0915 - Wednesday - Pathology Airway Diseases and Lung Cancer - Churg PDF

Pathology: Normal Lung, Lung Cancer,
COPD, and Airways Disease
Andrew Churg, MD
Departments of Pathology
University of British Columbia
and Vancouver General Hospital
Vancouver, BC
achurg@mail.ubc.ca
© 2014 American College of Chest Physicians

Disclosure
I have no conflicts of interest to disclose

Objectives
After this session, you will be able to discuss:

1: Normal lung anatomy
2: The pathology of lung cancer
3: The pathology of COPD and Asthma
4: Other forms of airways disease
5. The features of lung transplant rejection

Topics
•  Normal lung anatomy

•  Lung cancer
•  COPD
•  Airway diseases
•  Asthma
•  Infectious bronchiolitis
•  Bronchiolitis obliterans (constrictive bronchiolitis)
•  Transplant rejection

Normal lung (formalin
vapor fixed)
Bronchovascular bundle
Bronchovascular
bundle: bronchi
and pulmonary
artery branches run
together

Bronchovascular bundle
01-3517
Normal bronchus
Bronchus defined
by presence of
cartilage
Bronchial glands

Interlobular Normal Lung
septum
Pleura
Interlobular
Bronchioles septum

Interlobular septa
01-3517
Normal membranous bronchiole:
Bronchioles are defined by lack of cartilage
Pulmonary
artery branch
Membranous bronchiole
Alveoli
09-12948
Membranous bronchiole (MB): continuous wall
Respiratory bronchiole (RB): partially alveolated wall
Alveolar duct (AD): completely alveolated wall
RB
RB
AD
AD MB
Alveoli
1H-75 © 2014 American College of Chest Physicians
Common Types of Lung Cancer
•  Usually smoking related
•  Squamous cell carcinoma
•  Adenocarcinoma
•  Bronchoalveolar carcinoma (adenocarcinoma in situ)
•  Small cell carcinoma
•  Large cell carcinoma
•  Not smoking related

•  Carcinoid

A 65 year old man with a 40
pack-yr smoking history
presents with hemoptysis and
is found to have a mass
involving the right upper lobe
bronchus. On the right is a
picture of the biopsy. The
correct diagnosis is:
1.  Squamous cell
carcinoma
2.  Small cell carcinoma
3.  Adenocarcinoma
4.  Not a carcinoma of any
kind
Squamous Cell Carcinoma
•  Not the most common type of lung cancer

•  Strongly smoking related
•  Usually fairly bulky central lesions
Usually accessible by bronchoscopy
Good yield on washing/brushing/sputum cytology
•  May cause obstructive (golden) pneumonia behind tumor
•  May cause bronchiectasis behind tumor
•  May cause lobar collapse

Squamous cell ca
with lower lobe
collapse and distal
bronchiectasis
Bronchiectasis
Tumor
Collapsed
lower lobe
C82-‐79
Squamous Cell Carcinoma
•  Pathologic definition of squamous cell

carcinoma
•  Cells make keratin and/or
•  Cells are connected by intercellular bridges

Squamous cell ca
Keratinized
cells
18308-‐1 © 2014 American College of Chest Physicians

Squamous cell ca
Intercellular bridges

Adenocarcinoma
•  The most common type of lung cancer

•  Most adenocarcinomas are smoking-related
However, adenocarcinoma is the common type of
lung cancer in non-smokers
•  Many adenocarcinomas are peripheral lesions
•  Often not accessible by bronchoscopy
•  Core needle biopsy or FNA often needed for initial
diagnosis

Adenocarcinoma
Peripheral,
subpleural lesion

Adenocarcinoma
Pathologic definition of adenocarcinoma

•  Makes glands and/or secretes mucin
•  Mucin can be demonstrated by PAS (periodic acid
Schiff) or mucicarmine stain, or sometimes on H&E
•  This definition is being replaced to a certain extent by an
immunohistochemical definition (TTF-1 and/or Napsin
positive)

Adenocarcinoma
Mucin
Glands

Bronchoalveolar Carcinoma (BAC), now called
Adenocarcinoma in Situ (AIS)
•  Usually peripheral lesions

•  Pure BAC/AIS appears as ground glass nodules on CT
•  Believed to be the in situ phase of adenocarcinoma
•  New ATS/ERS classification (J Thor Oncol 2011) suggests using
“adenocarcinoma in situ” instead of BAC
•  By definition tumor cells grow along alveolar walls (lepidic growth)
•  By definition tumor cells do not invade
•  Is 100% curable by local wedge resection

BAC: Appears as a ground glass opacity
The greater the amount of solid

opacity, the greater the likelihood of
invasive carcinoma
06-3659-2
BAC/AIS
06-3659
BAC/AIS: Lepidic growth and mild fibrosis of underlying alveolar walls
06-3659-2
BAC/AIS: Lepidic growth/cytologic atypia
06-3659-4
Needle core bx of peripheral lung nodule in a cigarette smoker
vs07-111-1
Tumor cells show lepidic growth 07-111
The correct diagnosis for the
images in the last slide is:
1.  Atypical adenomatous hyperplasia
(AAH)
2.  Bronchoalveolar carcinoma/
adenocarcinoma in situ (BAC/AIS)
3.  Adenocarcinoma, NOS
4.  Malignant but whether this is a BAC/
AIS or invasive adenocarcinoma
cannot be determined on this type of
biopsy (complete excision required)
Bronchoalveolar Carcinoma (BAC)
= Adenocarcinoma in situ (AIS)
•  By definition BAC/AIS are not invasive

•  Can only be diagnosed if the whole lesion is available
to the pathologist so that invasive adenocarcinoma
can be ruled out
•  Hence core needle biopsies can only suggest a
diagnosis of BAC/AIS
•  Resection needed for definitive diagnosis

BAC/AIS and Invasive Adenocarcinoma
•  BAC/AIS believed to be the precursor lesion of many

(? all) peripheral adenocarcinomas
•  Invasion required for a diagnosis of adenocarcinoma
•  Over time BAC/AIS develops central scar and then
central invasive adenocarcinoma
•  Increasing evidence that peripheral adenocarcinomas
that are largely BAC with less than 5mm of central
invasion can be treated by wedge resection rather than
lobectomy (however, this idea is controversial)
Survival Using Sub-lobar Resection for Pure BAC (AIS)
D Arenberg Chest 2007

Proposed New
IASLC/ATS/ERS
ClassiﬁcaHon of
Adenocarcinomas

(Travis et al: J Thoracic Oncol
2011)

Proposed New IASLC/ATS/ERS
Classification of Adenocarcinomas
(Travis et al: J Thoracic Oncol 2011)
•  For lesions < 3cm in diameter

•  Nonmucinous BAC now classified as “adenocarcinoma in situ”
Can be treated by wedge excision
•  Solitary tumors with predominantly lepidic growth and less than
5mm of invasion classified as “minimally invasive adenocarcinoma”
•  Solitary tumors with predominantly lepidic growth and more than
5mm of invasion classified as “lepidic predominant adenocarcinoma
•  Mucinous BAC viewed as invasive mucinous adenocarcinomas

Lepidic growth, <5mm invasion =
Pure lepidic growth = BAC/AIS
“Minimally invasive adenoca”
<5mm
Lepidic growth, >5mm

>5mm
invasion = “Lepidic
predominant adenoca”
Adenocarcinoma with peripheral lepidic growth and
< 5mm of invasion: Under new proposed classification:
Minimally Invasive Adenocarcinoma
1mm invasive focus
VS11-‐20176
1mm focus of invasion: Correct Dx: Minimally invasive
adenocarcinoma (or BAC with 1mm of invasive carcinoma)

1mm focus of invasion: Correct Dx: Minimally invasive
adenocarcinoma (or BAC with 1mm of invasive carcinoma)
As yet unclear whether these tumors can be treated

by wedge excision alone

Some good prognosis imaging patterns
(K Suzuki Ann Thor Surg 2006)
Pure GGO (Presumably AIS or MIA) GGO predominant =

<50% “Solid” (? MIA or LPA)

Solid High grade Papillary Intermediate grade
Acinar Intermediate grade Micropapillary High grade
From Yoshizawa et al: Mod Path 2011 © 2014 American College of Chest Physicians
Stage 1 Adenocarcinoma: Disease Free Survival by Histologic PaYern
Low grade (incl AIS)
Intermediate grade
High grade
From Yoshizawa et al: Mod Path 2011

What’s Important at Present
BAC/AIS Any Kind of Invasive

Adenocarcinoma
(including Minimally
Invasive Adenocarcinoma)
Many thoracic surgeons

will do a wedge followed
Many thoracic surgeons
by a completion lobectomy
will do a wedge and stop
if you make a diagnosis of
if you make a diagnosis
invasive carcinoma on
of BAC/AIS on frozen
frozen section of the wedge
section of the wedge
Small Cell Carcinoma

•  Usually central lesions (peripheral lesions
uncommon)
•  Usually accessible by bronchoscopy
•  Good yield on washing/brushing/sputum cytology
•  Usually widespread at presentation
•  Primary lesion may be very small
•  Surgery usually contraindicated

Small Cell Carcinoma
Pathologic definition:
•  Cells usually 2-3 times size of a lymphocyte
•  Cells have very high nuclear:cytoplasmic
ratio
•  Nuclei often mold to each other
•  Usually very high mitotic rate
•  Usually extensive necrosis of tumor
•  Older name of “oat cell carcinoma” no longer
used

Small cell carcinoma
77-‐9368-‐2 © 2014 American College of Chest Physicians

Small cell carcinoma
Small cells
Scanty cytoplasm
High N:C ratio
Fine stippled chromatin
77-‐9368
Small cell carcinoma Squamous cell carcinoma

Large Cell Carcinoma

•  Tumors usually central
Usually accessible by bronchoscopy
Good yield on washing/brushing/sputum cytology but distinction from
adenocarcinoma on cytology alone is difficult
•  By definition relatively large cells that do not have the features
of squamous or adenocarcinoma
•  By immunohistochemistry, most large cell carcinomas are
adenocarcinomas, some are squamous cell carcinomas, and some
show no differentiation

Large cell carcinoma

Does not have features of squamous or adenocarcinoma

Why the Old Pathologic Diagnosis “Small
Cell vs Non-Small Cell Carcinoma” Isn’t
Good Enough Any More
•  BAC/AIS can be treated by wedge resection

•  Small cell carcinoma treated by chemotherapy/radiation rather
than surgery
•  Most adenocarcinomas and squamous cell carcinomas have
metastasized at time of presentation and chemotherapy is the
only treatment option

Why the Old Pathologic Diagnosis “Small Cell vs
Non-Small Cell Carcinoma” Isn’t Good Enough
Any More
•  Increasingly targeted therapy depends on cell type
•  Adenocarcinomas may respond to:
•  EGFR inhibitors (Iressa, Tarceva)
•  Pemetrexed (Alimta)
•  Anti-VEGF therapy (Bevacizumab)
•  Crizotinib for tumors with ALK-EML4 translocation
•  Squamous cell carcinomas

•  Typically do not show EGFR or kRAS mutations
•  May bleed massively with anti-VEGF therapy (Bevacizumab)
•  Often harbor FGFR1 mutations: targeted therapy being developed
Role of Immunohistochemistry in
Subclassifying Lung Cancers - I
Squamous Adeno Small Cell

p63+ TTF-1+ TTF-1+
CK5/6+ p63- Chromogranin+
TTF-1- CK5/6- Synaptophysin+
(CK7- or +) (CK7+) CD56+
Napsin- Napsin + Napsin-
CK = cytokeratin
Role of Immunohistochemistry in
Subclassifying Lung Cancers - II
•  Sorting out small cell from non-small cell

carcinoma
•  Separating squamous cell from adenocarcinoma
•  Also useful for sorting out primaries from mets
•  If tumor not classifiable by immunochemistry, then
the term “non-small cell carcinoma” is still
appropriate
•  Immunochemistry most useful when the biopsy is
very small or tumor poorly differentiated
Poorly differentiated carcinoma on bx
?Features suggestive of squamous cell

Tumor is p63 and CK5/6 + p63
Confirms diagnosis of
squamous cell ca
CK5/6

Carcinoid
•  Most common lung tumor after bronchogenic
carcinoma
•  Not smoking related
•  Cells are neuroendocrine cells and contain
neurosectory granules
Serotonin (carcinoid syndrome -- rare)
ACTH (Cushing’s syndrome – rare)
•  All carcinoids are malignant
“Typical” carcinoid = low grade, 90% 10 yr survival
“Atypical” carcinoid = high grade, 35-60% 10 yr survival
Carcinoid - Pathology
•  Usually central endobronchial tumors
•  Usually slow growing: produce bronchiectasis
behind tumor
•  Always invade bronchial wall
Cannot cure by curretting
•  By microscopy a variety of “neuroendocrine” growth
patterns
Bland appearing cells, round or spindled
Very vascular tumors –tend to bleed when biopsied
•  By immunochemistry positive for synaptophysin,
chromogranin, TTF-1, CD56
Carcinoid
Tumor in distended bronchus
Bronchial wall
87-‐3332
Carcinoid
Distal
bronchiectasis

Carcinoid Note high vascularity

Carcinoid Synaptophysin CD56

COPD Etiologies
•  Cigarette smoke (most cases in North America)

•  Occupational dust exposure (for ex, coal miners)
•  Occupational fume exposure
•  ? High levels of ambient air pollution
•  Cooking with biomass fuels

Anatomic/Clinical Entities in COPD
•  Emphysema
•  Small airway remodeling (small airway disease)
•  Bronchial mucus gland hyperplasia with excess mucus
production (chronic bronchitis)
•  Vascular remodeling with pulmonary hypertension
•  Acute exacerbation
Purely clinical entity—no clear anatomic correlate

Acini and Lobules
•  Acinus consists of all airways and parenchyma distal to the
last generation (terminal) membranous bronchiole
•  Lobule consists of all tissue bounded by interlobular septa
•  Up to 6 acini are found in the center of the lobule, hence
“centrilobular” and “centriacinar” are roughly equivalent
•  Acini are not diagnostically useful but lobules are
•  High resolution CT scans can see lobules
•  Many diseases have distinct distributions within the lobule

Lobule (case of lymphangitic ca)
Lobule
Interlobular
septum
01-3517
Interlobular septa
Lobule
Pleura
152314 © 2014 American College of Chest Physicians

Emphysema: Definition
A condition of the lung characterized by abnormal
permanent enlargement of airspaces distal to the
terminal bronchiole, accompanied by destruction of
their walls and without obvious gross fibrosis
•  Centrilobular (centriacinar)
•  Panlobular (panacinar)
•  Paraseptal (distal acinar)

Centrilobular (Centriacinar) Emphysema
•  Holes are in centers of lobules (acini) with

surrounding normal lung
•  Upper zone predominant
•  Classic cigarette smoke-associated form of
emphysema

Centrilobular Emphysema
UR07-‐181
Centrilobular (centriacinar) Emphysema
Emphysema: Centrilobular
(centriacinar)

Centrilobular Emphysema
Emphysematous area =
destroyed respiratory
MB bronchiole
RB
MB=membranous bronchiole Surrounding normal

RB=respiratory bronchiole parenchyma
Panlobular (Panacinar) Emphysema
•  Holes throughout lobule (acinus)

•  Usually lower zone predominant
•  Associated with α-1-antitrypsin
deficiency
•  Associated with cigarette smoking

Panlobular Emphysema

Panlobular Emphysema
A37-‐3
Paraseptal Emphysema
(Distal acinar emphysema)
d under pleura
•  Holes with walls perpendicular to the pleura
•  Can have some degree of fibrosis in walls
•  Etiologies uncertain but seen in smokers
•  Also associated with spontaneous pneumothorax in
young (nonsmoking) adults

Paraseptal Emphysema
Pleura
Pleura
The best way to diagnose emphysema is by:
1.  VATS biopsy

2.  Transbronchial biopsy
3.  Core needle biopsy
4.  CT scan

Comments re Emphysema
•  CT scan is a very accurate method of diagnosing
emphysema and assessing severity
•  Pathologically emphysema is best diagnosed on
gross specimens of resected lobes or lungs or
autopsy specimens
•  Biopsy specimens are not suitable for evaluating
emphysema
•  No one does a surgical lung biopsy to diagnose
emphysema!

Cigarette Smoke-Induced
Airway Disease
•  Smoker’s respiratory bronchiolitis (RB) affects
respiratory bronchioles
•  Small airway remodeling (small airway disease)
affects predominantly membranous bronchioles, and
to some extent respiratory bronchioles
•  Chronic bronchitis affects large airways (bronchi)

Smoker’s Respiratory BronchioliHs (“RB”)
Respiratory
Bronchiole
Smoker’s
macrophages
C84-‐64
Normal membranous bronchiole Small Airway Remodeling -‐ CigareYe Smoker
09-12948 03-‐2758
Small Airway Remodeling in CigareYe Smokers
Small Airway Disease-‐-‐CigareYe Smoker
1. Narrowed or obliterated lumen

2. Increased fibrous tissue in airway
wall leading to thick airway wall
Mucus plug 3. Inflammation in airway wall
4. Mucus plugs in lumen
Result: Decreased flow/turbulent

flow
03-‐2758

Significance of Cigarette Smoke-Induced
Airway Disease
•  Small airway remodeling is an important cause of

airflow obstruction
•  Chronic bronchitis probably does not produce airflow
obstruction (controversial)!
•  Defined entirely by sputum production
•  Associated with clinical exacerbations (infectious episodes
with functional deterioration)

Findings in Asthma
•  Thickened airway basement membrane
•  Most consistent finding (in large airways)
•  Increased airway smooth muscle
•  Most consistent finding in large and small airways
•  Eosinophils in airway wall or lumen
•  Denuded airway epithelium
•  Increased goblet cells in airway epithelium
•  Mucus plugs in airways
•  Which features are present in an individual case is
very variable
PaHent dying in status asthmaHcus
Thick BM
Mucus plug
in lumen
Increased
smooth muscle
AC06-‐0239
Increased airway
Thick
smooth muscle
basement
membrane
Airway
epithelium
denuded

Asthma: eosinophils in airway wall

Infectious Bronchiolitis
•  In immunocompetent patients: wide range of agents but especially seen
with:
•  Mycoplasma
•  Viral infections of all types
•  Very variable morphology
•  Acute inflammation
•  Chronic inflammation
•  Acute inflammation in lumen, chronic inflammation in wall
•  Airway epithelial damage
•  Morphology usually does not indicate agent unless viral inclusions found
•  Culture or serology crucial
•  Immunohistochemistry sometimes helpful (viruses)
•  Viral inclusions more commonly seen in immunocompromised patients
Influenza - bronchiolitis Chronic inﬂammatory cells in airway
wall
PMNs in lumen
Damaged airway
epithelium
6G-‐77
Herpes simplex – Immunocompromised paHent
NecroHzing airway
centered lesion
MB
VA06-‐90 © 2014 American College of Chest Physicians

Herpes simplex
Immunohistochemistry

Long Term Sequelae of
Infectious Bronchiolitis
•  Reported long term uncommon (morphologic)

sequelae
•  Bronchiolitis obliterans (incl Swyer-James syndrome)
•  Bronchiectasis
•  Lung abscess
•  Interstitial fibrosis
•  Reported long term clinical sequelae
•  Airway hyper-reactivity/asthma
Constrictive Bronchiolitis
(Bronchiolitis Obliterans)
•  Etiologies
•  Fume inhalation (example, farmer’s lung)
•  Collagen vascular disease, esp RA
•  Post-infectious (example, Swyer-James syndrome)
•  Inflammatory bowel disease
•  Drug-induced
•  Associated with bronchiectasis (especially cystic fibrosis)
•  Lung transplantation (BO syndrome)
•  Idiopathic
•  Progressive, fixed airflow obstruction
•  Air-trapping on CT but fibrotic bronchioles are too small to be seen on
imaging © 2014 American College of Chest Physicians
ConstricHve bronchioliHs in RA
Courtesy Dr. Nestor Muller

Constrictive Bronchiolitis - Pathology
•  Narrowed or obliterated airway lumen a
consistent finding airflow obstruction
•  Early: inflammatory cells or granulation tissue in
lumen
•  Late: Collagen deposition between epithelium
and smooth muscle
•  NB: Completely obliterated bronchioles appear
as scars on H&E
•  Easily missed/dismissed as nonspecific scars
•  Elastic stains crucial to making the diagnosis
Normal membranous bronchiole:
Pulmonary
artery branch
Membranous bronchiole
09-12948
Early ConstricHve BronchioliHs in RA
Granulation tissue
Narrowed lumen

Old ConstricHve BronchioliHs ? Secondary to Methotrexate ? Caused by RA
Markedly narrowed
lumen
Dense collagen
between epithelium
and muscle

Lung Transplant Rejection
Risk Factors for Acute Rejection
•  HLA incompaHbility
•  Pre-‐exisHng anH-‐HLA anHbodies
•  Viral infecHons
-  community acquired
- ? CMV
Knopp C and Estenne M. Semin Respir

Crit Care Med 2006;27:521-‐533 © 2014 American College of Chest Physicians
CP1068888-45
Transplant Rejection: Revised ISHLT Formulation
A. Acute Rejection = perivascular and interstitial

inflammation
2005 FormulaHon
A 0 None
A 1 Minimal
A 2 Mild
A 3 Moderate
A 4 Severe
Grade A2: Mild acute rejection
Perivascular lymphoid
infiltrate >3 cells thick
Grade A2

CP1068888-13
Grade A3: Moderate acute rejection
Perivascular lymphoid infiltrate
extends into surrounding alveolar
walls

VS06-‐495
Revised ISHLT Formulation
B. Acute Rejection: Airway inflammation =

lymphocytic bronchiolitis
2005 FormulaHon
B 0 None
B 1R Low grade
B 2R High grade
B X Ungradeable
Grade B 2R Airway rejecHon
Chronic inflammatory
cells in airway wall and
epithelium

ISHLT Revised Formulation
Chronic rejection =
C. obliterative bronchiolitis
D. graft arteriosclerosis
2005 FormulaHon
C 0 None
C 1 Present
D 0 None
D 1 Present
Transplant-associated bronchiolitis
obliterans (“BOS”)

CP1068888-28
What to Think About When Your
Pathologist Tells You a Thoracoscopic
Biopsy is Completely Normal
•  Surgeon missed the lesion
•  Pathologist missed the lesion
•  Constrictive bronchiolitis (bronchiolitis obliterans)
•  Respiratory bronchiolitis with interstitial lung disease
(RBILD)
•  Pulmonary hypertension
•  Changes of asthma
•  No one does a biopsy to diagnose emphysema!
Topics
•  Normal lung anatomy
•  Lung cancer
•  COPD
•  Airway diseases
•  Asthma
•  Infectious bronchiolitis
•  Bronchopneumonia
•  Bronchiolitis obliterans (constrictive
bronchiolitis)
•  Transplant rejection

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Pathology: Normal Lung, Lung Cancer,

COPD, and Airways Disease

© 2014 American College of Chest Physicians

I have no conflicts of interest to disclose

© 2014 American College of Chest Physicians

After this session, you will be able to discuss:

© 2014 American College of Chest Physicians

• Normal lung anatomy

© 2014 American College of Chest Physicians

© 2014 American College of Chest Physicians

© 2014 American College of Chest Physicians

© 2014 American College of Chest Physicians

• Not smoking related

© 2014 American College of Chest Physicians

• Not the most common type of lung cancer

© 2014 American College of Chest Physicians

• Pathologic definition of squamous cell

© 2014 American College of Chest Physicians

18308-­‐1 © 2014 American College of Chest Physicians

18308-­‐3 © 2014 American College of Chest Physicians

• The most common type of lung cancer

© 2014 American College of Chest Physicians

© 2014 American College of Chest Physicians

Pathologic definition of adenocarcinoma

© 2014 American College of Chest Physicians

163327-­‐1 © 2014 American College of Chest Physicians

• Usually peripheral lesions

© 2014 American College of Chest Physicians

The greater the amount of solid

• By definition BAC/AIS are not invasive

© 2014 American College of Chest Physicians

• BAC/AIS believed to be the precursor lesion of many

© 2014 American College of Chest Physicians

© 2014 American College of Chest Physicians

• For lesions < 3cm in diameter

© 2014 American College of Chest Physicians

Lepidic growth, >5mm

1mm invasive focus

© 2014 American College of Chest Physicians

As yet unclear whether these tumors can be treated

© 2014 American College of Chest Physicians

Pure GGO (Presumably AIS or MIA) GGO predominant =

© 2014 American College of Chest Physicians

Acinar Intermediate grade Micropapillary High grade

Low grade (incl AIS)

From Yoshizawa et al: Mod Path 2011

BAC/AIS Any Kind of Invasive

Many thoracic surgeons

• Strongly smoking related

© 2014 American College of Chest Physicians

© 2014 American College of Chest Physicians

77-­‐9368-­‐2 © 2014 American College of Chest Physicians

© 2014 American College of Chest Physicians

• Strongly smoking related

© 2014 American College of Chest Physicians

169670-­‐1 © 2014 American College of Chest Physicians

169670-­‐2 © 2014 American College of Chest Physicians

• BAC/AIS can be treated by wedge resection

© 2014 American College of Chest Physicians

• Squamous cell carcinomas

Squamous Adeno Small Cell

• Sorting out small cell from non-small cell

© 2014 American College of Chest Physicians

•  Normal lung anatomy

•  Not smoking related

•  Not the most common type of lung cancer

•  Pathologic definition of squamous cell

18308-‐1 © 2014 American College of Chest Physicians

18308-‐3 © 2014 American College of Chest Physicians

•  The most common type of lung cancer

163327-‐1 © 2014 American College of Chest Physicians

•  Usually peripheral lesions

•  By definition BAC/AIS are not invasive

•  BAC/AIS believed to be the precursor lesion of many

•  For lesions < 3cm in diameter

•  Strongly smoking related

77-‐9368-‐2 © 2014 American College of Chest Physicians

•  Strongly smoking related

169670-‐1 © 2014 American College of Chest Physicians

169670-‐2 © 2014 American College of Chest Physicians

•  BAC/AIS can be treated by wedge resection

•  Squamous cell carcinomas

•  Sorting out small cell from non-small cell

•  Cigarette smoke (most cases in North America)

•  Holes are in centers of lobules (acini) with

•  Holes throughout lobule (acinus)

1.  VATS biopsy

Small Airway Disease-‐-‐CigareYe Smoker

03-‐2758 © 2014 American College of Chest Physicians

•  Small airway remodeling is an important cause of

VA06-‐90 © 2014 American College of Chest Physicians

•  Reported long term uncommon (morphologic)