Pulmonary/Mediastinum Flashcards
What are key diagnostic features of the following major noninfectious causes of granulomatous lung disease? Sarcoidosis, hypersensitivity pneumonitis, hot tub lung, Wegener granulomatosis, Churg-Strauss syndrome, aspiration pneumonia, talc granulomatosis, and rheumatoid nodule.
SARCOIDOSIS: Prominent, well-formed, discrete, nonnecrotizing granulomas in pleura, interlobular septa, and walls of bronchioles. Normal lung away from granulomas. HYPERSENSITIVITY PNEUMONITIS: Prominent interstitial chronic inflammation. Scattered, small, poorly formed granulomas or multinucleated giant cells in interstitium. HOT TUB LUNG: Granulomas within bronchiolar lumens. History of hot tub use. WEGENER GRANULOMATOSIS: Supperative granulomas with “dirty” necrosis. Necrotizing vasculitis. CHURG-STRAUSS SYNDROME: Necrotizing granulomas. Necrotizing vasculitis. Prominent eosinophils. ASPIRATION PNEUMONIA: Vegetable material surrounded by foreign body-type granulomas or multinucleated giant cells. TALC GRANULOMATOSIS: Interstitial foreign body-type granulomas containing talc, microcrystalline cellulose, or crospovidone. RHEUMATOID NODULE: Active, seropositive rheumatoid arthritis. Multiple, bilateral lung nodules. Subpleural necrotizing granuloma.
Aspiration pneumonia. What is seen histologically?
Surgical lung bxs from pts with chronic recurrent aspiration of gastric contents commonly show patchy BOOP. The specific finding that distinguishes aspiration from other causes of BOOP comprises airway-centered granulomas with central suppuration or foreign-body giant cells with exogenous material. These can be very focal and sometimes require a diligent search. Less commonly, organizing pneumonia is minimal or absent, and instead, the findings are those of acute bronchiolitis with or without bronchopneumonia characterized by airway-centered acute inflammation and necrosis. Aspirated materials comprise vegetable matter, skeletal muscle, or crystalline inorganic fillers found in oral medications. Depending on the age of the process, organic material ranges from recognizable plant cellular structures and skeletal muscle to amorphous, degenerated, pale eosinophilic material within peribronchiolar interstitium. Inorganic fillers from medications usually take the form of either microcrystalline cellulose, which is chunky and strongly birefringent, or crospovidone, which are small, round, hematoxyphilic globules. Occasionally, bxs demonstrate only airway-centered, suppurative granulomas without exogenous material, a combination of findings that raises the possibility of aspiration but is not conclusive. In such cases, special stains should be used to exclude granulomatous infection.
Carney Triad.
Characterized by the presence of at least 2 of the following 3: Gastric epithelioid leiomyosarcoma (now called GIST), extraadrenal paraganglioma, pulmonary hamartoma/chondroma. Primarily affects young women. Not familial.
Ciliocytophthoria is classically seen in what infection?
Adenovirus infection in the respiratory system. Ciliocytophthoria are decapitated ciliated columnar cells, where only the terminal bar and cilia are seen.
Describe the histologic appearance of chronic necrotizing pulmonary aspergillosis and allergic bronchopulmonary aspergillosis.
In CNPA, Aspergillus infection results in semi-invasive, chronic, indolent, cavitary disease in patients who have preexisting lung disease or are mildly immunocompromised. It is characterized by necrotizing granulomas containing Aspergillus hyphae. The granulomas may cause extensive parenchymal consolidation, may lead to bronchiectatic cavities, or may be exclusively bronchocentric. The bronchocentric cases may be accompanied by nonnecrotizing granulomas in a lymphangitic distribution. A nonnecrotizing vasculitis can occur. Eosinophils are not prominent. ABA is a noninvasive form of Aspergillus lung disease characterized by a hypersensitivity response to Aspergillus antigens, occuring mostly in asthmatic patients. Less commonly, other fungi such as Curvularia and Candida may cause similar morphologic changes. ABA results in a distinctive tissue reaction characterized by the triad of mucoid impaction of bronchi, bronchocentric granulomatosis, and eosinophilic pneumonia. However, an individual component of the triad may be present in isolation. Also, each of the features of the triad can occur in isolation in other conditions.
Erdheim-Chester disease and the lung?
A rare nonfamilial histiocytic disorder of unknown etiology. It primarily affects middle-aged and older adults. There are sclerotic changes in long-bone diaphyses and metaphyses with bone pain. About half of cases have involvement of nonosseous tissue, and lung involvement occurs in ~20% of cases. Histologically, there is accumulation of foamy or clear histiocytes with variable amounts of associated fibrosis and a variable lymphoplasmacytic infiltrate. Histiocytes and associated fibrosis and inflammation lie in a characteristic lymphangitic distribution: subpleural, intralobar septal, and bronchovascular. Generally immunopositive for CD68 and factor XIIIa and negative for CD1a. S-100 is variably positive.
Examples of pseudoneoplastic lesions in the lower airway and their related neoplastic mimes.
Pseudocarcinomatous epithelial hyperplasia (squamous cell carcinoma and adenocarcinoma). Fibrohyaline plaques of pleura (desmoplastic mesothelioma). Florid mesothelial hyperplasia (epithelial mesothelioma). Localized tumefactive organizing pneumonia (inflammatory sarcomatoid carcinoma). Selected examples of lymphocytic interstitial pneumonia (lymphoma). Pulmonary chondroid/lipomatous/muscular hamartomas (metaplastic carcinomas). Other examples include inflammatory pseudotumor, nodular lymphoid hyperplasia, apical cap AKA apical scar, round atelectasis, sclerosing (fibrosing) mediastinitis, and hyalinizing granuloma,
Examples of pseudoneoplastic lesions in the upper airway and their related neoplastic mimes.
Pseudocarcinomatous epithelial hyperplasia (squamous cell carcinoma). Oral organ of Chievitz (low-grade squamous or mucoepidermoid carcinoma). Necrotizing sialometaplasia (squamous or mucoepidermoid carcinoma). Radiation effects on mucosal epithelia (squamous carcinoma). Benign lymphoepithelial lesion of salivary gland (lymphomas). Traumatized antral/choanal polyps (polypoid sarcomatoid carcinomas). Glial heterotopias (peripheral nerve sheath tumors). Benign fibroosseous lesions (low-grade fibrosarcoma or osteosarcoma).
How can you tell granulomas in Wegener granulomatosis from infectious granulomas?
In Wegener granulomatosis, there are necrotizing granulomas with necrotizing vasculitis. The granulomas are supperative with a highly irregular contour. Vasculitis is primarily neutrophils. No lymph node involvement. No organisms found. Clinical picture of upper respiratory tract symptoms, multifocal lung involvement, kidney disease, and positive ANCA. Infectious granulomas are more likely solitary lesions. Admixed compact, sarcoid-like, nonnecrotizing granulomas with regular contours. Vasculitis is non-necrotic and primarily lymphocytes. Lymph node involvement present. Organisms found.
IHC for separating reactive mesothelial proliferations from mesothelioma?
Desmin positive in ~85% of reactive mesothelial proliferations and ~10% of mesothelioma. EMA positive in ~20% of reactive mesothelial proliferations and ~80% of mesothelioma. p53 positive in 0% of reactive mesothelial proliferations and ~45% of mesothelioma. GLUT-1 positive in 0% of reactive mesothelial proliferations and ~90% of mesothelioma.
Mesothelioma types.
Benign (3): Benign (papillary) mesothelioma. Benign multi cystic mesothelioma. Adenomatoid tumor. (All 3 are more common in the peritoneal cavity than in the pleural cavity.)
Malignant (4): –Epithelioid mesothelioma. MC histologic type of malignant mesothelioma. Common secondary patterns of epithelioid MM are: tubulopapillary, acinar (glandular), adenomatoid (microglandular), and solid. Uncommon secondary patterns are: clear cell, deciduoid, adenoid cystic, signet ring, small cell, and rhabdoid. –Spindle cell or sarcomatoid mesothelioma. Are predominantly or entirely composed of spindle tumor cells. They tend to be more nodular and less plaque-like than those composed of cuboidal mesothelial cells and are often accompanied by hemorrhage, necrosis, and cystic change. Secondary patterns of sarcomatoid MM may have anaplastic and giant cells, osteosarcomatous areas, chondrosarcomatous areas, or be lymphohistiocytoid.
–Desmoplastic mesothelioma. Most are a subtype of sarcomatoid MM, but rare epithelioid desmoplastic MM can occur. Is accompanied by abundant deposition of fibrous tissue. Must be distinguished from areas of dense inflammatory fibrosis (fibrous pleuritis). –Variants with unresolved histogenetic questions: MM with squamous differentiation (pleural squamous cell carcinoma). Mucoepidermoid carcinoma of the pleura.
Pulmonary Langerhans-cell histiocytosis.
Previously called histiocytosis X or pulmonary eosinophilic granuloma. Characterized by infiltration in lung parenchyma of CD1a-positive histiocytes = Langerhans cells. The earliest abnormality is an interstitial infiltrate of Langerhans cells, predominantly around small airways. With progression of PLCH, the infiltrates develop into temporally heterogenous, roughly symmetrical, stellate nodules containing variable numbers of Langerhans cells, eosinophils (which may be scant to absent), lymphocytes, and fibroblasts. The surrounding lung parenchyma may be normal. The nodules may become cystic. Central scarring eventually develops. Generally immunopositive for CD1a and S-100 and negative for CD68.
Rosai-Dorfman disease and the lung?
AKA sinus histiocytosis with massive lymphadenopathy, is a rare, acquired, pseudoneoplastic hematopoietic proliferation of distinctive histiocytic/phagocytic cells within lymph node sinuses and lymphatics in extranodal sites. Typically affects children and young adults but not always. Unknown etiology. Most often involves cervical lymph nodes. ~3% of patients have lung involvement and lesions may arise as one or more masses involving the trachea and bronchi, or as diffuse involvement of pulmonary interstitium in some. Nodular areas contain dense infiltrates of lymphocytes with intermixed large pale histiocytes, arranged both singly and in small clusters. Rosai-Dorfman histiocytes have abundant eosinophilic cytoplasm and exhibit round to oval nuclei with one or more prominent nucleoli. Nuclei may be multilobulated and may exhibit mild atypia. Emperipolesis is present and may be conspicuous. Generally immunopositive with CD68, CD14, CD15, CD64, S-100, HAM56. Generally negative with markers of dendritic differentiation such as CD1a, CD21, CD23, and CD35.
Two non-Langerhans-cell histiocytoses with pathology in the lung?
Erdheim-Chester disease and Rosai-Dorfman disease.
Usual interstitial pneumonia.
UIP is the MC of the idiopathic interstitial pneumonias, which include respiratory bronchiolitis interstitial pneumonia/desquamative interstitial pneumonia, acute interstitial pneumonia (AKA Hamman-Rich disease) and nonspecific interstitial pneumonia. UIP is the histologic counterpart of the clinical syndrome referred to as idiopathic pulmonary fibrosis and is typically diagnosed in pts 50-70 yo. UIP is a disease of pathologic fibrosis. Some degree of interstitial inflammation is usually present, especially in areas of honey comb change, but the very patchy inflammation is overshadowed by fibrosis as the dominant finding. The most notable feature at low magnification is the variegated nature of the fibrosis. UIP typically has spatial heterogeneity, where minimally affected areas are juxtaposed with dense and often confluent fibrosis. UIP can also have temporal heterogeneity, where most of the fibrosis consists of dense collagen deposits that contrast with scattered, small, interstitial, subepithelial foci of pale blue, immature collagen with admixed myofibroblasts, so-called fibroblast foci. Fibrosis in UIP is often sufficiently advanced by the time of bx to result in architectural distortion in the form of collagenous scarring and honeycomb change. Honeycomb change refers to cystically dilated airspaces within zones of scar. A mucopurulent exudate is often present within the dilated airspaces, accumulating as a consequence of the stasis of secretions in these areas.
What are 3 tumors in the PEComa famiy that are seen in tuberous sclerosis?
Angiomyolipoma, clear cell “sugar” tumor, and lymphangioleiomyomatosis.
What are the 2 most common forms of pulmonary Aspergillosis with granuloma formation?
Aspergillus may cause invasive, saprophytic, or allergic lung disease, depending primarily on the immune status of the host. The 2 most common forms of lung involvement by Aspergillus (aspergilloma and invasive aspergillosis) do not feature granulomas. However, granulomas are a prominent feature of 2 less common forms of pulmonary aspergillosis: chronic necrotizing pulmonary aspergillosis and allergic bronchopulmonary aspergillosis).
What nuclear features and types of inclusions are seen in pulmonary viral infections (herpes simplex and herpes zoster, CMV, measles, RSV, and adenovirus)?
Herpes simplex and herpes zoster: Nuclear features are multinucleation, molding, and peripheral margination of chromatin. Inclusions are intranuclear and eosinophilic (Cowdry type A). CMV: Nuclear feature is enlargement. Intranuclear inclusions are large and basophilic with a halo, and cytoplasmic inclusions are small and basophilic. Measles: Nuclear feature is multinucleation. Intranuclear inclusions are eosinophilic, and intracytoplasmic inclusions are multiple and eosinophilic. RSV: Nuclear feature is multinucleation. Inclusions are cytoplasmic and basophilic with a halo. Adenovirus: One type of nuclear inclusion seen is a large basophilic inclusion usually filling the entire nucleus and obscuring chromatin detail (smudge cell). The other type of nuclear inclusion seen are eosinophilic inclusions that resemble the Cowdry A inclusion of HSV.
Why are transbronchial biopsies so effective in detecting sarcoidosis?
There is a lymphantic distribution to the granulomas of sarcoidosis. In the lung, lymphatics run in the pleura, interlobular septa, and bronchovascular bundles (bronchi/bronchioles and arteries).
Why is “talc granulomatosis” a misnomer?
Because talc (hydrated magnesium silicate) is not the only excipient used in medications. Excipients are inactive substances used as carriers for the active ingredients of medications. In oral pills/tablets, they act as fillers, binders, and disintegrants. Other excipients are microcrystalline cellulose and crospovidone. Microscopically the inclusions are: large sheet/platelike and strongly birefringent (talc), fiber/rod-like and strongly birefringent (microcrystalline cellulose) or deep blue and coral-like (crospovidone). In contrast, while sarcoidosis can have birefringent foreign material in granulomas as well, they are often small, crystalline, and are present in less amounts than with the excipients.
What is Austrian syndrome?
Austrian syndrome was first described by Robert Austrian in 1957. The classical triad consists of meningitis, pneumonia, and endocarditis all caused by Streptococcus pneumoniae. It is associated with alcoholism, due to the presence of hyposplenia, and can been seen in males between 40–60 years old.
Organizing pneumonia (Bronchiolitis Obliterans Organizing Pneumonia). What causes it?
Organizing pneumonia, formerly referred to as BOOP, is seen secondary to a variety of lung injuries and as a component of several specific lung diseases. The same histologic pattern occurs as an idiopathic clinical syndrome called cryptogenic organizing pneumonia (COP; formerly referred to as idiopathic bronchiolitis obliterans organizing pneumonia), classified with the idiopathic interstitial pneumonias. Organizing pneumonia is a common response to infectious or inflammatory injury to lungs, including viral or other infections, as a drug reaction, as a reaction to chemotherapy or radiation therapy, after inhalation of fumes or toxic compounds, as a postobstructive finding distal to an obstructed airway, as a result of aspiration, and in bone marrow transplant recipients. This pattern can also be a component of specific lung diseases, including hypersensitivity pneumonia, eosinophilic pneumonia, collagen vascular diseases involving the lungs, and Wegener granulomatosis. Cause cannot be determined from biopsy; clinical history is needed. Clinically, acute onset with cough, shortness of breath, fever, and malaise. Some patients have self-limited disease; excellent prognosis with steroid treatment; steroid resistance can lead to death.
Organizing pneumonia (BOOP) histologic features?
On low power, there are evenly spaced nodules or plugs of organizing connective tissue and inflammation that obliterates terminal airways. There are plugs of granulation tissue (fibroblasts in an edematous or myxoid stroma) in the lumens of bronchioles, alveolar ducts, and adjacent alveoli. The fibroblastic plugs in bronchioles and alveolar ducts is the “bronchiolitis obliterans” component and the fibroblastic plugs in alveoli is the “organizing pneumonia” component. The plugs are formed by spindled fibroblasts in pale-staining matrix with serpiginous or elongated shape. Rounded nodules of granulation tissue in alveolar spaces are called Masson bodies. There may be accompanying interstitial lymphocytes or other inflammation. Thickened alveolar septae and rare neutrophils can be seen. Transbronchial biospy may fail to sample bronchioles, and the only finding may be the granulation tissue in the alveoli. Intra-alveolar collections of foamy macrophages may result from the bronchiolar obstruction. There may be findings that suggest the etiology, such as viral inclusions in viral pneumonias, foreign-body giant-cells in aspiration, or poorly formed granulomas and multinucleated giant-cells in hypersensitivity pneumonitis. Histopathologic clues to the etiology of organizing pneumonia may not be present, and clinical correlation is necessary to determine the underlying cause. If an identifiable etiology is excluded, then the diagnosis is cryptogenic organizing pneumonia. The organizing pneumonia may resolve with or without residual scarring.
Cryptogenic organizing pneumonia/Idiopathic bronchiolitis obliterans organizing pneumonia. What causes it?
Cryptogenic organizing pneumonia (COP), formerly termed idiopathic BOOP, consists of proliferation of granulation tissue within small airways, alveolar ducts, and alveoli. The clinical syndrome occurs most often in middle-aged to older adults and is often preceded by a flu-like illness. Persistent nonproductive cough and shortness of breath are the usual presenting symptoms. Most, but not all, patients respond rapidly to steroids, and in most cases the prognosis is excellent. COP is an idiopathic clinical syndrome, but similar lesions can be seen in various specific pulmonary injuries. These identifiable causes of organizing pneumonia must be excluded clinically and pathologically before a diagnosis of COP can be made.