Difference between revisions of "Pulmonary cytopathology"

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Pulmonary cytopathology (view source)

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'''Pulmonary cytopathology''' is a subset of [[cytopathology]].
[[Image:Macrophages in bronchial wash specimen -- very high mag.jpg|thumb|right|Pulmonary macrophages. Bronchial wash. [[Diff-Quik]]. (WC)]]
[[Image:Bronchial cells - bronchial wash - 2 -- very high mag.jpg|thumb|right|Benign bronchial cells. Bronchial wash. [[Pap stain]]. (WC)]]
'''Pulmonary cytopathology''', also '''lung cytology''', is a subset of [[cytopathology]].


This article deals only with pulmonary cytopathology (FNAs, sputum samples).  An introduction to cytopathology is in the ''[[cytopathology]]'' article.  An introduction to lung pathology is in the ''[[lung]]'' article.
This article deals only with pulmonary cytopathology (FNAs, sputum samples).  Pleural cavity specimens are dealt with in the ''[[mesothelial cytopathology]]'' article.
 
An introduction to cytopathology is in the ''[[cytopathology]]'' article.  An introduction to lung pathology is in the ''[[lung]]'' article.


=Introduction=
=Introduction=
==Normal cytology==
*Cells with cilia = good.
*Cells with "terminal bar" (apical red band-like region associated with cilia) = good.
==Specimen types==
==Specimen types==
#Bronchial brushings.
#Bronchial brushings.
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#Bronchoalveolar lavage (BAL).
#Bronchoalveolar lavage (BAL).
#Endobronchial ultrasongraphic transbronchial needle aspiration (EBUS-TNA).
#Endobronchial ultrasongraphic transbronchial needle aspiration (EBUS-TNA).
#[[Endoscopic ultrasound-guided fine needle aspiration]].


==Adequacy criteria==
==Adequacy criteria==
*Want to see pulmonary macrophages (large cells with bubbly green/brown cytoplasm, eccentric reniform nucleus).
===EBUS===
**Ciliated cells may be from the nasopharynx - not proof of lung parenchymal tissue.
There is a proposed standard for EBUS specimens:<ref name=pmid22246929>{{Cite journal  | last1 = Nayak | first1 = A. | last2 = Sugrue | first2 = C. | last3 = Koenig | first3 = S. | last4 = Wasserman | first4 = PG. | last5 = Hoda | first5 = S. | last6 = Morgenstern | first6 = NJ. | title = Endobronchial ultrasound-guided transbronchial needle aspirate (EBUS-TBNA): a proposal for on-site adequacy criteria. | journal = Diagn Cytopathol | volume = 40 | issue = 2 | pages = 128-37 | month = Feb | year = 2012 | doi = 10.1002/dc.21517 | PMID = 22246929 }}</ref>
*> 5 low power fields (×10 objective) with >= 100 lymphocytes and < 2 groups of bronchial cells.
 
Note:
*A simplified version: 5 fields of view x 100 cells/1 field of view = 500 cells.
 
===Other specimens===
Brushings, washes and lavages:
*One should see pulmonary macrophages (large cells with bubbly green/brown cytoplasm, eccentric reniform nucleus).
 
Notes:
*Ciliated cells may be from the nasopharynx - not proof of lung parenchymal tissue.
*There is no generally accepted standard for bronchial brushings, washes and lavages. A house standard at a larger teaching centre is:<ref>UHN PCY50001.08 P.11.</ref>
**Sputum: >= 10 pulmonary macrophages.
 
==Normal cytology==
*Cells with cilia = good.
*Cells with "[[terminal bar]]" (band at luminal aspect of cell - associated with cilia) = good.
 
===Images===
====Cartilage====
<gallery>
Image: Bronchial cartilage - ebus -- intermed mag.jpg | Cartilage - intermed. mag. (WC)
Image: Bronchial cartilage - ebus -- high mag.jpg | Cartilage - high mag. (WC)
</gallery>
 
====Epithelium====
<gallery>
Image: Bronchial epithelium - ebus -- intermed mag.jpg | Bronchial epi. - intermed. mag. (WC)
Image: Bronchial epithelium - ebus -- high mag.jpg | Bronchial epi. - high mag. (WC)
Image: Bronchial epithelium - ebus -- very high mag.jpg | Bronchial epi. - very high mag. (WC)
</gallery>
<gallery>
Image: Bronchial cells - bronchial wash -- high mag.jpg | EBCs - high mag.
Image: Bronchial cells - bronchial wash -- very high mag.jpg | EBCs - high mag.
Image: Bronchial cells - bronchial wash - 2 -- high mag.jpg | EBCs - high mag.
Image: Bronchial cells - bronchial wash - 2 -- very high mag.jpg | EBCs - high mag.
</gallery>
 
==Reactive bronchial cells==
===Cytology===
Features:
*Clusters of small round cells.
*+/-Grooves.
 
====Images====
<gallery>
Image: Bronchial epithelium with inflammation -- high mag.jpg | BBE - high mag.
Image: Bronchial epithelium with inflammation -- very high mag.jpg | BBE - very high mag.
Image: Bronchial epithelium with inflammation - alt -- very high mag.jpg | BBE - very high mag.
</gallery>
<gallery>
Image: Reactive bronchial cells -- very high mag.jpg | RBCs - very high mag.
Image: Reactive bronchial cells -- extremely high mag.jpg | RBCs - extremely high mag.
</gallery>
=====www=====
*[http://www.cytologystuff.com/gallery/images_large/slide0612.jpg Reactive bronchial cells (cytologystuff.com)].<ref>URL: [http://www.cytologystuff.com/study/section12ng.htm http://www.cytologystuff.com/study/section12ng.htm]. Accessed on: 19 August 2015.</ref>


There is no generally accepted standard for pulmonary specimens. An in-house standard is:<ref>UHN PCY50001.08 P.11.</ref>
==Actinomycetes==
*Sputum: >= 10 pulmonary macrophages.
{{Main|Actinomycetes}}
 
Image:
*[http://www.cytologystuff.com/gallery/images_large/slide0540.jpg Actinomycetes (cytologystuff.com)].<ref>URL: [http://www.cytologystuff.com/study/section11ng.htm http://www.cytologystuff.com/study/section11ng.htm]. Accessed on: 26 October 2015.</ref>


=Infection=
=Infection=
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Features:
Features:
*Casts of frothy material/large proteinaceous debris - approximately the size of an alveolus.
*Casts of frothy material/large proteinaceous debris - approximately the size of an alveolus.
DDx:
*[[Pulmonary alveolar proteinosis]].


==Aspergillosis==
==Aspergillosis==
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Image:
Image:
*[http://commons.wikimedia.org/wiki/File:Pulmonary_aspergillosis.jpg Aspergillosis (WC)].
<gallery>
Image:Pulmonary_aspergillosis.jpg | Aspergillosis. (WC)
</gallery>


==Zygomycosis==
==Zygomycosis==
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Image:
Image:
*[http://commons.wikimedia.org/wiki/File:Zygomycosis.jpg Zygomycosis (WC)].
<gallery>
Image:Zygomycosis.jpg | Zygomycosis. (WC)
</gallery>


==Crytococcus==
==Crytococcus==
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**Seen well on Pap stain... harder to see on rapid Romanowsky stain.
**Seen well on Pap stain... harder to see on rapid Romanowsky stain.
*Spherical - 5-15 micrometres.
*Spherical - 5-15 micrometres.
Image:
*[http://commons.wikimedia.org/w/index.php?title=File:Cryptococcus.jpg Cryptococcus (WC)].


DDx:  
DDx:  
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**Has broad based budding.
**Has broad based budding.
*Coccidioidomycosis - larger (20-60 micrometers).
*Coccidioidomycosis - larger (20-60 micrometers).
Image:
<gallery>
Image:Cryptococcus.jpg | Cryptococcus. (WC)
</gallery>


=Cancer=
=Cancer=
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| '''Present'''
| '''Present'''
| Present r/i squamous (strong)
| Present r/i squamous (strong)
|-
| Image
| [[Image:Lung small cell carcinoma -- extremely high mag.jpg|thumb|center|120px|SmCC - Pap stain. (WC)]]
| [[Image:Lung adenocarcinoma - Pap stain -- very high mag.jpg|thumb|center|120px|LA - Pap stain. (WC)]]
| [[Image:Squamous carcinoma - lung FNA -- very high mag.jpg|thumb|center|120px|SCC - Pap stain. (WC)]]
| <!-- Value -->
|}
|}


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==Adenocarcinoma==
==Adenocarcinoma==
{{Main|Adenocarcinoma of the lung}}
===General===
*Most common type of lung cancer.
*Most common type of lung cancer.


===Cytology===
===Cytology===
Features:
Features:
*Eccentric nucleus:
**+/-Nuclear grooves.
**+/-Nuclear pseudoinclusions.
*Nucleolus.
*Nucleolus.
**Good ones are visible with 10X objective (virtually excludes SCLC).
**Good ones are visible with 10X objective (virtually excludes SCLC).
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*Abundant cytoplasm - virtually excludes small cell carcinoma.
*Abundant cytoplasm - virtually excludes small cell carcinoma.
*Vacuoles with mucin (pink discolouration) - virtually diagnostic.
*Vacuoles with mucin (pink discolouration) - virtually diagnostic.
*Eccentric nucleus.
*Negatives: NO moulding.
**Important if no nucleolus visible.


Notes:
Notes:
*May be subtle, i.e. have minimal cytologic changes.  
*May be subtle, i.e. have minimal cytologic changes.  
*No nuclear moulding -esp. important if no nucleolus visible.


DDx:
DDx:
*[[Creola body]] - have cilia, may be subtle.
*Benign mesothelium (also sheets of cells).
*Benign mesothelium (also sheets of cells).
*Atypical adenomatous hyperplasia (AAH) - thought to be the precursor to adenocarcinoma.<ref name=pmid11235908>{{Cite journal  | last1 = Mori | first1 = M. | last2 = Rao | first2 = SK. | last3 = Popper | first3 = HH. | last4 = Cagle | first4 = PT. | last5 = Fraire | first5 = AE. | title = Atypical adenomatous hyperplasia of the lung: a probable forerunner in the development of adenocarcinoma of the lung. | journal = Mod Pathol | volume = 14 | issue = 2 | pages = 72-84 | month = Feb | year = 2001 | doi = 10.1038/modpathol.3880259 | PMID = 11235908 |url = http://www.nature.com/modpathol/journal/v14/n2/full/3880259a.html }}</ref>
*[[Atypical adenomatous hyperplasia]] (AAH) - thought to be the precursor to adenocarcinoma.<ref name=pmid11235908>{{Cite journal  | last1 = Mori | first1 = M. | last2 = Rao | first2 = SK. | last3 = Popper | first3 = HH. | last4 = Cagle | first4 = PT. | last5 = Fraire | first5 = AE. | title = Atypical adenomatous hyperplasia of the lung: a probable forerunner in the development of adenocarcinoma of the lung. | journal = Mod Pathol | volume = 14 | issue = 2 | pages = 72-84 | month = Feb | year = 2001 | doi = 10.1038/modpathol.3880259 | PMID = 11235908 |url = http://www.nature.com/modpathol/journal/v14/n2/full/3880259a.html }}</ref>
**AAH has a size criterion, ergo not really possible to diagnose on cytopathology specimen.
**AAH has a size criterion, ergo not really possible to diagnose on cytopathology specimen.
*Vegetable cell - contaminant.<ref name=pmid8384547>{{Cite journal  | last1 = Naryshkin | first1 = S. | last2 = Young | first2 = NA. | title = Respiratory cytology: a review of non-neoplastic mimics of malignancy. | journal = Diagn Cytopathol | volume = 9 | issue = 1 | pages = 89-97 | month =  | year = 1993 | doi =  | PMID = 8384547 }}</ref>
====Images====
<gallery>
Image: Lung adenocarcinoma - Pap stain -- high mag.jpg | LA - Pap - high mag. (WC)
Image: Lung adenocarcinoma - Pap stain -- very high mag.jpg | LA - Pap - very high mag. (WC)
Image: Lung adenocarcinoma - Pap stain - alt -- very high mag.jpg | LA - Pap - very high mag. (WC)
Image: Lung adenocarcinoma - Diff-Quik -- high mag.jpg | LA - [[Diff-Quik stain|DQ]] - high mag. (WC)
Image: Lung adenocarcinoma - Diff-Quik -- very high mag.jpg | LA - DQ - very high mag. (WC)
</gallery>


==Neuroendocrine tumours==
==Neuroendocrine tumours==
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The grouping can be divided into four types:<ref name=cancerorg_car>[http://www.cancer.org/docroot/CRI/content/CRI_2_4_1X_What_is_lung_carcinoid_tumor_56.asp http://www.cancer.org/docroot/CRI/content/CRI_2_4_1X_What_is_lung_carcinoid_tumor_56.asp]</ref>
The grouping can be divided into four types:<ref name=cancerorg_car>[http://www.cancer.org/docroot/CRI/content/CRI_2_4_1X_What_is_lung_carcinoid_tumor_56.asp http://www.cancer.org/docroot/CRI/content/CRI_2_4_1X_What_is_lung_carcinoid_tumor_56.asp]</ref>
*Small cell carcinoma.
*[[Small cell carcinoma of the lung|Small cell carcinoma]].
*Large cell neuroendocrine carcinoma.  
*Large cell neuroendocrine carcinoma.  
*Typical carcinoid.
*[[Typical carcinoid]].
*Atypical carcinoid.
*[[Atypical carcinoid]].


Cytologic features useful for differentiation:
Cytologic features useful for differentiation:
*Small cell carcinoma: necrosis, scant cytoplasm, mitoses.
*Small cell carcinoma: necrosis, scant cytoplasm, mitoses.
*Typical carcinoid: often more cytoplasm, no necrosis, low mitotic rate (MIB-1: scant staining).
*Typical carcinoid: often more cytoplasm, no necrosis, low mitotic rate (MIB1: scant staining).
*Atypical carcinoid: higher mitotic rate/MIB-1 than ''typical carcinoid'',<ref>WG. February 2010.</ref> no necrosis.
*Atypical carcinoid: higher mitotic rate/MIB1 than ''typical carcinoid'',<ref>WG. February 2010.</ref> no necrosis.


Notes:<ref name=cancerorg_car/>
Notes:<ref name=cancerorg_car/>
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**Chromatin clumping.
**Chromatin clumping.
**Marked nuclear size variation.
**Marked nuclear size variation.
*Nuclear moulding - most useful for distinguishing from NSCLC<ref>{{Cite journal  | last1 = Sturgis | first1 = CD. | last2 = Nassar | first2 = DL. | last3 = D'Antonio | first3 = JA. | last4 = Raab | first4 = SS. | title = Cytologic features useful for distinguishing small cell from non-small cell carcinoma in bronchial brush and wash specimens. | journal = Am J Clin Pathol | volume = 114 | issue = 2 | pages = 197-202 | month = Aug | year = 2000 | doi = 10.1309/8MQG-6XEK-3X9L-A9XU | PMID = 10941334 |url=http://ajcp.ascpjournals.org/content/114/2/197.full.pdf }}</ref><ref>URL: [http://onlinelibrary.wiley.com/doi/10.1002/dc.10297/abstract http://onlinelibrary.wiley.com/doi/10.1002/dc.10297/abstract]. Accessed on: 31 May 2011.</ref> -  '''key feature'''.
*Nuclear moulding - most useful for distinguishing from NSCLC<ref name=pmid10941334>{{Cite journal  | last1 = Sturgis | first1 = CD. | last2 = Nassar | first2 = DL. | last3 = D'Antonio | first3 = JA. | last4 = Raab | first4 = SS. | title = Cytologic features useful for distinguishing small cell from non-small cell carcinoma in bronchial brush and wash specimens. | journal = Am J Clin Pathol | volume = 114 | issue = 2 | pages = 197-202 | month = Aug | year = 2000 | doi = 10.1309/8MQG-6XEK-3X9L-A9XU | PMID = 10941334 |url=http://ajcp.ascpjournals.org/content/114/2/197.full.pdf }}</ref><ref>URL: [http://onlinelibrary.wiley.com/doi/10.1002/dc.10297/abstract http://onlinelibrary.wiley.com/doi/10.1002/dc.10297/abstract]. Accessed on: 31 May 2011.</ref> -  '''key feature'''.
*Stippled chromatin - '''key feature'''.
*Stippled chromatin - '''key feature'''.
*Scant cytoplasm - so scant it often near impossible to see - '''important feature'''.
*Scant cytoplasm - so scant it often near impossible to see - '''important feature'''.
*Small cells ~ 2x RBC.
*Small cells ~ 2x RBC.
*Bare nuclei common - very useful if present.
*Bare nuclei common - very useful if present.
*Necrosis - ''essential''.
**Cell fragmentation - smeared gray background (Pap stain), fragmented nuclei.


Notes:
Notes:
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*Small cell leukemias may mimic small cell carcinoma; difference: leukemias typically have smaller cells (~size of RBC vs. ~2x of RBC), and lymphoglandular bodies.
*Small cell leukemias may mimic small cell carcinoma; difference: leukemias typically have smaller cells (~size of RBC vs. ~2x of RBC), and lymphoglandular bodies.


Image:
====Image====
*[http://commons.wikimedia.org/wiki/File:Small_cell_lung_cancer_-_cytology.jpg Small cell carcinoma showing nuclear moulding (WC)].
=====Case 1=====
<gallery>
Image:Small_cell_lung_cancer_-_cytology.jpg | SmCC showing nuclear moulding - [[Field stain]]. (WC)
</gallery>
=====Case 2=====
<gallery>
Image: Lung small cell carcinoma - Diff-Quik -- high mag.jpg | SmCC - [[Diff-Quik]] - high mag. (WC)
Image: Lung small cell carcinoma - Diff-Quik -- very high mag.jpg | SmCC - Diff-Quik - very high mag. (WC)
Image: Lung small cell carcinoma - Diff-Quik -- extremely high mag.jpg | SmCC - Diff-Quik - extremely high mag. (WC)
Image: Lung small cell carcinoma -- very high mag.jpg | SmCC - [[Pap stain]] - very high mag. (WC)
Image: Lung small cell carcinoma -- extremely high mag.jpg | SmCC - Pap stain - extremely high mag. (WC)
</gallery>
=====Case 3=====
<gallery>
Image: Small cell carcinoma - BRB -- high mag.jpg | SmCC - high mag.
Image: Small cell carcinoma - BRB - alt -- high mag.jpg | SmCC - high mag.
Image: Small cell carcinoma - BRB - alt 2 -- high mag.jpg | SmCC - high mag.
 
Image: Small cell carcinoma - BRB -- very high mag.jpg | SmCC - very high mag.
Image: Small cell carcinoma - BRB - alt -- very high mag.jpg | SmCC - very high mag.
Image: Small cell carcinoma - BRB - alt 2 -- very high mag.jpg | SmCC - very high mag.
 
Image: Small cell carcinoma - BRB -- very high mag.gif | SmCC - high very mag.
</gallery>


==Squamous cell carcinoma==
==Squamous cell carcinoma==
{{Main|Squamous cell carcinoma}}
{{Main|Squamous cell carcinoma of the lung}}


===Microscopic===
===Cytology===
*Mix of spindle cells/epithelioid cells, present in clusters, +/-small number of single cells.
General - features:
*Keratinization:
*Nuclear features of malignancy (required):
**Orange/red staining on Pap stain.
***Poorly differentiated SCC = not orange/red.
**"Intense" (blue) staining of cells on rapid Romanowsky + pyknotic (small shriveled) nucleus.<ref>GS. 24 February 2010.</ref>
*"Dense" appearing cytoplasm.
**+/-Laminae (layers)/lines in the cytoplasm.
*Nuclear features of malignancy (required for diagnosis):
**Irregular nuclear membrane, e.g. notches, sharp discontinuities.
**Irregular nuclear membrane, e.g. notches, sharp discontinuities.
**Nuclear hyperchromasia - "jet-black" nuclei on Pap stain '''key feature'''.
**Nuclear hyperchromasia - "jet-black" nuclei on Pap stain '''key feature'''.
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**Variation of nuclear size from cell-to-cell.
**Variation of nuclear size from cell-to-cell.


Image(s):
Features - well-differentiated:
*[http://commons.wikimedia.org/wiki/File:Squamous_carcinoma_lung_2_cytology.jpg SCC (WC)].
*Classically single cells.
*Keratinized = orange/red staining on Pap stain.
**"Intense" (blue) staining of cells on rapid Romanowsky + pyknotic (small shriveled) nucleus.<ref>GS. 24 February 2010.</ref>
 
Features - poorly differentiated:
*Mix of spindle cells/epithelioid cells usu. present in clusters '''without''' a common border.
*Usu. lack keratinization, i.e. not orange/red.
*"Dense" appearing cytoplasm.
**+/-Laminae (layers)/lines in the cytoplasm.


Notes:
Notes:
*One should see abnormal squamous cells to call it SCC.
*One should see abnormal squamous cells to call it SCC.
**The default diagnosis is usually ''adenocarcinoma''.
**One should think of ''adenocarcinoma'' as the default - it is more common.
*Poorly differentiated SCC may look like adenocarcinoma.
*Poorly differentiated SCC may look like adenocarcinoma.
====Image====
=====Case 1=====
<gallery>
Image:Squamous_carcinoma_lung_1_cytology.jpg |SCC. (WC)
Image:Squamous_carcinoma_lung_2_cytology.jpg |SCC. (WC)
</gallery>
=====Case 2=====
<gallery>
Image: Squamous carcinoma - lung FNA -- high mag.jpg | SCC - high mag.
Image: Squamous carcinoma - lung FNA - alt -- high mag.jpg | SCC - high mag.
Image: Squamous carcinoma - lung FNA -- very high mag.jpg | SCC - very high mag.
Image: Squamous carcinoma - lung FNA - alt -- very high mag.jpg | SCC - very high mag.
Image: Squamous carcinoma - lung FNA -- high and very high mag - animation.gif | SCC animation - very high mag.
Image: Squamous carcinoma - lung FNA -- extremely high mag.jpg | SCC - extremely high mag.
Image: Squamous carcinoma - lung FNA - alt 2 -- extremely high mag.jpg | SCC - extremely high mag.
</gallery>


==Malignant melanoma==
==Malignant melanoma==
{{Main|Malignant melanoma}}
===Cytology===
Classic features:
Classic features:
#Loosely cohesive cells and single cells.
#Loosely cohesive cells and single cells.
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#The classic appearance of melanoma without pigment is closest to adenocarcinoma (which may have red nucleoli, large cells, abundant cytoplasm, occasional binucleation).
#The classic appearance of melanoma without pigment is closest to adenocarcinoma (which may have red nucleoli, large cells, abundant cytoplasm, occasional binucleation).
#*Differentiating morphologic features: adenocarcinoma - 3-D clusters of cells, no spindle-shaped cells.
#*Differentiating morphologic features: adenocarcinoma - 3-D clusters of cells, no spindle-shaped cells.
#Bug-eyed monster cells - may vaguely resemble a Reed-Sternberg cell (RSC) - diagnostic of Hodgkin's lymphoma (HL).
#Bug-eyed monster cells - may vaguely resemble a Reed-Sternberg cell (RSC) - diagnostic of [[Hodgkin's lymphoma]] (HL).
#*RSCs do not have the granular cytoplasm typical of melanoma.
#*RSCs do not have the granular cytoplasm typical of melanoma.
#*Nuclei usually adjacent, i.e. not at opposite poles of the cell.
#*Nuclei usually adjacent, i.e. not at opposite poles of the cell.
#*Background of melanoma different than HL.
#*Background of melanoma different than HL.


Images:
====Images====
*[http://commons.wikimedia.org/wiki/File:Melanoma_-_cytology_field_stain.jpg Bug-eyed monster cell in melanoma - Field stain (WC)].
<gallery>
Image:Melanoma_-_cytology_field_stain.jpg | Bug-eyed monster cell in melanoma. [[Field stain]]. (WC)
</gallery>


=Other=
=Other=
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**They can also been in Pap tests.
**They can also been in Pap tests.


Images:
====Images====
*[http://commons.wikimedia.org/wiki/File:Curshman%27s_Spiral.jpg Curschmann spiral (WC)].
<gallery>
Image:Curshman%27s_Spiral.jpg | Curschmann spiral. (WC)
</gallery>
www:
*[http://www.medeponyms.com/images/eponyms/creola_body.jpg Creola body (medeponyms.com)].<ref>URL: [http://www.medeponyms.com/entry/27/ http://www.medeponyms.com/entry/27/]. Accessed on: 31 March 2012.</ref>
*[http://www.medeponyms.com/images/eponyms/creola_body.jpg Creola body (medeponyms.com)].<ref>URL: [http://www.medeponyms.com/entry/27/ http://www.medeponyms.com/entry/27/]. Accessed on: 31 March 2012.</ref>


Line 293: Line 437:
*No cytologic features of malignancy.
*No cytologic features of malignancy.
*Fat.
*Fat.
==Drug-induced pulmonary toxicity==
===General===
*Need clinical history.
===Cytology===
Features:
*Macrophages - classic for amiodarone toxicity.
==Mucinous metaplasia==
===Cytology===
Features:
*Cluster of cells with abundant clear cytoplasm.
*Bland nuclei.
DDx:
*[[Signet ring cell carcinoma]] - often single cells.
==Lipoid pneumonia==
*[[AKA]] ''cholesterol pneumonia''.
*[[AKA]] ''lipid granulomatosis''.
*[[AKA]] ''lipoid pneumonitis''.
===General===
Etiology:
*Aspiration or inhalation of a fatty substance, e.g. mineral oils (for [[constipation]]<ref name=pmi17846847>{{Cite journal  | last1 = Simmons | first1 = A. | last2 = Rouf | first2 = E. | last3 = Whittle | first3 = J. | title = Not your typical pneumonia: a case of exogenous lipoid pneumonia. | journal = J Gen Intern Med | volume = 22 | issue = 11 | pages = 1613-6 | month = Nov | year = 2007 | doi = 10.1007/s11606-007-0280-7 | PMID = 17846847 }}</ref>), petroleum jelly.<ref name=pmid19901490/>
*Often does not have the classic associations seen in [[aspiration pneumonia]], i.e. intoxication, neurologic disease.
Clinical:
*Chronic cough<ref name=pmid26371101>{{Cite journal  | last1 = Bell | first1 = MM. | title = Lipoid pneumonia: An unusual and preventable illness in elderly patients. | journal = Can Fam Physician | volume = 61 | issue = 9 | pages = 775-7 | month = Sep | year = 2015 | doi =  | PMID = 26371101 }}</ref> - classic finding.
*+/-Dyspnea.<ref name=pmi17846847/>
*+/-Fever.
*Lower lobe air space disease - opacification (left>right).
*+/-[[Hemoptysis]] (uncommon).
Treatment:
*Stop exposure to lipoid material.<ref name=pmid26371101/>
DDx (clinical):
*Viral pneumonia.
*Others.
===Cytology===
Features:<ref name=pmid19901490>{{Cite journal  | last1 = Khilnani | first1 = GC. | last2 = Hadda | first2 = V. | title = Lipoid pneumonia: an uncommon entity. | journal = Indian J Med Sci | volume = 63 | issue = 10 | pages = 474-80 | month = Oct | year = 2009 | doi = 10.4103/0019-5359.57639 | PMID = 19901490 | URL = http://www.indianjmedsci.org/article.asp?issn=0019-5359;year=2009;volume=63;issue=10;spage=474;epage=480;aulast=Khilnani }}</ref>
*Macrophages with multiple fat droplets.
**Often fill the cytoplasm.
*Nucleus often eccentric; '''not''' distorted (as seen in signet ring cells).
DDx:
*[[Signet ring cell carcinoma]].
*[[Gastroesophageal reflux disease]] - also ''Oil red O'' +ve.<ref>{{Cite journal  | last1 = Hopkins | first1 = PM. | last2 = Kermeen | first2 = F. | last3 = Duhig | first3 = E. | last4 = Fletcher | first4 = L. | last5 = Gradwell | first5 = J. | last6 = Whitfield | first6 = L. | last7 = Godinez | first7 = C. | last8 = Musk | first8 = M. | last9 = Chambers | first9 = D. | title = Oil red O stain of alveolar macrophages is an effective screening test for gastroesophageal reflux disease in lung transplant recipients. | journal = J Heart Lung Transplant | volume = 29 | issue = 8 | pages = 859-64 | month = Aug | year = 2010 | doi = 10.1016/j.healun.2010.03.015 | PMID = 20466562 }}</ref>
====Image====
*[http://www.indianjmedsci.org/viewimage.asp?img=IndianJMedSci_2009_63_10_474_57639_u2.jpg Lipoid pneumonia (indianjmedsci.org)].<ref name=pmid19901490/>
===Stains===
*[[Oil red O stain]] +ve.<ref name=pmid25374742>{{Cite journal  | last1 = Yampara Guarachi | first1 = GI. | last2 = Barbosa Moreira | first2 = V. | last3 = Santos Ferreira | first3 = A. | last4 = Sias | first4 = SM. | last5 = Rodrigues | first5 = CC. | last6 = Teixeira | first6 = GH. | title = Lipoid pneumonia in a gas station attendant. | journal = Case Rep Pulmonol | volume = 2014 | issue =  | pages = 358761 | month =  | year = 2014 | doi = 10.1155/2014/358761 | PMID = 25374742 }}</ref>
*Iron stain -ve.


==Non-specific inflammation==
==Non-specific inflammation==
Michael
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