SURGICAL

PATHOLOGY
LUNG AND PLEURA
Reference: Rosai et al

Aguda, Mary Grace

Alfonso, Hannah Febe
Atia, Philemon

2
Basir, Hujefi
Baua, Vanessa Jing
Bhamidipathi, Venkata Ram
Bravo, Blessei Jane
Campos-Baccay, April
Conag, Rich Mark
Felipe, Richie
Lanuza, Odessa
Roxas, Nancy

2
PLEURA
SURGICAL PATHOLOGY-GROUP 2
 INTRO: ANATOMY
PLEURA
• Visceral and parietal layers are lined by mesothelial cells
• Mesodermally derived

Mesothelial cells
• Flat or low cuboidal
• Ultrastucturally: apical tight junctions, desmosomes, long and slender
surface microvilli, and bundles of cytoplasmic tonofilaments
• Immunohistochemically: shows ractivity for both low and high molecular
weight keratins
 INTRO: ANATOMY
Subserosal cells
• Ultrastructure: composed of fibroblasts and express the vimentin but not
keratin
• Proliferation of ‘multipotential subserosal cells’ or ‘submesothelial
fibroblasts’ -> they coexpress keratin and vimentin and develop surface
differentiation

Pleural space
• drained by three adjacent lymphatic pathways that
• connect separately into hilar, retroperitoneal, and lower mediastinal
• lymph node groups.
 PLEURITIS AND OTHER
NON-NEOPLASTIC LESIONS
• Inflammatory diseases of the lung may spread to the pleura.

• pulmonary lesion may completely resolve but leave a pleural symphysis (fusion
between the two pleural layers) secondary to prominent pleural fibrosis, which can be
several centimeters thick.

• underlying lung parenchyma may be perfectly normal, but its expansion is prevented
by the surrounding rigid and contracted thickened pleura.

• If this dense fibrous layer is peeled off, pulmonary function improves markedly
 MARKED INFLAMMATORY
PLEURAL THICKENING
• Occur as the result of organization of a hematoma formed after a penetrating wound
of the thorax.

• best time to perform decortication of this lesion: 3–5 weeks after the injury

MICROSCOPICALLY
– material obtained represents an organized hematoma composed of fibrous tissue
– Elastic fibers are absent
o indication that the underlying pleura is not part of the process
 TUBERCULOSIS
• can involve the pleura in various ways:
• complication of a subpleural primary lung infection
• direct extension from reinfection pulmonary disease
• result of hematogenous spread
TUMORS
 BENIGN MESOTHELIOMA
(PAPILLARY)
• relatively common in the peritoneal cavity but extremely rare in the pleura
• The distinction with malignant epithelial mesothelioma is made on the basis of the lack of
significant atypia and the well-circumscribed, solitary nature of the lesion.
• The diagnosis should be entertained only if the mesothelial proliferation is well differentiated
throughout and grossly localized, a combination that is very rarely encountered in the pleural
cavity.
 WELL-DIFFERENTIATED PAPILLARY
MESOTHELIOMAS
• multicentric, extensive, and/or associated with pleural effusion
• Should be regarded with great caution and not classified as benign.
• They are generally associated with an indolent clinical course and long survival, but tend to
spread widely and may behave aggressively.
 2 TYPES of Benign
Mesothelial Proliferation
1. Benign multicystic mesothelioma
2. Adenomatoid tumor
*Both are very uncommon in the pleura
 MALIGNANT MESOTHELIOMA
GENERALITIES:
• older adults and young individuals
• following radiation therapy for Hodgkin lymphoma
• presents with chest pain and pleural effusion.
• initially involves the lower half of a hemithorax, but spread to the rest of
the pleural cavity is the rule.

Morphologic features
Invasion: most reliable criterion of malignancy
 MALIGNANT MESOTHELIOMA

Grossly: classic presentation: multiple Microscopically: the neoplastic formations

gray or white ill-defined nodules in a may form papillae or pseudoacini or grow
diffusely thickened pleura as solid nests
 MALIGNANT MESOTHELIOMA
Histochemical, immunohistochemical, and electron microscopic features
 produce large amounts of hyaluronic acid seen on Alcian blue or colloidal iron stains
 mucicarmine-positive or PAS-positive material in the cytoplasm: diagnosis of
mesothelioma very unlikely

Markers seen on both tumors:

 Pankeratin, Epithelial membrane antigen (EMA), Basement membrane components
 S-100 protein

Molecular and genetic features

Homozygous deletion of P16- most common genetic change
NF2 gene mutation- 2nd
 MALIGNANT VARIANTS

SPINDLE CELL OR SARCOMATOID MESOTHELIOMA

• a form of malignant mesothelioma predominantly or entirely composed of spindle tumor cells,
which 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.
 MALIGNANT VARIANTS
DESMOPLASTIC MESOTHELIOMA
• a subtype of spindle cell malignant mesothelioma accompanied by abundant deposition of fibrous
tissue.

LYMPHOHISTIOCYTOID MESOTHELIOMA
• a subtype of sarcomatoid mesothelioma
• characterized microscopically by a diffuse proliferation of atypical histiocyte-like malignant
mesothelial cells admixed with numerous lymphocytes (almost exclusively of T-cell type) and a lesser
number of plasma cells.

DECIDUOID MESOTHELIOMA
• characterized by the presence of large tumor cells with an abundant ground glass cytoplasm that
simulates the appearance of decidual cells.
 MALIGNANT VARIANTS
Malignant mesothelioma with squamous differentiation (pleural squamous cell carcinoma)
• has been described in patients with a history of chronic empyema or therapeutic
pneumothorax.

Mesothelioma with clear cell features

• can be confused with lung carcinoma and metastatic carcinoma, particularly from the kidney.
The cytoplasmic clearing is most often due to the accumulation of glycogen, in which case the
alternative term glycogen-rich mesothelioma has been used.

TREATMENT: None. Bulk resection of the tumor combined with radiation therapy and/or
systemic chemotherapy has sometimes resulted in long-term remissions.
 SOLITARY FIBROUS TUMOR
Gross: the lesion is well circumscribed, firm,
lobulated, gray–white to yellow–white, with frequent
whorling and fasciculation. mean diameter is 6 cm.
Solitary fibrous tumor can present as a mural nodule
within a large pleural-lined cyst.

Microscopically:
In the typical benign case, there is a tangled network
of fibroblast-like cells, squeezed in between
abundant collagen fibers, many of which have a
keloid-like quality. The degree of cellularity varies a
great deal from area to area.
OTHER PRIMARY TUMORS
SOFT TISSUE-TYPE TUMORS
o Epithelioid hemangioendothelioma
o Angiosarcoma
o Synovial sarcoma
o Fibromatosis (desmoid tumor)
o Calcifying fibrous pseudotumor
o Liposarcoma
o Chondrosarcoma
o Malignant fibrous histiocytoma
o Gastrointestinal stromal tumor (GIST)
 MALIGNANT LYMPHOMA
INVOLVING THE PLEURA
• Usually associated with systemic disease
• most frequent type is diffuse large B-cell lymphoma, followed by follicular lymphoma.

Tumor referred to as pyothorax-associated lymphoma

• a form of diffuse large B-cell lymphoma accompanied by chronic inflammation.
• It is associated with Epstein–Barr virus (EBV) but not human herpesvirus 8 (HHV8).
 METASTATIC TUMORS
• Most malignant tumors involving the pleura are of metastatic nature
• 75% are metastatic carcinomas.
• second only to congestive heart failure as the cause of pleural effusions in patients over
50 years of age.
• Dyspnea, cough, and chest pain are the most common presenting symptoms.
• Most malignant pleural effusions are greater than 500 mL.
• fluid is most often serous to serosanguineous, but it may be frankly hemorrhagic.
• The most common sites for the primary lesion are lung (33%), breast (20.9%), and
stomach (7.3%).
• Approximately 90% of the lung, breast, and ovarian malignant effusions are ipsilateral to
the primary lesion.
• A malignant pleural effusion may be the first evidence of the existence
BIOPSY AND CYTOLOGY
• very useful for the DDX between inflammatory and neoplastic processes.
• when the possibility of malignancy is considered in the presence of pleural effusion, a
cytologic examination of the pleural fluid should always be performed, regardless of the
gross appearance of the fluid.

DIAGNOSTIC CYTOLOGY
• cells of mesothelioma: singly or in clusters with scalloped borders
• cytoplasm: dense and often has small, regular, centrally located vacuoles
• Nuclei: atypical, nucleocytoplasmic ratio is greatly altered, and multinucleated forms may
be present.
• presence of a high content of hyaluronic acid in a pleural effusion favors the diagnosis of
mesothelioma.
anatomy
ANATOMY
Two Main Components of Lung Parenchyma:
• Bronchi and bronchioles
• Alveoli
Alveoli
• lined by type I and type II (granular) pneumocytes
• type II: produce surfactant
Main cell types of the bronchial–bronchiolar epithelium:
• Basal Cells
• Neuroendocrine (Kulchitsky-Type) Cells
• Ciliated Cells
• Serous Cells
• Clara Cells
• Goblet Cells
ANATOMY

Goblet and ciliated cells

• decrease in number as one
approaches the terminal bronchioles

Kulchitsky-type cells
Clara cells
• Numerous in the bronchial and
• number increases proportionally bronchiolar epithelium of fetus and
• have a secretory function neonate
• represent the main progenitor cells after • very scanty and difficult to demonstrate
bronchiolar injury in the adult

Submucosal glands
• associated with the larger bronchi
• serous and mucous cells
• exhibit oncocytic changes in older indiv.
ANATOMY

Metaplastic bone
• age-related change (seen in the bronchial cartilage)

Lymph vessels
• drain to intrapulmonary peribronchial and hilar lymph nodes

Intrapulmonary Lymph Nodes

• found in peribronchial region, sometimes in the peripheral lung
ANATOMY

Pulmonary Arteries
• have both an internal and external elastic membrane

Pulmonary Veins
• have a single(outer) elastic layer.

Ectopic Tissues
• found in otherwise normal lung, include: skeletal muscle (sometimes present
extensively in the newborn lung, a condition known as rhabdomyomatosis),
neuroglial elements, pancreas, and adrenal cortex
NON NEOPLASTIC
NON NEOPLASTIC LESIONS

BIOPSY
TRANSBRONCHIAL BIOPSIES
• Useful for infections,
sarcoidosis, a whole host of
parenchymal lung diseases and
neoplasms .

OPEN LUNG BIOPSY

• The lingula or right middle lobe
tips should be avoided because
of their tendency to show more
fibrosis .
NON NEOPLASTIC LESIONS

CYSTIC DISEASES
CONGENITAL CYSTIC DISEASE
• Generic term for any cystic process present at birth.
• Morphologic types of congenital cystic disease include:
o pulmonary sequestration
o congenital lobar emphysema
o bronchogenic cyst
o nebulous “congenital bronchiectasis”
o cystic adenomatoid transformation
NON NEOPLASTIC LESIONS

CYSTIC DISEASES
CONGENITAL LOBAR EMPHYSEMA
(congenital lobar hyperinflation)
• Occurs in young children
• affects only one of the upper lobes or the right middle lobe of the lung
• pathologic change: massive overdistention of the alveolar spaces not
accompanied by tissue destruction
• Causes severe compression of other structures
NON NEOPLASTIC LESIONS

CYSTIC DISEASES
NON NEOPLASTIC LESIONS

CYSTIC DISEASES
CYSTIC ADENOMATOID TRANSFORMATION
• Characterized by- variously sized intercommunicating cysts lined by an
‘adenomatoid’ cuboidal-to-ciliated pseudostratified columnar epithelium
• association with bronchial atresia
• Solitary lesions usually involve a lower lobe.
• Some of the patients have associated pulmonary or extrapulmonary
anomalies.
• Treatment Of Choice: lobectomy
NON NEOPLASTIC LESIONS
NON NEOPLASTIC LESIONS

CYSTIC DISEASES
ACQUIRED CYSTIC DISEASES
• end stage of interstitial pneumonia or other inflammatory diseases.
• Lung cysts can also develop in the Ehlers–Danlos syndrome.
• Unilateral multicystic lung disease presents as gelatinous vesicular or grape-
like structures that resemble normal or molar placental tissue (‘placentoid
bullous lesion’).
NON NEOPLASTIC LESIONS

EMPHYSEMA
• Increase size of airspaces distal to the terminal bronchiole associated with
destruction of their walls.
• most important morphologic substrate of COPD
• Emphysematous bullae are large (1 cm or greater) cystic spaces covered by a
thin, stretched pleura.
• Giant bullae can result in an appearance vaguely reminiscent of chorionic villi,
a change that has been designated as placental transmogrification.
• Symptoms may result from hemorrhage, infection, compression of adjacent
lung, or pneumothorax.
• Bleb may rupture into the free pleural space, causing pneumothorax, and
sometimes the microscopic change known as reactive eosinophilic pleuritis
NON NEOPLASTIC LESIONS

EXTRALOBAR
• tissue is enveloped by its own pleural covering and exists as a nodule apart
from the lung, at any level from the thoracic inlet to the diaphragm, or
abdominal cavity
• 90% of cases occur in the left side.
• Other congenital malformations, especially diaphragmatic hernias, occur in
approximately 20% of patients.
• association with polyhydramnios and edema has been observed.
• arterial supply: one or several small arteries from the aorta or one of its
branches
• venous drainage: azygos system
NON NEOPLASTIC LESIONS

INTRALOBAR
• The variety, symptomatic, is characteristically located within the lower lobe,
especially in the posterior basal segment.
• About 60% of the cases occur on the left side.
• segment is supplied by a large artery arising from the aorta or one of its
branches; this artery arises above the diaphragm in 75% of the patients and
below the diaphragm in the remainder.
• Failure of the surgeon to appreciate this fact may result in the patient's death
from hemorrhage.
NON NEOPLASTIC LESIONS
NON NEOPLASTIC LESIONS

BRONCHIECTASIS
• Permanent dilation of bronchial lumina usually associated with destruction of
some elements of the bronchial wall and inflammatory changes in the
surrounding lung parenchyma

• TWO CATEGORIES:
• Obstructive variety
• Results from partial or total obliteration of the bronchial lumen by a
neoplasm, foreign body, localized inflammatory process in the bronchial
wall, inspissated mucus secretion (seen in cystic fibrosis), or extended
compression.
• Nonobstructive (postinflammatory)
NON NEOPLASTIC LESIONS

BRONCHIECTASIS
Microscopically

• Chronic inflammation of the bronchial wall is a constant finding.

• Lymphocytes predominate and germinal centers can be encountered,
particularly in younger patients.
• Multiple small solid foci of proliferating spindle cells with saccular bronchiectasis.
These formations, traditionally known as tumorlets, represent nodular
hyperplasia of Kulchitsky-type neuroendocrine cells and are histogenetically
related to carcinoid tumors
NON NEOPLASTIC LESIONS

BRONCHIECTASIS
Complications of bronchiectasis
• Bronchopleural fistula with empyema
• Brain abscess
• Amyloidosis

Surgical resection
• Unilateral disease
• Hemorrhage or repeated pulmonary infections
• Obstructive variety of the disease
NON NEOPLASTIC LESIONS
NON NEOPLASTIC LESIONS

ABSCESS
• Most follow the aspiration of foreign material, are a complication of
pneumonia (sometimes on an immunodeficiency background), or
represent secondary infections of lung carcinomas.
• Embolism from distant sources does not cause unilocular abscesses
but can cause multiple bilateral abscesses.

Most common locations of lung abscesses

• Right lower lobe,
• Rght upper lobe (subapical segment)
• Left lower lobe
NON NEOPLASTIC LESIONS

LUNG ABSCESSES IN CHILDREN

• Streptococcus species
• Staphylococcus aureus
• Klebsiella pneumoniae

Intravenous antibiotics- TOC in children

Small unilocular abscesses
• aspiration and drainage or partial resection of the lobe
Larger lesions - lobectomy
NON NEOPLASTIC LESIONS
NON NEOPLASTIC LESIONS

GRANULOMATOUS INFLAMMATION
• characterized by a nodular collection of histiocytes (epithelioid macrophages) surrounded
by a rim of lymphocytes.
• Microscopic examination is insufficient to establish a specific diagnosis
• important to submit a sample for
a)bacteriologic,
b)mycologic
c) molecular genetics examination( now being increasingly done)
d)Perform stains for mycobacteria (Ziehl–Neelsen) and fungi
(Gomori methenamine silver, GMS) in the sections in every case.
NON NEOPLASTIC LESIONS

GRANULOMATOUS INFLAMMATION
TUBERCULOSIS
Bacteria infection with formation of tubercles( nodules) especially in lungs

for pathology laboratory

Biopsy obtained with the fiberoptic bronchoscope
Material procured via fine needle aspiration
Open-lung biopsy
Surgical specimen
SURGICAL PROCEDURE
Resectional – wedge excision
Subsegmental resection
Lobectomy
Pneumonectomy
NON NEOPLASTIC LESIONS

GRANULOMATOUS INFLAMMATION
TUBERCULOSIS

TUBERCULOUS CAVITIES
• Removed in patients after prolonged antimicrobial therapy
• Potential danger exists d/t long-term persistence of viable organisms in this material.

TUBERCULOMAS
• Tumor-like but non neoplastic mass, usually in lungs or brain, due to aggregation or
enlargement of caseous infection)
• adults , an expression of tuberculous reinfection rather than a primary Ghon focus.
NON NEOPLASTIC LESIONS

GRANULOMATOUS INFLAMMATION
SARCODOSIS
• Aka Hutchinson or Boeck’s diseases, because these dermatologist observed skin eruptions
caused by the disease is a multisystemic disease of unknown cause.jkm
• Diffuse pulmonary disease without radiographic evidence of node involvement
• Combination of lymph node enlargement and diffuse pulmonary disease

MICROSCOPIC HALLMARK : COMPACT, NONCASEATING GRANULOMA

• mainly composed of epithelioid cells but also containing Langhans giant cells and
lymphocytes
NON NEOPLASTIC LESIONS

GRANULOMATOUS INFLAMMATION
ATYPICAL MYCOBACTERIOSIS
Caused by:
a)M. avium
b)M. kansasii
c)M. malmoense
• Seen in
a) Immunocompromised hosts
b)Patients with preexisting lung disease (chronic obstructive lung disease, previous
tuberculosis, pneumoconiosis, bronchiectasis, and lung carcinoma)
NON NEOPLASTIC LESIONS

GRANULOMATOUS INFLAMMATION
WEGENER GRANULOMATOSIS
( now known as polyangiitis w/ granulomatosis)

• Best known member of the group of diseases

designated by Liebow as pulmonary angiitis and
granulomatosis

TRIAD of:
1. necrotizing angiitis
2. aseptic necrosis (involving both UR T and
lungs)
3. focal glomerulitis
NON NEOPLASTIC LESIONS

OTHER GRANULOMATOUS INFLAMMATIONS

ASPERGILLOSIS
• Secondary colonization of a lung abscess or some other cavitary process
(‘aspergilloma’)- allergic bronchopulmonary aspergillosis
• An invasive or necrotizing pulmonary aspergillosis
• Gomori methenamine silver stain (GMS): most useful to identify fungal organisms

DIROFILARIASIS
• incidental solitary nodule on x-ray examination, multiple and/or symptomatic.
• Microscopically
• There is a histiocyte-rimmed necrotic nodule containing fragments of Dirofilaria inmitis.
NON NEOPLASTIC LESIONS

DIFFUSE PULMONARY INJURY

AND INTERSTITIAL LUNG
DISEASE
NON NEOPLASTIC LESIONS

DIFFUSE ALVEOLAR DAMAGE (DAD)

• morphologic changes - nonspecific nature
• etiologic agent cannot be determined from the microscopic picture alone.
• cells mainly of type II (granular) pneumocytic type, may exhibit atypia, mitotic
activity, intracytoplasmic lipid accumulation, and cytoplasmic hyaline (Mallory)
bodies.
NON NEOPLASTIC LESIONS

ACUTE INTERSTITIAL PNEUMONIA (AIP)

• rapidly progressive form of interstitial pneumonia
• synonymous with the Hamman–Rich syndrome
• There is no identifiable initiating event.
• Microscopically- Appearance is equivalent to that of the organizing phase of DAD,
the most striking feature being the brisk interstitial fibroblastic proliferation.
NON NEOPLASTIC LESIONS

BRONCHIOLITIS OBLITERANS–ORGANIZING
PNEUMONIA (BOOP)
Morphologically
• HALLMARK of the disease: fibroblastic plugs (‘Masson bodies’) filling air spaces
NON NEOPLASTIC LESIONS

USUAL INTERSTITIAL PNEUMONIA (UIP)

• insidious onset and a chronic evolution, many of the patients dying of respiratory
failure after an average of 4–5 years.
Microscopically
• primarily interstitial inflammatory and fibrosing process
• single most important feature - marked regional variation in the nature and
degree of the infiltrate, with a distinct patchwork appearance and evidence of
architectural derangement
• Honeycombing- Late stages of UIP
NON NEOPLASTIC LESIONS

DESQUAMATIVE INTERSTITIAL PNEUMONIA (DIP)

• filling of the alveolar spaces by large mononuclear cells, associated with relatively
minor interstitial changes.
• Radiographically
• ground-glass type of opacification is seen bilaterally in the periphery of the lung
bases
NON NEOPLASTIC LESIONS

Respiratory bronchiolitis-associated
interstitial lung disease (RBILD)
• common incidental finding in heavy smokers
• Histologically
• accumulation of alveolar macrophages within respiratory bronchioles spilling into
neighboring alveoli
NON NEOPLASTIC LESIONS

NONSPECIFIC INTERSTITIAL
PNEUMONIA/FIBROSIS (NSIP)
• particularly related to CT disorders and generally have a better prognosis than UIP
• main morphologic difference is that it lacks the characteristically heterogeneous pattern of
lung involvement of the latter
NON NEOPLASTIC LESIONS

ORGANIZING PNEUMONIA
• if – instead of resolving – the disease organizes and becomes localized, shadows occurring
in the lung may be mistaken for tumor .
Grossly
• The involved area is sharply outlined and very firm, but the architecture of the lung is
retained.
• The cut surface is solid and gray–red to light yellow.
• The process extends to the pleura, which is invariably thickened
Microscopically
• exudate composed of fibrin and acute inflammatory cells in various degrees of organization,
sometimes accompanied by necrotizing changes in the bronchi.
NON NEOPLASTIC LESIONS

LIPOID PNEUMONIA
• a complication of debilitating disease found as an incidental post mortem

Two types:
• Exogenous
• Endogenous

Microscopically
• Both forms exhibit sudanophilic lipoid material, inflammatory cells, proliferating alveolar
cells, and young fibroblasts occupying large spaces.
• There may also be reactive endarteritis.
• The marked hyperplasia of alveolar cells and histiocytes may cause confusion in cytology or
frozen section interpretation.
NON NEOPLASTIC LESIONS

ASPIRATION PNEUMONIA
• Is due to the aspiration of food, and is a well-recognized complication in debilitated patients

Radiographically
• lesions can be bilateral or unilateral
• When solitary, they can simulate a neoplastic process

Microscopically
• changes are mainly represented by BOOP, usually in combination with multinucleated giant
cells, acute bronchopneumonia and/or bronchiolitis, and suppurative granulomas.
• key finding: presence of foreign material, most often vegetable or other food remnants
NON NEOPLASTIC LESIONS

EOSINOPHILIC PNEUMONIA
• embraces all pulmonary infiltrations associated with peripheral eosinophilia, as well as
infiltrations of the lung by eosinophils with or without peripheral eosinophilia
• Women (between 20 and 50 year-old)
• Löffler syndrome - acute form of eosinophilic pneumonia
• fleeting pulmonary infiltrates with eosinophilia and lasting no more than a month
Radiography
• distinctly peripheral distribution of the infiltrate
Microscopic change :
• Alveolar and interstitial infiltration by eosinophils, but there are also plasma cells and
histiocytes
• Charcot–Leyden crystals
• occasionally there is mild angiitis, granulomatosis with giant cell formation, some fibrosis
with organization, mucous plugging, and bronchiolitis with necrosis
NON NEOPLASTIC LESIONS

PNEUMOCYSTIS CARINII PNEUMONIA

• nonbacterial opportunistic infection.
• most cases are seen in chronically debilitated and immunosuppressed
• may spread to extrapulmonary sites and become disseminated

MICROSCOPIC FEATURES
• typical case is characterized by a foamy or honeycombed intra-alveolar
exudate accompanied by a lymphoplasmacytic interstitial infiltrate
• in other cases, this may present as epithelioid granulomas, focal
multinucleated giant cells, marked interstitial fibrosis, vasculitis, and
severe infiltration by alveolar macrophages
• calcification may also develop
NON NEOPLASTIC LESIONS

PNEUMOCYSTIS CARINII PNEUMONIA

DIAGNOSIS
• depends on the microscopic identification of the organism via sputum
or pulmonary secretions, or in tissue specimens from transbronchial,
percutaneous, or open biopsies
• most reliable stain for detecting the organism is Gomori methenamine
silver (GMS).
• the cystic form of the organism as appear
as round structures, up to 5 µm in
diameter, containing single or
paired discrete ‘intracystic bodies’
measuring 1–2
NON NEOPLASTIC LESIONS

OTHER PNEUMONIAS
CYTOMEGALOVIRUS PNEUMONIA
• usually seen in immunocompromised patients.
RADIOGRAPHIC FEATURES: small (2–4 cm) peripherally located nodules, as an acute miliary
pattern, or as a diffuse interstitial process.

MICROSCOPIC FEATURES
• predominantly mononuclear inflammatory infiltrate is seen in conjunction with edema
and hyperplasia of the alveolar epithelium
• in the diffuse pattern, these changes are associated with spherical areas of
hemorrhagic necrosis.
• Viral inclusion bodies can be detected in most but not all of the cases. These are
found both in the nucleus and in the cytoplasm.
NON NEOPLASTIC LESIONS

OTHER PNEUMONIAS
HERPES SIMPLEX PNEUMONIA
• may result in an interstitial process with mononuclear inflammation and
alveolar cell hyperplasia, or in a necrotizing bronchopneumonia.
• Intranuclear viral inclusions can be found at the edge of the necrotic
areas

ADENOVIRUS PNEUMONIA
• microscopically appears by virtue of the combination of smudged nuclei,
bricklike intranuclear inclusions in epithelial cells, and bronchiolitis
obliterans
NON NEOPLASTIC LESIONS
NON NEOPLASTIC LESIONS

LEGIONNAIRES DISEASE
• Microscopically - intra-alveolar accumulation of neutrophils, macrophages, fibrin.
• many cases also show a leukocytoclastic neutrophilic inflammatory infiltrate,
small vessel vasculitis, and necrosis.
• DIAGNOSIS: Dieterle silver impregnation stain has proved to be the most
reliable

NOCARDIOSIS - opportunistic lung infection

• Approximately onehalf of the reported cases have occurred in patients who
have a history of organ transplantation, immunosuppression, steroid usage, or
chemotherapy.
• MICROSCOPIC FEATURES: appear as that of focal bronchopneumonia, with the
formation of microabscesses and ill-defined granulomas. Gram stain shows
slender, slightly beaded, branching f ilamentous bacilli.
• DIAGNOSIS: open lung biopsy.
NON NEOPLASTIC LESIONS

LUNG IN AIDS
Pulmonary disease occurs frequently abnormalities seen include :
during the course of AIDS
cytomegalovirus pneumonia
Pneumocystis pneumonia
MANAGEMENT AND DIAGNOSIS: atypical mycobacteriosis and tuberculosis
• bronchoalveolar lavage candidiasis,
• transbronchial biopsy aspergillosis
• open lung biopsy—highest toxoplasmosis,
diagnostic yield
cryptococcosis
histoplasmosis
blastomycosis,
microsporidiosis
Kaposi sarcoma
NON NEOPLASTIC LESIONS

LUNG AND TRANSPLANTATION

• Most nonleukemic deaths after bone marrow transplantation are caused by
graft-versus-host disease and interstitial pneumonia.

INTERTITIAL PNEUMONIA
• incidence - 20% to 50%,
• fatality rate - 50–70%.
• most common type is infectious, with cytomegalovirus as the most frequently
encountered pathogen

• Acute cellular rejection - is seen as perivascular accumulation of mononuclear

inflammatory cells and eosinophils, often accompanied by bronchiolar inflammation.
• Chronic rejection - manifested by fibrosis narrowing the lumen of bronchioles, arteries,
and veins
NON NEOPLASTIC LESIONS

PNEUMOCONIOSIS
PNEUMOCONIOSIS
• non-neoplastic reaction of the lungs to inhaled mineral or organic dust, exclusive
of asthma, bronchitis, and emphysema.
ANTHRACOSIS
• presence of carbon particles in the lung.
• result is coal worker's pneumoconiosis,

SILICOSIS
• deposition in the lung of particles of silica (quartz, silicon dioxide).
• micronodular scars along the lymphatic network, particularly around
bronchovascular bundles.
• silicosis in the presence of rheumatoid arthritis are referred to as Caplan
syndrome.
NON NEOPLASTIC LESIONS

PNEUMOCONIOSIS
Mixed dust fibrosis
• from mixed dust exposure, including silica and quartz.
• affects foundry workers, arc welders, hematite miners, and boiler scalers.

Asbestosis
• early stages as interstitial pneumonia with predominantly ‘mural’ or
desquamative features.
• later stages the interstitial fibrosis becomes more diffuse and results in
honeycomb lung .
NON NEOPLASTIC LESIONS

EXTRINSIC ALLERGIC ALVEOLITIS (hypersensitivity alveolitis)

• generic term given to an acute, subacute, or chronic inflammatory process centered
in the alveoli and representing a tissue reaction to an inhaled allergen.
• MicroscopicallY- interstitial and intra-alveolar alveolitis with a predominance of
lymphocytes, granulomas , intra-alveolar ‘buds’ made up of fibroblasts and other
mesenchymal cells, and fibrosis.
• Fibrosis is associated with a generally poor prognosis.
• Silo-filler's disease should be clearly separated from the aforementioned group,
since it is a form of chemical pneumonitis secondary to nitrogen dioxide inhalation
and is not characterized by the presence of granulomas.
NON NEOPLASTIC LESIONS

LANGERHANS CELL HISTIOCYTOSIS

• 3RD and 4TH decades of life.
• associated with smoking
• predominates in the upper lobes and can produce nodular as well as cavitary
lesions.
• Honeycombing of the lung is a characteristic feature in the late stage
• Spontaneous pneumothorax is a common complication.
• Microscopically- compact interstitial infiltrate, often subpleural, composed of
Langerhans cells, numerous eosinophils, and reactive mesothelial cells .
• Langerhans cells are the essential element for the diagnosis; they have an abundant
acidophilic cytoplasm and a vesicular nucleus, with typical grooves and indentations
NON NEOPLASTIC LESIONS

REACTIVE EOSINOPHILIC PLEURITIS

• nonspecific response to pleural injury that may closely simulate Langerhans cell
histiocytosis because of the mixture of eosinophils, mesothelial cells, and
histiocytes.
• this lesion does not show interstitial lung disease on radiographic examination
or Birbeck granules on electron microscopic examination.

ERDHEIM–CHESTER DISEASE
• idiopathic histiocytic disorder which can affect the lung, in conjunction with
bones and the central nervous system.

ROSAI–DORFMAN DISEASE
• seen in the lung parenchyma only exceptionally, in contrast to its relatively
frequent involvement of the upper respiratory tract
NON NEOPLASTIC LESIONS

VASCULAR DISEASE
PULMONARY VENO-OCCLUSIVE
DISEASE
• MC children and adolescents,
especially females.
• Pulmonary hypertension develops
accompanied by recanalization and
pseudoangiomatous changes.
• The etiology of the disease is
unknown; an influenza-like illness
has been found to precede many
cases of this condition, and an
immune-complex pathogenesis has
been suggested.[
CARCINOMA
CARCINOMA

GENERAL AND CLINICAL FEATURES

• More common in males than females.
• current male to female ratio is 1.5:1.

FACTORS
• CIGARETTE SMOKING- most significant factor
• 10-15% cases of carcinoma in non-smokers, majority are women, and
usually have ADENOCARCINOMA histology
• ASBESTOS- in 5% of cases
CARCINOMA

LUNG CARCINOMA
• Multiple- 2-5% of cases
• Considerable size when detected
• 60% are incurable due to distant metastasis

SIGNS AND SYMPTOMS

• late usually d/t partial or complete bronchial obstruction
• In decreasing frequency

Cough- most common hemoptysis

weight loss malaise
pain fever
LUNG CARCINOMA
CARCINOMA

LUNG CARCINOMA
DIAGNOSIS
• XRAY- solitary circumscribed mass, “coin lesion”
• Additional substances detected:
o Amylase
o Calcitonin
o Cea
o AFP
o Beta pregnancy specific glycoprotein
o EGF receptor
CARCINOMA

PATHOLOGIC AND
IMMUNOHISTOCHEMICAL
FEATURES
 Keratins
present in all types of lung carcinoma, but the
expression of individual keratins is dependent upon
the tumor subtype

ES1 Surfactant apoprotein A

a marker which stains
primarily a product of type II
selectively lung carcinoma in
(granular) pneumocytes
a more sensitive fashion than
TTF-1
GENERIC
IMMUNOMARKERS

Napsin A TTF-1(thyroid
highly sensitive marker transcription factor 1)
for pulmonary normal pulmonary airways
adenocarcinomas most useful markers of Most important!!
epithelial lung tumors designed by

tinyppt.com
 Sarcomatoid
carcinoma/carcinosarc
oma (including
Squamous cell carcinoma
pulmonary blastoma
(including some types of Large cell and pulmonary
clear cell carcinoma)
carcinoma endodermal tumor)
Adenocarcinoma Adenosquamous
(including carcinoma
Small cell
bronchioloalveolar
carcinoma carcinoma and
some types of clear
cell carcinoma)

MAJOR
CATEGORIES
The Power of PowerPoint | http://thepopp.com
CARCINOMA

SQUAMOUS CELL CARCINOMA

• Males-44%; majority
• Females- 25%
• Segmental bronchi- most common location
• bronchial mucosa adjacent to the tumor usually shows squamous metaplasia and
sometimes carcinoma in situ, occasionally extending several centimeters from the
main mass

MICROSCOPICALLY
• keratin pearls
• Whorl formation and definite stratification of tumor cells- presumptive evidence
• Electron microscope: tonofilaments, complex desmosome, basal lamina formation
CARCINOMA

SQUAMOUS CELL CARCINOMA

MORPHOLOGIC FEATURE
• oncocytoid appearance of tumor cells (due to increased mitochondrial density)
• giant cell foreign body reaction to keratin
• palisaded granulomas
• extensive infiltration by neutrophils and other inflammatory cells- malignant
fibrous histiocytoma-like pattern

GENETIC ALTERATIONS
• allelic loss of 3p (implicating many tumor suppressor genes)
• TP53 alteration (point mutation or homozygous deletion)
• P16/CDKN2A inactivation
• gain of 3q24-qter –characteristic and common alteration
CARCINOMA

SQUAMOUS CELL CARCINOMA

CARCINOMA

ADENOCARCINOMA
• comprise over half of all lung carcinomas in females and a lower
percentage of those in males
• more common in males than in females

GROSS MORPHOLOGY
• poorly circumscribed gray–yellow lesions
• may be single or multiple
• If they secrete abundant mucin, they have a gelatinous, glairy
appearance

LOCATION
• Peripherally- in 65% of cases
• Visceral pleura- 77%  pleural fibrosis or puckering
CARCINOMA
CARCINOMA

ADENOCARCINOMA
The TWO morphologic signs of glandular differentiation:
• formation of tubules or papillae
• secretion of mucin
CARCINOMA

ADENOCARCINOMA
IMMUNOHISTOCHEMICALLY
• keratin 7- evidence of glandular differentiation
• TTF-1- usually positive- negative in other metastatic tumors
• Napsin A- positive in most cases
• Negativity for CDX2- DDx with metastatic colorectal adenocarcinoma, but this
does not apply to mucinous adenocarcinomas
• Negativity for estrogen receptors- DDx with metastatic breast carcinoma, but
not an absolute criterion
• Positivity for surfactant apoprotein (PE-10)- DDx with other types of primary
lung carcinoma and – most important – with metastatic adenocarcinoma.
• Cathepsin B and basement membrane components are also encountered
CARCINOMA

ADENOCARCINOMA
GENETIC ALTERATIONS
• TP53 -50%; related to cigarette smoking
• G–T transversions are the footprints of the effects of tobacco carcinogens.
• P16/CDKN2A inactivation
• 3p allelic loss -FHIT/FRAB3 and RASSF1A
Tumor Suppressor Genes
-STK11/LKB1
• KRAS mutation -indicator of poor prognosis in adenocarcinoma
-occurs in tumors of ever-smokers
• EGFR (epidermal growth factor receptor) gene mutations
-occurs in tumors of never-smokers
CARCINOMA

CLEAR CELL CARCINOMA

• predominantly or exclusively composed of cells with clear cytoplasm
• Clear cells usually contain abundant glycogen and may also contain mucin
CARCINOMA

BRONCHIOLOALVEOLAR CARCINOMA (BAC)

GROSS PRESENTATION
• single peripheral nodule
• multiple nodules
• diffuse pneumonic-like infiltrate

MICROSCOPIC PRESENTATION
• mucinous and
• nonmucinous types
CARCINOMA

A. MUCINOUS TYPE
GROSS PRESENTATION:
• Glistening appearance
• underlying lung architecture is preserved
• occasional distortion of air spaces by pools of mucus
MICROSCOPIC PRESENTATION:
• well-differentiated mucin-containing columnar cells that line
respiratory spaces in a ‘lepidic’ fashion without invading the stroma
• tumor nodules have a topographic association with bronchioles rather
than bronchi
• sharp separation is often found between the neoplastic and the
normal cell- useful diagnostic feature
CARCINOMA

B. NONMUCINOUS TYPE 60-65 % of cases

GROSS PRESENTATION:
• gray–white foci of parenchymal consolidation
• associated with a central scar

MICROSCOPIC PRESENTATION
• pattern of growth is ‘lepidic’, without stromal infiltration
• cells are cuboidal rather than columnar
• have a bright eosinophilic neoplasm
• degree of nuclear atypia and nucleolar prominence is greater than in the
mucinous variety.
• Apical spouts may be present as indicators of Clara cell differentiation
• Hobnail cells may be present
• Eosinophilic intranuclear inclusions (PAS-positive) -represent a useful
diagnostic sign
CARCINOMA

MUCINOUS vs. NONMUCINOUS

Mucinous Non mucinous

Ultrastructural bronchiolar goblet cells Clara cells and/or type II

pneumocytes
Immunohistochemical CK7–/CK20+/TTF-1– CK7+/CK20–/TTF-1+/CDX2–
/CDX2+,
Natural history better prognosis
CARCINOMA
SMALL CELL CARCINOMA
• 10–20% of all lung cancers
• males
• median age is 60 years
• 85% or more are smokers
• typically a lesion of the central portions of the lung

GROSS APPEARANCE:
• white–tan
• Soft
• friable
• extensively necrotic

MICROSCOPIC APPEARANCE:
• pattern of growth
• generally solid, but there may be streams and ribbons, rosettes and
pseudorosettes, or tubules and ductules
CARCINOMA
CARCINOMA
SMALL CELL CARCINOMA
METASTASES Less common sites include:
• Distant metastases are more – gastrointestinal tract
common in: – pancreas
– liver – thyroid
– other areas of lung – spleen
– adrenal – ovary
– bone and bone marrow – pituitary gland
– kidney – skin
– central nervous system – skeletal muscle

TREATMENT
Multidrug chemotherapy - treatment of choice for small cell carcinoma
CARCINOMA
SMALL CELL CARCINOMA
FACTORS AFFECTING PROGNOSIS
1. Age- younger than 40 years of age have a very poor prognosis
2. Sex- Women have a worse survival rate than men
3. Location- superior pulmonary sulcus have a better prognosis than the others

Stage. TNM stage is regarded by most as the single most important prognostic
parameter in lung carcinoma
Tumor size. Large tumors have a worse prognosis than smaller neoplasms of the same
histologic type
Other metastatic
LESIONS
OTHER METASTASES

OTHER PRIMARY TUMORS

HAMARTOMA
- occurs in adults
- more common in males
- usually solitary but can be multiple
- most common location: lung parenchyma (just beneath the pleura)
- presents in most instances as an asymptomatic clearcut shadow on a
chest x-ray or CT scan
- usually small, although occasionally it may occupy
an entire lobe
Pulmonary hamartoma
- seen associated with the peculiar change known as placental
transmogrification, characterized by the formation of placental villus-like
formation in the lung parenchyma.
OTHER METASTASES

Grossly, it is sharply delineated and Microscopically, the peripheral hamartoma

lobulated is made up of normal cartilage arranged in
islands, fat, smooth muscle, and clefts lined
by ciliated or nonciliated respiratory
epithelium
OTHER METASTASES

OTHER PRIMARY TUMORS

CARCINOID TUMOR AND OTHER NEUROENDOCRINE CARCINOMAS

Typical carcinoid tumor, CENTRAL type

• most common type, known in the past as bronchialadenoma
• usually presents as a slow-growing, solitary polypoid within a major bronchus
• most common primary lung neoplasm in the pediatric age group

Typical carcinoid tumor, PERIPHERAL type (and tumorlet)

• arises in the peripheral lung, often immediately beneath the pleura
• usually asymptomatic and discovered incidentally
• tends to be multiple
OTHER METASTASES

OTHER PRIMARY TUMORS

OTHER METASTASES
Grossly, typical carcinoid tumors of the
central type are predominantly
intrabronchial but also infiltrate the
bronchial wall, may extend to the
surrounding parenchyma, and may even
reach the pleura or the myocardium
Microscopically- made up of small uniform cells
having central nuclei with scanty or no mitotic
activity and a moderate amount of finely granular
cytoplasm. It may grow in
the form of compact nests, ribbons, and festoons;
in a diffuse solid fashion; and – rarely – in a
pseudopapillary or true papillary configuration
OTHER METASTASES

OTHER PRIMARY TUMORS

TUMORLET (carcinoid tumorlet)
• the term given to a nodular proliferation of small spindle cells seen in
relation to bronchioles
• often in association with bronchiectasis and other conditions associated
with scarring, including that associated with intralobular sequestration.
OTHER METASTASES

Microscopically, it is composed of spindle Grossly, it presents grossly as a nonencapsulated

cells that may closely simulate the gray to tan nodule not bearing an anatomic
appearance of smooth muscle cells; it is relationship with a bronchus.
not unusual for this lesion to be
misdiagnosed as leiomyoma as a result
OTHER METASTASES

PARAGANGLIOMAS
• Gross: exceptionally in the lung, solitary (usually peripheral but sometimes
endobronchial) masses
• Microscopic: prominent ‘Zellballen’ pattern throughout the tumor and the presence
of a population of S-100 protein-positive sustentacular cells at the periphery of the
nests
• Treatment: Excision is usually curative

OTHER NEURAL TUMORS

a) Ganglioneuroblastoma : one combined with carcinoid tumor
b) Gangliocytic paraganglioma : one associated with Cushing syndrome
OTHER METASTASES

MINUTE MENINGOTHELIOID NODULES

AND MENINGIOMA
• Gross: incidental finding in surgically excised lungs, the lesions presenting as one
or more 1–3 mm tan–yellow nodules intimately connected with blood vessels
lesions are disseminated and bilateral, associated with symptoms of restrictive
pulmonary disease.

• Microscopic : total lack of neurosecretory granules or other features suggestive

of neuroendocrine differentiation.

• Immunohistochemically: negative for keratin and positive for vimentin, EMA,

CEA, CD56, and progesterone receptors
OTHER METASTASES

SO-CALLED SCLEROSING HEMANGIOMA

• Gross: asymptomatic small, solitary
nodule, very slow growing, well
circumscribed but not encapsulated,
solid (but sometimes cystic), and tan or
yellow, sometimes with hemorrhagic
areas

• Microscopically: there is a compact

growth of polygonal cells with relatively
abundant eosinophilic cytoplasm,
arranged in a solid as well as a papillary
or sclerotic pattern
 VASCULAR TUMORS
1. Hemangioma
2. Hemangiomatosis
3. Hemangiopericytoma
4. Glomus tumor
5. Kaposi sarcoma
6. Angiosarcoma
7. Lymphangioma and diffuse lymphangiomatosis
8. Lymphangiomyomatosis
9. Epithelioid hemangioendothelioma
10. Epithelioid hemangioma
HEMANGIOMA
o more commonly in children
o either endobronchial or parenchymal
o Microscopically - most are of the capillary type

HEMANGIOMATOSIS
o Multifocal
o Can present with symptoms and signs of pulmonary hypertension (pulmonary
capillary hemangiomatosis) or with picture of interstitial lung disease.
o Most are secondary to pulmonary veno-occlusive disease rather than primary
vascular tumors

HEMANGIOPERICYTOMA
o primary lung tumor but most cases would be placed in other categories s/a
pleuropulmonary solitary fibrous tumor
o notorious trap is the misdiagnosis of a solitary lung metastasis of endometrial
stromal sarcoma as a hemangiopericytoma
GLOMUS TUMOR
o exceptionally involve the lung
o appearance similar to that of its more common cutaneous and soft tissue
counterparts
o malignant example is glomangiosarcoma

KAPOSI SARCOMA
o usually a manifestation of AIDS
o occurs in immunocompetent individuals
o distribution of the disease typically follows lymphatic channels

ANGIOSARCOMA
o present as a single mass or as diffuse pulmonary infiltrates as an expression of a
primary lung malignancy
LYMPHANGIOMA AND DIFFUSE LYMPHANGIOMATOSIS
o extremely rare
o more common in children
LYMPHANGIOMYOMATOSIS
o diffusely involve both lungs
o occurs exclusively in women
o generally during their reproductive years
o leads to respiratory insufficiency, spontaneous pneumothorax, and chylous pleural effusion

EPITHELIOID HEMANGIOENDOTHELIOMA
o currently used term for the neoplastic process originally described in the lung as intravascular
bronchioloalveolar tumor (IV-BAT)
o typically appearing as multiple nodules
o Occurs in young adults
o over 80% are females

EPITHELIOID HEMANGIOMA
o angiolymphoid hyperplasia with eosinophilia
 LYMPHOID TUMORS AND TUMORLIKE
CONDITIONS
lung can be involved by various types of lymphoproliferative processes
either secondarily or as the only manifestation of the disease
lung infiltration can be peribronchial/perivascular, nodular alveolar, interstitial, pleural, or
(more commonly) a combination of them

primary lymphomas of the lung can be divided

into SIX BROAD CATEGORIES:
1. Large cell lymphoma of conventional type
2. Small lymphocytic proliferations
3. Plasmacytoma
4. Hodgkin lymphoma
5. Leukemias
6. Lymphomatoid granulomatosis
LARGE CELL LYMPHOMA
o conventional type presents as a large mass
o occupying most of a lobe and is often accompanied by foci of necrosis
o pattern of growth is predominantly intrabronchial
Microscopically
 monomorphic infiltrate of large lymphoid cells is present
 most are diffuse large B-cell lymphomas
 rare resemble mediastinal large B-cell lymphoma

SMALL LYMPHOCYTIC PROLIFERATIONS

Most patients are elderly and asymptomatic
lesion presents as a solitary nodule or infiltrate on a CXR film
Microscopic features said to favor this diagnosis
 absence of hilar lymph node involvement
 numerous germinal centers
 presence of other inflammatory cells
 features of Castleman disease in rare cases
o Lesions are neoplastic in nature and represent small B-cell (low grade) lymphomas
PLASMACYTOMA
o used as a diagnostic term only for neoplastic lesions composed almost
entirely of mature and immature plasma cells
o Morphologically resembles amyloid but is not congophilic - Crystal
storing histiocytosis

HODGKIN LYMPHOMA
o involve the lung parenchyma
o usually associated with nodal involvement, direct extension from the
mediastinum (thymus) being frequent in the nodular sclerosis form
o occur most frequently in women and older individuals
o usually appear as nodular lesions on chest x-ray film
o Lymphoid tumors and tumorlike conditions
LEUKEMIC INVOLVEMENT
 found at autopsy in 30–40% of the chronic lymphocytic forms
 15–20% of the chronic myelogenous types
 over 60% of the adult acute forms
 most of them do not result in clinical manifestations
o occasionally,significant pulmonary impairment results from the infiltrate of chronic
lymphocytic leukemia acquiring a selective bronchiolocentric distribution

LYMPHOMATOID GRANULOMATOSIS
a. usually presents in middle age with well-defined bilateral rounded mass densities
b. radiographically may resemble metastases
Cases of lymphomatoid granulomatosis have been reported in:
 immunosuppressed transplant recipients
 in association with Sjögren syndrome
 in HIV-infected patients
key microscopic picture is the presence of a polymorphic infiltrate rich in plasma cells, immunoblasts,
and atypical large lymphoid cells, with a tendency to involve the walls of pulmonary vessels and to collect
in the sub endothelial spaces
OTHER METASTASES

SALIVARY GLAND-TYPE TUMORS

• analogous to those of salivary gland neoplasms occur in the lung
• arising from submucous bronchial glands
• Most located within the main bronchi

ADENOID CYSTIC CARCINOMA

o most common type
o usually centered in major bronchi and often involves the trachea
o primary treatment is surgical excision
o ultimate prognosis is very poor
o should be distinguished from basaloid carcinoma with adenoid cystic carcinoma-like
pattern
OTHER METASTASES

MUCOEPIDERMOID CARCINOMAS
o usually present as an exophytic intrabronchial mass
o divided into low-grade and high-grade varieties

CLEAR CELL TUMOR ('SUGAR TUMOR’)

o presents grossly as a round or ovoid mass of small size, usually located in the
peripheral lung
o usually occurs in adults
o Grossly
 generally small
 sharply outlined
 red–tan
OTHER METASTASES

MISCELLANEOUS PRIMARY TUMORS

1. Squamous papillomas
2. Granular cell tumor
3. Benign lung tumors
4. Solitary fibrous tumor
5. Synovial sarcoma
6. Primary sarcomas
7. Malignant melanoma
8. Germ cell tumors
9. Congenital peribronchial myofibroblastic tumor
OTHER METASTASES

BENIGN LUNG TUMORS

Includes:
1. intrapulmonary thymoma
2. Schwannoma
3. Neurofibroma
4. Ganglioneuroblastoma
5. blue nevus
6. microcystic fibromyxoma
7. bronchial lipoma (endobronchial, peripheral, and
OTHER METASTASES

METASTATIC TUMORS
• lung is a very common site of metastatic disease
• sometimes as the only expression of distant tumor spread
• Most metastases are multiple, bilateral, sharply outlined, and rapidly growing
• particularly true for metastases from some types of carcinoma (breast,
gastrointestinal tract, and kidney), sarcomas, and melanomas
• range from miliary nodules to ‘cannonball’ lesions and are more common in the
lower lobes
• Other metastases (particularly from carcinomas of stomach, breast, pancreas, and
prostate) tend to present as widespread neoplastic involvement of the pulmonary
perivascular and peribronchial lymphatics (so-called lymphangitic carcinomatosis),
which may result in severe dyspnea
OTHER METASTASES

METASTATIC TUMORS
• (cont) and pulmonary hypertension, sometimes in the absence of chest x-ray
abnormalities
• It should be remembered that many metastatic cancers to the lung (particularly
from large bowel and pancreas) can line the alveolar walls in a ‘lepidic’ fashion,
simulating bronchioloalveolar carcinomas.
• greatest advance in this field is represented by the detection of TTF-1, a nuclear
transcription factor detectable immunohistochemically which, with very few
exceptions, is present only in pulmonary and thyroid epithelium
• Other specific lung markers - surfactant (but less sensitive) & Napsin A.
Thank you!