Lungs Flashcards
1
Q
T-F- the apices of the lung rise above the clavicle?
T-F- the lung does not cover any portion of the mediastinum upon inhalation?
A
True
False
2
Q
Of the conducting airways, which section is the weakest link and why?
A
bronchioles- they do not have cartilage like the trachea and bronchi do
3
Q
What does a normal gross lung specimen look and feel like?
A
light red brown
spongy
4
Q
The connective tissue of the visceral pleura is lined by what type of cells? What is their ultrastructural hallmark?
A
mesothelial cells- long slender microvilli
5
Q
What type of cell comprises 90-95% of the alveolar lining? what shape are they?
A
Type I pneumocyte- flat epithelial- gas exchange
6
Q
What is the type II pneumocyte shape? What happens to these cells during inflammation?
A
cuboidal- surfactant production and antimicrobials
increase in number
7
Q
What are the 4 key mechanism (mechanical and cellular) for pulmonary defense?
A
Tracheobronchial clearance (cilia and goblet)
Cough
Alveolar macrophages
lymphatics
8
Q
What are common ways to suppress the cough reflex?
A
stroke, post-operative
9
Q
What are common ways to injure mucociliary clearance?
A
tobacco
10
Q
What are the 4 common ways to lose/impair host defense mechanisms that she gives?
A
smoking, ethanol, stroke, heart failure
11
Q
What are the histological findings [2] of classic bacterial pneumonia (strep pneumonia)?
A
- intra alveolar exudate- fibrin and neutrophils
2. Alveolar capillary congestion
12
Q
What are the two basic patterns of bacterial pneumonia?
The pattern of involvement really depends on what two things?
A
- patch bronchopneumonia or whole lobe lobar pneumonia
2. bacterial virulence and innate defenses
13
Q
In bronchopneumnia we know we see a plug of fibrin and neutrophils, but what happens to the wall of the bronchiole?
A
it gets inflamed as well
14
Q
What are the 4 pathological stages of bacterial pneumonia?
A
congestion
red hepatization
gray hepatization
resolution
15
Q
What pathological stage of pneumonia (bacterial) is characterized by vascular engorgement, alveolar fluid, few neutrophils, numerous bacteria?
A
congestion
16
Q
What pathological stage of bacterial pneumonia is characterized by firm, airless, massive exudate, neutrophils and fibrin?
A
red hepatization
17
Q
What pathological stage of bacterial pneumonia is characterized by a dry surface, disintegration of RBCs, and a strong fibropurulent exudate?
A
gray hepatization
18
Q
During resolution of bacterial pneumonia- enzymatic digestion of the exudate produces granular semifluid debris. What 4 things can happen to it?
A
- resorbed
- ingested by macrophages
- expectorated
- organized by fibroblasts growing in it
19
Q
What is the clinical presentation of bacterial pneumonia? Review[6]
A
abrupt onset high fever shaking chills productive cough pleuritis
20
Q
What type of bacterial pneumonia is very important to find, but won’t show on a gram stain but shows up with a silver stain?
A
legionella
21
Q
What does viral and atypical bacterial pneumonia primarily effect?
A
the interstitium- the damage can predispose to other bacterial pneumonias
22
Q
What is the best example of atypical bacterial pneumonia?
A
Mycoplasma
but don’t forget chlamydia
23
Q
Atypical pneumonia may have a moderate amount of sputum, but what doesn’t it have?
A
consolidation and significant alveolar exudate
24
Q
Mycoplasm bronchiolitis looks like what?
A
inflammation of a bronchiole mucosa with patchy infiltrates and swelling in the peribronchial interstitial space, SURROUNDING ALVEOLI LOOK PRETTY NORMAL
25
Clinical speaking, what does viral/atypical pneumonia look like?
```
'walking pneumonia'
chest cold
low grade fever
headache
muscle aches
insidious onset
```
26
What are the common pathogens for community acquired pneumonia? hospital acquired?
1. strep pneumonia and haemophilus influzae
| 2. staph aureus and pseudomonas
27
Review the following common virus for CA pneumonia
parainfluenza
adenovirus
influenza
RSV
28
What should we remember when looking at a biopsy of an immunocompromised host?
low virulence/opportunistic pathogens may be the causing factor
tissue pathology or inflammation may be minimal
29
Review the following CD4 levels and the pneumonia causing agents
<200 PCP, Aspergillus
30
What virus shows both intranuclear and intracytoplasmic inclusions?
CMV
31
What do we see cellularly in the case of food particles (maybe from GERD) that have been aspirated in the lungs?
multinucleate giant cells within alveolar spaces trying to digest--> airway centered granulomatous inflammation
32
What are three common risk factors for aspiration pneumonia that have polymicrobial infectious agents?
```
impaired consciousness (alcoholics)
severe reflux (GERD)
Poor swallowing (stroke, neck cancer etc.)
```
33
What are the common causative organisms in lung abcesses? What are the common etiologies 4 ?
1. 60% are anaerobic bacteria
| 2. aspiration, poorly treated bacterial infection, septic emboli, neoplasia
34
On gross specimen, what should surround an abcess? What does the x ray look like? Microscopic?
1. hyperemic rim
2. AIR-FLUID LEVELS
3. neutrophils and fibrin surrounded by granulation tissue
35
what creates a -frothy bubbly and lacks a cellular intra-alveolar infiltrate exudate?
PCP
36
How do we stain PCP?
Silver stain from bronchoalveolar lavage
37
Where do we find histoplasma?
soil with bird droppings or bat droppings
38
Histoplasmosis causes what type of lesion? What does it appear as on CXR?
1. granulomatous nodule with central necrosis and fibrous wall (like TB)
2. Coin lesion- if they contain calcifications they are almost always benign
39
In the histoplasmosis silver stain, are the organisms small or large?
small- 4 microns (may also see budding)
40
What populations are at risk for initial exposure to M. tuberculosis to cause primary pulmonary tuberculosis?
poor
homeless
incarcerated
southern latitudes
41
T-F- primary pulmonary tuberculosis is normally symptomatic? T-F-- rates are decreasing
False and false
42
What percentage of TB infected people develop clinically significant disease?
5
43
Primary pulmonary tuberculosis looks like what in the gross lung?
peripheral granuloma with hilar adenopathy (hilar nodes will be dark-anthracosis- not in the areas of the granuloma)
44
At the edge of a necrotizing granuloma, what cells do we readily see?
multinucleate giant cells.
45
IF we have a CT scan of someone with nodules in their lung, what do we see that can tell us that they are benign?
central calcification
46
Where is the lesion primarily in secondary pulmonary tuberculosis? who gets it?
1. apical and posterior (apical shadow)
| 2. reactivation of primary or new infection in previously sensitized host
47
What are the differential diagnosis usually seen with tuberculosis?
malignancy
fungal infection
lymphoma
48
T-F-- PPD test need intact cell-mediated immunity?
True- it is a Type IV hypersensitivity test
49
What is defined as a rapid onset of severe life threatening respiratory insufficiency, cyanosis and severe arterial hypoxemia refractory to oxygen therapy?
ARDS
| - remember that ARDS can be caused by infections, sepsis, toxic fumes, drug and medication reactions,etc
50
What does a CXR of ARDS look like? what is the mortality rate?
1. extensive opacities in both lungs
| 2. 60% +
51
What is the difference of ARDS and diffuse alveolar damage (DAD)?
ARDS is a clinical diagnosis and DAD is pathological (DAD = hyaline membranous disease or acute lung injury)
52
What are the 4 characteristics of diffuse alveolar damage-pathology injury to capillary endothelium?
increased cap. permeability
interstitial and intra-alveolar edema
fibrin exudation
hyaline membrane formation
53
What are the 4 phases of DAD?
exudative-->transition-->proliferative-->fibrotic
Corresponds to
edema---> hyaline membrane-->inflammation-->fibroplasia
NOTE:hyaline formation happens very early in exudative stage
54
In DAD- what does diffuse mean?
The entire alveoli is damaged- not the whole lung or lobe is damaged
55
Alveolar spaces are filled with what in DAD?
balls of fibroblasts
56
Is bronchiectasis and pneumonitis obstructive pulmonary diseases or restrictive pulmonary disease?
bronchiectasis is obstructive
pneumonitis is restrictive
57
What is described as increase in resistance to airflow due to partial or complete obstruction at any level of airway?
Obstructive lung disease
| - can get air in but can't get it out
58
What is described as a reduced expansion of lung parenchyma and decreased total lung capacity
Restrictive lung diseases
| - can get the air out, but can't get it in well.
59
Most of the obstructive pulmonary diseases have the bronchus as their main anatomic site, which one has the acinus as its main site?
emphysema
60
What obstructive disease characterized by airway dilation and scarring?
bronchiectasis
61
What obstructive disease is characterized by mucous gland hyperplasia and hyper secretion? smooth muscle hyperplasia?
chronic bronchitis
| ASthma
62
What obstructive disease is characterized by airspace enlargement; wall destruction
emphysema
63
What two lung diseases are grouped together for COPD?
emphysema and bronchitis
64
In emphysema- there is destruction to the walls past the terminal bronchiole…is there fibrosis? what is it associated with [2]?
No
cigarette smoke and alpha-1 antitripsin deficiency
65
What type of emphysema is the most common?
centriacinar 95%
- central, more common in upper lobes, common in smokers
66
What type of emphysema is associated with alpha 1 antitrypsin?
panacinar- uniform enlargement, more common in lower zones
67
On a gross specimen- what would be the diff between panacinar and centriacinar?
panacinar does not have normal tissue between the problematic areas. ITS PRETTY MUCH THE SAME DEAL UNDER MICROSCOPE TOO
68
What does smoking decrease that leads to higher levels of elastase?
alpha-1 antitrypsin
69
What cells are releasing the elastase?
| What where do we get the anti-protease?
1. neutrophils and macrophages
| 2. in the serum and tissue fluids
70
The critical event in emphysema is the loss of alveolar walls, what two things does this lead to?
decreases gas exchange and reduces the elastic tissue content of the lungs
71
Symptoms of emphysema appear after how much of the parenchyma was damaged? what do they include?
1/3
dyspnea, weight loss, eventually overdistension
72
What is an air filled space that measures more than 1cm in diameter in the distended state of emphysema? what can this lead to?
1. subpleural bullae
| 2. pneumothorax
73
What are the 3 major complications of emphysema?
respiratory acidosis and coma
right sided heart failure
pneumothorax and collapsed lung
74
What is described as a persistent cough with sputum production for at least 3 consecutive months in at least two consecutive years?
chronic bronchitis
| - smokers and smog laden cities
75
What is the difference in chest radiograph of bronchitis and emphysema?
bronchitis will have prominent vessels and a large heart, emphysema will show hyperinflation and a small heart
76
Is bronchitis the blue bloater or the pink puffer?
blue bloater
77
How are the bronchioles narrowed in bronchitis?
mucous plugs
inflammation
fibrosis
78
What are the clinical symptoms of chronic bronchitis?
persistent cough with mucous
dyspnea
hypercapnea, hypoxemia and mild CYANOSIS
79
Review the complications of chronic bronchitis complications-
progression to COPD
cor pulmonale and HF
atypical metaplasia and dysplasia (cancer opportunity)
80
what is characterized by recurrent episodes of wheezing, breathlessness, chest tightness, and cough?
asthma
81
What can cause non atopic asthma?
cold or exercise
82
T-F- in asthma there is an increase in smooth muscle cells, inflammatory cells, but less mucous secretion?
false- more mucous too
83
In bronchial asthma, the attack is reversible, but overtime will permanently remodel. review the things that will happen upon remodeling
thickening of the airway wall
sub-basement membrane fibrosis
increased vascularity
increase in size of the submucosal glands
hypertrophy/hyperplasia of the bronchial wall muscle
84
What is a curschmann spiral?
a mucous cast of a small bronchiole
85
What is charcot-leyden crystal?
collections of crystalloid made up of an eosinophilic lysophospholipase binding protein galactic 10
86
What are the main 4 symptoms of an asthma attack?
chest tightness
dyspnea
wheezing
cough
87
Review the following major asthma complications
status asthmaticus
progressive hyperinflation
bacterial infections
cor pulmonale and heart failure
88
What are the major etiologies of bronchiectasis (permanent dilation of conducting airway)?
bronchial obstruction with inflammation
congenital/hereditary conditions
cystic fibrosis, primary ciliary dyskinesia, necrotizing pneumonia
89
Is bronchiectasis a whole lung or whole lobe thing?
No- just distal to the obstruction
90
On a microscope, what should we look for in bronchiectasis?
1. inflammation
| 2. dilation of airways with a much larger diameter than blood vessels- remember they should be the same.
91
Why do bronchiectasis patients get so many infections?
they can not clear the pooled secretions from the affected portion
92
In restrictive lung diseases, where is the fibrosis and inflammation taking place?
most peripheral and delicate interstitial in the alveolar walls
93
How are the majority of chronic interstitial lung diseases diagnosed?
history, CT, PFTs and serology
RARELY IS TISSUE EXAMINATION NEEDED
94
The clinical diagnosis of idiopathic pulmonary fibrosis is equal to what?
the pathological diagnosis of usual interstitial pneumonia
95
What are the key his to features of usual interstitial pneumonia?
1. patchy intersitial fibrosis w/ temporal heterogeneity
2. fibroblasts!! fibroblastic foci
3. honeycomb fibrosis
96
IN idiopathic pulmonary fibrosis, where does the honeycombing and fibrosis begin?
in the periphery
97
In usual interstitial pneumonia, what is found between the honeycombing and the uninvolved lung under a microscope
this is where you will find the fibroblastic foci
98
What is the prognosis of UIP/IPF? what are the symptoms?
1. mean survival is 3 years, transplantation is the only definitive therapy
2. progression of dyspnea, dry cough, hypoxemia, cyanosis and clubbing
99
What is a non-neoplastic lung reaction to inhalation of organic and inorganic particles, chemicals and fumes?
pneumoconiosis
| asbestos, coal dust, silicosis
100
What really distinguishes asbestos from UIP under the microscope?
asbestos bodies (golden brown, fusiform or beaded rods with translucent center)
101
What other things are caused by asbestos but are not asbestosis?
mesothelioma and pleural plaques
102
Does the presence of asbestos body diagnose asbestosis?
No- other changes (characteristic pattern of fibrosis) are necessary
103
What is a systemic granulomatous disease of unknown cause? is it caseating? where is the distribution heavy?
1. sarcoidosis
2. no necrosis in the center
3. lymphatics, bronchi, and blood vessels
104
What do we see on gross specimen of patients with sarcoidosis?
tan areas- nodules with sclerosis
105
What two things might we see under high magnification of sarcoidosis?
asteroid body- star shaped eosinophilic structure
| schaumann body- concentric calcification
106
What is characterized by an immunologically mediated, interstitial lung disorder caused by inhaled organic dusts in susceptible individuals?
hypersensitivity pneumonitis
107
What are the two most common antigens for HP?
```
Farmers lung (termophilic actinomycetes)
Bird Fancier's lung
```
108
What are the 3 key his to findings in hypersensitivity pneumonia?
1. poorly formed granulomas (non-caseating)- small clusters of histiocytes
2. interstitial pneumonitis- lymphocytes, plasma cells, macrophages
3. fibrosis and honeycombing
109
Do metastasis to the lung outnumber primary lung neoplasms?
They are much more frequent.
110
Are lung cancers the most common type of cancer in men and women? what about the most common deaths?
No- they are the 2nd in both
| Yes they are the most common cancers for cancer deaths
111
Why did lung cancer deaths in women lag behind men?
The pattern of heavy smoking in women started a couple decades behind men and quitting in large groups was the same.
112
What is the overall 5 year survival for primary lung cancer?
15%
113
What are the 4 major symptoms for primary lung cancer?
cough, weight loss, chest pain, dyspnea
114
Besides smoking, what are a couple major risk factors for primary lung cancer?
radon gas
| industrial hazards
115
Is low dose CT or CXR better at reducing lung cancer mortality when used for screening?
LDCT by 20%
Risks- radiation exposure, high false positive rates, potential for over diagnosis
116
What is required to make a confident diagnosis of lung cancer?
a piece of tissue from the primary tumor site!
sputum cytology, bronchoscopy, FNA, open lung biopsy, pleural fluid biopsy
117
What two variables does lung cancer prognosis and treatment really on?
histological classification and stage.
118
Is surgery a primary mode of treatment for small cell lung cancer?
no radiation and chemotherapy
119
What are the three major things for staging?
Tumor, Nodes, Metastasis
120
What are the two major types of non-small cel carcinomas in the lung?
squamous cell carcinoma and adenocarcinoma
121
Who does 90% of squamous cell carcinomas occur in? where are they usually located? what are the key his to findings?
1. cigarette smokers
2. CENTRALLY in the main stem, lobar, segmental
3. keratin pearls, keratinization, intercellular bridges
122
What is the common cancer P63 and P40 stain for in immunohistochemistry? What about TTF-1?
1. squamous cell carcinoma
| 2. lung adenocarcinoma
123
What are the key his to findings in adenocarcinoma?
gland formation and mucin production
124
Who do we see with adenocarcinoma of the lungs often?
non-smokers, women, asian
125
What is a common gross finding in adenocarcinoma?
pleural puckering
126
What are the 4 types of adenocarcinoma? which ones are more aggressive?
1. papillary, micropapillary, solid, acinar
| 2. micropapillary and solid
127
In adenocarcinoma of the lung, is EGFR mutations more common in people that have smoked or non-smokers? what mutation correlate with worse outcomes?
1. Non-smokers are 40-50% while smokers are 10%
| 2. KRAS
128
What are the two immunihistochemistry markers for adenocarcinoma?
TTF-1 (thyroid cancer also expresses)
| Napsin
129
What is a non-invasive adenocarcinoma of the lung that grows along the alveolar surfaces.?
What is the survival? is it related to smoking? 2 main subtypes?
1. bronchoalveolar carcinoma
2. 100% if small
3. over represented in non-smokers
4. mutinous and non-mucinous
130
Bronchoalveolar carcinoma often mimics pneumonia, what is the appearance of the tumor in gross anatomy?
spongy because it lacks desmoplasia
remember it's not invasive
131
Which subtype of bronchoalveolar carcinoma often lacks TTF-1 marker? does BAC grow in single file lines on the alveolar walls? which type of BAC comes as a solitary mass? multifocal mass?
1. mucinous
2. yes
3. non-mucinous
4. mucinous
132
What cancer is positive for TTF-1, chromogranin, and synaptophysin?
small cell carcinoma
133
Review the key features of small cell carcinoma-
```
small cells
scant cytoplasm
granular nuclear chromatin (salt/pepper)
high mitotic rate
nuclear molding.
(MORPHOLOGY CAN LOOK SIMILAR TO LYMPHOCYTES)
```
134
T-F- in small cell carcinoma, most patients appear with metastasis to lymph nodes?
Yes- and diagnosis is often made from material aspirated from a lymph node
135
What is it called when nuclei push up against each other?
nuclear molding
| Also remember they are fragile and have a streaming effect when smeared on glass
136
What neuroendocrine tumor is at the far end of the spectrum from small cell carcinoma?
1. carcinoid tumor
| - localized, low stage, amenable by surgery
137
What do we find in a his to slide of carcinoid tumor?
trabecular pattern, round nuclei, decent amount of cytoplasm, ovoid to spindle shaped
138
Which asbestos fiber type is more tumorigenic? less tumorigenic?
1. amfibole
| 2. crysolite and crocidolite
139
What is the latency period of malignant mesothelioma?
20-45 post exposure
140
What lung tumor do we think of with WT-1, CK5/6, and D2-40 immunohistochemistry?
mesothelioma
141
Is epithelial cells or sarcomatoid mesothelioma more common in histology of mesothelioma?
epithelial is 60%
142
Does mesothelioma have a good prognosis?
No 50% die in 1st year the rest die within 2.
