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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*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>
*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>
*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>
===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>


=Basic approach=
=Basic approach=
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=Normal lung=
=Normal lung=
==Lung anatomy==
:''Benign lung'' redirects here.
===Airway===
===Lung anatomy===
====Airway====
*Bronchus = has cartilage.
*Bronchus = has cartilage.
*Bronchiole = non-cartilaginous airway.
*Bronchiole = non-cartilaginous airway.


===Pleura===
=====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.
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*'''A'''rteries (which were once thought to contain air) are with the '''a'''irway.
*'''A'''rteries (which were once thought to contain air) are with the '''a'''irway.


==Lung histology==
===Lung histology===
===Cells===
====Bronchial mucosa====
*Ciliated pseudostratified epithelium.
*Minimal/mild inflammation.
*Small amount of smooth muscle.
 
Metaplastic changes:
*Goblet cells - described in association [[asthma]] and [[COPD]].<ref>{{cite journal |authors=Rogers DF |title=The airway goblet cell |journal=Int J Biochem Cell Biol |volume=35 |issue=1 |pages=1–6 |date=January 2003 |pmid=12467641 |doi=10.1016/s1357-2725(02)00083-3 |url=}}</ref>
*Squamous - may precede dysplasia and malignancy.
 
====Lung parenchyma====
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.  


Image:
=====Images=====
<gallery>
Image: Benign bronchial epithelium -- low mag.jpg | BBE - low mag. (WC)
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)].
*[http://www.proteinatlas.org/dictionary/normal/lung/detail+1/magnification+1 Pneumocytes (proteinatlas.org)].


===Small airways===
===Sign out===
The trip to the alveolus:<ref>Hegele. 27 October 2009.</ref>
====Missed endobronchial biopsy====
#Membranous bronchiole.
<pre>
#Terminal bronchiole - dilation distal to this = emphysema.
RIGHT UPPER LOBE, ENDOBRONCHIAL BIOPSY:
#Respiratory bronchiole.
- SMALL FRAGMENT OF BENIGN BRONCHIAL MUCOSA WITH INFLAMMATION.
#Alveolar duct - dilated in [[ARDS]].
 
#Alveolus.
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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==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====
www:
*[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>
<gallery>
Image:Pulmonary_hamartoma_-_low_mag.jpg | Pulmonary hamartoma - low mag. (WC)
Image:Pulmonary_hamartoma_-_intermed_mag.jpg | Pulmonary hamartoma - intermed. mag. (WC)
Image:Pulmonary_hamartoma_-_high_mag.jpg | Pulmonary hamartoma - high mag. (WC)
</gallery>
 
===IHC===
*S100 +ve - highlights the fat.
 
===Sign out===
<pre>
LUNG LESION, LEFT UPPER LOBE, WEDGE RESECTION:
- PULMONARY HAMARTOMA WITH MILD FOCAL ACUTE INFLAMMATION AND SURROUNDING EDEMA.
- SURROUNDING LUNG WITH MILD EMPHYSEMATOUS CHANGES.
</pre>
 
====Micro====
The sections show lung with a well circumscribed lesion with a fibrous capsule partially lined by respiratory-type epithelium.  The lesion consists of abundant respiratory epithelium and glands with focal sheeting and small collections of neutrophils focally.  Small foci of degenerative changes are seen.  The epithelium of the lesion as a gland cytomorphology.  Mitotic activity is not readily apparent.  Fat is not identified as a component of the lesion.  Around the periphery of the lesion pulmonary edema is present. 
 
The piece surrounding lung more distant from the lesion has mild emphysematous changes.  No interstitial fibrosis is identified.  No significant inflammation is present.  The arteries are approximately the size of accompanying airway.  The arteries have no appreciable intimal thickening.


==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.
Michael
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