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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, discusses an approach to the lung, and the tumours that afflicit it.  Medical lung disease is dealt with in the ''[[medical lung disease]]'' article.
[[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.   


==Basic approach==
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.
 
=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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Most of the things that come to pathology are in the ''mass/nodules'' category and lung tumours (discussed below).  The other categories are dealt with in the [[medical lung disease]] article.
Most of the things that come to pathology are in the ''mass/nodules'' category and lung tumours (discussed below).  The other categories are dealt with in the [[medical lung disease]] article.


==Normal histology==
'''Anatomical approach:'''
===Cells===
*Pleura - thickening?
*Airspace - filling?
*Alveolar walls - thickening?
*Airways - inflammation?
*Vessels - thickening?
 
=Normal lung=
:''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===
====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:
*Type I pneumocyte - cover most of the alveolar surface.
*Type I pneumocyte - cover most of the alveolar surface.
*Type II pneumocyte - stem cell, produce surfactant.
*Type II pneumocyte - stem cell, produce surfactant.
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*Macrophages.
*Macrophages.


===Lung lobule===
Rare:
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>
*Pulmonary neuroendocrine cells:<ref name=pmid18001162>{{cite journal |author=Cutz E, Yeger H, Pan J |title=Pulmonary neuroendocrine cell system in pediatric lung disease-recent advances |journal=Pediatr. Dev. Pathol. |volume=10 |issue=6 |pages=419–35 |year=2007 |pmid=18001162 |doi=10.2350/07-04-0267.1 |url=}}</ref>
*Arterial vessels travels with the bronchus.
**Histomorphology:
*Venules travel in the septae.
***Single cells.
***Small clusters ~ 6 cells ("neuroepithelial bodies").
**Identified with [[immunostains]]:
***Serotonin.
***Bombesin.
***Chromogranin A.
***Synaptic vesicle 2.
 
=====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)].
 
===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>PPP P.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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**Image: [http://pathhsw5m54.ucsf.edu/case27/images27/bronchiol.jpg Bronchiolization (ucsf.edu)].
**Image: [http://pathhsw5m54.ucsf.edu/case27/images27/bronchiol.jpg Bronchiolization (ucsf.edu)].


*Smoker's macrophages = brown-pigmented macrophages - assoc. with smoking.<ref>PPP P.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.


There are separate articles for:
*[[Pneumonia]].
*[[Diffuse lung diseases]], e.g. ''[[usual interstitial pneumonia]]''.
*[[Pulmonary hypertension]].
==Lung transplant pathology==
{{Main|Lung transplant pathology}}
=Specific diagnoses=
==Bronchogenic cyst==
==Bronchogenic cyst==
===General===
*Benign.
*Benign.
*Usually in mediastinum.
*Usually in [[mediastinum]] or hilum.<ref name=Ref_PCPBoD8_363>{{Ref PCPBoD8|363}}</ref>
*Fit into the bigger category of ''[[foregut cyst]]''.


===Microscopy===
===Microscopic===
Features:<ref>[http://asianannals.ctsnetjournals.org/cgi/content/full/16/3/246/F3 http://asianannals.ctsnetjournals.org/cgi/content/full/16/3/246/F3]</ref>
Features:<ref name=pmid18515678>{{Cite journal  | last1 = Chen | first1 = C. | last2 = Zheng | first2 = H. | title = Extralobar pulmonary sequestration in the hilum. | journal = Asian Cardiovasc Thorac Ann | volume = 16 | issue = 3 | pages = 246-8 | month = Jun | year = 2008 | doi =  | PMID = 18515678 | url=http://asianannals.ctsnetjournals.org/cgi/content/full/16/3/246 }}</ref>
*Cyst lined by respiratory epithelium.  
*Cyst lined by respiratory epithelium.  
====Images====
<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)].
==Pulmonary hamartoma==
{{Main|Pulmonary hamartoma}}
==Malformations==
Come in three flavours:
#Congenital pulmonary airway malformation (CPAM).
#Extralobar sequestration (ELS).
#Intralobar sequestrations (ILS).
===Congenital pulmonary airway malformation===
*Previously known as ''congenital cystic adenomatoid malformation'' (CCAM).<ref>URL: [http://radiopaedia.org/articles/congenital-pulmonary-airway-malformation http://radiopaedia.org/articles/congenital-pulmonary-airway-malformation]. Accessed on: 10 February 2012.</ref>
General:
*Classified according to density:<ref name=Ref_Klatt100>{{Ref Klatt|100}}</ref>
**Type I = mostly large cysts.
**Type II = mostly small cysts.
**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====
Features:<ref name=Ref_Klatt100>{{Ref Klatt|100}}</ref>
*Irregular cystic spaces with bronchial epithelium.
**Bronchial epithelium = cilia, pseudostratified.
===Extralobar sequestration===
General:
*Typically not connected to airway tree/[[trachea]].
*Blood supply arises from aorta, ''not'' the pulmonary artery.
*Mass lesion.
*Associated with other congenital anomalies.<ref name=Ref_PCPBoD8_363>{{Ref PCPBoD8|363}}</ref> The most common are diaphragmatic abnormalities - including congenital diaphragmatic hernia.<ref name=pmid8460228>{{Cite journal  | last1 = Rosado-de-Christenson | first1 = ML. | last2 = Frazier | first2 = AA. | last3 = Stocker | first3 = JT. | last4 = Templeton | first4 = PA. | title = From the archives of the AFIP. Extralobar sequestration: radiologic-pathologic correlation. | journal = Radiographics | volume = 13 | issue = 2 | pages = 425-41 | month = Mar | year = 1993 | doi =  | PMID = 8460228 | url=http://radiographics.rsnajnls.org/cgi/pmidlookup?view=long&pmid=8460228 }}</ref>
====Microscopic====
Features:<ref name=Ref_Klatt100>{{Ref Klatt|100}}</ref>
*Abnormal airways:
**Dilated irregularly shaped bronchi.
***Wavy luminal contour/undulating contour (normal ~ round/ovoid).
**Distal airways with ciliated epithelium.
*+/-Infection.
**+/-Interstitial fibrosis due to inflammation.


Image:
Image:
*[http://commons.wikimedia.org/wiki/File:Bronchogenic_cyst_high_mag.jpg Bronchogenic cyst (wikimedia.org)].
*[http://www.sonoworld.com/Fetus/Case.aspx?CaseId=1500&answer=1 Extralobular sequestration - several images (sonoworld.com)].
==See also==
 
===Intralobar sequestration===
General:
*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.
 
==Bronchopulmonary dysplasia==
*Abbreviated ''BPD''.
===General===
*Developmental.
*Assoc. with prematurity.<ref>{{Cite journal  | last1 = Chang | first1 = LW. | title = [Incidence and risk factors of bronchopulmonary dysplasia in premature infants in 10 hospitals in China]. | journal = Zhonghua Er Ke Za Zhi | volume = 49 | issue = 9 | pages = 655-62 | month = Sep | year = 2011 | doi =  | PMID = 22176899 }}</ref>
 
===Microscopic===
Features:
*Large alveoli.
*Bronchiolar fibrosis.
*Interstitial fibrosis.
 
Images:
*[http://www.pathologyoutlines.com/topic/lungnontumorBPD.html BPD (pathologyoutlines.com)].
 
==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}}


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