Interstitial Disease................................................................................................................................................................... 2
COPD ....................................................................................................................................................................................... 7
Pulmonary Vascular Disease ................................................................................................................................................. 12
Pulmonary Neoplasia ............................................................................................................................................................ 16
Lung Infections ...................................................................................................................................................................... 22
Lung Development / Pediatric Lung Disease ........................................................................................................................ 29
1
Interstitial Disease
Similar findings –combine clinical / path / radiology / etc for Dx
Open lung biopsy more helpful Diffuse interstitial lung diseases
Interstitium: note that it supports the capillaries! Chronic
Type II cells make surfactant, type I are large flat squamous cells Chronic inflammatory infiltrates ± lung
fibrosis (IPF, collagen vascular
diseases)
Granulomatus disorders
Dusts (EAA / pneumoconiosis)
Acute
Diffuse alveolar damage (DAD)
Acute interstitial pneumonia (idiopathic)
Chronic interstitial pneumonitis: chronic inflammation in pulmonary interstitium; relatively nonspecific lesion (lots of causes)
UIP (usual interstitial pneumonitis): these histologic patterns (path correlate of IPF)
Can also see in RA & other collagen vascular diseases (same findings; need to separate clinically / lab info / etc)
Drug reactions can mimic IPF findings too
Pathogenesis of IPF
Repeated stimuli sequential lung healing aberrant wound healing fibrosis
See temporal heterogenetity in lesions (some young fibroblast foci, others well healed scars)
2
IPF: Path Findings
L to R: CXR, CT, gross, wedge biopsy. Note small lungs with honeycombing in lower lobes / subpleural areas
Interstitial widening, F: fibroblast foci (recent injury) Remodeling of walls (L) honeycombing (R) (now have no
chronic inflammation, I: interstitial inflammation (PCs, capillaries), ↓compliance, bronchiolar-type epithelium mucus
fibrosis lymphocytes) production & congestion.
Left:
F: fibroblast foci (more recent)
C: collagen (pinker, older)
3
Pneumoconiosis
ILD related to inhaled inorganic dust (asbestos, silica, etc.)
Specific reactions correspond to certain irritants
Dusts can be fibrogenic (aspestos, silica, etc.) or inert (coal dust, iron – siderosis)
Inert dusts generally just give you an abnormal CXR but aren’t clinically a problem
Can also have mixed exposure (modified response, not like any single component)
Silica
CXR: Large silicotic
nodules
Dense, hyaline pleural
nodules ± pigmented
dust
Silicosis
Asbestos
CXR: Calcified pleural plaques & interstitial thickening
Similar to UIP at large view
Asbestos fibers (DUMBELL SHAPED ferruginous bodies)
o Characteristic, can be in Mϕ
Asbestosis
Siderosis (iron)
Make sure to do AFB stain & fungal workup if you see granulomas!
4
Sarcoid
Another ILD with granulomas
Multisystem disease: related to T-lymphocyte dysfunction
Sarcoid EAA
Well formed Poorly formed
Granulomas
Randomly distributed Mostly in interalveolar septa
BOOP Rare Frequently present
Upper lobe Pachy infiltrates
CXR
Hilar adenopathy No adenopathy
Disease Systemic Isolated to lung
5
Hyaline membranes – pink, dead epithelial cells
CXR: Cloudy
(fibrin looks more beady). Interstitial widening too
6
COPD
Epithelium Types
Bronchi : ciliated pseudostratified columnar
Bronchioles: flatter (more cuboidal)
Alveoli: flat (pneumocytes: type I & II)
Terminal bronchioles:
Lack cartilage
Muscle layer about 20% of thickness
Important in disease processes
7
Asthma
Pathophysiology
Extrinsic: type I hypersensitivity
st
o 1 exposure: Sensitization
(Ag recognized by T-cell, etc)
nd
o 2 exposure: mast cells / hypersensitivity
response (mucus secretion, ↑ inflammation, muscle
contraction bronchoconstriction)
Intrinsic: non-immune (viral infections, drugs, inhaled
irritants, stress, exercise)
o Mast-cell independent (eos have big role)
o Same kinds of downstream reactions
Path Features:
Intraluminal secretions:
plasma, inflammatory cells, desquamated epithelial cells.
Airway epithelial desquamation
Goblet cell hyperplasia
o Can result in mucus plug
Airway inflammation: lymphocytes (CD4 mostly) / eosinophils
o Charcot-Leyden crystals: pink; from eos’ products
“Hyalinized basement membrane: collagen fibrils”.
It would be weird to see this stuff in practice (Bx of asthma? Yeah right.)
8
COPD
Cigarette smoking is the big deal, ↑↑ COPD in females recently
Chronic obstructive pulmonary disease: disease state characterized by presence of:
chronic bronchitis or emphysema
with airflow obstruction, which may be accompanied by airway hyperreactivity
may be partially reversible but is relatively fixed
Chronic Bronchitis
Emphysema
Emphysema: Abnormal and permanent enlargement of
airspaces distal to terminal bronchioles
accompanied by destruction of their walls
without obvious fibrosis
Morphologic types
of emphysema
Centriacinar (centrilobular)
Panacinar (panlobular)
Paraseptal (distal acinar)
Irregular
(very commonly overlap)
9
Centriacinar Emphysema
Features
Respiratory bronchiole affected
Normal alveoli
Upper lobes ( worst in apical segments)
Black pigment in wall commonly
Can involve alveoli if severe
(DDx from panacinar may be impossible)
Predominantly in smokers (also coal workers)
Upper lobes
anthracotic
pigment
deposited in
scarred
terminal
bronchioles
Panacinar Emphysema
Paraseptal emphysema
Distal portion of acini affected
Adjacent to pleura, lobular septae, at margins of lobules
Also seen adjacent to fibrosis, scarring, atelectasis
Upper half of lung = more severe
Multiple confluent airspaces
o See picture: larger, cyst-like spaces
Most likely frequent cause of spontaneous pneumothorax in young adults
o (usually tall thin males)
10
Irregular emphysema
Acinus irregularly involved
Usually associated with parenchymal scarring
Very common; often asymptomatic
Pathogenesis of Emphysema
• Alveolar inflammation: ↑↑ PMNS & Mϕ
• Protease/antiprotease imbalance
– Neutrophil: source of elastase
– Macrophage: source of metalloprotease
– Loss of antiproteolytic proteins:
alpha1 antitrypsin deficiency
• Alveolar cell apoptosis
• Oxidative stress: interaction with others
He had a summary table at the end of his notes; there were so many corrections made verbally in lecture that it seemed useless.
11
Pulmonary Vascular Disease
Pulmonary & Bronchial Arteries: Dual Blood Supply to Lungs
Pulmonary Arteries: carrying deoxygenated blood from heart to lungs
In order from proximal (near hilum) to distal (alveoli):
Type of
Size Description Pictures
artery
500-70 microns Only pulmonary vessels that can regulate blood flow
Muscular (Medium) via vasoconstriction
Path findings
Pulmonary vascular remodeling (intima, media, adventitia changed) – depends on severity & size of artery
13
Classification of Pulmonary HTN
1. Pulmonary Arterial Hypertension
a. Idiopathic (think young women 3:1 vs men) Mild/moderate PAH Severe PAH
b. Familial COPD Idiopathic
c. Associated with other diseases (same vascular morphology in the lung as idiopathic PAH: ILD Collagen vascular Dz
congenital systemic pulmonary shunts, HIV, collagen vascular disease, liver disease and others) Sleep apnea HIV infection
2. Pulmonary hypertension with left heart disease Congenital heart
3. Pulmonary hypertension associated with primary lung disease and/or hypoxemia malformation (LR shunt)
4. Pulmonary hypertension due to chronic thrombotic and/or embolic disease Sarcoidosis
5. Miscellaneous
Other Path Findings (chronic obstructive lung diseases, primary interstitial lung dz like IPF, etc.)
Disease processes Picture
This artery shows both medial
hypertrophy (M) and fibro-intimal
hyperplasia (F) with fibroblasts &
Muscular hyperplasia myoblasts.
Vascular Anything that ↑ pressures
remodeling (remodeling is response)
Fibrous intimal thickening Can see both, or just one
14
Pulmonary Emboli
Epidemiology: about 600k/yr, most from lower leg
PE usually doesn’t cause pulmonary infarction (dual blood supply; would need double infarct) but can if…
↓ LV function or CHF (not perfusing bronchial circulation)
Chronic thromboemboli:
Can lyse, be incorporated into intima, or become recanalized (restore blood flow)
If multiple pulmonary arteries: superimposed pulmonary HTN see vascular remodeling as above Saddle embolus wedged in PA branch point
o Need >80% arteries blocked
Path findings
o Thickening of intima & lumen
o Fibrotic bridges in vascular lumen (organization of previous thrombi)
15
Pulmonary Neoplasia
Notes on terminology: MORPHOLOGICAL VARIANTS OF LUNG CANCER
Small cell vs non-small-cell- Squamous cell carcinoma
lung-cancer: previously didn’t Adenocarcinoma
distinguish between NSCLC Small cell carcinoma
because treatment was the same;
(pulmonary carcinoid)
now need to subtype
Large cell lung cancer: probably Derived from airway epithelial cells
poorly differentiated squamous cell carcinoma or adenocarcinoma
Also see squamous metaplasia in other airways (widespread tobacco smoke injury)
Carcinoma can develop from sites of in situ squamous carcinoma / dysplasia
Adenocarcinoma
Histology:
IRREGULAR gland formation
+/- mucin secretion MAJOR FEATURES
> 80% in smokers (non-smoker with
Cytology: lung cancer: think adenocarcinoma)
Round / oval nuclei Involve SMALLER AIRWAYS
o Use transthoracic needle biopsy
Prominent nucleoli
More peripherally located
Less hyperchromasia than squamous cell
16
Can’t differentiate grossly
Glandular appearance
Bronchoalveolar Carcinoma
“Lepidic” growth pattern – like butterflies on a tree
(malignant cells on alveoli) MAJOR FEATURES
Can grow extensively through lungs (mimic pneumonia) Variant of adenocarcinoma,
If confined to small area/nodular: resect Uncommon but only 50% in smokers
Involve peripheral lung
Can have focal BAC in adenoCa
Malignant cells grow along alveolar
walls without invasion
Alveolar walls well preserved, less fibrous Malignant cells growing along
stroma / tissue reaction alveolar walls
17
Large Cell Carcinoma
Probably just adenocarcinomas or squamous cell carcinomas that
aren’t differentiated enough to allow histologic classification
MAJOR FEATURES
Mostly in smokers
↓ LCC Dx with ↑ use of IHC
Airways of all sizes / locations
Can have giant cell (large, bizarre cells) or neuroendocrine differentiation LARGE, AGGRESSIVE tumors
Signals poor prognosis if one of these variants
Smaller cells with “salt-pepper” type of chromatin (finely Can have COMBINED small cell / non-small-cell carcinoma
granulated); lots of mitoses (aggressive) Left: SCLC + adenocarcinoma; Right: SCLC + squamous
carcinoma
Small cell carcinoma might be epithelial in origin (combined small cell / NSCLC variants – differentiated differently?)
If combined SCLC / NSCLC: might only get one type on Bx!
18
Carcinoid Tumors
Usually central (involve airway)
Presentation: bronchial obstruction
NEUROENDOCRINE differentiation
DOES NOT PROGRESS to small cell lung cancer (although may look similar – neuroendocrine differentiation)
Occluding bronchial lumen Small, round cells without many mitoses (not SCLC)
Organoid pattern: stroma + capillaries between ball-like tumor
cell collections: like in normal neuroendocrine organs (adrenal
medulla, parathyroids, etc.) – also neuroendocrine marker +
Staging
Clinical staging: assessment of radiographic studies
Pathological staging: examination of tissue
19
Molecular Stuff
p53 mutation common in all variants (more aggressive)
Detection
Sx: only in advanced stages of disease (metastasis / paraneoplastic syndromes)
Primary cancers (cough / hemoptysis) = advanced too
Means survival is down (worse stage IV vs I, although both are bad)
Diagnosis
Depends on location of tumor; anything you see on radiography needs to be confirmed with histology / cytology
Sputum cytology Centrally located cancers
Bronchial brushings (e.g. squamous cell, exfoliates a lot of cancer cells into airways, can get with sputum)
Bronchial biopsy (if needed) (SCLC central too)
Trans-thoracic needle biopsy / aspirate Peripherally-located cancers (e.g. adenocarcinoma)
Open lung biopsy (if needed) that are inaccessible via bronchoscopy
20
Cigarette Smoking and Lung Cancer
Smoking causes cancer (surgeon general – 1964; first reports in 50s)
The Changing Cigarette (or, why ↑adenocarcinoma and ↓ squamous cell carcinoma)
NOW: ADENOCARCINOMA IS THE MOST COMMON LUNG CANCER IN BOTH SMOKERS AND NON-SMOKERS
Mesothelioma
>80 associated with ASBESTOS EXPOSURE
Glandular or sarcomatous differentiation
Pleural lesions (mesothelium) – see picture
Poor prognosis
2k pts / yr (vs 200k for conventional lung cancers)
Metastatic Carcinoma
Lots of other cancers like to metastasize to the lungs
Frequently MULTIPLE METASTATIC WELL-DEFINED NODULES
o (vs single & invasive for primary lung cancer)
Pleural lymphatic spread common too
21
Lung Infections
1/6 of all deaths in US every year! Why?
Large surface of alveolar space exposed to contaminated air TYPES OF PNEUMONIAS
Aspiration (nasopharyngeal flora)
Effects of other disease on immune system Gross Classification (CXR)
Lobar vs bronchopneumonia
Bacterial Pneumonia Etiological Classification (clinical)
Classification: Community-acquired (CAP)
Lobar & bronchopneumonia Nosocomial (hospital-acq, HAP)
CAP (community-acquired) Aspiration pneumonia (bacterial & chemical)
Pyogenic pneumonia Atypical pneumonia
(uncommon bacteria & viruses)
Pathogens
Chronic pneumonia
Strep or pneumococcus pneumoniae
(fungi, uncommon bacteria – nocardia)
Also staph, pseudomonas, gram neg bacteria
Clinical picture:
Abrupt onset of fever, chills, productive mucopurulent cough, pleuritic chest pain.
Acute Bronchopneumonia
PMNs are key cells
Not limited by line of demarcation (fissure)
between two lobes
Early pneumonia: fibrin Fluid, prominent Advanced organizing pneumonia: lung trying
PMNs, Mϕ cleaning up
exudation into alveolar capillaries, cells into to heal; like granulation tissue. Fibroblast foci
debris now
spaces alveolar spaces (lighter texture, lots of spindle-like fibroblasts)
22
The Pneumonia Syndromes
Community Acquired Acute Pneumonia (bacterial)
Chronic Pneumonias (mycobacteria, granulomatous)
Community Acquired Atypical Pneumonia (viral)
Necrotizing Pneumonias & Lung Abscess
Nosocomial Pneumonias (bacterial)
Pneumonia in the Immunocompromised Host
Aspiration Pneumonia (bacterial & chemical)
23
Thickening of alveolar Interstitial pneumonia with RSV: characteristic giant cells
Interstitial Pneumonia.
wall; no PMNs diffuse alveolar damage:
MONOnuclear infiltrate:
HYALINE MEMBRANES form,
Mϕ & lymphocytes in interstitium
↓ gas exchange
(not PMNs)
(ARDS is correlate)
Aspiration Pneumonia
Patient: markedly debilitated (unconscious, stroke victims, alcoholics, repeated vomiting)
Abnormal swallowing & gag reflex
Chronic Pneumonia
Think NOCARDIA: #1 for chronic pneumonia!
24
Tuberculosis
M. tuberculosis is causative agent; chronic, communicable dz
Slender, acid-fast rods (lots of lipids resist decolorization) Granulomatous Infection DDx:
o Stains: carbol fuschin & decolorize with alcohol; TB (+ atypical mycobacteria)
fluorescent (auramine-rhodamine) more sensitive Fungal infections
Drug resistance is big problem
TB: Course
First infection: 1° TB
Inhalation lung proliferates in mid-lung subpleural location
Taken up by pulmonary alveolar Mϕ
25
o Some Mϕ degrade / present mycobacterium hypersensitivity
o In others, phagolysosome inhibition survives & proliferates in Mϕ regional lymph nodes
< 3wks: unchecked proliferation in Mϕ & airspaces (bacteremia!)
Ghon lesion:
3wks post infection: well formed granulomas, caseation necrosis, PPD + initial focus of 1° infection
o Mϕ present to T-cells TH1 secrete IFN-γ activate Mϕ NOS, TNF
ROS (kill bacteria/ cells) caseous necrosis, tissue destruction Ghon complex:
TNFα monocyte recruitment diff to Mϕ granulomas Ghon lesion + lymph node
Implications of 1° TB
Hypersensitivity, ↑ resistance; can harbor viable bacteria (later reactivation)
Can progress without interruption (progressive 1° TB)
o Immunocompromised (esp HIV+, certain racial groups)
o Can’t mount cell-mediated response
o Can resemble acute bacterial pneumonia: (consolidation, pleural effusion,
hilar adeopathy)
o Lymphohematogenous dissemination: rare & bad
TB meningitis, miliary TB, death possible
Common features:
Immunocompromised pts
(AIDS, cancer, BMT)
Poorly formed granulomas, fibrosis
Hemmorhagic infarction with sparse inflammatory infiltrate Aspergillus infection with Aspergillus ball 45° branching septate hyphae
Hyphae: invade blood vessels & alveolar septae infarction
Southwest US
Coccidiomycosis
Forms spherules (see pic)
27
Has a MUCOID CAPSULE
shows up as empty space on normal stains
can stain with special stains
Cryptococcus
Important in AIDS pts
Variable sizes
Double-walled appearance
Blastomycosis
+ acute inflammation
Pneumocystis Pneumonia
Pathogenesis:
Hypoxia, restrictive defect
Reproduces in association with Type I pneumocytes
Active disease: lungs only
o trophozoite feeds enlarges transforms to cyst form
o Cyst ruptures, new trophozoites released, attached to alveolar lining cells
Clinical Presentation:
Can have minimal symptoms or fever, dyspnea, dry cough
Can progress to respiratory failure (alveolar filling on CXR)
28
Lung Development / Pediatric Lung Disease
Lung Development
Lung: foregut derivative
Week Name What happens
th
26 day Lung appears: bud from caudal end of laryngeotracheal sulcus
0-5 Embryonic period Lung buds form lobar bronchi, major segmental branches
5-16 Pseudoglandular period Bronchial branching continues, cartilage develops
20 Surfactant production starts in type II pneumocytes
24-26 Surfactant sufficient to provide lung stability (ABCA3 produced, etc)
25 Thin air-blood barrier formed; theoretically can maintain respiration
26 - term Terminal Sac / “ Alveolar” period Shallow distal airspaces develop
th
After 16 week: bronchial tree has developed Later: closer to term. Alveoli have subdivided over &
Couldn’t breathe yet over, connect to airways. Blood vessels from
(airways=arrows, airspaces=arrowheads are separate) mesenchyme have invaded alveolar walls
29
Surfactant
Made by type II pneumocytes (produced, stored in lamellar bodies, secreted)
ABCA3 protein involved in transport of material into LB
Note that capillaries really wander back and forth across septae (not in middle) – from one side to other
LB secreted (phospholipids,
SEM from inside capillary TEM of alveolar septa; note capillary Lamellar bodies in type II
etc) ↓ surface tension in
Arrow : type II pneumocyte wandering back and forth between pneumocytes
lung!
Arrowheads: capillaries adjacent alveoli
Why surfactant?
There’s an air liquid interface (starling forces leak out liquid), so
alveoli want to collapse
LaPlace’s Law
The smaller an alveolus gets, the smaller it wants to be
Alveolar stability due to tissue forces (elasticity – tethering) and alveolar lining layer
Surfactant especially important in newborns
o 2/3 of alveolar stability provided by surfactant in newborns, ↓ in adults
30
Idiopathic Respiratory Distress Syndrome
A.k.a. “hyaline membrane disease” (older name; infections / other causes of alveolar damage can also produce path findings)
Path findings:
Abnormal pattern of lack of expansion in lung
Distal airspaces collapsed
Distal airways dilated & lined with hyaline membranes (eosinophilic)
o Looks like DAD in ARDS! From cellular debris from alveolar lining
Septal lymphatics dilated ± focal hemorrhage, edema
Complications:
Development of PDA (reopen / fail to close)
Bronchopulmonary dysplasia
Interstitial emphysema (pulmonary alveolar air) & sequelae
Treatment of IRDS:
Artificial surfactant; Give O2 + mechanical ventilation
Lung: all collapsed, looks like liver IRDS: most of lung collapsed with hyaline membranes (like DAD + collapse)
Alveolar ducts are main damage site Genetic surfactant protein deficiency
(rest is collapsed) Lots of proteinaceous material / Mϕ
31
Bronchopulmonary Dysplasia – complication of treatment for IRDS
All you need to know from this part: bronchopulmonary dysplasia is a complication of treatment for IRDS
“Old” BPD: 28-32 wks gestation, complication of RDS & “New” BPD: <28wks, may be complication of RDS treated
treatment (high O2, vigorous +-pressure ventilation) with surfactant (or premature birth)
Structural damage to airspaces, airways w/ fibrosis Development / growth abnormalities in lung:
↓ alveoli, simplified alveoli
“old type”BPD with interstitial fibrosis “New type” BPD with collapsed areas, big open
areas, simplified alveoli
Path findings:
Cystic spaces around
bronchovascular bundles & septae of
lung (see pictures)
o Can misinterpret as “cystic
malformation”
32
Meconium Aspiration Syndrome
Meconium = fetal poop (green bile formation)
Findings
Green stained placenta
Meconium in larynx
Patchy infiltration on CXR (like aspiration + pneumonia)
Mucus & squamous cells in bronchioles & other small
airways, etc. on path
o Mucus is key (squamous cells in any
cause of newborn respiratory death)
Mechanism:
Mucus blocks bronchioles like ball valve
air trapping
Pressure builds up, can dissect out of alveolus,
get pulmonary interstitial air
Perinatal Pneumonia
CLASSIFICATION OF PERINATAL PNEUMONIA
Transplacental Part of a systemic congenital infection (usually maternal origin)
Present at birth
Intrauterine Aspiration pneumonia (infected amniotic fluid)
Aspiration
Young CF pt: bronchopneumonia Older CF pt: accumulations of mucus, Bronchiectasis (B) – airways too big,
scarring, bronchiectasis too far out in lung. F = fibrosis too
Right:
Left: Pseudomonas
more bronchiectasis making a biofilm
in CF patient; clogged in abnormal
with purulent debris secretions (hard
to eradicate)
34