, 114

Venous system (see also Cardiovascular, Portal system), 112-114, 169

Cavity, 10

Cranial sinuses, 135

Drainage, 112, 114, 205, 210

Gastric veins, 112

Hepatic veins, 112, 114

Jugular (external, internal), 57, 71, 135, 139, 144, 169, 193

Lymphatic system, 53, 57, 60

Mesenteric (superior, inferior), 112, 210, 221

Metastasis via venous blood, 230

Pancreatic vein, 112

Portal system, 100, 112-114, 210, 221, 237

Pulmonary, 105, 108, 110, 111, 153-156

Splenic, 112, 114, 210, 237

Subclavian, 53, 56, 63

Thyroid, 144, 205

Veins (see also Vessels), 55, 57, 59, 60, 71, 99, 102, 103, 105, 107, 109-111, 114

Ventral (anterior, underside), 10, 12, 15, 16

Ventricle, heart, 103, 105, 107, 108, 110

Ventricular bands (see Vocal cords)

Venules (small veins), 111, 114, 154

Vermilion border (lip), 39, 170, 172

Vertebra, cervical, 203

Spinal cord (spine), 10, 13

Thoracic, 203

541
Vertebral cavity, 10

Vertebral column (cervical, thoracic, lumbar, sacral, coccyx), 343, 359, 361,362

Vertical plane, 10, 15, 16

Vessels (see also Arteries, Capillaries), 262, 333, 441

Blood, 31, 53, 63, 65, 66, 71-73, 99, 101, 102, 105, 109-111, 113, 114, 119, 153-157,

166, 205, 210, 229, 244, 249, 262, 333, 441

Coronary, 103

Functions of, 99, 101, 102, 111, 113, 114

Heart, 103, 109, 111, 114, 115

Histologic type of cancer, 441

Lymph (afferent, efferent), 135, 153, 155, 156, 166, 205, 210, 229, 262, 441

Obstruction (embolus, thrombus), 119, 122

Pulmonary veins, 101, 102, 105, 108, 110, 111, 153-156

Skin, 23, 27

Thrombus, 119, 122

Tumors of, 229

Villi (lacteals) (small intestine), 215, 220

Lymphatics originating in, 57

Villous adenoma, 222

Villus (Villi), 57

Visceral (viscera), 13, 15, 17, 229

Heart layers, 104, 107, 108

Lymph nodes (see Abdomen), 81, 83, 84

Peritoneum (mesentery), 166, 210

Pleura, 13, 153, 156, 160-162

Thoracic viscera, 10

Visceral lymph nodes, 77, 80

Mediastinal (anterior, posterior), 77, 79, 80, 158, 160

Tracheobronchial (carinal, hilar, peritracheal), 77, 80

Visceroceptors (receptors), 411,413, 414

Vitamins, 211,229

Vocal cords (ventricular bands, voice box), 147

False, 143, 148

Paralysis, 154, 158

True, 143-145, 148, 162

Tumors of, 145

Voluntary muscle, 377, 397, 401

Vomer (facial bone), 360, 365

Vulva (pudendum, external genitalia), 267, 273, 275, 276, 289, 291, 294, 307, 308, 441

Clitoris, 289, 291, 294

Histologic type of cancer, 441

Labia (majora, minora), 289, 291, 292, 294

Lymphatic drainage from, 46, 85, 293

Malignancies, skin of, 36, 43

Melanoma, skin of, 39

Mons pubis, 289, 291, 294

Spread of disease from, 290

Tumors of, 290, 293, 295

542
Waldeyer's ring, 68-70, 94

Lymphoma in, 94

Waste from, 249, 347, 356

Blood, 249, 347, 356

Kidneys, 249, 252

Water, 211, 214, 215, 219, 220, 249, 251, 252

Wharton's duct (parotid), 185

White blood cell counts, 119, 123, 124

Wilms' tumor, 253, 255, 256, 441

Primary site for, 441

Wirsung (pancreatic) duct, 215, 237

Wrist (carpal) bone), 351, 356, 367, 369, 373

Zygomatic/malar (facial) bone, 360, 365

543