Difference between revisions of "Pulmonary pathology"

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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.
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=Lung specimens=
=Lung specimens=
*Ultrasound-guided needle core biopsy - for peripheral lesions.
*CT-guided or ultrasound-guided needle core biopsy - for peripheral lesions.
*Transbronchial biopsy - for central lesions.
*Transbronchial biopsy - for central lesions.
*"Open lung biopsy" - typically a ''video-assisted thoracic surgery'' (VATS) - done for [[diffuse lung diseases]].
*"Open lung biopsy" - typically a ''video-assisted thoracic surgery'' (VATS) - done for [[diffuse lung diseases]].
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*Pneumonectomy - 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.
*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=
=Basic approach=
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=Normal lung=
=Normal lung=
==Lung anatomy==
:''Benign lung'' redirects here.
===Lung anatomy===
====Airway====
*Bronchus = has cartilage.
*Bronchus = has cartilage.
*Bronchiole = non-cartilaginous airway.
*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>
*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.
*Parietal pleura = covers the chest wall.


===Lung lobule===
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>
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.
*Arterial vessels travels with the bronchus.
*Venules travel in the septae.
*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>
*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: arteries (which were once thought to contain air) are with the airway.
Memory device:  
*'''A'''rteries (which were once thought to contain air) are with the '''a'''irway.


==Lung histology==
===Lung histology===
===Cells===
====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.  


===Small airways===
=====Images=====
The trip to the alveolus:<ref>Hegele. 27 October 2009.</ref>
<gallery>
#Membranous bronchiole.
Image: Benign bronchial epithelium -- low mag.jpg | BBE - low mag. (WC)
#Terminal bronchiole - dilation distal to this = emphysema.
Image: Benign bronchial epithelium -- intermed mag.jpg | BBE - intermed. mag. (WC)
#Respiratory bronchiole.
Image: Benign bronchial epithelium -- high mag.jpg | BBE - high mag. (WC)
#Alveolar duct - dilated in [[ARDS]].
Image: Benign bronchial epithelium -- very high mag.jpg | BBE - very high mag. (WC)
#Alveolus.
 
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>
 
====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.
 
Comment:
Deepers were cut (x3). The radiologic findings are noted.  A re-biopsy is recommended.
</pre>
 
=====Alternate=====
<pre>
Lung, Left Lower Lobe, Endobronchial Biopsy:
- Respiratory bronchiolitis.
- Benign bronchial epithelium.
- NEGATIVE for granulomatous inflammation.
- NEGATIVE for evidence of mass lesion.
 
Comment:
Immunostains were done and compatible with bronchial epithelium (napsin negative,
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=
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*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)].
 
===IHC===
*S100 +ve - highlights the fat.


==Malformations==
==Malformations==
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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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==Pulmonary infarct==
==Pulmonary infarct==
*[[AKA]] ''lung infarct'', ''lung infarction'', ''pulmonary infarction''.
*[[AKA]] ''lung infarct'', ''lung infarction'', ''pulmonary infarction''.
===General===
{{Main|Pulmonary infarct}}
*Uncommon because of the dual blood supply (systemic via the bronchial arteries, pulmonary via the pulmonary arteries).
 
Common causes:<ref>URL: [http://emedicine.medscape.com/article/908045-overview http://emedicine.medscape.com/article/908045-overview]. Accessed on: 12 April 2012.</ref>
*[[Pulmonary embolism]].
*[[Sickle cell disease]].
 
Less common causes:
*Lymphoma, esp. [[acute promyelocytic leukemia]].
*Drugs, e.g. chemotherapy.
*[[Vasculitis]].
*Others.
 
===Gross===
*Lung periphery, classically described as wedge-shaped.
 
Note:
*In a histologic section, the classic wedge-shaped infarct is triangular:
**Base of triangle on the pleural aspect.
**Point furthest from the pleura close to the compromised artery that lead to infarction.
 
Image:
*[http://www.sciencephoto.com/media/258474/enlarge Pulmonary infarct (sciencephoto.com)].
*[http://www.flickr.com/photos/pulmonary_pathology/3732297830/ Pulmonary infarct (flickr.com)]
 
===Microscopic===
Features:
*[[Necrosis]] of alveolar walls - loss of nuclei.
*Alveolar hemorrhage.
 
Image:
*[http://commons.wikimedia.org/wiki/File:Pulmonary_infarct_intermed_mag.jpg Pulmonary infarct - low mag. (WC)].


=See also=
=See also=
Michael
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