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Pulmonary pathology (view source)

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The '''lung''' is a forgotten organ in pathology, 'cause radiologists can diagnose much with high resolution CT (HRCT) and a bit of history. This article introduces the lung and discusses an approach to the lung.   
[[Image:Benign bronchial epithelium and lung parenchyma -- intermed mag.jpg|thumb|right|350px|Lung parenchyma (left) and bronchial epithelium (right) on a biopsy. [[H&E stain]]. (WC)]]
This article introduces '''pulmonary pathology''' and discusses an approach to lung specimens.   


Medical lung disease is dealt with in the ''[[medical lung disease]]'' article.
Medical lung disease is dealt with in the ''[[medical lung disease]]'' article.
Tumours of the lung are dealt with in [[lung tumours]] article.  Lung [[cytopathology]] is dealt with in the ''[[pulmonary cytopathology]]'' article.
Tumours of the lung are dealt with in [[lung tumours]] article.  Lung [[cytopathology]] is dealt with in the ''[[pulmonary cytopathology]]'' article.


==Basic approach==
=Lung specimens=
*CT-guided or ultrasound-guided needle core biopsy - for peripheral lesions.
*Transbronchial biopsy - for central lesions.
*"Open lung biopsy" - typically a ''video-assisted thoracic surgery'' (VATS) - done for [[diffuse lung diseases]].
**These specimens should be sectioned to create pieces with a large surface area; ideally, it should be one large piece per block, so one can appreciate the architecture.
*Lobectomy - usually for cancer.
*Pneumonectomy - usually for cancer.
*Explantation - in the context of [[lung transplantation pathology|lung transplantation]] - done for [[cystic fibrosis]] [[Idiopathic pulmonary fibrosis]] and other causes.
 
==Lung core biopsies==
*Inadequacy rate for percutaneous biopsies ~5% in one series.<ref name=pmid22977650>{{Cite journal  | last1 = McSweeney | first1 = SE. | last2 = O'Regan | first2 = KN. | last3 = Mc Laughlin | first3 = PD. | last4 = Crush | first4 = L. | last5 = Maher | first5 = MM. | title = Evaluation of the efficacy and safety of percutaneous biopsy of lung. | journal = Open Respir Med J | volume = 6 | issue =  | pages = 82-8 | month =  | year = 2012 | doi = 10.2174/1874306401206010082 | PMID = 22977650 }}</ref>
*Length 0.5-1.5 cm enough for EGFR testing.<ref name=pmid22006985>{{Cite journal  | last1 = Zhuang | first1 = YP. | last2 = Wang | first2 = HY. | last3 = Shi | first3 = MQ. | last4 = Zhang | first4 = J. | last5 = Feng | first5 = Y. | title = Use of CT-guided fine needle aspiration biopsy in epidermal growth factor receptor mutation analysis in patients with advanced lung cancer. | journal = Acta Radiol | volume = 52 | issue = 10 | pages = 1083-7 | month = Dec | year = 2011 | doi = 10.1258/ar.2011.110150 | PMID = 22006985 }}</ref>
 
=Basic approach=
All lung pathology can be grouped into one of six categories (as per Leslie).  The radiology directly correlates to the pathologic grouping, except that ''air space disease'' encompasses three pathologic categories (ALI, CCI, AFD).
All lung pathology can be grouped into one of six categories (as per Leslie).  The radiology directly correlates to the pathologic grouping, except that ''air space disease'' encompasses three pathologic categories (ALI, CCI, AFD).


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*Vessels - thickening?
*Vessels - thickening?


==Normal histology==
=Normal lung=
===Cells===
:''Benign lung'' redirects here.
===Lung anatomy===
====Airway====
*Bronchus = has cartilage.
*Bronchiole = non-cartilaginous airway.
 
=====Small airways=====
The trip to the alveolus:<ref>Hegele. 27 October 2009.</ref>
#Membranous bronchiole.
#Terminal bronchiole - dilation distal to this = emphysema.
#Respiratory bronchiole.
#Alveolar duct - dilated in [[ARDS]].
#Alveolus.
 
====Pleura====
*Visceral pleura = covers the lung.<ref>URL: [http://www.ouhsc.edu/histology/Glass%20slides/14_15.jpg http://www.ouhsc.edu/histology/Glass%20slides/14_15.jpg]. Accessed on: 10 October 2012.</ref>
*Parietal pleura = covers the chest wall.
 
Note:
*[[Pleural invasion]] is an important prognosticator in lung cancer and should be considered if the tumour is close to the pleura.
 
====Lung lobule====
Lung lobule:<ref>[http://lib.hku.hk/denlib/exhibition/rarebook/mouth_hygiene_plate.jpg http://lib.hku.hk/denlib/exhibition/rarebook/mouth_hygiene_plate.jpg]</ref>
*Arterial vessels travels with the bronchus.
*Venules travel in the septae.
 
Note:
*Arterial vessels in the lung should be approximately the same size as its accompanying airway.<ref name=Ref_PPP266>{{Ref PPP|266}}</ref>
 
Memory device:
*'''A'''rteries (which were once thought to contain air) are with the '''a'''irway.
 
===Lung histology===
====Cells====
Common:
Common:
*Type I pneumocyte - cover most of the alveolar surface.
*Type I pneumocyte - cover most of the alveolar surface.
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***Synaptic vesicle 2.  
***Synaptic vesicle 2.  


===Lung lobule===
=====Images=====
Lung lobule:<ref>[http://lib.hku.hk/denlib/exhibition/rarebook/mouth_hygiene_plate.jpg http://lib.hku.hk/denlib/exhibition/rarebook/mouth_hygiene_plate.jpg]</ref>
<gallery>
*Arterial vessels travels with the bronchus.
Image: Benign bronchial epithelium -- low mag.jpg | BBE - low mag. (WC)
*Venules travel in the septae.
Image: Benign bronchial epithelium -- intermed mag.jpg | BBE - intermed. mag. (WC)
Image: Benign bronchial epithelium -- high mag.jpg | BBE - high mag. (WC)
Image: Benign bronchial epithelium -- very high mag.jpg | BBE - very high mag. (WC)
 
Image: Benign bronchial epithelium and lung parenchyma -- intermed mag.jpg | Lung & BBE - intermed. mag. (WC)
Image: Benign bronchial epithelium and lung parenchyma -- high mag.jpg | Lung & BBE - high mag. (WC)
</gallery>
www:
*[http://www.proteinatlas.org/dictionary/normal/lung/detail+1/magnification+1 Pneumocytes (proteinatlas.org)].
 
===Sign out===
====Missed endobronchial biopsy====
<pre>
RIGHT UPPER LOBE, ENDOBRONCHIAL BIOPSY:
- SMALL FRAGMENT OF BENIGN BRONCHIAL MUCOSA WITH INFLAMMATION.
 
COMMENT:
The clinical history of a mass is noted.
 
This biopsy does not show neoplastic tissue; however, the biopsy may not be representative
of the lesion seen.
</pre>


*Arterial vessels in the lung should be approximately the same size as its accompanying airway.<ref name=Ref_PPP266>{{Ref PPP|266}}</ref>
====Missed lung biopsy====
<pre>
Submitted as "Lung Mass" (Left Lower Lobe), Core Biopsy:
- Tiny cluster of indeterminate cells insufficient for a diagnosis, see comment.
- Benign lung parenchyma.
- NEGATIVE for definite lesion.


Memory device: arteries (which were once thought to contain air) are with the airway.
Comment:
Deepers were cut (x3). The radiologic findings are noted.  A re-biopsy is recommended.
</pre>


===Small airways===
=====Alternate=====
The trip to the alveolus:<ref>Hegele. 27 October 2009.</ref>
<pre>
#Membranous bronchiole.
Lung, Left Lower Lobe, Endobronchial Biopsy:
#Terminal bronchiole - dilation distal to this = emphysema.
- Respiratory bronchiolitis.
#Respiratory bronchiole.
- Benign bronchial epithelium.
#Alveolar duct - dilated in [[ARDS]].
- NEGATIVE for granulomatous inflammation.
#Alveolus.
- NEGATIVE for evidence of mass lesion.


===Anatomy - terms===
Comment:
*Bronchus = has cartilage.
Immunostains were done and compatible with bronchial epithelium (napsin negative,
*Bronchiole = non-cartilaginous airway.
TTF-1 negative, CK7 positive, CK20 negative, CDX2 negative, beta-catenin membranous
staining) and lung parenchyma (napsin positive, TTF-1 positive, CK7 positive,
CK20 negative, CDX2 negative, beta-catenin membranous staining).
</pre>


==Pathology terminology==
=Pathology terminology=
*Siderophages = mononuclear phagocyte with hemosiderin.<ref>http://medical-dictionary.thefreedictionary.com/siderophore</ref>
*Siderophages = mononuclear phagocyte with hemosiderin.<ref>http://medical-dictionary.thefreedictionary.com/siderophore</ref>


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*Smoker's macrophages = brown-pigmented macrophages - assoc. with smoking.<ref name=Ref_PPP236>{{Ref PPP|236}}</ref>
*Smoker's macrophages = brown-pigmented macrophages - assoc. with smoking.<ref name=Ref_PPP236>{{Ref PPP|236}}</ref>


=Detail articles=
==Malignancy - lung cancer==
==Malignancy - lung cancer==
{{main|Lung cancer}}
{{main|Lung cancer}}
This often comes to the pathologist.
This pretty much always comes to the pathologist.  


==Medical lung disease==
==Medical lung disease==
{{main|Medical lung disease}}
{{main|Medical lung disease}}
Includes discussion of things like acute infectious pneumonia and idiopathic pulmonary fibrosis.


Pulmonary hypertension is dealt with in its own article ''[[pulmonary hypertension]]''.
There are separate articles for:
*[[Pneumonia]].
*[[Diffuse lung diseases]], e.g. ''[[usual interstitial pneumonia]]''.
*[[Pulmonary hypertension]].


==Lung transplant pathology==
==Lung transplant pathology==
{{Main|Lung transplant pathology}}
{{Main|Lung transplant pathology}}


=Specific diagnoses=
==Bronchogenic cyst==
==Bronchogenic cyst==
===General===
===General===
*Benign.
*Benign.
*Usually in [[mediastinum]] or hilum.<ref name=Ref_PCPBoD8_363>{{Ref PCPBoD8|363}}</ref>
*Usually in [[mediastinum]] or hilum.<ref name=Ref_PCPBoD8_363>{{Ref PCPBoD8|363}}</ref>
*Fit into the bigger category of ''foregut cyst''.
*Fit into the bigger category of ''[[foregut cyst]]''.


===Microscopic===
===Microscopic===
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*Cyst lined by respiratory epithelium.  
*Cyst lined by respiratory epithelium.  


Images:
====Images====
*[http://commons.wikimedia.org/wiki/File:Bronchogenic_cyst_high_mag.jpg Bronchogenic cyst (WC)].
<gallery>
Image:Bronchogenic_cyst_high_mag.jpg | Bronchogenic cyst. (WC)
</gallery>
www:
*[http://asianannals.ctsnetjournals.org/cgi/content/full/16/3/246/F3 Bronchogenic cyst (ctsnetjournals.org)].
*[http://asianannals.ctsnetjournals.org/cgi/content/full/16/3/246/F3 Bronchogenic cyst (ctsnetjournals.org)].


==Pulmonary hamartoma==
==Pulmonary hamartoma==
===General===
{{Main|Pulmonary hamartoma}}
*Benign.
 
See also: ''[[Hamartoma]]''.
 
===Gross===
*Well circumscribed lesion.
 
===Microscopic===
Features:
*Cartilage - '''key feature'''.
**Single cells in lacunae surrounded by abundant matrix.
***Paucicellular vis-a-vis malignant lesions.
*Fat (adipocytes) - '''key feature'''.
*Respiratory epithelium (columnar epithelium with cilia).
 
Notes:
*No nuclear atypia.
 
Images:
*[http://forums.studentdoctor.net/showthread.php?t=207741 Pulmonary hamartoma (studentdoctor.net)].
*[http://www.path.utah.edu/casepath/pm%20cases/pmcase8/Hamartoma2.jpg Lung hamartoma (path.utah.edu)].<ref>URL: [http://www.path.utah.edu/casepath/pm%20cases/pmcase8/pmcase8part4.htm http://www.path.utah.edu/casepath/pm%20cases/pmcase8/pmcase8part4.htm]. Accessed on: 9 June 2011.</ref>
*[http://commons.wikimedia.org/wiki/File:Pulmonary_hamartoma_-_low_mag.jpg Pulmonary hamartoma - low mag. (WC)].
*[http://commons.wikimedia.org/wiki/File:Pulmonary_hamartoma_-_high_mag.jpg Pulmonary hamartoma - high mag. (WC)].


==Malformations==
==Malformations==
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**Type II = mostly small cysts.
**Type II = mostly small cysts.
**Type III = solid mass.
**Type III = solid mass.
====Gross====
*Cystic or solid mass.
Image:
*[http://www.humpath.com/local/cache-vignettes/L500xH370/jpg_cpam_type2_adenomatoid_malformation_10abc-0569f.jpg CPAM (humpath.com)].<ref>URL: [http://www.humpath.com/spip.php?article8685&id_document=22510 http://www.humpath.com/spip.php?article8685&id_document=22510]. Accessed on: 8 April 2012.</ref>


====Microscopic====
====Microscopic====
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===Extralobar sequestration===
===Extralobar sequestration===
General:
General:
*Typically not connected to airway tree/trachea.
*Typically not connected to airway tree/[[trachea]].
*Blood supply arises from aorta, ''not'' the pulmonary artery.
*Blood supply arises from aorta, ''not'' the pulmonary artery.
*Mass lesion.
*Mass lesion.
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Features:<ref name=Ref_Klatt100>{{Ref Klatt|100}}</ref>
Features:<ref name=Ref_Klatt100>{{Ref Klatt|100}}</ref>
*Abnormal airways:  
*Abnormal airways:  
**Dilated irregularly shaped airways.
**Dilated irregularly shaped bronchi.
***Wavy luminal contour/undulating contour (normal ~ round/ovoid).
**Distal airways with ciliated epithelium.
**Distal airways with ciliated epithelium.
*+/-Infection.
*+/-Infection.
**+/-Interstitial fibrosis due to inflammation.
Image:
*[http://www.sonoworld.com/Fetus/Case.aspx?CaseId=1500&answer=1 Extralobular sequestration - several images (sonoworld.com)].


===Intralobar sequestration===
===Intralobar sequestration===
General:
General:
*Classically identified due to recurrent infections or bronchiectasis.<ref name=Ref_PCPBoD8_363>{{Ref PCPBoD8|363}}</ref>
*Classically identified due to recurrent infections or [[bronchiectasis]].<ref name=Ref_PCPBoD8_363>{{Ref PCPBoD8|363}}</ref>
*''Intralobular sequestration'' can be considered a variant of ELS; it is like an ELS but surrounded by normal lung.
*''Intralobular sequestration'' can be considered a variant of ELS; it is like an ELS but surrounded by normal lung.


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*[http://www.pathologyoutlines.com/topic/lungnontumorBPD.html BPD (pathologyoutlines.com)].
*[http://www.pathologyoutlines.com/topic/lungnontumorBPD.html BPD (pathologyoutlines.com)].


==See also==
==Pulmonary infarct==
*[[AKA]] ''lung infarct'', ''lung infarction'', ''pulmonary infarction''.
{{Main|Pulmonary infarct}}
 
=See also=
*[[Medical lung disease]].
*[[Medical lung disease]].
*[[Thyroid]].
*[[Thyroid]].
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*[[Heart]].
*[[Heart]].


==References==
=References=
{{reflist|2}}
{{reflist|2}}


==External links==
=External links=
*[http://www.flickr.com/photos/pulmonary_pathology/with/5613145721/ Pulmonary pathology (flickr.com)].
*[http://www.flickr.com/photos/pulmonary_pathology/with/5613145721/ Pulmonary pathology (flickr.com)].


[[Category:Pulmonary pathology]]
[[Category:Pulmonary pathology]]
Michael
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