at 3 - Pathology in Clinical Practice

Question 1

Histologically what difference would be seen between UIP and NSIP?

Answer 1

UIP = usually interstitial pneumonia
- basal changes
- peripheral/subpleural
- not much ground glass
- honeycombing
- nil on antibodies
NSIP = non specific interstitial pneumonia
- anything non specific
- generally better prognosis than classical UIP
- no honeycombing, only mild inflammatory changes

Question 2

What are the 3 classifications of causes of granulpmatous lung disease?

Answer 2

Bugs - TB, fungi
inflammatory - sarcoidosis, extrinsic allergic alveolitis
Vasculitic - churg strauss, wegeners, poluartetisis nodosa

Question 3

What is sarcoidosis?
Which population is it most common in?
What is the rule of 1/3rds?

Answer 3

multi system disease of unknown aetiology
non-caseating granulomas
more common in afro-caribbean
1/3 get better without treatment
1/3 get better with short treatment
1/3 need long term treatment

Question 4

What would you see on a CXR of pulmonary sarcoidosis?

Answer 4

bilateral hilar lymphanopathy
infiltrates - ground glass appearance
fibrosis - anywhere in the lungs

Question 5

What are some examples of extra pulmonary aspects of sacrcoidosis/

Answer 5

skin
eyes
heart
neuro
liver

Question 6

What is EAA?

Answer 6

extrinsic allergic alveolitis
granulomatis disease
caused by inhalation of organic particles e.g. hay, bird proteins, fungi
antibody formation and T cell sensitisation –> hypersensitivity

Question 7

How is EAA diagnosed?

What is the treatment?

Answer 7

idenfication of potential antigen
CXR and HRCT –> underlying fibrosis
blood - precipitins, Normal IgE (as hypersensitivty)
resolution/improvement after cessation of exposure

antigen avoidance
steroids

Question 8

What is vasculitis?

Give examples

Answer 8

inflammation of blood vessels
may obstruct vessels or cause bleeding
often multi systemic, commonly renal

Wegener’s granulomatosis
Goodpasture’s disease

Question 9

One of the most common complications of vasculitis is pulmonary haemorrhage.
How would a patient with this present?

Answer 9

dyspnoa
haemoptysis
looks opaque on CXR
PFTs show high gas transfer
visualise at bronchoscopy

Question 10

What are the clinical features of lung cancer?

Answer 10

smoker
haemoptysis 
weight loss
dyspnoea
cough
chest pain
hoarse voice

Question 11

What 4 things do you need to know about the lung cancer once you know it’s there?

Answer 11

which lobe?
local spread
metastatic spread
tissue diagnosis - biopsy
specific tumour markers - tumours may have mutations in their DNA which response to treatment

Question 12

What are the 2 basic types of lung cancer?
How do you find out which one the patient has?
Why is it important to find this out?

Answer 12

non small cell carcinoma - 80% cases
small cell carcinoma -20%
tissue biopsy
need to know cell type to guide treatment

Question 13

What can a bronchoscopy do?

Answer 13

Visualisation and sampling (limited by anatomy)
Brushing
Washing
Biopsy

Question 14

What techniques are used for staging and tissue diagnosis?

Answer 14

EBUS = endobronchial ultrasound to sample lymph nodes

Cervical mediastinoscopy = sample lymph nodes in mediastinum

Question 15

How are non-small cell and small cell lung cancers classified?

Answer 15

Non-small cell 
TNM
Tumour = size
Number of lymph nodes involved 
Metasases = present or not

Small cell
limited or extensive

Question 16

How are non-small cell and small cell lung cancers managed?

Answer 16

Non-small cell
- surgey, radiotherapy, chemotherapy
Small cell
- chemotherpay, cranial radiotherapy (prevent metastases
- more aggressive so not eligible for surgery

Question 17

What are some local complications of lung cancer?

What are the symptoms of these complications?

Answer 17

SVC obstruction
- fixed raised IJV pressure
- lips cyanosed
- collaterals visible on skin
Horners syndrome - interruption of the cervical sympthetic chain
- ptosis, miosis, enopthalmos
Recurrent laryngeal nerve palsy
- paralysis of vocal cords --> hoarse voice 
Pleura involved --> pleural fluid

Question 18

How does lung cancer spread?

What are the common locations of spread?

Answer 18

via lymphatics or blood

commonly pleura, brain and bone

Question 19

What are the clinical features of pleural effusion?

Answer 19

SOB
pain?
of underlying cause
reduced expansion
dull percussion note
reduced vocal resonance

Question 20

Where does the pleural fluid come from in a pleural effusion?

Answer 20

leakage into pleural space - non-respiratory pathologies
produced by pathology in the pleural space - cancer/infection
decreased removal from the pleural space - lymph obstruction

Question 21

What is the difference between transudates and exudates?
When is each seen?
Which would be bilateral PE and which would be unilateral?

Answer 21

Transudates = protoein30g/l
unilateral
malignancy and infection

Question 22

What are the main causes of exudative plural effusion?

Answer 22

MR BALDY SPIT

• bronchial cancer
• abscesses
• pneumonia
• TB

Question 23

How are PE’s investigated and managed?

Answer 23

Tap fluid –> protein, glucose, cells, culture To determine cause
Aspirate and Drain

Question 24

What 2 things can exposure to asbestos cause?

Answer 24

benign - plaques and effusion

asbestosis - fibrosis, 43% clubbed

Question 25

What is the treatment for asbestosis?

Answer 25

avoid further exposure and stop smoking

steroids don’t work!

Question 26

What is mesothelioma?
What are the typical syndromes that are different from a lung cancer?
What is the treatment?

Answer 26

Most common complication of asbestosis
Cancer of the pleura

pain

chemotherapy, radiotherapy (can spread only needle tract), surgery to remove plura, immuno/gene therapy