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Pulmonary Pathology Online

Examination of Lobectomy or Pneumonectomy Specimens for Neoplastic or Non-Neoplastic Lesions

 Dr Sampurna Roy MD      

 

                                                                                                                      

 

 

Examination of lobectomy or pneumonectomy specimens for neoplasia:

Indication:

- To determine the histological type of a lung tumour which is easier on large specimen than on biopsy material.

Examination of lobectomy specimens for non-neoplastic diseases:

Indication:

-  Cysts (congenital or acquired, secondary to emphysema or inflammation) and inflammatory lesions such as bronchiectasis, bullae and sequestrations.

-  Sometimes for localized areas of consolidation and organizing pneumonia, inflammatory pseudotumour, Wegener’s granulomatosis and rheumatoid nodule.

Malignant Lung Tumours:

Primary lung carcinomas can be classified as squamous cell carcinoma, adenocarcinoma, small cell carcinoma, large cell carcinoma and giant cell carcinoma.

Small cell carcinomas are usually too advanced for treatment by surgery and are, therefore, not seen in excision specimens.

Pure large cell and giant cell carcinoma are diagnosed only after features of squamous and glandular differentiation have been excluded.

Clear cell change may be a feature of any type of carcinoma.

Some carcinomas show mixed differentiation (adenosquamous carcinomas), combination of malignant epithelial and mesenchymal elements (carcinosarcomas and pulmonary blastomas) or spindle cell areas.

Some show such a degree of pleomorphism that classification is not  possible.

Primary sarcomas of the lung are rare. The most commonly seen include leiomyosarcoma and rhabdomyosarcoma.

Pulmonary lymphomas are treated by chemotherapy rather than excision.

Benign Tumours and Tumor-like conditions:

These are most commonly excised from asymptomatic patients after incidental findings on chest radiography.

These include benign mesenchymoma (pulmonary hamartoma), inflammatory pseudotumor, sclerosing hemangioma and nodular amyloidosis.

 

An approach to histopathological reporting of lobectomy specimens:

(I) Neoplasia:

The report should contain the following information:

Histological type and degree of differentiation:

(i) Squamous cell carcinoma ;

(ii) Adenocarcinoma ; 

(iii) Large cell carcinoma ;

(iv) Giant cell carcinoma,

Features important for staging: Involvement of bronchial resection margin;  involvement of pleura; vascular invasion; involvement of lymph nodes .

Features in the lung away from the neoplasm: Squamous metaplasia,  dysplasia, or in situ malignancy in bronchial epithelium ;  Obstructive pneumonitis with the features of endogenous lipid pneumonia ; Sarcoid-like granulomas in the lung and lymph nodes ; Asbestos bodies.

Preexisting lung disease:  Emphysema ;  Desmoplasia ; Non-fibrotic changes in the alveoli (hyaline membrane formation ; interstitial inflammation, hyperplasia of alveolar lining cells).

Important features in specific tumour:

Carcinoid tumour: High mitotic rate and necrosis are associated with aggressive behaviour (atypical carcinoid); nuclear pleomorphism alone is not a reliable indicator; Spindle cell morphology ; oncocytic change, and melanin pigment ;

Adenoid cystic carcinoma: Spread in the walls of airways, and involvement of perineural spaces.

                                                                                     

(II) Non-neoplastic lesions:

- Cystic and cavitating lesions:  

Contents of cavity:  

Pus in lung abscess; aspirated foreign material; caseous material in tuberculosis; mycetoma - usually aspergilloma  ;

Lining epithelium:

Respiratory, squamous, enteric, mucinous ; squamous epithelium in re-epithelialization of a cavity ;

Cyst wall:

Granulation tissue with fibrosis ;

Bronchial seromucous glands and cartilage in bronchogenic cyst; 

Pancreatic tissue and mucous glands in enteric cysts ;

Multiple cysts lined by respiratory epithelium in adenomatoid malformations;

Focal granulomatous malformation with scattered giant cells in mycetoma; 

Necrotizing granulomas with caseation necrosis in mycobacterial infection; 

Mycetoma formation associated with other diseases such as tuberculosis, emphysema with bulla formation and late stage sarcoidosis with fibrosis.

- Inflammatory lesions:   

Lumen of bronchi and bronchioles:

Pus in cystic fibrosis ;

Mucus plugging in allergic bronchopulmonary aspergillosis ;

Fungal hyphae within mucus in allergic bronchopulmonary aspergillosis and as mycetoma in complicated bronchiectasis ;

Bacterial colonies (botryomycosis) ;

Eosinophils in allergic bronchopulmonary aspergillosis.

Epithelium:

Mucinous metaplasia in cystic fibrosis ;

Squamous metaplasia in bronchiectasis and non-specific inflammatory conditions ; 

Ulceration and replacement by granulation tissue in bronchiectasis and allergic bronchopulmonary aspergillosis.

Bronchial wall: 

Non-specific inflammation with fibrosis in bronchiectasis ;

Follicular lymphoid aggregates in follicular bronchiectasis ;

Granulomatous inflammation with numerous histiocytes , scattered giant cells, and eosinophils in allergic bronchopulmonary aspergillosis/ bronchocentric granulomatosis.

Lung parenchyma:

Non-specific inflammation and fibrosis with organizing pneumonia in bronchiectasis ;

Mucus plugging in obstructive pneumonitis ;

Carcinoid tumorlets associated with bronchiectasis  ; 

Necrotizing granulomas with caseation necrosis in mycobacterial infection ;

Coagulative fibrinoid necrosis in the centre of a rheumatoid nodule ; 

Vasculitis in Wegener’s granulomatosis ; 

Vascular infiltration with atypical lymphoid cells in angiocentric lymphoma.

 

Further reading:

Comparison of operative mortality and complications between bronchoplastic lobectomy and pneumonectomy in lung cancer patients.

Sleeve lobectomy versus pneumonectomy for lung cancer: a comparative analysis of survival and sites or recurrences.

Morbidity, mortality, and long-term survival after sleeve lobectomy for non-small cell lung cancer.

 

 

Dr Sampurna Roy  MD

Consultant  Histopathologist (Kolkata - India)


 

 

 

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