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Pulmonary Pathology Online

Histopathological Reporting of Pulmonary Parenchymal Biopsies

Dr Sampurna Roy MD

 

An approach to histopathological reporting of the pulmonary parenchymal biopsies:

I) In the bronchioles:

- Peribronchial or peribronchiolar inflammation:

Non-specific:  Reactive lymphoid follicles as in follicular bronchiectasis  or follicular bronchiolitis  ;  Granulomatous .

- Obliterative changes in bronchioles with fibrous scarring, as in bronchiolitis obliterans:

- Organizing granulation tissue in bronchiolar lumina, as in cryptogenic organizing pneumonia  (also known as bronchiolitis obliterans organizing pneumonia or BOOP).

II) In the alveoli and interstitium:

- Architecture:

- Destruction of alveolar walls without fibrosis in emphysema ;

- Destruction of alveolar walls with interstitial and intra-alveolar fibrosis, alveolar collapse, and bronchiolization in advanced interstitial lung disease;

- Alveolar walls:

- Interstitial inflammatory infiltration ;

- Focal acute inflammation with central necrosis and scattered giant cells in fungal pneumonias;

- Heavy lymphocytic infiltrate, as in lymphoid interstitial pneumonia (LIP), extrinsic allergic alveolitis, monomorphic and atypical lymphoid infiltrate, as in malignant lymphoma;

- Non-necrotizing well formed granulomas in sarcoidosis ;

- Non-necrotizing poorly formed granulomas in extrinsic allergic alveolitis ;

- Necrotizing granulomas in mycobacterial and fungal infection ;

- Palisaded granulomas in Wegener’s granulomatosis and rheumatoid nodules ;

- Interstitial fibrosis;

- Asbestos bodies;

- Amyloid;

- Smooth muscle cells in lymphangioleiomyomatosis ;

- Lymphatic infiltration by tumour cells as in extra-pulmonary primary adenocarcinoma (lymphangitis carcinomatosa), lymphoma, Kaposi's sarcoma , epithelioid hemangioendothelioma ;

- Calcification- metastatic in the elastic of alveolar walls, dystrophic in areas of long-standing fibrosis;

- Calcified bodies (Schaumann bodies) in areas of hyaline fibrosis in sarcoidosis;

- Hemosiderin deposition in areas of hemorrhage;

- Alveolar lining cells:

- Hyaline membranes in diffuse acute alveolar damage;

- Proliferation of type II pneumocytes in the reparative phase of hyaline membrane disease;

- Multinucleate giant cells:

- Giant cell interstitial pneumonia (hard metal disease);

- Giant cell pneumonia ( measles infection in children, occasionally respiratory syncytial virus infection  or parainfluenza B);

- Viral inclusions, such as cytomegalovirus  or measles;

- Cytoplasmic hyaline in type II pneumocytes, first identified in asbestosis but also seen in other conditions;

- Atypical cells: seen with some cytotoxic drugs such as busulfan or bleomycin;

- Bronchiolisation of distal air spaces in advanced diffuse pulmonary fibrosis;

- Squamous metaplasia as a result of chronic inflammation ;

- Tumour cells lining alveoli in bronchioloalveolar carcinoma, which may be mucus secreting or non-mucus secreting.

- Alveolar lumina:

- Inflammatory cells:

- polymorphs in bacterial pneumonias ;

- eosinophils in eosinophilic pneumonia ;

- histiocytes/macrophages - foamy in obstructive pneumonitis or lipid pneumonia , containing fine lipofuscin pigment in desquamated interstitial pneumonia, 'blue bodies' associated with lysosomal accumulation in such  conditions as DIP ;

- multinucleate foreign body giant cells, often associated with cholesterol crystal clefts, in obstructive pneumonitis or pulmonary alveolar proteinosis  ;

- Granular eosinophilic debris, often with cholesterol crystals, in pulmonary alveolar proteinosis ;

- Granular and foamy lightly eosinophilic material in pneumocystis pneumonia ;

- Hemorrhage or accumulation of haemosiderin-laden macrophages in hemorrhagic diathesis, pulmonary capillaritis, idiopathic pulmonary hemosiderosis, pulmonary venous hypertension ;

- Intra-alveolar irregular laminated calcospherites in pulmonary microlithiasia ;

- Organizing exudates (Masson bodies -Masson's Tumour) in organizing pneumonia ;

III) In the blood vessels:

- Vasculitis:

- Eosinophil infiltration with granuloma formation in Churg-Strauss syndrome ;

- Extravascular granulomas and areas of necrosis in Wegener’s granulomatosis ;

- Granulomas in vessel walls in sarcoidosis , necrotizing sarcoidal granulomatosis, and reaction to talc particles in drug addicts ;

- Capillaritis with alveolar hemorrhage in Wegener’s granulomatosis, microscopic polyarteritis and hypersensitivity vasculitis ;

- Infiltration of vessel walls by atypical lymphoid cells in angiocentric lymphoma (lymphomatoid granulomatosis) ;

- Pulmonary hypertension and thromboembolic disease:

- Muscular arteries - medial hypertrophy in hypoxic pulmonary hypertension, pulmonary venous hypertension and plexogenic pulmonary arteriopathy ; subintimal longitudinal muscle fibres in hypoxic pulmonary hypertension ;

- Intimal thickening-eccentric in thromboembolic pulmonary hypertension, associated with organizing thrombus or other embolic material, concentric in plexogenic pulmonary arteriopathy ; dilatation lesions, plexiform lesions and fibrinoid necrosis in plexogenic pulmonary arteriopathy ;

- Muscularization of arterioles in hypoxic pulmonary hypertension ;

- Veins:

- Obliteration by connective tissue in pulmonary veno-occlusive disease ;

- Thickening of the media with arteriolization in pulmonary venous hypertension ;

- Replacement of the vein wall by a network of capillaries with abnormal capillaries in alveolar walls in pulmonary capillary hemangiomatosis.

 

 

Dr Sampurna Roy  MD

Consultant  Histopathologist (Kolkata - India)

 

 


 

 

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