Flashcards in Lungs Deck (142):
T-F- the apices of the lung rise above the clavicle?
T-F- the lung does not cover any portion of the mediastinum upon inhalation?
Of the conducting airways, which section is the weakest link and why?
bronchioles- they do not have cartilage like the trachea and bronchi do
What does a normal gross lung specimen look and feel like?
light red brown
The connective tissue of the visceral pleura is lined by what type of cells? What is their ultrastructural hallmark?
mesothelial cells- long slender microvilli
What type of cell comprises 90-95% of the alveolar lining? what shape are they?
Type I pneumocyte- flat epithelial- gas exchange
What is the type II pneumocyte shape? What happens to these cells during inflammation?
cuboidal- surfactant production and antimicrobials
increase in number
What are the 4 key mechanism (mechanical and cellular) for pulmonary defense?
Tracheobronchial clearance (cilia and goblet)
What are common ways to suppress the cough reflex?
What are common ways to injure mucociliary clearance?
What are the 4 common ways to lose/impair host defense mechanisms that she gives?
smoking, ethanol, stroke, heart failure
What are the histological findings  of classic bacterial pneumonia (strep pneumonia)?
1.intra alveolar exudate- fibrin and neutrophils
2.Alveolar capillary congestion
What are the two basic patterns of bacterial pneumonia?
The pattern of involvement really depends on what two things?
1. patch bronchopneumonia or whole lobe lobar pneumonia
2. bacterial virulence and innate defenses
In bronchopneumnia we know we see a plug of fibrin and neutrophils, but what happens to the wall of the bronchiole?
it gets inflamed as well
What are the 4 pathological stages of bacterial pneumonia?
What pathological stage of pneumonia (bacterial) is characterized by vascular engorgement, alveolar fluid, few neutrophils, numerous bacteria?
What pathological stage of bacterial pneumonia is characterized by firm, airless, massive exudate, neutrophils and fibrin?
What pathological stage of bacterial pneumonia is characterized by a dry surface, disintegration of RBCs, and a strong fibropurulent exudate?
During resolution of bacterial pneumonia- enzymatic digestion of the exudate produces granular semifluid debris. What 4 things can happen to it?
2. ingested by macrophages
4. organized by fibroblasts growing in it
What is the clinical presentation of bacterial pneumonia? Review
What type of bacterial pneumonia is very important to find, but won't show on a gram stain but shows up with a silver stain?
What does viral and atypical bacterial pneumonia primarily effect?
the interstitium- the damage can predispose to other bacterial pneumonias
What is the best example of atypical bacterial pneumonia?
but don't forget chlamydia
Atypical pneumonia may have a moderate amount of sputum, but what doesn't it have?
consolidation and significant alveolar exudate
Mycoplasm bronchiolitis looks like what?
inflammation of a bronchiole mucosa with patchy infiltrates and swelling in the peribronchial interstitial space, SURROUNDING ALVEOLI LOOK PRETTY NORMAL
Clinical speaking, what does viral/atypical pneumonia look like?
low grade fever
What are the common pathogens for community acquired pneumonia? hospital acquired?
1.strep pneumonia and haemophilus influzae
2.staph aureus and pseudomonas
Review the following common virus for CA pneumonia
What should we remember when looking at a biopsy of an immunocompromised host?
low virulence/opportunistic pathogens may be the causing factor
tissue pathology or inflammation may be minimal
Review the following CD4 levels and the pneumonia causing agents
<200 PCP, Aspergillus
What virus shows both intranuclear and intracytoplasmic inclusions?
What do we see cellularly in the case of food particles (maybe from GERD) that have been aspirated in the lungs?
multinucleate giant cells within alveolar spaces trying to digest--> airway centered granulomatous inflammation
What are three common risk factors for aspiration pneumonia that have polymicrobial infectious agents?
impaired consciousness (alcoholics)
severe reflux (GERD)
Poor swallowing (stroke, neck cancer etc.)
What are the common causative organisms in lung abcesses? What are the common etiologies 4 ?
1. 60% are anaerobic bacteria
2. aspiration, poorly treated bacterial infection, septic emboli, neoplasia
On gross specimen, what should surround an abcess? What does the x ray look like? Microscopic?
1. hyperemic rim
2. AIR-FLUID LEVELS
3. neutrophils and fibrin surrounded by granulation tissue
what creates a -frothy bubbly and lacks a cellular intra-alveolar infiltrate exudate?
How do we stain PCP?
Silver stain from bronchoalveolar lavage
Where do we find histoplasma?
soil with bird droppings or bat droppings
Histoplasmosis causes what type of lesion? What does it appear as on CXR?
1. granulomatous nodule with central necrosis and fibrous wall (like TB)
2. Coin lesion- if they contain calcifications they are almost always benign
In the histoplasmosis silver stain, are the organisms small or large?
small- 4 microns (may also see budding)
What populations are at risk for initial exposure to M. tuberculosis to cause primary pulmonary tuberculosis?
T-F- primary pulmonary tuberculosis is normally symptomatic? T-F-- rates are decreasing
False and false
What percentage of TB infected people develop clinically significant disease?
Primary pulmonary tuberculosis looks like what in the gross lung?
peripheral granuloma with hilar adenopathy (hilar nodes will be dark-anthracosis- not in the areas of the granuloma)
At the edge of a necrotizing granuloma, what cells do we readily see?
multinucleate giant cells.
IF we have a CT scan of someone with nodules in their lung, what do we see that can tell us that they are benign?
Where is the lesion primarily in secondary pulmonary tuberculosis? who gets it?
1. apical and posterior (apical shadow)
2. reactivation of primary or new infection in previously sensitized host
What are the differential diagnosis usually seen with tuberculosis?
T-F-- PPD test need intact cell-mediated immunity?
True- it is a Type IV hypersensitivity test
What is defined as a rapid onset of severe life threatening respiratory insufficiency, cyanosis and severe arterial hypoxemia refractory to oxygen therapy?
- remember that ARDS can be caused by infections, sepsis, toxic fumes, drug and medication reactions,etc
What does a CXR of ARDS look like? what is the mortality rate?
1. extensive opacities in both lungs
2. 60% +
What is the difference of ARDS and diffuse alveolar damage (DAD)?
ARDS is a clinical diagnosis and DAD is pathological (DAD = hyaline membranous disease or acute lung injury)
What are the 4 characteristics of diffuse alveolar damage-pathology injury to capillary endothelium?
increased cap. permeability
interstitial and intra-alveolar edema
hyaline membrane formation
What are the 4 phases of DAD?
edema---> hyaline membrane-->inflammation-->fibroplasia
NOTE:hyaline formation happens very early in exudative stage
In DAD- what does diffuse mean?
The entire alveoli is damaged- not the whole lung or lobe is damaged
Alveolar spaces are filled with what in DAD?
balls of fibroblasts
Is bronchiectasis and pneumonitis obstructive pulmonary diseases or restrictive pulmonary disease?
bronchiectasis is obstructive
pneumonitis is restrictive
What is described as increase in resistance to airflow due to partial or complete obstruction at any level of airway?
Obstructive lung disease
- can get air in but can't get it out
What is described as a reduced expansion of lung parenchyma and decreased total lung capacity
Restrictive lung diseases
- can get the air out, but can't get it in well.
Most of the obstructive pulmonary diseases have the bronchus as their main anatomic site, which one has the acinus as its main site?
What obstructive disease characterized by airway dilation and scarring?
What obstructive disease is characterized by mucous gland hyperplasia and hyper secretion? smooth muscle hyperplasia?
What obstructive disease is characterized by airspace enlargement; wall destruction
What two lung diseases are grouped together for COPD?
emphysema and bronchitis
In emphysema- there is destruction to the walls past the terminal bronchiole…is there fibrosis? what is it associated with ?
cigarette smoke and alpha-1 antitripsin deficiency
What type of emphysema is the most common?
- central, more common in upper lobes, common in smokers
What type of emphysema is associated with alpha 1 antitrypsin?
panacinar- uniform enlargement, more common in lower zones
On a gross specimen- what would be the diff between panacinar and centriacinar?
panacinar does not have normal tissue between the problematic areas. ITS PRETTY MUCH THE SAME DEAL UNDER MICROSCOPE TOO
What does smoking decrease that leads to higher levels of elastase?
What cells are releasing the elastase?
What where do we get the anti-protease?
1. neutrophils and macrophages
2. in the serum and tissue fluids
The critical event in emphysema is the loss of alveolar walls, what two things does this lead to?
decreases gas exchange and reduces the elastic tissue content of the lungs
Symptoms of emphysema appear after how much of the parenchyma was damaged? what do they include?
dyspnea, weight loss, eventually overdistension
What is an air filled space that measures more than 1cm in diameter in the distended state of emphysema? what can this lead to?
1. subpleural bullae
What are the 3 major complications of emphysema?
respiratory acidosis and coma
right sided heart failure
pneumothorax and collapsed lung
What is described as a persistent cough with sputum production for at least 3 consecutive months in at least two consecutive years?
- smokers and smog laden cities
What is the difference in chest radiograph of bronchitis and emphysema?
bronchitis will have prominent vessels and a large heart, emphysema will show hyperinflation and a small heart
Is bronchitis the blue bloater or the pink puffer?
How are the bronchioles narrowed in bronchitis?
What are the clinical symptoms of chronic bronchitis?
persistent cough with mucous
hypercapnea, hypoxemia and mild CYANOSIS
Review the complications of chronic bronchitis complications-
progression to COPD
cor pulmonale and HF
atypical metaplasia and dysplasia (cancer opportunity)
what is characterized by recurrent episodes of wheezing, breathlessness, chest tightness, and cough?
What can cause non atopic asthma?
cold or exercise
T-F- in asthma there is an increase in smooth muscle cells, inflammatory cells, but less mucous secretion?
false- more mucous too
In bronchial asthma, the attack is reversible, but overtime will permanently remodel. review the things that will happen upon remodeling
thickening of the airway wall
sub-basement membrane fibrosis
increase in size of the submucosal glands
hypertrophy/hyperplasia of the bronchial wall muscle
What is a curschmann spiral?
a mucous cast of a small bronchiole
What is charcot-leyden crystal?
collections of crystalloid made up of an eosinophilic lysophospholipase binding protein galactic 10
What are the main 4 symptoms of an asthma attack?
Review the following major asthma complications
cor pulmonale and heart failure
What are the major etiologies of bronchiectasis (permanent dilation of conducting airway)?
bronchial obstruction with inflammation
cystic fibrosis, primary ciliary dyskinesia, necrotizing pneumonia
Is bronchiectasis a whole lung or whole lobe thing?
No- just distal to the obstruction
On a microscope, what should we look for in bronchiectasis?
2. dilation of airways with a much larger diameter than blood vessels- remember they should be the same.
Why do bronchiectasis patients get so many infections?
they can not clear the pooled secretions from the affected portion
In restrictive lung diseases, where is the fibrosis and inflammation taking place?
most peripheral and delicate interstitial in the alveolar walls
How are the majority of chronic interstitial lung diseases diagnosed?
history, CT, PFTs and serology
RARELY IS TISSUE EXAMINATION NEEDED
The clinical diagnosis of idiopathic pulmonary fibrosis is equal to what?
the pathological diagnosis of usual interstitial pneumonia
What are the key his to features of usual interstitial pneumonia?
1. patchy intersitial fibrosis w/ temporal heterogeneity
2. fibroblasts!! fibroblastic foci
3. honeycomb fibrosis
IN idiopathic pulmonary fibrosis, where does the honeycombing and fibrosis begin?
in the periphery
In usual interstitial pneumonia, what is found between the honeycombing and the uninvolved lung under a microscope
this is where you will find the fibroblastic foci
What is the prognosis of UIP/IPF? what are the symptoms?
1. mean survival is 3 years, transplantation is the only definitive therapy
2. progression of dyspnea, dry cough, hypoxemia, cyanosis and clubbing
What is a non-neoplastic lung reaction to inhalation of organic and inorganic particles, chemicals and fumes?
asbestos, coal dust, silicosis
What really distinguishes asbestos from UIP under the microscope?
asbestos bodies (golden brown, fusiform or beaded rods with translucent center)
What other things are caused by asbestos but are not asbestosis?
mesothelioma and pleural plaques
Does the presence of asbestos body diagnose asbestosis?
No- other changes (characteristic pattern of fibrosis) are necessary
What is a systemic granulomatous disease of unknown cause? is it caseating? where is the distribution heavy?
2. no necrosis in the center
3. lymphatics, bronchi, and blood vessels
What do we see on gross specimen of patients with sarcoidosis?
tan areas- nodules with sclerosis
What two things might we see under high magnification of sarcoidosis?
asteroid body- star shaped eosinophilic structure
schaumann body- concentric calcification
What is characterized by an immunologically mediated, interstitial lung disorder caused by inhaled organic dusts in susceptible individuals?
What are the two most common antigens for HP?
Farmers lung (termophilic actinomycetes)
Bird Fancier's lung
What are the 3 key his to findings in hypersensitivity pneumonia?
1. poorly formed granulomas (non-caseating)- small clusters of histiocytes
2. interstitial pneumonitis- lymphocytes, plasma cells, macrophages
3. fibrosis and honeycombing
Do metastasis to the lung outnumber primary lung neoplasms?
They are much more frequent.
Are lung cancers the most common type of cancer in men and women? what about the most common deaths?
No- they are the 2nd in both
Yes they are the most common cancers for cancer deaths
Why did lung cancer deaths in women lag behind men?
The pattern of heavy smoking in women started a couple decades behind men and quitting in large groups was the same.
What is the overall 5 year survival for primary lung cancer?
What are the 4 major symptoms for primary lung cancer?
cough, weight loss, chest pain, dyspnea
Besides smoking, what are a couple major risk factors for primary lung cancer?
Is low dose CT or CXR better at reducing lung cancer mortality when used for screening?
LDCT by 20%
Risks- radiation exposure, high false positive rates, potential for over diagnosis
What is required to make a confident diagnosis of lung cancer?
a piece of tissue from the primary tumor site!
sputum cytology, bronchoscopy, FNA, open lung biopsy, pleural fluid biopsy
What two variables does lung cancer prognosis and treatment really on?
histological classification and stage.
Is surgery a primary mode of treatment for small cell lung cancer?
no radiation and chemotherapy
What are the three major things for staging?
Tumor, Nodes, Metastasis
What are the two major types of non-small cel carcinomas in the lung?
squamous cell carcinoma and adenocarcinoma
Who does 90% of squamous cell carcinomas occur in? where are they usually located? what are the key his to findings?
1. cigarette smokers
2. CENTRALLY in the main stem, lobar, segmental
3. keratin pearls, keratinization, intercellular bridges
What is the common cancer P63 and P40 stain for in immunohistochemistry? What about TTF-1?
1. squamous cell carcinoma
2. lung adenocarcinoma
What are the key his to findings in adenocarcinoma?
gland formation and mucin production
Who do we see with adenocarcinoma of the lungs often?
non-smokers, women, asian
What is a common gross finding in adenocarcinoma?
What are the 4 types of adenocarcinoma? which ones are more aggressive?
1. papillary, micropapillary, solid, acinar
2. micropapillary and solid
In adenocarcinoma of the lung, is EGFR mutations more common in people that have smoked or non-smokers? what mutation correlate with worse outcomes?
1. Non-smokers are 40-50% while smokers are 10%
What are the two immunihistochemistry markers for adenocarcinoma?
TTF-1 (thyroid cancer also expresses)
What is a non-invasive adenocarcinoma of the lung that grows along the alveolar surfaces.?
What is the survival? is it related to smoking? 2 main subtypes?
1. bronchoalveolar carcinoma
2. 100% if small
3. over represented in non-smokers
4. mutinous and non-mucinous
Bronchoalveolar carcinoma often mimics pneumonia, what is the appearance of the tumor in gross anatomy?
spongy because it lacks desmoplasia
remember it's not invasive
Which subtype of bronchoalveolar carcinoma often lacks TTF-1 marker? does BAC grow in single file lines on the alveolar walls? which type of BAC comes as a solitary mass? multifocal mass?
What cancer is positive for TTF-1, chromogranin, and synaptophysin?
small cell carcinoma
Review the key features of small cell carcinoma-
granular nuclear chromatin (salt/pepper)
high mitotic rate
(MORPHOLOGY CAN LOOK SIMILAR TO LYMPHOCYTES)
T-F- in small cell carcinoma, most patients appear with metastasis to lymph nodes?
Yes- and diagnosis is often made from material aspirated from a lymph node
What is it called when nuclei push up against each other?
Also remember they are fragile and have a streaming effect when smeared on glass
What neuroendocrine tumor is at the far end of the spectrum from small cell carcinoma?
1. carcinoid tumor
- localized, low stage, amenable by surgery
What do we find in a his to slide of carcinoid tumor?
trabecular pattern, round nuclei, decent amount of cytoplasm, ovoid to spindle shaped
Which asbestos fiber type is more tumorigenic? less tumorigenic?
2. crysolite and crocidolite
What is the latency period of malignant mesothelioma?
20-45 post exposure
What lung tumor do we think of with WT-1, CK5/6, and D2-40 immunohistochemistry?
Is epithelial cells or sarcomatoid mesothelioma more common in histology of mesothelioma?
epithelial is 60%