Journal of the Italian Society of Anatomic Pathology and Diagnostic Cytopathology, Italian Division

152 Pages·2011·6.44 MB·English

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Journal of the Italian Society of Anatomic Pathology
and Diagnostic Cytopathology,
Italian Division of the International Academy of Pathology
Editor-in-Chief W.F. Grigioni, Bologna Governing Board
Marco Chilosi, Verona G. Inghirami, Torino SIAPEC-IAP
L. Leoncini, Siena President:
Associate Editor M. Lestani, Arzignano Vol. 102 December 2010
G.L. Taddei, Firenze
Roberto Fiocca, Genova G. Magro, Catania
A. Maiorana, Modena Vice President:
Managing Editor E. Maiorano, Bari A. Carbone, Milano
Roberto Bandelloni, Genova A. Marchetti, Chieti
D. Massi, Firenze General Secretary:
Scientific Board M. Melato, Trieste A. Sapino, Torino
R. Alaggio, Padova F. Menestrina, Verona Past President:
G. Angeli, Vercelli G. Monga, Novara
O. Nappi, Napoli
M. Barbareschi, Trento R. Montironi, Ancona
G. Barresi, Messina B. Murer, Mestre Members:
C.A. Beltrami, Udine V. Ninfo, Padova G. Caruso, Bari
G. Bevilacqua, Pisa M. Papotti, Torino F. Crivelli, Gallarate
M. Bisceglia, S. Giovanni R. M. Paulli, Pavia R. Giardini, Cremona
A. Bondi, Bologna G. Pelosi, Milano D. Ientile, Palermo
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CONTENTS the cohesiveness and coalescence of granulomas, the presence of
fibrosis and the amount and quality of the associated inflammatory
infiltrate. The most interesting approach to granulomatous lung
DIFFUSE PARENCHYMAL LUNG
disease is indeed represented by their pattern of distribution within
DISEASES: A PRACTICAL GUIDE the secondary lobule; in fact, granulomas can be distributed along
lymphatic routes (e.g. sarcoidosis), randomly (miliary infections,
FOR THE PATHOLOGIST
e.g. mycobacterial and fungal infections), or along the airways
(hypersensitivity pneumonitis, hot tub lung, aspiration pneumonia
and sometimes infections). We propose a combined radiological-
The pathologist’s approach to bronchoscopic biopsies histopathological approach for defining the morphological features
and anatomic localization of granulomatous ILDs. In addition, a
T.V. Colby
detailed review of their clinical features is provided, together with a
Bronchoscopically retrieved biopsies of lung tissue often pro- description of the main procedures used to obtain respiratory sam-
vide valuable information for diagnosis and patient management. ples for pathology and microbiology studies in these patients.
There value is often relative: the findings are part of the database
for a patient and correlated with the other clinical and radiologic
data that is available. Less commonly the findings are diagnostic, Small airways diseases
providing a specific diagnosis that is the major arbiter of man-
M. Barbareschi, A. Cavazza, F. Calabrese, R. Carella,
agement. The pathologist’s task with these specimens is to get as
M. Maffessanti, K.O. Leslie
much value from them as possible. This cannot be done by tabu-
lating microscopic findings alone; correlation of the pathologic The histopathology of the small airways is frequently quite sub-
findings with the clinical and radiologic findings is a necessary tle, even in cases with clinically severe disease. In the present
part of this exercise. paper, we will demonstrate some recognizable straightforward
pathological changes in the small airways, and also provide a
list of clinico-pathological conditions that should be considered
The pathologist’s role in the diagnosis of idiopathic pulmonary
when each is encountered. In the second part of the paper, we
fibrosis
will briefly overview some general histological patterns of le-
M. Chilosi, S. Tomassetti, A. Carloni, B. Murer sions and specific diseases that may involve the small airways.
The basic lesions will be subdivided into inflammatory (acute,
Diagnosis of idiopathic pulmonary fibrosis (IPF) is challeng- chronic, granulomatous, with or without necrosis), proliferative
ing, and the cooperation between different specialists including (epithelial or mesenchymal), and remodeling reactions. Inflam-
pulmonologists, radiologists and pathologists is highly recom- matory and proliferative reactions may lead to a the third category
mended in order to optimize the diagnostic process, avoiding of remodeling reactions, characterized by a variety of distortions
unnecessary and harmful invasive procedures. The recognition of normal bronchiolar architecture, including occlusion, constric-
of the usual histological pattern of interstitial pneumonia is not tion, dilatation (with or without mucostasis), tortuosity and nodu-
easy in some cases, and immunohistochemical markers can be larity. In addition to this schematic distinction, it is important to
applied to better visualize subtle microenvironmental changes recognize that these lesions are frequently combined together and
in lung parenchyma. New data regarding the complex patho- evolve with one another. Each of the 3 reaction patterns may be
genesis of IPF is helping to understand the severe lung remod- exquisitely bronchiolar, or may extend in the surrounding paren-
eling that characterizes this disease, and may also provide new chyma. In this case, it is important to distinguish between lesions
diagnostic criteria. that extend from the bronchiole to the parenchyma or vice versa
(such as in organizing pneumonia patterns, where the main lesion
is in the parenchyma). As most of these lesions are part of a dy-
Diffuse alveolar damage
namic process, it is important to recognize that a single causative
V. Poletti, G.L. Casoni, A. Cancellieri, S. Piciucchi, A. Dubini, agent may produce distinct pathologic features at different times
M. Zompatori in the natural history of the disease. In addition, the same clinical
disease may result in a variety of pathologic lesions. Accordingly,
Diffuse alveolar damage (DAD) is a characteristic histopatho-
there may be not always be an unequivocal relationship between
logic pattern that has time dependent findings: intraalveolar and
the clinical disease/condition and specific histopathologic lesions
interstitial oedema, and hyaline membranes in the acute phase,
in the small airways.
myofibroblastic accumulation in the alveolar spaces and type II
alveolar cell proliferation in the proliferative phase and fibrosis in
the more advanced phases. The diagnosis of DAD is sometimes The lung and systemic disease.
feasible on small specimens obtained by transbronchial lung A practical approach for the surgical pathologist
biopsy or on cytological slides. Surgical lung biopsy is rarely
F. Schneider, H.D. Tazelaar
needed.
The lungs are frequently abnormal in patients with connec-
tive tissue disease and inflammatory bowel disease. This article
Granulomatous lung disease highlights the more significant pathology to affect such patients,
and compares the histology and prognosis to those with similar
A. Cancellieri, G. Dalpiaz, R. Trisolini, E. Ricchiuti, A. Pesci
pathology with no underlying disease.
Granulomas are a frequent challenge for pathologists, which can
be identified both in histological and cytological material in a Smoking-related interstitial lung diseases
number of conditions. With regard to interstitial lung diseases,
A. Caminati, P. Graziano, N. Sverzellati, S. Harari
granulomas can be associated with infection (e.g. mycobacterial),
immunological conditions (e.g. hypersensitivity pneumonitis), or In pulmonary pathology, a wide spectrum of morphological
may be idiopathic (e.g. sarcoidosis). Considering morphology, changes is related to the consequences of smoking, and recogniz-
features that should be identified are the presence of necrosis, ing them on surgical specimens and on small transbronchial biop-
sies represents a challenge for the pathologist. Respiratory bron- Rare diffuse diseases of the lung.
chiolitis, also referred to as smoker’s bronchiolitis, is a common Pulmonary alveolar proteinosis, lymphangioleiomyomatosis,
histologic feature found in the lung tissue of cigarette smokers. amyloidosis
When identified as the sole histopathologic finding in the clini-
P. Morbini, F. Guddo, P. Contini, M. Luisetti, M. Schiavina,
cal setting of symptomatic interstitial lung disease, a diagnosis of
M. Zompatori
respiratory bronchiolitis-interstitial lung disease is made. Since
smoking is recognized to cause a variety of histologic patterns Pulmonary alveolar proteinosis (PAP), lymphangioleyomioma-
encompassing respiratory bronchiolitis, respiratory bronchiolitis- tosis (LAM) and amyloidosis are three unrelated diseases of rare
interstitial lung disease, desquamative interstitial pneumonia and occurrence, with characteristic histopathological features.
pulmonary Langerhans cell hystiocytosis, smoking-related inter- A pattern of alveolar filling with granular pink material accumu-
stitial lung disease may be a useful concept to keep in mind for lation is characteristic of PAP. This material can be recognized in
the pathologists. The relationship of smoking with each of these lung biopsies, but also in bronchial lavage fluid. PAP is clinically
entities has been largely established on the basis of epidemiologic related to the abnormal clearance of alveolar surfactant, most
evidence. Although they have been retained as distinct and sepa- commonly due to the disruption of the granulocyte macrophage-
rate conditions in various classifications of interstitial lung dis- colony stimulating factor signalling pathway. Whole lung lavage
eases, these entities share a number of clinical, radiologic, and is the treatment of choice.
pathologic features suggesting that they represent a spectrum LAM is characterized by cystic lung degeneration and interstitial
of patterns of interstitial lung disease occurring in predisposed proliferation of LAM cells, which express both melanocyte and
individuals who smoke. Evaluation of histologic features, par- smooth muscle cell markers, has a typical cystic pattern on CT
ticularly in surgical lung biopsy samples, is important in mak- scan, can be associated clinically with abdominal angiomyolipo-
ing the distinction between these disorders. However, even after mas and limphangioleiomyomas, and occurs in female patients,
tissue biopsy, it may sometimes be difficult to clearly separate either in isolation or as a manifestation of tuberous sclerosis. Sex
these entities. Recently, respiratory bronchiolitis-interstitial lung hormone manipulation is the therapy of choice in this otherwise
disease with fibrosis has been described and postulated that this progressive disease.
is a smoking-related condition distinct from fibrotic non-specific Diffuse interstitial or perivascular amyloid deposits in the lung
interstitial pneumonia. can form in the context of systemic amyloidosis, usually associ-
ated with myeloma or monoclonal gammopathy, and less often
Pulmonary eosinophilic infiltrates with chronic inflammatory diseases. Nodular amyloid deposits,
in contrast, are not associated with systemic lung disease, and
G. Rossi, A. Tironi, R. Dore, N. Nannini, M.C. Mengoli,
present instrumentally as a coin lesion or lung mass. Isolated tra-
M. Bertolani, L. Richeldi
cheobronchial amyloidosis is another rare form that is not related
Pulmonary eosinophilic infiltrates include an heterogeneous to systemic disease. In all conditions, amyloid has a typical waxy,
group of disorders characterized by the presence of eosinophils in amorphous, slightly eosinophilic stain, stains red with Congo
the lungs as detected by bronchoalveolar lavage or tissue biopsy, red and presents a characteristic apple-green birefringence under
with or without blood eosinophilia. The disease can be idiopathic polarized light, which is essential for diagnosis.
(simple pulmonary eosinophilia, acute and chronic eosinophilic
pneumonia, hypereosinophilic syndrome), secondary (to drugs,
parasites, fungal and mycobacterial infection, irradiation, toxic Diffuse parenchymal lung diseases: when you see, think!
products) or associated with diffuse lung diseases (connective tis-
sue diseases and some neoplasms). A. Cavazza, G. Rossi, M. Barbareschi, S. Damiani, C. Comin,
Pathologists faced with eosinophils in the lungs (either on cytology B. Murer
or biopsy) should keep in mind several possibilities, although a diag-
In this article, a series of tables (presented in alphabetic order)
nosis of certainty is rarely based on morphology alone. Correlation
summarize the differential diagnosis of diffuse parenchymal lung
with laboratory tests, imaging studies and clinical presentation has
diseases starting from the most frequent elementary lesions.
a key role, even if some pulmonary eosinophilic diseases are suf-
ficiently characteristic on clinico-radiologic ground to not require
a biopsy (e.g. some drug reactions, parasitic infections, idiopathic
hypereosinophilic syndrome, allergic bronchopulmonary aspergil-
losis). Nevertheless, pathologists can play a central role because
they can be the first to note eosinophils in the lungs of a very sick
patient. Knowledge of histologic features and a striking collabora-
tion with other physicians are necessary to achieve correct diagnosis
and to establish adequate treatments.

pathologica 2010;102:431
Diffuse parenchymal lung diseases:
a practical guide for the pathologist
Introduction
B. MURER, A. CAVAzzA*
Dipartimento di Patologia Clinica, Unità Operativa di Anatomia Patologica, Ospedale dell’Angelo, Venice; * Dipartimento Oncologico,
Unità Operativa di Anatomia Patologica, Ospedale S. Maria Nuova, Reggio Emilia, Italy
A large number of diseases may affect the lung paren- histological knowledge by clinicians and radiologists is
chyma more or less diffusely: despite the numerous very helpful as well), but also a positive attitude includ-
excellent publications and seminars on this topic, the ing an open mind, the capacity to listen and to use the
diagnosis of diffuse parenchymal lung diseases (DPLD, different pieces of information coming from the others,
also known as interstitial lung diseases or interstitial and so on.
pneumonias) remains a challenge for the pathologist. In This special issue of Pathologica devoted to DPLD is
addition to the large number of different (and frequently intended to be a practical guide for the pathologist. To-
overlapping) entities and the lack of experience of many gether with several experts of the Gruppo Italiano di
pathologists (and many clinicians and radiologists as Patologia Pleuropolmonare (GIPP), we had the privi-
well), probably the main difficulties are due to the fre- lege to collaborate with several well-known clinicians
quent absence in this field of histologic findings which and radiologists to “distill” the most relevant clinical
are diagnostic per se: the lung parenchyma has a limited and radiological information, and with some Ameri-
repertoire of responses to damage, and so the same his- can colleagues and friends which are real “guru” in this
tology (e.g. an area of fibrosis) can be due to different field: with their contributions, they share an experience
diseases; conversely, the same disease (e.g. a drug reac- which is authentically unique. Acute lung injury, idio-
tion) can result in different histologies. The possibilities pathic fibrosing interstitial lung diseases, DPLD related
of sampling errors (and more in general of low-quality to smoking, granulomatous lesions, small airways dis-
biopsies) and disagreement among pathologists further eases, eosinophilic infiltrates, the lung in systemic dis-
complicates matter. For these reasons, the field of DPLD eases, a group of miscellaneous disorders and the ap-
forces the pathologist to a profound change of mental- proach to bronchoscopic biopsies are covered, focusing
ity, shifting from the traditional reassuring situation in on the most relevant diagnostic clues. We conclude with
which biopsy is the single gold standard, to a more com- a chapter entitled “When you see, think!”, in which we
plex and stimulating paradigm in which the histology is tabulate in alphabetic order the most frequent elemen-
just one piece of the diagnostic puzzle, and diagnosis re- tary lesions encountered by the pathologist, giving some
quires a dynamic multidisciplinary approach integrating clues on how these “histologic signs” can be transformed
clinical, radiological and pathological data. The pathol- (sometimes!) into “diseases”.
ogist dealing with biopsies performed for DPLD needs We are indebted with Prof. Marco Chilosi for his sup-
not only to be expert in histology, but also to profitably port and for providing the opportunity to compile this
interact with clinicians and radiologists: this requires issue, and to the authors for their outstanding contribu-
some basic clinical and radiological knowledge (some tions. We hope you will enjoy their efforts.
Correspondence
Bruno Murer, Dipartimento di Patologia Clinica, Unità
Operativa di Anatomia Patologica, Ospedale dell’Angelo,
via Paccagnella 11/a, 30174 Venice, Italy - E-mail: Bruno.
[email protected]
pathologica 2010;102:432-442
The pathologist’s approach to bronchoscopic biopsies
T.V. COLBY
Department of Laboratory Medicine and Pathology, Mayo Clinic, Arizona
Key words
Transbronchial biopsy • Bronchoscopic biopsy • Pathology
Summary
Bronchoscopically retrieved biopsies of lung tissue often provide a specific diagnosis that is the major arbiter of management. The
valuable information for diagnosis and patient management. There pathologist’s task with these specimens is to get as much value from
value is often relative: the findings are part of the database for a them as possible. This cannot be done by tabulating microscopic
patient and correlated with the other clinical and radiologic data that findings alone; correlation of the pathologic findings with the clini-
is available. Less commonly the findings are diagnostic, providing cal and radiologic findings is a necessary part of this exercise.
Background and basic approach The following represents my approach to these speci-
mens in the format of questions that one should address
Bronchoscopic biopsies are common specimens for pa- oneself.
thologists to encounter. They provide useful informa-
tion for diagnosis and management of patients with lung 1. What kind of biopsy is it?
disease. In the case of transbronchial biopsies, compli- Endobronchial biopsies, often from visible lesions, are
cations are relatively few: pneumothorax in less than distinct from transbronchial biopsies, taken from tissue
5%, significant bleeding in less than 2%, and death is surrounding the airway and taken to assess alveolar dis-
extremely rare (0.1-0.2% of cases) 1. ease.
Most authorities recommend evaluation of at least three Diagnostic bronchoscopic biopsies should be separated
separate levels of the tissue obtained by transbronchial from tissue taken at the time of a therapeutic bronchos-
biopsy 1-3. If no significant pathology is encountered ad- copy in which the pathologic diagnosis is often known
ditional levels can be examined 2. Because of their small (for example, ablation of an endobronchial tumor, place-
size, delicate nature and manner of retrieval, broncho- ment of a stent, etc.).
scopic biopsies are subject to a number of artifacts in-
cluding: “sponge effect” when placed too tightly between 2. Should I initially review the specimen with
sponges (some recommend that sponges be avoided in or without clinical information?
the processing of these specimens), crush artifact, tele- Some pathologists make every effort to review cases in a
scoping of vessels, cribiform strips of bronchial epithe- “blinded” fashion in order to get an unbiased interpreta-
lium simulating a cribiform carcinoma, atalectasis, fresh tion. This is a useful exercise and should be done when
hemorrhage and fibrin from the procedure, and bubble feasible; we all have gone down the wrong path when
artifact 1 2 4 5. These artifacts are discussed further in the examining a case with a predetermined bias. In prac-
specific sections below. tice, one has (often been given) some information prior
The majority of bronchoscopic biopsies are done in pa- to biopsy review and “blinded” review may not always
tients suspected to have malignancies and their diagnosis be possible. Regardless of how one approaches the bi-
rate approaches 100% for visible lesions 3. Nevertheless opsy the most important exercise is clinical-radiologic-
they are used in many other settings and pathologists pathologic correlation and continuing reassessment of
must be familiar with the advantages and limitations of the pathologic findings as clinical and radiologic infor-
the various types of bronchoscopic biopsies. mation is gained.
Correspondence
Thomas V. Colby, Department of Laboratory Medicine and
Pathology, Mayo Clinic Arizona, 13400 E. Shea Blvd., Scottsdale,
Az 85259 USA - E-mail: [email protected]
the pathologist’s approach to bronchoscopic biopsies 433
3. What do I see? Occasional eosinophils are noted in the biopsy: a history
The pathologist should make a mental tabulation of what of eosinophilia could confirm their significance and in
is present in the biopsy (bronchial epithelium, bronchial some cases the radiologic findings of eosinophilic pneu-
wall, alveolar tissue, pleura, et al.) and what pathologic monia are also sufficiently characteristic to further con-
abnormalities are present in those tissue compartments. firm a diagnosis of eosinophilic pneumonia.
To start, one can just make a list of the findings. Once Malignant cells are identified: a history of prior neo-
I have my list, I find it useful to try to guess the clini- plasm (such as melanoma, breast carcinoma, etc.) then
cal and radiologic findings as an initial effort in clinico- helps direct further workup.
pathologic correlation. I form a preliminary impression Prussian blue positive pigmented macrophages are pres-
that may be a specific diagnosis or, more commonly, ent and hemorrhage is considered: if there is a positive
is in the form of description/list of the pathologic find- smoking history then the Prussian blue positivity could
ings: acute lung injury with hyaline membrane, organiz- be explained on the basis of “smoker’s macrophages.”
ing pneumonia, interstitial cellular infiltrate, type 2 cell Acute lung injury with fibrin/hyaline membranes is pres-
metaplasia, increased macrophages, etc. ent: a history of immunosuppression would necessitate a
routine battery of special stains for microorganisms.
4. What are the available clinical Nodular scarring is noted in the transbronchial biopsy:
and radiologic data? in a smoker with upper lobe nodular and cystic changes
Armed with my preliminary diagnosis or description/list on CT one could then do additional stains for pulmonary
of the pathologic findings I am then ready to add in the Langerhans’ cell histiocytosis.
clinical findings. This should include at a minimum age, Eosinophilic intra-alveolar material is present and pro-
sex, clinical history and radiologic findings. This may be teinosis is considered: a localized radiologic lesion
obtained from the medical record or from conversations might suggest a proteinosis-like reaction around some
the patient’s physicians. other process whereas the classic “crazy paving” CT of
proteinosis would support strongly the diagnosis.
5. I then ask myself the question: “Can I make The biopsy suggests alveolar hemorrhage (with or with-
a diagnosis for this biopsy in the context out capillaritis): a history of hematuria would provide
of the immediately available information?” support for a pulmonary renal syndrome with alveolar
There is no simple answer here and each case must be hemorrhage.
individualized depending the findings in the biopsy and And there are many, many other examples.
on the clinical circumstances and/or discussions with the
7. Where do I get this clinical
clinicians involved in the case.
and radiologic information?
6. What additional information may be Most of this sort of information can be found in the med-
needed and how can it be helpful? (eg. ical record, but there is no substitute for talking with the
special stains, more clinical-radiologic clinician and the radiologist to get the most up to date
information, more laboratory information, information on a given patient.
deeper levels, etc.)
8. Now do I have enough information
Additional clinical information often proves enlighten-
to render an opinion?
ing. Information from cultures or other specimens (eg.
BAL or cytologic preparations) may be important. The I have gone through my initial evaluation, gotten added
clinical history may provide a trigger to do additional information from other sources, and am again ready to
stains for microorganisms; if a neoplasm is suspected address the key questions:
histochemical and immunistochemical stains may prove a. “Can I make a specific diagnosis that explains the
useful in identification and subclassification. If sam- clinical and radiologic findings?”
pling error is a possibility, additional levels should be b. “Can I at least explain the clinical and radiologic
obtained. One often appreciates additional histologic findings with the pathologic changes (ie. a descrip-
features on second and third review of a biopsy (ie. the tive diagnosis) on the bronchoscopic biopsy even in
importance of continued reassessment as more clinical the absence of a specific pathologic diagnosis?”
information is obtained). Here are some examples: c. “Are the findings on the bronchoscopic biopsy inade-
A few granulomas are present on the transbronchial bi- quate to explain the clinical and radiologic findings?”
opsy: if the radiologic findings are limited to the middle ….in which case the specimen is noninformative/
lobe infection would be more likely whereas if CT shows noncontributory to the diagnosis and management
an upper lobe distribution with bilateral perilymphatic and additional specimens are needed if a pathologic
nodules, sarcoidosis would be much more likely. diagnosis is necessary.
A granuloma and some interstitial inflammation are The answer to these questions of course is that each case
present and hypersensitivity pneumonitis is consid- must be individualized. Some cases are straightforward:
ered: in this situation the smoking history is useful since there is an endobronchial mass and squamous carcinoma
smoker’s rarely get hypersensitivity pneumonitis and is present on the biopsy; a specific diagnosis can be ren-
most patients with that condition are nonsmokers. dered. For the patient who has a chronic process with dif-
434 t.V. colby
fuse ground glass infiltrates on the CT scan, one may see • Acute diffuse lung disease.
only nonspecific inflammatory changes on the biopsy. • Chronic diffuse lung disease.
In this example pathologic findings are present that can • Airway disease.
account for the clinical and radiologic findings yet there
remain many possible causes for those changes and a spe- 1. Transbronchial biopsy in the setting
cific diagnosis cannot be made. The distinction between of a localized parenchymal mass/infiltrate
simply tabulating the presence of pathologic findings in a There are obviously many possibilities that can account
bronchoscopic biopsy from making a specific diagnosis is for a mass or infiltrate in the lung including neoplasms,
important and is discussed further below. infections, non-infectious lesions, etc. As a general rule
one mentally tabulates the pathologic findings that are
9. Are there times when additional clinical present and tries to identify diagnostic features. Deep-
information is not going to be useful? er levels may be appropriate if neoplasm is suspected.
Yes. There are some endobronchial and transbronchial Stains for microorganisms, immunistochemical workup
biopsies for which no amount of clinical information and other studies will be determined by the clinical set-
will help reach a diagnosis. Scant fragments of normal ting. When the localized mass or infiltrate is caused by a
tissue in a case where neoplasm is suspected or frag- neoplasm or an infection with recognizable organisms, a
ments of normal alveoli in the setting of interstitial lung relatively small specimen is often diagnostic.
disease would be examples. What some of the histologic traps that could be misin-
terpreted in the setting of a localized pulmonary mass or
infiltrate?
Biopsy types and clinical settings • Crush artifact (of lymphocytes, lymphoma, non-
in which they are encountered small cell carcinoma, or some other tumor) mimick-
ing small cell carcinoma and other malignancies.
Endobronchial Biopsies
Fig. 1. transbronchial biopsy showing pleural tissue. in this case
1. What are the clinical setting and bronchoscopic find-
the pleural tissue is pinched on itself and simulates a cribriform
ings? process. nevertheless, a thin layer of cells typical of mesothelial
Knowing the clinical problem will help determine what to cells can be seen lining the cyst and they are cytologically identi-
cal to the other stripped cells filling the space.
look for in the endobronchial biopsy specimen. The bron-
choscopy report may explain exactly what was seen and
a
what was biopsied and whether a neoplasm or some other
process such as an infection is known or suspected. If the
patient is immunosuppressed and infection is in the dif-
ferential stains for organisms should always be done. If a
lesion was seen clinically that cannot be explained by the
biopsy findings, sampling error may be an issue. Images
taken by the bronchoscopist may be available for review
and can be correlated with the biopsy findings.
2. What are some of the traps should I look out for with
endobronchial biopsies?
• Crush artifact (of lymphocytes, lymphoma, non-
small cell carcinoma, or some other tumor) mimick-
ing small cell carcinoma or other malignancy.
• Bronchial mucosal ulcer (often with fibrin) and reac- b
tive squamous epithelium mimicking squamous car-
cinoma.
• Acellular or inflammatory endobronchial material
(such as allergic mucin or inflammatory exudate
containing organisms) overlooked since one is con-
centrating on the viable tissue.
Transbronchial Biopsies
The clinical setting in which the transbronchial biopsy
has been taken directs the approach the pathologist takes;
it will help determine what to look for and the likelihood
of various diagnoses. The following broad groups are
recognized and will be discussed separately:
• Localized parenchymal mass/infiltrate.