Anatomic Pathology

Surgical Pathology

The Department of Pathology at Nationwide Children’s is nationally recognized as a center of excellence for pediatric surgical pathology.  As is widely recognized, children are not small adults, and many pathologic conditions in children are either unique to the pediatric population or have a unique presentation in the pediatric age group. Our pathologists have extensive experience with evaluation and diagnosis of pediatric surgical specimens in a variety of disciplines including:

  • General surgical pathology
  • Cardiovascular pathology
  • Cytology
  • Renal pathology
  • Neuropathology, eye and muscle pathology
  • Hematopathology
  • Gastrointestinal and liver pathology
  • Transplant pathology
  • Oral pathology
  • Placental pathology and products of conception

Surgical Pathology and Consultation Services

Our laboratory offers comprehensive services in surgical pathology to meet the needs of our clients and patients.We accept specimens and histologic slides for primary diagnosis or second opinions. We offer routine histopathology, electronmicroscopy, enzymehistochemistry, immunofluorescence, immunohistochemistry, in situ hybridization and special staining as necessary for the complete diagnostic workup of referred cases. Digital capture of microscopic images, including whole slide imaging, is also available upon request. Difficult and unusual cases are almost always scrutinized by inter-departmental consultations, and our pathology reports often represent the consensus opinion of several subject matter experts. We routinely keep our clients informed of the progress in their cases and are available for case discussions as necessary.

Technical-Only Services

In addition to complete workup of cases,we offer technical-only services in the areas listed below.

Immunohistochemistry and Special Stains: We offer a large menu of antibodies and histochemical stains routinely used in evaluating child and adult specimens. See the brochure insert for the current available menu.

Enzyme Histochemistry: Enzyme histochemistry, including acetylcholinesterase, is available for the evaluation of gastrointestinal dysmotility, and a full battery of enzyme histochemical techniques is available for the examination of skeletal musclebiopsies.

Immunofluorescence: Direct immunofluorescence (IF) isoffered for renal and skin biopsies. Please contact the laboratory for additional information about specimen and transportation requirements.

Electron Microscopy: Transmission electron microscopy (TEM) is available for the evaluation of cilia, renal tissue, skeletal muscle, lymphocytes, platelets and tumors. Please see the following section for additional information on electron microscopy services.

Electron Microscopy

We offer complete electron microscopy services including processing, embedding, ultrathin sectioning, evaluation with digital image capture under electron microscope and preparation of the diagnostic report. The laboratory is equipped with an electron microscope with a digital camera system that provides excellent high-resolution images. Operation of the scope is performed by an experienced electron microscopist under supervision of our pathologists with expertise in ultrastructural evaluation of each specimen type listed below.

For a full consultation, the pathology report will include description and interpretation of ultra structural findings. Alternatively, the digital images can be rapidly transferred by a secure internet system to referring institutions for interpretation by a local pathologist.

Ciliary Biopsies

In the case of suspected ciliary dysmotility, our facilities examine ciliated respiratory epithelium from sinonasal or tracheal mucosa for structural abnormalities. For biopsies obtained away from Nationwide Children’s, training is available for onsite evaluation of ciliary motility.

Skeletal Muscle Biopsies

We also offer complete evaluation of skeletal muscle biopsies and accept skeletal muscle samples when the remainder of the biopsy evaluation is performed at the referring institution. For complete skeletal muscle biopsy evaluation, send the specimen directly to the Nationwide Children’s Neuromuscular Laboratory.

Kidney Biopsies

The Electron Microscopy Laboratory also accepts the glutaraldehyde-fixed portion of kidney biopsies for ultrastructural examination. Digital images are then sent by a secure internet system to the referring institution for interpretation. Complete kidney biopsy workup is done by Laboratory Services.

Tumor Samples

Electron microscopy may occasionally provide additional information for tumor classification. We can perform electron microscopy on tumor samples evaluated by an outside pathologist or offer electron microscopy as an ancillary study as part of a surgical pathology consultation.

Platelets  and Lymphocytes

Electron microscopy of platelets is useful to identify genetic storage pool defects. We use special techniques to evaluate platelet dense granule deficiency, since platelets readily undergo degranulation when disturbed. We recently established a normal platelet dense granule range for the pediatric population. Ultrastructural evaluation of lymphocytes is also available for identification of metabolic diseases that involve storage in these cells.

To perform these studies, it is recommended that the patient have their blood drawn in our main campus outpatient laboratory. The specimen will then be transported directly to our Electron Microscopy Laboratory.

Miscellaneous Specimens

Electron microscopy may provide diagnostic information in a variety of other conditions. Contact Laboratory Services before sending samples other than those listed above.

Cardiovascular Pathology

Our team has extensive experience and expertise in the evaluation of congenital and acquired heart disease in children and adults. Dissection techniques are specifically tailored to preserve specimen integrity, and very small and macerated specimens are dissected using fine instruments and a dissecting microscope. The laboratory includes equipment for obtaining high quality digital images to document the gross and microscopic findings. Special areas of expertise include latex injection for complex vascular anatomy, conduction system dissection and histopathologic evaluation.

The range of services offered includes primary dissection of specimens, secondary evaluation of previously dissected specimens, histopathologic consultations and electron microscopy. The following specimen types are commonly accepted for consultation, and additional services may be provided upon request.

  • Fresh or formalin-fixed heart specimens including autopsy materials
  • Endomyocardial biopsies for evaluation of cardiomyopathy, neoplasms or transplant rejection Heart valves
  • Glutaraldehyde fixed biopsies for ultrastructural evaluation with or without an interpretive report
  • Second opinion with a consultation report on previously prepared histological sections and/or electron microscopic preparations

Educational Experience in Congenital Heart Disease

In addition to diagnostic services, the Department of Pathology offers a 1-to-2-week educational experience in congenital heart disease pathology. The course includes access to an extensive congenital heart disease registry, systematic independent study, instructor-led educational sessions and recommended reading materials. Please contact the laboratory for additional information and scheduling.

Renal Pathology

The Anatomic Pathology Laboratory offers workup of medical kidney biopsies including light microscopy, special stains, immunofluorescence, immunohistochemistry and electron microscopy. The biopsies are interpreted by pathologists with experience in adult and pediatric renal biopsy pathology, including renal transplant pathology. Depending on each client’s needs, several levels of kidney biopsy evaluation are offered including:

  • Complete workup of biopsies with a diagnostic report issued by one of our pathologists
  • Immunofluorescence, immunohistochemistry and/or electron microscopy with an interpretive report by one of our pathologists

Neuropathology, Eye and Muscle Pathology

We are proud to offer extensive expertise and resources in pediatric neuropathology. We offer a large collection of immunohistochemical panels to aid in the diagnosis of the neoplasms of the nervous system, inflammatory conditions and neurodegenerative diseases. In addition, referring pathologists can request consultation services in neuro-autopsy, eye pathology and electron microscopy.

Neurosurgical Biopsies and Autopsy Neuropathology

We provide comprehensive diagnostic workup of biopsies or excised specimens from any neoplastic or non-neoplastic condition of the central and peripheral nervous system. Additionally, consultation services are available for autopsy neuropathology, as well as surgical and post-mortem eye pathology.

Epilepsy Resections

Nationwide Children’s is a Level III Epilepsy Care Center and our neuropathologists have extensive experience in performing the diagnostic workup of these complex resection specimens. We have a vast panel of markers available for examination of resected specimen and apply the most recent classification system by International League Against Epilepsy (ILAE) to all focal cortical dysplasia cases.

Muscle and Nerve Biopsies

The Neuromuscular Disorders Program at Nationwide Children’s consists of a multidisciplinary staff that diagnoses and treats disorders affecting peripheral nerves and muscles in children and adults. The Neuromuscular Laboratory processes approximately 150 muscle and nerve biopsies each year, complete with all necessary immunostaining and electron microscopy. To facilitate the collection and transport of an optimal biopsy to our facility, the Laboratory will provide a preassembled biopsy kit to our external clients. The neuromuscular pathology staff is available to discuss the findings of the biopsies with the referring physicians to achieve a better understanding of the clinical and pathological correlations.


Nationwide Children’s Laboratory Services provides consultations and reference laboratory testing on all hematologic disorders in children. Our staff of experienced pediatric hematopathologists provides comprehensive services to cover all necessary diagnostic procedures on referred specimens and is available for case discussions with referring pathologists and clinicians as necessary. Our services include the following general categories.

Bone Marrow Biopsies

We perform morphologic, cytochemical and immunophenotypic examinations of bone marrow aspirate, core biopsies and touch imprints. Flow cytometry is available using a panel of markers tailored for the work-up of pediatric leukemias, lymphomas and other hematopoietic neoplastic disorders. DNA ploidy studies as well as molecular and cytogenetics studies are coordinated through the laboratory and incorporated into the final diagnosis as necessary.

Lymph Node Biopsies

We provide consultation on difficult cases of reactive and neoplastic causes of lymphadenopathy, including evaluation of glass slides, paraffin blocks, immunophenotyping by flow cytometry and molecular testing as necessary. Our marker panels are tailored for hemapoietic disorders in children and young adults.

Peripheral Blood Specimens

Services include the pathologic examination of peripheral blood smears tailored for the pediatric anemia, cytopenias, red blood cell abnormalities, storage diseases and malignancies, all of which follow an instrument-based CBC analysis. We also offer immunophenotyping of white blood cells by flow cytometry to evaluate for suspected congenital or acquired immunodeficiency or neoplastic processes. Hemoglobin electrophoresis with written interpretive consultation is offered in order to evaluate thalassemia and hemoglobinopathies. Coagulation testing with consultation as well as thrombotic tendency testing is also available.

Platelet Electron Microscopy

Platelet electron microscopy is a gold standard in the investigation of many bleeding disorders such as dense granule deficiency. There are time and transportation constraints to consider prior to collecting the ACD blood sample. Therefore, we will gladly connect with your team to discuss the basic preparation necessary to ensure optimal specimen handling and evaluation of platelets by electron microscopy.

Gastrointestinal and Liver Pathology

Gastrointestinal (GI) and hepatobiliary disorders in children pose unique diagnostic challenges that are not often encountered in the adult population. Our GI/liver pathology group brings many years of experience in evaluation of pediatric disorders and is committed to providing timely diagnostic workup followed by clinicopathological correlations as necessary. In particular, we welcome the opportunity to provide the primary diagnosis or second opinions in the following areas.

Motility  Disorders

Disorders of gastrointestinal motility, including Hirschsprung disease and various forms of neuronal dysplasia, often present diagnostic challenges for the general pathologist, especially given that the pathophysiology of dysmotility continues to evolve. Our pathologists have expertise in primary diagnosis of dysmotility, and in evaluation of biopsies from patients with dysmotility whose symptoms persists or recurs after surgical procedures. When indicated, workup includes enzyme histochemistry for acetylcholinesterase and immunohistochemical stains such as Calretinin and PGP 9.5.

Celiac Disease, Inflammatory Bowel Disease and Related Disorders

Although the diagnosis of uncomplicated and fully developed celiac disease is straightforward, the spectrum of findings and the overlap with other forms of autoimmune enteropathy can be challenging. Similarly, pediatric inflammatory bowel disease can present with histopathological features that are either atypical or unique to the pediatric patient population. In addition to routine histological evaluation by expert pediatric GI pathologists, our staff has experience with interpretation of multiple ancillary studies such as immunohistochemical stains for CD3, Ki67 and TTG. In addition, our laboratory can coordinate and process molecular studies for viral etiologies such as CMV as necessary.

Liver Pathology

Our liver pathology experts provide comprehensive services in evaluation of pediatric liver biopsies including special stains, immunohistochemistry and electron microscopy. In addition, our laboratory can coordinate and process routine or molecular studies for infectious etiologies as necessary.

Transplant Pathology

Accurate interpretation of biopsies from transplanted organs is critical for optimizing long-term graft survival. Our pathologists have experience in the evaluation of heart, lung, liver, small bowel and kidney transplant biopsies.

Standard procedures for heart biopsies include specific microtomy protocols, examination of H+E stains taken at several levels in the block and C3d and C4d immunohistochemical stains on paraffin sections for evidence of antibody mediated rejection with CD68 immunostaining. Heart biopsies are classified based on International Society for Heart and Lung Transplantation (ISHLT) grading system and standardized nomenclature for heart biopsies.

We perform PAS, trichrome and Jones stains on every kidney biopsy and use the Banff classification and recommendations for evaluation of these biopsies. Electron microscopy is available on glutaraldehyde-fixed portions of kidney biopsies to identify additional features of chronic antibody mediated rejection including chronic transplant glomerulopathy and peritubular capillary basement membrane multi-layering. When recurrent or de novo glomerular disease is suspected, we perform a full panel of immunofluorescence stains along with electron microscopy. Immunohistochemical stains are available for BK virus (SV40) and other viral pathogens.

Transplant lung biopsy evaluation includes trichrome and elastic stains to assess for obliterative bronchiolitis and chronic transplant vasculopathy. Routine stains for pathogenic organisms include Gram, acid fast and GMS stains. Results are reported according to ISHLT grading system and consensus criteria for lung biopsies.

Whole organs obtained at explant surgery or autopsy are also accepted for consultation. In addition to evaluation of acute rejection, explanted hearts are examined thoroughly for chronic coronary transplant vasculopathy. Lungs are examined for obliterative bronchiolitis and chronic vasculopathy.

Placental Pathology and Products of Conception

Pathologic examination of the placenta should be considered when complications develop during pregnancy or delivery. With adverse fetal outcome, including pregnancy loss and recurrent pregnancy loss, placental examination should be considered mandatory. Pathologic changes in the placenta provide insight into the mechanisms of fetal and maternal complications. Our pathologists are experts in placental pathology and can provide complete and accurate information based on histopathologic changes, including evidence of infected fetal membranes, maternal underperfusion, fetal vascular thrombo-occlusive disease, vascular lesions and inflammatory processes involving the placental villi.

Placental Pathology

We offer complete gross and histologic examination of the placenta on referred cases. The gross examinations are performed by experienced pathologist assistants using a systematic protocol under direct pathologist supervision. This is followed by a detailed histological examination by our expert pathologists. Consultation with the Cytogenetics and Molecular Genetics Laboratory is available when indicated.

Fetal Examination

We offer detailed fetal examination in cases where the fetus is less than 20 weeks gestational age with no signs of life at delivery. Fetal examinations include the use of a dissecting microscope if necessary to evaluate developmental anomalies in all possible detail. Routine examination includes skeletal evaluation by radiographs, external description, examination of organs in situ as well as following removal from the body, and histopathology. Consultation with the Cytogenetics and Molecular Genetics Laboratory is available when indicated.

Infants Transferred to Nationwide Children’s

When infants are transferred to our hospital, the placenta, or the glass slides if the placenta has been previously processed for histopathology, will be requested from the transferring facility for examination in order to provide optimal care for our patients.

Perinatal and Pediatric Autopsy

Perinatal and pediatric autopsies provide important information for quality improvement, education, medical management of future pregnancies and future reproductive choices. In recent studies, major unexpected findings were discovered in 20 to 30 percent of pediatric autopsies, clarifying the cause of death or differential diagnosis in approximately 50 to 65 percent of the autopsies. Permission for autopsy should especially be requested for cases that involve:

  • Intrauterine fetal demise or other adverse pregnancy outcomes
  • Unexpected death at any age
  • Undiagnosed disorder leading to death
  • Unexpected complications of a disorder or treatment
  • Unanswered clinical questions regarding nature or extent of disease, cause of death or effects of treatment
  • Multiple malformations without a defined syndrome
  • Undefined, possible familial disorder
  • Indications of potential medicolegal issue

We are experts in a wide range of pediatric autopsies including stillborn fetuses, sudden unexpected deaths in infants and older children, complex congenital disorders and patients with solid organ and bone marrow transplants. Autopsies are routinely performed on patients up to 18 years of age. Autopsies are also performed on older patients with pediatric disorders who have been followed by Nationwide Children’s physicians.

The following facilities and expertise are available for performing perinatal and pediatric autopsies:

  • Radiographic evaluation of the entire skeletal system in infants and intrauterine fetal deaths
  • Detailed in situ examination, using a dissecting microscopic when needed
  • Digital photography for documentation of external and internal findings
  • On-site consultation with Medical Genetics with utilization of Cytogenetics and Molecular Genetics Laboratory as necessary
  • Ancillary studies (microbiologic cultures, toxicology, other tests)
  • Experienced pathologists’ assistants
  • Neuropathologists with expertise in pediatric pathology

Expertise in congenital heart disease as well as diseases of the lungs, liver, gastrointestinal system, hematopoietic system, kidneys, musculoskeletal system and placenta (placenta examination in all cases, when available).