Mostafa M.

Fraig
Editor

Diagnosis of
Small Lung Biopsy

An Integrated Approach

123
Diagnosis of Small Lung Biopsy
Mostafa M. Fraig
Editor

Diagnosis of Small
Lung Biopsy
An Integrated Approach
Editor
Mostafa M. Fraig, MD
William M. Christopherson Professor of Pathology
and Internal Medicine
Department of Pathology and Laboratory Medicine
School of Medicine, University of Louisville
Louisville, KY, USA

ISBN 978-1-4939-2574-2 ISBN 978-1-4939-2575-9 (eBook)

DOI 10.1007/978-1-4939-2575-9

Library of Congress Control Number: 2015936666

Springer New York Heidelberg Dordrecht London

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To my wife, Lamia, and our two lovely sons, Yousef and Karim,
who provided love and care that were the inspiration for this
endeavor, for them I am eternally indebted.
Preface

No doubt, there are several excellent pulmonary pathology textbooks with

comprehensive and encyclopedic coverage of the topic in the market.
However, we sensed a void when it comes to more pressing issue; when it
comes to small biopsies, what the general pathologist deal with in their daily
practice is more nuanced and different from what we can appreciate on a
large resection specimen. In the current era, when we as pathologists are
asked to do more with less, it becomes imperative that we adjust our perspec-
tive and sharpen our tools.
Most cases of lung lesions are biopsied with tiny biopsies from fine needle
aspiration, needle cores, transbronchial biopsy, and more recently cryobiop-
sies. In all these instances, the tissue is scant and the artifacts abound. Yet the
information expected to be gleaned from such biopsy is remarkable consider-
ing the size and the hindrances. There is a void in the library for a book to
provide a concise and synoptic approach to the interpretation of this type of
biopsies. This book is an attempt to provide this type of approach. It is to be
as beside the microscope quick reference for the general pathologist and
pathologist in training to get a quick understanding of basic pulmonary
pathology.
The authors are attempting to provide practical tips and tried methods for
the interpretation of these biopsies based on interaction with radiologists and
pulmonologists, medical oncologists, and other multidisciplinary team mem-
bers over the years. The reduction in the amount of tissue has to be compen-
sated for by the provision of more clinical and imaging information to
complete the picture. It is a difficult task in the busy shuffle of daily practice
to expect such information on regular basis. However, current billing practice
is requiring this information to be included on the requisition form. The intro-
duction and promotion of Electronic Health Records (HER) is providing an
easy access to such information to the average pathologist even in small com-
munity setting and have take to advantage of that.
Lung biopsies are expensive and difficult to obtain and every effort should
be made to maximize the benefit and information gained from them. This
includes talking to the physician taking care of the patient and discussing the
history and clinical suspicion.
The integrated approach is nothing new and every book tries to cover the
clinical and radiologic findings in the discussion of a given disease in the lung.

vii
viii Preface

In this book, we try to reiterate and emphasize the importance of those findings
in the proper interpretation of those small biopsies. Descriptive diagnoses can
be useless and even downright harmful when they are rendered in isolation and
without an understanding of the clinical context.
We hope this book can serve its intended purpose and be a modest contri-
bution to the enrichment of pulmonary pathology practice.

Louisville, KY, USA Mostafa M. Fraig, M.D.

Contents

1 Small Sample Lung Biopsy Techniques in the Diagnosis

of Airway and Parenchymal Lung Diseases ................................ 1
Rafael L. Perez
2 Principles of Imaging Lung Disease ............................................. 13
James G. Ravenel
3 Types of Biopsies ............................................................................ 21
Mostafa M. Fraig
4 Airspace-Occupying Diseases ....................................................... 29
Mostafa M. Fraig
5 Interstitial Lung Diseases in Small Lung Biopsies ...................... 39
Mostafa M. Fraig
6 Diagnosis of Granulomatous Disease
and Vasculitis in Small Lung Biopsies.......................................... 51
Sanjay Mukhopadhyay
7 Benign Tumors of the Lung in Small Lung Biopsies .................. 81
Mostafa M. Fraig
8 Malignant Tumors of the Lung in Small Lung Biopsies............. 91
Mostafa M. Fraig

Index ...................................................................................................... 101

ix
Contributors

Mostafa M. Fraig Department of Pathology and Laboratory Medicine,

School of Medicine, University of Louisville, Louisville, KY, USA
Sanjay Mukhopadhyay Department of Anatomic Pathology, Cleveland Clinic,
Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland,
OH, USA
Rafael L. Perez Department of Medicine, University of Louisville School
of Medicine, Louisville, KY, USA
James G. Ravenel Department of Radiology and Radiologic Services,
Medical University of South Carolina, Charleston, SC, USA

xi
 Small Sample Lung Biopsy
Techniques in the Diagnosis
of Airway and Parenchymal
Lung Diseases
Rafael L. Perez
Introduction
Nonsurgical approaches to sample focal or diffuse,
solid, or infiltrative pathology of the lung offer the
advantages of lower risk, comfort, and cost com-
pared to surgical biopsy techniques. However,
sample size obtained by nonsurgical techniques
can challenge pathological assessment. Sampling
error and artifacts of manipulation, in addition to
small size, are problematic. These problems may
be overcome to some extent by providing multiple
intact samples that are well directed by various
imaging techniques. Ultimately, a collaborative
approach between the clinician, pathologist, and
radiologist will optimize diagnosis.
This chapter will focus on the nonsurgical
techniques used to obtain small samples of pul-
monary tissue characterized by location of the
pathological tissue in the airways and lung paren-
chyma. How the pathological diagnosis informs
the clinician’s assessment and approach to the
case in question will demonstrate the importance
of an accurate diagnosis. Most small tissue sam-
ples obtained by nonsurgical approaches are in
the sub-centimeter size range, but can reach
1 cm depending on the technique used. Therefore,
R.L. Perez, M.D. (*)
Department of Medicine, University of Louisville
School of Medicine, 530 South Jackson Street,
Louisville, KY 40202, USA
e-mail: rafael.perez@louisville.edu
M.M. Fraig (ed.), Diagnosis of Small Lung Biopsy: An Integrated Approach,
DOI 10.1007/978-1-4939-2575-9_1, © Springer Science+Business Media New York 2015
1
we define small lung biopsy samples as tissue
obtained by nonsurgical techniques that are 1 cm
or less in the longest axis.
Small lung biopsy samples are obtained by
various techniques. Flexible fiberoptic bronchos-
copy (FOB) with endobronchial and transbron-
chial biopsy with forceps is a standard procedure
performed by all pulmonologists, while endo-
bronchial biopsy via rigid scope, cryobiopsy, and
navigational bronchoscopy biopsy require addi-
tional training and experience. Transthoracic core
biopsy is a radiological procedure. All of these
procedures have in common that they can be per-
formed outside the operating room.
Small Sample Lung Biopsy
Techniques by Fiberoptic
Bronchoscopy
In 1966, Dr. Shigeto Ikeda introduced the tech-
nique of flexible fiberoptics to access and visually
inspect the lungs [1]. The advantages of flexible
FOB as a nonsurgical procedure quickly brought it
into widespread use. It could be performed in
much less complicated settings than the operating
room, and moderate sedation with topical anesthe-
sia could be used in most cases. Elective FOB is a
routine outpatient procedure where various
applications to sample bronchial and parenchymal
tissues in stable non-acute individuals can be
obtained. FOB is easily transportable to the oper-
ating room and to the acute care setting where it
1
2 R.L. Perez
has an important diagnostic and therapeutic role in
the intensive care units.
The bronchoscope has been refined over time
for a variety of applications [2–4]. Bronchoscopes
have working channels of 1.4–2.8 mm in diame-
ter, the larger ones to allow the use of an array of
interventional instruments. Preparation and per-
formance for FOB regardless of the type of pro-
cedure requires the same key considerations.
Foremost is patient safety. Many who come to
bronchoscopy already have underlying lung dis-
ease that affects ventilation and oxygenation.
Benzodiazepines and opioids generally used for
sedation and comfort may degrade both critically.
A clinical professional, usually a trained nurse,
monitors ventilation, oximetry, blood pressure,
and other vital signs continuously during the pro-
cedure. Reversal agents are on hand, and the
equipment and drugs are within reach to adminis-
ter cardiopulmonary resuscitation, if necessary.
A current history and physical is required before
the procedure with emphasis on allergies, con-
comitant medications, and coagulation status.
The history and physical speaks not only to
patient safety but also to the reason why the indi-
vidual is having the procedure and the anticipated
samples to be obtained. It is imperative that the
appropriate media and fixatives are available and
ready to receive the samples.
Most diagnostic tissue sampling is done with
the standard instrument that typically returns tis-
sue samples measuring only a few millimeters.
Therefore, a high degree of specificity is para-
mount to obtain an accurate diagnosis. The oper-
ating characteristics of the FOB also vary
depending on the location of the abnormal tissue
to be sampled. The diagnostic accuracy of a
directly visualized endobronchial lesion is better
than a lesion located in the lung parenchyma.
Parenchymal lesions may be sampled under flu-
oroscopic guidance, but the more distal and
smaller the lesion, the greater the chance of sam-
pling error. The accuracy of obtaining a diagnos-
tic sample from deep in the lung parenchyma has
increased greatly in the past few years using
navigational bronchoscopy as described in a
subsequent section.
Endobronchial Diseases Diagnosed
by Small Sample Lung Biopsies
Sampling of the airways affords the lowest risk to
benefit ratio involved in FOB. The abnormalities
are usually visible, so the diagnostic accuracy is
good. Complications, mostly bleeding, can be
directly controlled with topical vasoconstrictors
or tamponade. Forceps sometimes accompanied
by bronchial brushings and washings are used to
take multiple biopsy samples of the lesion. There
are no specific guidelines for the number of endo-
bronchial biopsies that needs to be taken to maxi-
mize diagnostic yield. Four to five samples are
common, but the aware bronchoscopist may
obtain greater numbers since the samples are
small, and sufficient tissue for special stains or
biomarkers may be required. Table 1.1 lists the
spectrum of diseases diagnosed by sampling of
the airways.
Endobronchial Tumors
Endobronchial biopsies in adult patients are
mostly done for the diagnosis of bronchogenic
malignancies. Patients with bronchogenic malig-
nancies come to biopsy with symptoms that are
generally not specific, overlap with other airway
diseases, and involve other organ systems as the
disease progresses [5]. Wheezing, cough, and dys-
pnea are the most common symptoms in tumors of
the airways and are shared with diseases that cause
Table 1.1 Endobronchial diseases diagnosed by small
sample lung biopsies
Endobronchial tumors
• Malignant
• Carcinoid tumors
• Hamartomas
Infectious and other endobronchial diseases
• Mycoplasma and viral
• Endobronchial tuberculosis
• Allergic bronchopulmonary aspergillosis
• Bronchocentric granulomatosis
• Sarcoidosis
1 Small Sample Lung Biopsy Techniques in the Diagnosis of Airway…
airflow obstruction, most notably chronic obstruc-
tive pulmonary disease and asthma. The classic
paraneoplastic symptoms associated with some
bronchogenic cancers that lend some diagnostic
specificity are not common. Hypertrophic osteoar-
thropathy, a periosteal inflammatory condition of
the long bones, and hypercalcemia can be found in
squamous cell cancer of the lung. The Lambert–
Eaton myasthenic syndrome with weakness and
visual disturbance is seen in small cell lung cancer.
Bronchorrhea is occasionally associated with ade-
nocarcinoma in situ. Hemoptysis is occasionally
the presenting symptom for bronchogenic cancer
and portends more extensive involvement of the
airway and poorer outcome [6]. Pneumonia,
especially if it is recurrent in the same location,
may indicate an obstructing lesion of the airway.
Bronchoscopy may be a challenge in such cases
because of the inflammation with swelling and
purulence that make it difficult to biopsy the
lesion. The clinician may elect to postpone the
procedure until the pneumonia is treated and well
into resolution.
Like their malignant counterparts, benign
endobronchial tumors present with similar symp-
toms of airway obstruction with wheezing,
cough, dyspnea, and sometimes with hemoptysis
or post-obstructive pneumonia. Carcinoid tumors
are derived from neuroendocrine tissues of the
gastrointestinal (GI) and respiratory tracts. They
are predominantly found in the GI tract, but up to
20 % occur in the airways [7, 8]. Compared to
tumors in the GI tract, pulmonary carcinoids are
less likely to produce the carcinoid syndromes of
flushing, diarrhea, and heart failure. They can be
found from the most proximal to the most distal
conducting airways where neuroendocrine rests
are found. On bronchoscopy, they have a very
smooth, shiny, and sometimes very vascular sur-
face in contrast to malignant tumors that have
irregular lobulated borders with varying degrees
of necrosis.
Hamartomas are the most common benign lung
tumors, but only 10 % of those occur in the bronchi
[9]. They usually come to attention in patients who
present with post-obstructive symptoms or by
chance in an abnormal chest film. On broncho-
scopic inspection, they have no distinguishing
3
features that separate them from malignant lesions.
The histological diagnosis leads to a second thera-
peutic bronchoscopy with the removal of the tumor
that is curative in most cases.
Infectious and Other Endobronchial
Abnormalities
Diseases of the airways extend well beyond the
malignant and benign tissue transformations
described above. These diseases include infectious
and noninfectious disorders that present with a
broad constellation of symptoms that may extend
beyond the respiratory system. The history and
presentation of the individual is more complex
with questions about immune status and lung
function abnormalities at the forefront. Fever and
metabolic abnormalities also become more promi-
nent. The path to bronchoscopy usually takes
longer and only after clinical, laboratory, and
radiological evaluation has not yielded an answer.
Fever and weight loss will put infection at the
top of the disease differential, so tissue sampling
for both histological examination and culture and
staining is prepared. On inspection, infections of
the airways can take any form such as single or
multiple nodules, ulcerated epithelium, discolored
patches, or even only mild erythema and edema.
Bronchial washings and brushings typically
accompany tissue biopsies in these cases. Multiple
samples for culture are taken first to avoid any pos-
sibility of contamination of the bronchoscope
channel or forceps with fixative. While a positive
culture of a non-commensal or opportunistic
organism is sufficient to initiate specific therapy,
demonstration of tissue invasion may be necessary
in some circumstances.
Diffuse infections of the airways can cause
them to become hyperresponsive and produce
symptoms that are indistinguishable from asthma.
Though asthma is very prevalent worldwide,
individual cases sometimes present out of context
with respect to risk factors, a history of atopy,
exacerbating exposures, or response to therapy.
The clinician may therefore elect to perform
inspection and biopsy of the airways. Mycoplasma
pneumoniae has been associated with and even
4 R.L. Perez
implicated as the cause of asthma in some case
series, the latter conclusion on the basis that the
asthma was controlled after treating the infection
[10]. Rhinovirus, respiratory syncytial virus, and
influenza viruses have a strong relationship with
asthma exacerbations and may be relevant in
chronic uncontrolled asthma that may lead one to
obtain bronchial tissues for examination [11].
The key point on reviewing bronchial biopsies of
subjects with reactive airways is that, in addition
to the anticipated inflammatory changes, aware-
ness and detection of concurrent infection will
aid the clinician with treatment.
Endobronchial tuberculosis is an uncommon
manifestation of infection with Mycobacterium
tuberculosis (MTB) [12, 13]. Cough, wheezing,
fever, and dyspnea are nonspecific symptoms, and
it is not usually detectable on plain chest radiogra-
phy. Moreover, sputum cultures for MTB may be
negative. On bronchoscopy, the lesions have no
distinguishing features that would make the oper-
ator suspect MTB. The lesions may appear as
endobronchial masses or ulcerations. They may
obstruct airways or cause tracheal or bronchial
stenosis. Expedient identification and medical
treatment of endobronchial MTB are therefore
essential to prevent fixed stenosis and need for
surgical reconstruction.
Allergic bronchopulmonary aspergillosis
(ABPA) and bronchocentric granulomatosis
(BCG) are entities that overlap with asthma in
their clinical presentation [14, 15]. ABPA is
mostly associated with Aspergillus fumigatus,
but other fungi less commonly produce a similar
syndrome. In addition to the symptoms and
examination findings of asthma, the presence of
mucus plugging or infiltrates may lead to bron-
choscopic examination and biopsy of the involved
airways. The hallmark demonstration of fungal
hyphae in bronchial tissue, along with supportive
findings of elevated IgE and cutaneous reactivity
or precipitins to A. fumigatus, significantly
impacts therapy. In ABPA, systemic steroids are
required in addition to bronchodilator therapy. In
recalcitrant cases, treatment with antifungals
may be necessary.
BCG was first described in 1972 by Liebow as
a focal bronchial and bronchiolar destructive
granulomatous lesion [16, 17]. About one third
of individuals with BCG have asthma, and three
fourths of them will have A. fumigatus hyphae
detected in their bronchial biopsies. Of the two
thirds who do not have asthma, hyphae are pres-
ent in only about one third. Radiographically,
BCG may appear as a lung mass that will prompt
the bronchoscopic examination. Steroid treat-
ment is very effective, but the disease may recur
so individuals must be monitored regularly.
Sarcoidosis is a multisystemic granulomatous
disease of unknown etiology with a variety of
clinical presentations depending on the organ
involved [18]. Respiratory symptoms are nonspe-
cific and include chest tightness, cough, and dys-
pnea on exertion. A high proportion of patients
with pulmonary sarcoidosis will have some evi-
dence of airflow obstruction suggesting endo-
bronchial involvement with this disease [19].
On bronchoscopy, the bronchial mucosa may
appear normal to erythematous with “cobbleston-
ing” that indicates a heavy granuloma burden in
the airways. The yield of random biopsies of the
bronchial mucosa depends on the degree of
involvement and in practice is a supplement to
transbronchial biopsies and transbronchial nee-
dle aspiration of enlarged hilar, paratracheal, or
other mediastinal nodes.
Parenchymal Diseases Diagnosed
by Small Sample Lung Biopsies
New technologies have extended the reach and
accuracy of small sample biopsies of solid and
infiltrative diseases in the lung parenchyma.
Table 1.2 lists parenchymal diseases categorized
by radiological appearance. This categorization is
useful for differential diagnosis and the selection
of the biopsy technique and approach to diagnosis.
Unlike endobronchial diseases, imaging using
fluoroscopy and ultrasound assists in the localiza-
tion and biopsy of lesions in the lung parenchyma.
New tools for performing navigational bronchos-
copy, linear and radial endobronchial ultrasonog-
raphy, and cryobiopsy have extended the reach and
accuracy of bronchoscopic biopsy of even the
deepest pulmonary abnormalities.
1 Small Sample Lung Biopsy Techniques in the Diagnosis of Airway…
Table 1.2 Parenchymal diseases diagnosed by small
sample lung biopsies
Focal solid parenchymal lesions
• Lung masses
• Metastatic disease
• Solitary pulmonary nodules
Focal and diffuse infiltrative diseases
• Granulomatous diseases
– Sarcoidosis
– Hypersensitivity pneumonitis
• Non-granulomatous diseases
– Idiopathic pulmonary fibrosis
– Nonspecific interstitial pneumonitis
– Smoking-related interstitial lung diseases
– Organizing pneumonia
Focal Solid Parenchymal Lesions
Standard flexible fiberoptic biopsy guided by
fluoroscopy is the mainstay procedure for locat-
ing and sampling solid parenchymal lesions.
Fluoroscopy is also used for safety purposes
mainly to mitigate and assess for pneumothorax.
Lung masses that are larger and centrally located
are usually approached in this way. Lesions that
are smaller and located peripherally are more
accurately biopsied using navigational or
ultrasound-guided bronchoscopy as described
below [20, 21].
Lung masses by definition are discrete lesions
greater than 3 cm in diameter by radiography
[22]. A single mass in an adult is considered to be
malignant until proven otherwise. Age, smoking
history, and presence of chronic obstructive pul-
monary disease all increase the pretest probabil-
ity of primary lung cancer [23]. Therefore, it is
imperative that the bronchoscopic sample dem-
onstrates malignancy to avoid a more invasive
biopsy approach. Radio- or chemotherapy is very
rarely undertaken without a true-positive histo-
logical evidence of malignancy. The bronchosco-
pist maximizes diagnostic yield using fluoroscopy
to locate the mass and take multiple transbron-
chial biopsies using a forceps “punched” into the
lung parenchyma. Angling the tip of the broncho-
scope slightly with each pass is done to sample
different regions of the mass. Finally, ample tissue
5
must be recovered for possible biomarker probing
that may influence therapy.
Nonmalignant lung masses can sometimes be
seen in chronic inflammatory and granulomatous
diseases produced by infection, as pulmonary
involvement in autoimmune diseases, or through
environmental exposures. Though mostly pre-
senting as lung nodules, fungal infections may
sometimes present radiographically as lung
masses [24]. Histoplasmosis or blastomycosis
may present as a mass-like consolidations in
immunocompetent patients, while cryptococcosis
is found mainly in immunosuppressed individu-
als. Similar to malignant masses, the diagnostic
approach is by transbronchial biopsy supple-
mented by bronchial washings with saline for
culture.
Mass-like lung densities may also be seen in
autoimmune diseases like sarcoidosis, rheuma-
toid arthritis, and granulomatosis with polyangi-
itis. When lung masses are detected in the context
of an autoimmune disease, the individual is often
on immunosuppressive therapy. Opportunistic
infection must be considered, and appropriate
preparation to receive samples for Pneumocystis
jirovecii, other fungi, and acid-fast organisms
should be done. Often, bronchoalveolar lavage
(BAL) supplements biopsy by accessing deep
respiratory surfaces not obtained by simple wash-
ings. BAL involves wedging the bronchoscope
into a fourth- to sixth-generation bronchus to pro-
duce a tight seal. Then, sterile saline is instilled in
30–50 mL. Aliquots are recovered by gentle suc-
tion. An acceptable BAL sample will demonstrate
a “foamy” meniscus in the suction receptacle
indicating recovery of pulmonary surfactant from
alveolar surfaces and return few to no ciliated
epithelial cells indicating little contamination
from the conducting airways.
Occupational exposures to silica, coal dust,
beryllium, and kaolin will produce one or more
discrete lesions that must be differentiated from
malignancy. The occupational history must be pro-
vided to the reviewing pathologist to prepare the
appropriate microscopic assessment for the pres-
ence of particulates. Beryllium is indistinguish-
able from sarcoidosis histologically, but the lack of
certain extrapulmonary manifestations found in
6 R.L. Perez
sarcoidosis and the exposure history will increase
the confidence that the noncaseating granulomas
are the result of beryllium exposure [25].
Metastatic malignancies to the lungs may
present as solitary or multiple lesions of varying
size. Colorectal cancers occasionally present as
solitary nodules. Identifying these lesions as origi-
nating from these organs is key since resection
may improve survival [26]. In the setting of known
cancer, patients with solitary metastases may go
directly to surgery after risk assessment. However,
if diagnosis is elected, then navigational bronchos-
copy, described in more detail below, can accu-
rately sample even peripheral metastases 1 cm in
diameter or more.
Lymphangitic metastases are typically
addressed with standard transbronchial biopsy
with fluoroscopic guidance. Five to six passes in
one selected lung lobe are done and yield an
almost 70 % chance of diagnosis [27]. Although
the risk of pneumothorax is low, the bronchosco-
pist never performs transbronchial biopsy in both
lungs in the same procedure.
The approach to the diagnosis of solitary or
multiple pulmonary nodules begins with a thor-
ough interview of the patient emphasizing respi-
ratory exposures and risk assessment. Then, the
decision to observe over time, perform biopsy, or
go directly to resection can be made. The advent
of low-dose computerized tomography (LDCT)
and comfort of practitioners to order this test
have produced an upsurge of studies demonstrat-
ing pulmonary nodules. Indeed, in the National
Lung Screening Trial in the United States in
which over 53,000 individuals at risk for lung
cancer underwent LDCT, a reduction in lung
cancer mortality and discovery of earlier stage
disease were demonstrated [28]. Still, the vast
majority of nodules assessed were benign
through observation over time or by diagnostic
sampling or by resection. Biopsy and resection
incur both cost and risks including mortality.
The challenge is the decision to wait and watch
biopsy or resect.
Solitary pulmonary nodules are by definition
single nodular lesions of 3-cm diameter or less
surrounded by normal lung tissue [22]. Location
and size, along with risk factors for malignant
potential, determine to a large degree how the
nodule is to be approached. Sub-centimeter
nodules may be observed by serial radiology and
applying various algorithms based on risk, smok-
ing history, and lung function [29]. Nodules that
are one or more centimeters in diameter may be
resected or sampled for diagnosis. Risk factors
for malignancy, surgical risks, and patient desires
determine the approach.
The advent of electromagnetic guidance has
improved the diagnostic reach and accuracy of
bronchoscopy in the assessment of pulmonary
nodules by a technique called navigational bron-
choscopy. Navigational bronchoscopy is a com-
plicated procedure that matches the location of a
subject’s lesion on computerized tomography to
the anatomy of the subject who is enveloped in a
magnetic field during the procedure [30]. A pro-
cess called “registration” matches the image and
magnetic field. Then, a probe with an extended
working channel is inserted through the broncho-
scope and guided to the lesion through a virtual
image on screen. Once the lesion is located, the
extended channel is locked in place. A biopsy
forceps is inserted to sample the lesion under
fluoroscopic guidance. The diagnostic yield of
navigational bronchoscopy alone is about 60 %,
and when combined with radial endobronchial
ultrasound to confirm location, the yield
approaches 90 % [31].
Focal and Diffuse Infiltrative Diseases
Infiltrative diseases of the lung prove challenging
when diagnosis is attempted using small sample
biopsy techniques. Routine transbronchial lung
biopsy may be attempted in settings where there
is clear expertise by both the clinical and patho-
logical personnel involved in making the diagno-
sis. In general, granulomatous lung diseases like
sarcoidosis and hypersensitivity pneumonitis are
more likely to be diagnosed by transbronchial
lung biopsy [32] than the non-granulomatous
idiopathic interstitial pneumonias (IIPs) including
idiopathic pulmonary fibrosis [33, 34]. Surgical
lung biopsy is recommended for the latter despite
the attendant risks of anesthesia and operation
1 Small Sample Lung Biopsy Techniques in the Diagnosis of Airway…
in patients who may already have significant
pulmonary impairment.
Sarcoidosis is a granulomatous multisystemic
disease with unknown etiology [18]. The most
commonly involved organ is the lung, and it is
thought that the causative agent or agents gain
access via the respiratory route. The respiratory
symptoms are nonspecific ranging from general-
ized chest discomfort, or tightness, to cough and
wheezing. In many cases, the disease is suspected
on the basis of accompanying symptoms such as
dry mouth and eyes (Sjogren’s syndrome), pain
in the large joints, or even unexplained weight
loss. Acute disease may present with painful iritis
or uveitis and occasionally erythema nodosum of
the lower extremities. The classic noncaseating
granulomas are not found in the joints or nodo-
sum lesions, but in the more chronic keloid-like
lesions that can be found on any region of the
body. The diagnosis can be reliably made by skin
biopsy alone in the context of the presenting ill-
ness and exclusion of mycobacterial or fungal
infection or lymphatic malignancies.
As noted in a previous section, pulmonary sar-
coidosis often involves the airways and can be
sampled by endobronchial biopsy. Parenchymal
disease usually presents with several components
that include mediastinal and hilar adenopathy
with or without pulmonary infiltrates.
Occasionally, sarcoidosis may present with mul-
tiple pulmonary nodules or as a lung mass.
Finally, pulmonary impairment may be present
with no radiological evidence of disease in the
lungs. In all of these presentations, standard
transbronchial lung biopsy has a very good diag-
nostic yield of up to 90 % when 4–5 transbron-
chial biopsies are performed [32]. In cases where
there is obvious adenopathy abutting the airways,
endobronchial ultrasound-guided fine-needle
aspiration is becoming the preferred way to make
the diagnosis because of its high yield and better
safety profile compared to transbronchial lung
biopsy [35, 36].
Hypersensitivity pneumonitis (HP), or extrin-
sic allergic alveolitis, is a granulomatous lung
disease caused by a host of environmental anti-
gens [37, 38]. The acute form presents with
fever, cough, dyspnea, malaise, and diffuse
7
pulmonary infiltrates in the sensitized individual.
The symptoms resolve when the antigen is
removed and recur on exposure to the antigen.
The predominant immune response in acute
disease is the Arthus, or type III hypersensitivity
response, involving immune complexes. The
more subtle subacute presentation with cough,
dyspnea, and fatigue displays centrilobular infil-
trates by computerized tomography. Subacute HP
represents a transition to cell-mediated immu-
nity generating the granulomatous response that
characterizes this disease. Continued exposure
to the antigen may result in chronic HP of which
the hallmark is the development of pulmonary
fibrosis. The removal of the individual from the
exposure is paramount to prevent disease pro-
gression. Therapy with corticosteroids is effec-
tive, but should not supplant avoidance of the
causative antigen.
Like sarcoidosis, the granulomatous phase of
HP is readily obtainable by transbronchial biopsy.
The site of biopsy is guided by radiological appear-
ance. The disease tends to be concentrated in the
upper lobes, and this is where multiple passes with
the biopsy forceps are taken. Although adenopathy
is not a prominent feature of HP, this disease may
need to be differentiated from sarcoidosis in some
cases. In this situation, some clinicians elect to
perform BAL with cell differential and flow
cytometry to assess the ratio of CD4 to CD8 lym-
phocytes. Both diseases present with a lympho-
cytic alveolitis, but sarcoidosis has an elevated
CD4/CD8, usually greater than 3, while HP pres-
ents with an inverted ratio of less than 1.
While standard bronchoscopy with transbron-
chial biopsy is sufficient to diagnose diffuse gran-
ulomatous diseases, the diagnostic accuracy drops
significantly in diffuse non-granulomatous lung
diseases [33, 34]. A new bronchoscopic biopsy
technique born out of endobronchial cryotherapy
may enhance the diagnostic accuracy of the trans-
bronchial approach to diagnosis in diffuse lung
diseases. Cryobiopsy uses a super cold probe to
obtain parenchymal lung tissue of up to 1 cm in
diameter [39]. The probe is inserted through the
bronchoscope into the region of interest. The
tip is cooled to −89 °C by rapidly expanding
nitrous oxide gas. Within seconds, the probe and
8 R.L. Perez
bronchoscope are removed as a unit to recover
the tissue for fixation. Bleeding does not appear to
be increased by cryobiopsy compared to standard
forceps biopsy, but the risk of pneumothorax may
be increased by this technique. Nevertheless, the
advantage of cryobiopsy is that it recovers tissue
that has three times the sectional area of transbron-
chial biopsies and avoids the crush artifact com-
monly seen in the latter procedure. This technique
will likely find application in the focal and diffuse
parenchymal lung diseases described below.
The IIPs, autoimmune-related interstitial lung
diseases, and the more recently recognized group
of smoking-related interstitial lung diseases [40]
require ample tissue to make a confident diagno-
sis. Sufficient tissue is usually obtained by surgi-
cal lung biopsy, typically by video-assisted
thoracoscopy, or VATS. Aside from the complex-
ity and risks of general anesthesia and surgery,
selection of biopsy sites by VATS or open lung
biopsy is critical. The tissue is preferably sam-
pled in transitional areas of varying degrees of
disease activity to enhance pathological descrip-
tion and diagnostic accuracy. Surgical experience
and collaboration between the surgeon, clinician,
and radiologist are needed to acquire optimal
tissue for sectioning.
Idiopathic pulmonary fibrosis, or IPF, is the
most common of the IIPs [41]. It has a highly
variable disease progression with random exacer-
bations and is uniformly fatal. Dyspnea on exer-
tion, with profound exercise hypoxemia, and
sometimes violent cough paroxysms are the pro-
gressive symptoms. There is no approved drug
therapy in the United States as of this writing.
The disease at one time required the pathological
finding of usual interstitial pneumonitis (UIP) on
lung biopsy, but the findings of lower lobe pre-
dominant peripheral reticular infiltrates, traction
bronchiectasis, honeycombing, and lack of
“ground-glass opacification” on high-resolution
computed tomography (HRCT) are now accepted
for the diagnosis of IPF [42]. Lung biopsy is not
required when other causes of diffuse lung
disease are excluded and these key findings are
displayed on HRCT. A recent update to the clas-
sification of IPF defines HRCT findings in IPF as
UIP, possible UIP, and inconsistent UIP. Lung
biopsy is recommended in the latter two designa-
tions, surgical risks permitting [42].
Nonspecific interstitial pneumonia, or NSIP,
presents with similar clinical symptoms and time
course as IPF but differs greatly in its pathogene-
sis and response to therapy [43]. There is much
overlap on HRCT findings between NSIP and
IPF, but NSIP tends to spare the subpleural paren-
chyma, and honeycombing is uncommon [44].
Ground-glass opacification is more common in
NSIP, but just over one half of the cases may not
have this feature. NSIP is found in a wide variety
of diseases that result from alterations of the
immune response such as the connective tissue
diseases, infections including HIV, and drug
reactions. However, the UIP pattern can be found
in these diseases as well, most often in rheuma-
toid arthritis-associated interstitial lung disease.
A proportion of individuals have the idiopathic
form of NSIP that occurs when no causative etiol-
ogy can be discerned after a thorough search. In
effect, there are no current clinical or radiological
findings that can confidently separate IPF/UIP
from NSIP. Differentiating NSIP from IPF is criti-
cal because NSIP has a variable, but significant,
response to immunomodulating therapies [43].
Lung biopsy is necessary for patients who present
with the idiopathic form of NSIP and may be con-
sidered when patients who have a known underly-
ing cause do not respond to therapy. In these
cases, the underlying histopathology may have
prominent areas of UIP intermingled with the
NSIP. Surgical lung biopsy is the accepted method
to obtain sufficient tissue for examination.
The role of transbronchial cryobiopsy is yet to be
determined.
The relationship between smoking and cer-
tain diffuse lung diseases has been recognized
over the past 50 years. Virtually, all smokers
develop respiratory bronchiolitis (RB) that can
be detected histologically [45, 46]. In general,
RB is not symptomatic, and lung function mea-
sures are normal. A minority of individuals will
progress with dyspnea and cough as they develop
the diffuse interstitial phase termed RB-ILD.
Pulmonary function testing will demonstrate a
1 Small Sample Lung Biopsy Techniques in the Diagnosis of Airway…
mixed restrictive and obstructive pattern with
decreased total lung capacity and relative
increase in residual volume indicating air trap-
ping. Radiologically, a patchy ground-glass
appearance may be noted. Desquamative inter-
stitial pneumonitis (DIP), more accurately an
influx of macrophages filling alveolar spaces,
presents as a uniformly restrictive impairment
and diffuse confluent ground-glass opacification
on CT scanning. The bronchiolocentric localiza-
tion of inflammatory cells of RB-ILD and alveo-
lar filling presentation of DIP can be found
together suggesting that they represent a spec-
trum of smoking-related inflammatory reaction
extending from respiratory bronchioles to the
alveolar spaces. Treatment of the smoking-
related ILD mandates tobacco cessation some-
times combined with corticosteroids. The
distribution of disease is such that surgical lung
biopsy is required to appreciate the extent and
pattern of DIP and RB-ILD.
Organizing pneumonia filling the alveolar
spaces and respiratory bronchioles has a variable
focal distribution that typically involves both
lungs. The primary form termed cryptogenic
organizing pneumonia, or COP, is found most
commonly in the sixth decade of life [47]. Unlike
most of the other IIPs, it has a very favorable
response to corticosteroid therapy. Secondary
organizing pneumonia can be found as a repara-
tive reaction to many forms of lung injury includ-
ing infection, autoimmune diseases, and
malignancies [48]. Perhaps because of the
underlying diseases, the outcome and survival
seem to be worse than in primary COP [49]. The
presenting symptoms in primary and secondary
organizing pneumonia are not specific with
cough and dyspnea on exertion being most com-
mon. Fever is variable and there are no distin-
guishing laboratory findings. The radiological
presentation is protean ranging from dense areas
of parenchymal consolidation, patchy broncho-
centric infiltrates, to discrete centrilobular densi-
ties [50]. Accurate diagnosis is currently made
mostly by surgical lung biopsy, but this approach
may be supplanted as experience grows with
transbronchial cryobiopsy.
9
Conclusion
The development of pulmonary diagnostic proce-
dures founded on FOB has allowed access to vir-
tually every region of the airways and lung
parenchyma avoiding the complexity, risks, and
costs of surgery. These procedures are transport-
able to settings outside the operating room into
specialized outpatient medical procedure units
and inpatient acute care wards including inten-
sive care units. The main drawback to these non-
surgical approaches is the limitation on the size
of the biopsy samples that are typically in the
sub-centimeter size range. Selection of sampling
technique, selection of the biopsy site, and pro-
curement of multiple samples overcome this
disadvantage to some extent. Most importantly,
the multidisciplinary collaboration between the
pathologist, radiologist, and clinician will yield
the highest diagnostic “wisdom.”
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 Principles of Imaging Lung Disease
James G. Ravenel
Imaging Techniques
Chest Radiograph
Chest radiography is best thought of as a screening
tool. Its strengths are ease and rapidity of acquisi-
tion and low radiation dose. Ideally, this is
obtained as a posterior-anterior (PA) and lateral
projection. In the PA projection, the X-ray beam
is behind the patient, and the radiographic cassette
is against the anterior chest wall in order to mini-
mize magnification of anterior structures. The lat-
eral projection is taken with the left chest adjacent
to the cassette to minimize magnification of the
heart. The chest X-ray can then be used to guide
further imaging work-up by providing an under-
standing of whether abnormalities are primarily
confined to the gas-containing regions of the lung
(airspace disease), the pulmonary interstitium
(the scaffolding of connective tissue that invests
pulmonary arteries, veins, lymphatics, and air-
ways), the mediastinum, or pleura. Based on this,
a selection of CT technique can be made that may
include the use of intravenous contrast, thin sec-
tions, expiratory images, and/or multi-planar
reformatted images.
J.G. Ravenel, M.D. (*)
Department of Radiology and Radiologic Services,
Medical University of South Carolina, 96 Jonathan
Lucas Street, MSC 323, Charleston, SC 29425, USA
e-mail: ravenejg@musc.edu
M.M. Fraig (ed.), Diagnosis of Small Lung Biopsy: An Integrated Approach,
DOI 10.1007/978-1-4939-2575-9_2, © Springer Science+Business Media New York 2015
2
Computed Tomography
Virtually, all scanners in use utilize multi-slice
helical technology meaning the data is obtained
continuously throughout a single breath hold.
As technology has advanced, the newest genera-
tion allows for the acquisition of isotropic datasets
in under 10 s. The significance of this lies in the
ability to reconstruct thin sections in any plane to
best display the relevant anatomy, assess the pul-
monary parenchyma, or obtain the volume of a
nodule. In these scanners, a volumetric acquisi-
tion replaces the need for axial inspiratory high-
resolution CT images. Thin-section (~1 mm) CT
is critical for the analysis of small pulmonary
nodules (<10 mm), in the evaluation of growth,
and the determination of part-solid and ground-
glass components.
High-resolution CT, typically performed for
the evaluation of interstitial lung disease, is some-
what of a misnomer. With previous CT technology,
it was not possible to obtain thin sections through-
out the chest in a single breath hold. Therefore,
individual thin sections (usually 1 mm) were
obtained in inspiration at intervals of 10–20 mm in
order to obtain a sampling across the lung paren-
chyma. These images are reconstructed in a man-
ner that accentuates the pulmonary interstitium.
In many institutions, the inspiratory supine images
are now obtained as a volumetric acquisition. In
additional, two adjuncts are typically performed:
expiratory images to assess for air trapping as a
manifestation of small airways disease and prone
13
14
inspiration to determine whether subtle attenuation
changes in the dependent portions of the lungs on
supine images were due to gravitational fluid shifts
or mild interstitial disease. These images are typi-
cally performed at three levels: top of the aortic
arch, tracheal carina, and apex of the diaphragms.
18F-FDG PET/CT
Positron emission tomography (PET) is used to
image various positron-emitting radionuclides,
predominately 18F-fluorodeoxyglucose (18F-FDG)
with the PET images superimposed onto a low-
dose attenuation correction CT (PET/CT).
18F-FDG-like glucose is transported into the
cell; however, once phosphorylated, it becomes
trapped. As such 18F-FDG acts as a surrogate for
glucose metabolism. Areas that have higher activ-
ity than background are often termed “hypermeta-
bolic” as raise the possibility than a given lesion is
a neoplasm. It is important to recognize that
(1) inflammatory lesion may also accumulate
high levels of 18F-FDG and (2) small neoplasms
and low-grade lung adenocarcinomas may not
accumulate 18F-FDG above background. This
means that CT morphology of lesions must be
taken into consideration.
Fig. 2.1 Airspace disease due to bacterial pneumonia. (a)
Frontal chest radiograph reveals poorly defined lower lobe
consolidation (C) with air bronchograms (arrow) and no
volume loss indicating an airspace-filling process. (b)
J.G. Ravenel
Interstitium, Alveolar Walls,
and Airspaces
The pulmonary parenchyma can be compartmen-
talized into various constituents that make up the
lung. While it can be difficult to absolutely delin-
eate these features with chest radiograph, thin-
section CT (TSCT) can often distinguish these
components. It is important to recognize that even
at “high” resolution, CT cannot image the alveolar
wall or normal intralobular septa, and thus abnor-
malities at this level cannot always be easily attrib-
uted to an alveolar filling or interstitial process [1].
The following is a lexicon with definitions and
relevant images of the terminology associated with
the pulmonary parenchyma [2]:
Airspace disease defines a process that fills the
alveolar spaces. The term itself does not define
density and may range from hazy ground-glass
opacity to dense consolidation (Fig. 2.1). An air
bronchogram is often present. It is otherwise a non-
specific term that can be associated with infection,
edema, hemorrhage, or cells/cellular debris.
Air trapping can be seen on expiratory images
as an accentuation of density between adjacent
areas of the lungs. When attenuation is measured,
areas of air trapping maintain their low attenuation
Axial CT image reveals two separate forms of airspace
disease: (1) dense anterior segmental consolidation (C)
and (2) bronchopneumonia pattern as evidenced posteri-
orly by centrilobular nodules (arrows)
2 Principles of Imaging Lung Disease
Fig. 2.2 Architectural distortion and honeycomb lung.
Axial TSCT reveals distortion of the inferior lingular seg-
ment (arrows) and extensive honeycomb change in the
right lower lobe (H)
Fig. 2.3 Lobar collapse. (a) Frontal radiograph reveals
volume loss in left hemithorax with elevation of left dia-
phragm due to left hilar neoplasm (arrow). (b) Lateral
values, whereas normal lung increases in density.
This is typically a manifestation of small airway
disease but can result from either luminal obstruc-
tion or concentric bronchial wall thickening [3].
Architectural distortion refers to the displace-
ment of normal lung structures with disruption of
the usual lung parenchyma. It is generally associated
with a fibrosing lung process (Fig. 2.2).
15
Fig. 2.4 Bronchiectasis. Axial CT in patient with cystic
fibrosis reveals cystic bronchiectasis (C) in the right lung
and varicoid (V) bronchiectasis in the left lung
radiograph confirms collapse with anterior displacement
of the major fissure (arrowheads)
Atelectasis is the loss of air and volume
caused by the collapse of the airspaces (Fig. 2.3).
It is therefore the opposite of airspace disease.
Bronchiectasis is defined as irreversible
dilation of the airways usually measured as 1.5×
the size of the adjacent artery [4]. It can be cylin-
drical (long and tubular), varicoid (variable lumen
size), or cystic (large gas-filled spaces) (Fig. 2.4).
16
Fig. 2.5 Subacute hypersensitivity pneumonitis. Axial
TSCT reveals both the heterogeneous generalized increase
in density of ground-glass opacity and ill-defined faint nod-
ular opacities centered in the secondary pulmonary lobule
The relatively small artery next to a dilated bron-
chus has been referred to as the “signet ring sign.”
Traction bronchiectasis is a unique subset of
bronchiectasis and is related to underlying paren-
chymal fibrosis [5]. As opposed to bronchiectasis
described above, the dilation is the result of exter-
nal retractile forces. When severe, it can be quite
difficult to segregate out from honeycomb lung.
Centrilobular nodules are hazy, ill-defined
nodules that are centered around the central
bronchus and artery in the secondary pulmonary
lobule (Fig. 2.5). These nodules do not extend out
to the interlobular septum and are classically
associated with subacute hypersensitivity pneu-
monitis and respiratory bronchiolitis [1].
Consolidation refers to generalized increased
density within the lung parenchyma. As such it is
less specific than airspace disease or atelectasis
and encompasses both of those possibilities.
Crazy-paving pattern combines ground-
glass opacity superimposed upon interlobular
septal thickening somewhat resembling paved
cobblestones. Although classically associated
with alveolar proteinosis, it can occur as part of
any disease process that involves both intersti-
tium and air spaces [6].
Emphysema, like its pathological counterpart,
is the irreversible destruction of alveolar walls. It
can be manifest as predominately lucency of the
secondary pulmonary lobule (centrilobular
emphysema) or more widespread destruction of
the lung parenchyma (panacinar emphysema).
J.G. Ravenel
Fig. 2.6 Lymphangitic carcinomatosis. Axial CT image
reveals smooth interlobular septal thickening (arrow-
heads) on the left compared with contralateral lung. Note
also small left pleural effusion (E)
Ground-glass opacity is used to describe a
hazy increase in lung attenuation that does not
obscure the underlying lung architecture (see
Fig. 2.5) [7]. It can be associated with airspace-
filling process or fibrosis that is below the resolu-
tion of CT. Because of this, the moniker of “active
alveolitis” is discouraged, although this may rep-
resent reversible cellular change in the setting of
interstitial lung disease.
Honeycombing is a late radiographic finding
of underlying fibrosis with stacked thick-walled
cystic structures (see Fig. 2.2). In the classic
basal and peripheral distribution, it helps to
define a usual interstitial pneumonitis pattern and
obviates the need for open lung biopsy [8]. It is
important to recognize that honeycombing pres-
ent within a pathologic specimen may not always
be evident at TSCT.
Infiltrate, as a term, should no longer be part
of the imaging lexicon as it means too many dif-
ferent things to too many people. It should be
understood as a nonspecific term in the vein of
opacity and may be used with appropriate
descriptors (air space, interstitial, etc.).
Interlobular septal thickening refers to any
process that results in increased conspicuity of the
walls of the secondary pulmonary lobule [1].
This may alternatively be described as reticular or
reticulonodular opacities depending on morphol-
ogy. Best seen perpendicular to the pleural surface,
smooth interlobular septal thickening (Fig. 2.6)
or reticular opacities are a classic manifestation
2 Principles of Imaging Lung Disease 17

of hydrostatic pulmonary edema. A beaded or

reticulonodular appearance can be seen with such
conditions as sarcoidosis and lymphangitic
carcinomatosis.
Miliary pattern is a form of interstitial disease
with small nodules (1–3 mm) confined to the inter-
stitium often in a random distribution without
septal thickening. Diagnoses classically associ-
ated with this pattern include disseminated infec-
tion, particularly tuberculosis and sarcoidosis.
Mosaic attenuation is a general term used to
describe differing lung densities. As such it can
be due to a mixture of ground-glass opacity and Fig. 2.7 Sarcoidosis. Axial CT reveals both subpleural/
normal areas of air trapping and normal lung or perilymphatic nodules (black arrowheads) and thickening
along bronchovascular bundles (white arrowheads). Note
areas of differential (mosaic) perfusion [9]. The also bilateral hilar adenopathy (A)
former two possibilities can be sorted out with
expiratory images as both ground-glass disease
and normal lung will both increase in density,
whereas air trapping will manifest as persistent
low density. Mosaic perfusion can be differenti-
ated by looking at the underlying vessels with
larger vessels going to areas of increased density
and small or diminutive vessels going to areas of
decreased density as in cases of chronic thrombo-
embolic pulmonary hypertension.
Opacity, like infiltrate, should denote a non-
specific increase in density and should be pre-
ceded by an appropriate descriptor such as air
space or interstitial.
Peribronchovascular nodule describes small Fig. 2.8 Active tuberculosis. Axial CT reveals branching
nodules (1–3 mm) that are discretely related to endobronchial nodules that appear like buds on a tree
the bronchial wall or peribronchial structures (arrows)
(Fig. 2.7). It therefore may be associated with
disease of the bronchus, adjacent vessels, or lym- seen in disease associated with distal mucoid
phatics. Nodules of this variety may also be impaction such as cystic fibrosis [10].
described as bronchocentric.
Perilymphatic nodule is quite similar in size
to peribronchovascular nodules but instead Nodules and Masses
resides in the interlobular septa (see Fig. 2.7).
This can be associated with interlobular septal By convention, a pulmonary nodule is defined as a
thickening and also may be described as reticulo- focal opacity surrounded by lung measuring less than
nodular opacities. 3 cm as defined by chest radiograph. A lesion
Tree-in-bud opacities are small nodules at greater than 3 cm in size is considered to be a mass.
the end of airways and are a manifestation of As a practical rule, the major task for the radiologist is
endobronchial spread of disease. Classically to distinguish between benign and malignant causes.
described with active tuberculosis (Fig. 2.8), they The presence of dense central calcification, the pres-
may be the result of any infectious process or be ence of macroscopic intralesional fat, and a lack of
18 J.G. Ravenel

Fig. 2.9 Pulmonary nodules. (a) Ground glass. (b) Part solid. (c) Solid

growth over 2 years are all strong predictors of benig-

nancy [11]. Morphologically, the lesions’ borders can
also help malignancy. Lesions with entirely smooth
borders are more likely to be benign, while lobulated
and spiculated nodules are more likely to be malig-
nant. CT is the primary means of nodule evaluation,
and the description of a nodule may lead to a refine-
ment of the differential diagnosis.
Ground-glass nodule is a nodule at TSCT
that is greater in density than the surrounding
lung but does not obscure the underlying struc-
ture of the interstitium (Fig. 2.9a). Some lesion
may contain internal bubble-like lucencies that
correspond to dilated alveolar spaces.
Part-solid nodule contains areas that are both Fig. 2.10 Invasive aspergillosis. Axial CT reveals solid
ground glass in density as well as components that nodular consolidation with faint surrounding ground-
are solid (Fig. 2.9b). Along with ground-glass nod- glass halo (arrowheads)
ules, these are lesions typically detected by CT as
incidental findings or at lung cancer screening and Halo sign refers to a ring of ground-glass
when malignant tends to be either premalignant, in opacity surrounding a centrally dense lesion with
situ, or low-grade invasive neoplasms [12]. or without cavitation. While classically associ-
Solid nodule is of sufficient density to obscure ated with invasive aspergillosis (the halo repre-
the underlying lung parenchyma (Fig. 2.9c). senting peripheral hemorrhage) (Fig. 2.10), it can
Cavitation refers to the process of internal be seen with any form of infection, vasculitis, or
necrosis leaving an internal area of gas within the malignancy [14].
lesion. The wall thickness around a cavity can Reversed halo sign (atoll sign) is the opposite
help predict malignancy as lesions with thick of the halo sign with ground-glass density cen-
irregular walls or external notches are more likely trally and a surrounding ring of solid density. It is
to be malignant [13]. Cavitation is distinct generally indicative of an inflammatory lesion,
from the bubble-like lucencies that can be seen in usually organizing pneumonia [15], but can also
low-grade adenocarcinomas described in ground- be seen with active infection and granulomatous
glass opacity above. inflammation.
2 Principles of Imaging Lung Disease
Mediastinum
The mediastinum contains the central core struc-
tures of the thorax and is invested by the parietal
pleura [16]. The mediastinum is continuous with
the pulmonary interstitium at the hila where the
central bronchi, pulmonary arteries, veins, and
lymphatics enter the lung. The mediastinum is
also in direct continuity with the soft tissues of
the neck and continuous with the sub-peritoneal
spaces of the abdomen at the esophageal, inferior
vena cava, and aortic hiatus. Although no direct
fascial planes exist to separate mediastinal com-
ponents, the mediastinum is classically divided
into three components, each suggesting a specific
group of lesions. It is important to recognize that
all three sections are in continuity with each
other, and therefore involvement of more than
one compartment may occur.
Anterior mediastinum extends from the pos-
terior wall of the sternum to the ascending aorta
superiorly and the anterior pericardium inferi-
orly. Contents of this region include fat, thymus,
and lymphoid tissue. Ectopic thyroid and para-
thyroid tissue as well as germ cell rests may also
reside here, and thyroid goiters may descend
anteriorly into this space. The differential diag-
nosis derives from these tissues and classically
includes lymphoma, thymic tumors, germ cell
tumors, and thyroid lesions.
Middle mediastinum extends from the ante-
rior mediastinum to the anterior margin of the
thoracic spine and as such contains the visceral
structures of the mediastinum (the esophagus and
aorta can be variable as to whether they occupy
what is classically considered to be middle or
posterior mediastinum). The primary abnormali-
ties tend to be those arising from the lymphatics
such as mediastinal adenopathy from a primary
lung malignancy or lymphoma. Lesions arising
from the aorta and esophagus as well as congeni-
tal bronchopulmonary foregut duplication cysts
may also occupy the middle mediastinum.
Posterior mediastinum is the region extend-
ing posteriorly from the middle mediastinum
that encompasses predominately paraspinal soft
19
Fig. 2.11 Mediastinal compartments. Lateral radiograph
delineating approximate anatomic location of anterior
(A), middle (M), and posterior (P) mediastinum
tissues. Lesions in this region are often tumors of
neurogenic origin, extension of disk space infec-
tion, and lesions involving vertebral bodies.
Given the variability in position, lesions of the
descending aorta and esophagus may also local-
ize to the posterior mediastinum (Fig. 2.11).
Pleura
On chest radiographs, pleural effusions are often
manifest as blunting of the lateral or posterior
costophrenic sulci resulting in a meniscoid
appearance. Effusions of this type are usually
free to move throughout the pleural space. As
pleural fluid becomes more organized, it may
take on a lenticular appearance. In this setting,
loculation is usually present, and the fluid does
not shift with changing position. As a rule of
thumb, transudative effusions tend to be free
flowing, but exudative effusions can be either
free flowing or loculated. Thus the content of
pleural fluid cannot be based solely on imaging
appearance and should be based on pleural fluid
analysis. At CT, the split pleura sign, enhance-
ment of both visceral and parietal pleura, is often
used to suggest the possibility of an empyema.
20
It should be noted that chronic exudative effusions
and complex parapneumonic effusions can also
present with a split pleura sign [17].
Malignant pleural effusions are those with
tumor cells in the pleural space and most often
exudate. Effusions in lung cancer patients may
also result unrelated to the tumor itself (cardiac,
hepatic, renal disease, etc.) or may be due to cen-
tral venous obstruction, central lymphatic obstruc-
tion, or post-obstructive atelectasis/pneumonitis
[18]. The latter categories are considered “parama-
lignant.” Sampling of the fluid is considered
necessary to document a malignant effusion. CT
(and PET/CT) is not always diagnostic. Findings
suggesting a malignant effusion at CT include
parietal pleural thickness >1 cm, circumferential
thickening, nodules, and mediastinal pleural
involvement. Increased metabolic activity may be
seen associated with the pleura at PET/CT.
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1. Webb WR. Thin-section CT, of the secondary pulmo-
nary lobule: anatomy and the image—the 2004
Fleischner lecture. Radiology. 2006;239:322–38.
2. Hansell DM, Bankier AA, MacMahon H, McLoud
TC, Muller NL, Remy J. Fleischner society: glossary
of terms for thoracic imaging. Radiology. 2008;246:
697–722.
3. Arakawa H, Webb WR, McCowin M, Katsou G, Lee
KN, Seitz RF. Inhomogeneous lung attenuation at
thin-section CT: diagnostic value of expiratory scans.
Radiology. 1998;206:89–94.
4. Naidich DP, McCauley DI, Khouri NF, Stitik FP,
Siegelman SS. Computed tomography of bronchiecta-
sis. J Comput Assist Tomogr. 1982;6:437–44.
5. Desai SR, Wells AU, Rubens MB, DuBois RM,
Hansell DM. Traction bronchiectasis in cryptogenic
fibrosing alveolitis: associated computed tomographic
features and physiological significance. Eur Radiol.
2003;13:1801–8.
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6. Rossi SE, Erasmus JJ, Volpacchio M, Franquet T,
Castiglioni T, McAdams HP. “Crazy-paving” pattern
at thin section CT of the lungs: radiologic-pathologic
overview. Radiographics. 2003;23:1509–19.
7. Remy-Jardin M, Remy J, Giraud F, Wattinne L,
Gosselin B. Computed tomography (CT) assessment
of ground-glass opacity: semiology and significance.
J Thorac Imaging. 1993;8:249–64.
8. Lynch DA, David GJ, Safrin S, et al. High-resolution
computed tomography in idiopathic pulmonary fibro-
sis: diagnosis and prognosis. Am J Respir Crit Care
Med. 2005;172:488–93.
9. Worthy SA, Muller NL, Hartman TE, Swensen SJ,
Padley SP, Hansell DM. Mosaic attenuation pattern
on thin-section CT scans of the lung; differentiation
among infiltrative lung, airway, and vascular diseases
as a cause. Radiology. 1997;205:465–70.
10. Eisenhuber E. The tree-in-bud sign. Radiology.
2002;222:771–2.
11. Erasmus JJ, Connolly JE, McAdams HP, Roggli
VL. Solitary pulmonary nodules: part I. Morphologic
evaluation for differentiation of benign and malignant
lesions. Radiographics. 2000;20:43–58.
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Recommendations for the management of subsolid
pulmonary nodules detected at CT: a statement
from the Fleischner Society. Radiology. 2013;266:
304–17.
13. Honda O, Tsusubamoto M, Inoue A, et al. Pulmonary
cavitary nodules on computed tomography; differen-
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14. Primack SL, Hartman TE, Lee KS, Muller NL.
Pulmonary nodules and the CT halo sign. Radiology.
1994;190:513–5.
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high-resolution CT of cryptogenic organizing pneu-
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2003;180:1251–4.
16. Proto AV. Mediastinal anatomy: emphasis on conven-
tional images with anatomic and computed tomo-
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and transudates: diagnosis with contrast-enhanced CT.
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Mayo Clin Proc. 2008;83:235–50.
 Types of Biopsies
Mostafa M. Fraig
Types of Biopsies
Wedge Biopsy
It is considered the gold standard for diagnosing
lung conditions where a relatively large area of the
lung parenchyma is needed to scan for focal
changes or identify all the features required for
rendering a specific diagnosis. It is useful for diag-
nosing interstitial lung disease and other diffuse
diseases like hypersensitivity pneumonia and dif-
ferentiating it from nonspecific pneumonia or
other idiopathic interstitial pneumonias [1].
It is considered a complex surgical procedure
requiring splitting chest muscle and spreading the
ribs with disarticulation or resection near the
sternum. Patients are left with chest tubes and
stitches that could remain painful for weeks [1, 2].
Handling these biopsies requires removing the
stapled lines at the edge and inking the edge if
malignancy is suspected. The wedge is serially
sectioned starting from the cut surface going
toward the free pleural edge. The specimen is
usually entirely submitted for processing for max-
imum use of the tissue. There should be a set of
H&E-stained slides with other stains as needed
M.M. Fraig, M.D. (*)
Department of Pathology and Laboratory Medicine,
School of Medicine, University of Louisville,
530 South Jackson Street, Louisville, KY 40202, USA
e-mail: m.fraig@louisville.edu
M.M. Fraig (ed.), Diagnosis of Small Lung Biopsy: An Integrated Approach,
DOI 10.1007/978-1-4939-2575-9_3, © Springer Science+Business Media New York 2015
3
depending on the case. Some pathologists like to
perform pentachrome stains like Movat stains,
reticulin, Masson trichrome, iron stains, and AFB
and GMS stains on a routine basis. In our experi-
ence, these are not needed on all or on the major-
ity of cases, and they can result in more work and
cost for the lab.
Transbronchial Biopsy
This is the most frequent type of lung biopsy to
come to the pathology laboratory and usually
obtained by pulmonologists in the course of the
bronchoscopy procedure along with other sampling
methods such as bronchial brushings and washings
and bronchoalveolar lavages. This affords the labo-
ratory the variety of specimens to perform other
ancillary studies like microbiologic cultures on
the lavage fluid and spare some of the tissue for
histopathologic evaluation [3].
The tissue from this type of biopsy should be
handled gently, and squeezing the tissue with for-
ceps or leaving it out of formalin for a long time
to dry should be avoided. It is preferred to wrap it
in lens paper and not sponges as the latter could
introduce artifacts in the tissue. Several levels,
preferably three, should be performed with the
intervening sections kept on slides for further
stains or studies. This strategy saves most of the
tissue from being wasted during the process of
facing the block and preserves the focal areas of
interest for further evaluation.
21
22
For adequacy purposes, the biopsy should
contain at least one portion of the alveolated lung
if the disease process is mainly in that part of the
lung. Areas immediately next to the bronchial
wall are known to have many nonspecific findings
like fibrosis or chronic inflammation to be infor-
mative about the dominant disease in the lung
parenchyma, and the pathologist should be care-
ful not to overinterpret those areas.
Needle Core Biopsies
These are usually obtained during CT-guided
biopsy of the lung in the evaluation of peripheral
lung nodules that are less amenable to other
modalities for sampling. In the course of the pro-
cedure, the radiologist uses a coaxial needle to tar-
get the lesion and fix the lung so the lesion does
not move with respiration. This also helps to make
several passes into the lesion possible without the
need to retarget the needle. The biopsy needle is
then inserted inside the coaxial needle to reach the
lesion of concern. These needles could vary from
fine aspiration one to spring-loaded dissecting
ones (Tru-Cut® needles). In the latter, the core is
rolled on a slide, and the cellularity is evaluated as
well as the type of lesional tissue to avoid acellular
material or normal lung tissue. After confirming
the suitability of the targeting, subsequent passes
should be dedicated to obtaining tissue for H&E
evaluation or other ancillary studies such as immu-
nohistochemical stains, flow cytometric analysis,
and molecular testing. The latter requires enough
viable cells to be informative, and 4–5 cores are
better for this type of testing as the test is complex
and still relatively expensive. Repeated touch
imprints on every core are not required, and it usu-
ally results in shedding most of the cells on the
slides with few cells left in the core especially with
well-differentiated adenocarcinoma where the
cells are very discohesive and sparse [4–6].
On sectioning these specimens, the protocol
mentioned in the transbronchial biopsy section
above should apply here too. The sections should
be kept on charged slides for the anticipated
immunohistochemical stains. For the very impor-
tant molecular testing, thicker sections could be
made for DNA or RNA extraction.
M.M. Fraig
Fine-Needle Aspiration Biopsy
Fine-needle aspiration biopsy is sometimes the
only option available to adequately biopsy a
given lesion. The transbronchial needle, known
as Wang needle, has a larger gauge, 22, than the
spring-loaded dissecting needle or needles used
in the endobronchial ultrasound (EBUS) modal-
ity. For that reason, they are still useful in obtain-
ing a sizable specimen once the lesion or the
mass is identified by ultrasound.
The material obtained from fine-needle aspi-
ration is useful in providing smeared slides as
well as cell blocks for immunohistochemical
staining. It is also useful for other ancillary stud-
ies such as microbiologic testing, flow cytometric
analysis, and molecular testing. On-site adequacy
assessment is important in the triage as well as
providing real-time feedback to the operator per-
forming the procedure.
Cryobiopsy
Cryobiopsy is the latest type of biopsy that can
produce larger biopsies of alveolated lung through
the application of a flexible freezing probe to
the tissue and then extracting it along with the
surrounding tissue still attached to the probe.
The average size is 15 mm2 compared to 5 mm2
by the forceps-assisted biopsy [7]. The other
advantage besides the increased size of the biopsy
is the lack of crush artifacts frequently introduced
by the jaws of the forceps crushing the tissues.
For these reasons, cryobiopsy is becoming more
suitable for diagnosing diffuse interstitial diseases
that used to require wedge biopsy [1, 8, 9].
An example of a cryobiopsy is shown in Fig. 3.1.
The disadvantage is that the bronchoscope needs
to be withdrawn completely out of the lung with
the specimen as the specimen cannot pass through
the probe channel.
Ancillary Studies on Biopsy Material
Microbiology Studies: These could be performed
on the fluid from the bronchoalveolar lavage
collected in the course of bronchoscopy.
3 Types of Biopsies
Fig. 3.1 Low-magnification view of a transbronchial biopsy (left, a) and a cryobiopsy (right, b) for comparison. Notice
also the lost tissue from the center of the biopsy due to overfreezing
Alternatively the tissue that is removed with the
staple lines from the wedge biopsy could be used
for this purpose if sterile techniques are followed.
Other possibility is to dedicate one pass or
more from the fine-needle aspiration procedure for
that purpose if adequacy assessment is provided,
and it is one of the invaluable reasons to provide
the service. If there is a cell block, special stains
could be performed on the material to rule out
infections.
Flow Cytometry: Fine-needle aspiration
passes are used for this purpose especially from
lymph nodes in the chest when lymphoma is
entertained in the differential diagnosis. Needle
cores could be submitted in the suitable media,
RPMI, for further testing.
Immunohistochemical Staining: This should
be readily performed on sections from the tissue
biopsies regardless of the method of obtaining
them. Cell block material is also invaluable in this
regard as it is better to validate the control tissue
with formalin-fixed cell block than with alcohol-
fixed slides. An excellent cell block technique
involves letting the material clot first on a slide and
then scraping the clotted material in formalin. The
advantages are several. It is cheap requiring no
additional reagents and uses the patient’s blood as
a medium. It provides colored material that is easy
to visualize in paraffin unlike agar, for instance,
that is hard to distinguish from paraffin.
Molecular Testing: The emergence of tar-
geted chemotherapy in recent years required
pathologist to anticipate this type of testing on
23
newly diagnosed lung malignancies. At the cur-
rent time, only adenocarcinoma is the candidate
tumor for the testing for EGFR mutations and
reflex testing for ALK mutations. However, there
is a new trend for genetic profiling of lung tumors
to detect any mutations that could be targeted by
the available drugs used in other tumors. For
example, a BRAF mutation in a lung tumor, while
uncommon, may help in choosing a chemothera-
peutic agent used in the treatment of melanoma
with the same mutation to treat the lung tumor.
The minimum number of cells for adequate
DNA extraction is often cited as 150 cells. Reports
of using the needle rinse for molecular have claimed
high percentage of recovery of tumor cells and
DNA for testing [10]. Different factors play a role in
the final adequacy as the presence of necrosis, nor-
mal cell contamination, and noncellular debris or
material contamination. Every effort should be
made to provide adequate material for such testing
whenever possible as the repeat biopsies are time
consuming and expensive to arrange for.
Common Artifacts and Nonspecific
Findings Identified in Small Lung
Biopsy
Several artifacts are known to be present in the
lung and could represent diagnostic pitfalls in the
interpretation of these biopsies. Some result from
the instrumentation handling and processing of
the tissue (Fig. 3.2).
24
Fig. 3.2 Nonspecific peribronchial fibrosis and chronic
inflammation are common, especially in older patients or
smokers. The abrupt transition from fibrosed areas to nor-
mal lung parenchyma should suggest that this is a focal
phenomenon and has no bearing on the disease process
Pseudo-atelectasis
Compression and squeezing the tissue between
the forceps jaws causes this artifact. One way to
differentiate this is to find sharp transition
between the area of compression and the normal
surrounding well-alveolated lung parenchyma.
On higher magnification, the slit-like air spaces
can discerned within those areas of compression.
This artifact makes it difficult to interpret those
areas affected by it. Gentle handling of the tissue
and keeping it moist should help eliminate most
of these artifacts. Careful interpretation is also
warranted by the pathologist.
Fresh Blood in the Biopsy
Usually this is the result of bleeding from the
biopsy procedure and does not indicate intra-
alveolar hemorrhage. In our experience, most
descriptive diagnoses of small biopsies list this
blood as one of the findings for lack of any specific
diagnosis. This could be confusing to the clinicians
and could lead them along the wrong path investi-
gating the underlying etiology for the alveolar
hemorrhage. True intra-alveolar hemorrhage is rec-
ognized by the presence of numerous hemosiderin-
laden macrophages that do not require iron stains
to be recognized as they are usually engorged with
M.M. Fraig
Fig. 3.3 Pigmented macrophages with tiny anthracotic
pigmentation are a frequent finding in smokers’ lungs and
should not be confused with hemosiderin-laden macro-
phages from alveolar hemorrhage
the characteristic chunky refractile material, which
is hemosiderin. In fact, iron stain could be prob-
lematic as it is positive on pigmented macrophages
from smokers and is reported as positive in those
cases, which again lead to the wrong conclusion of
presence of intra-alveolar hemorrhage where in
reality it is not the case (Fig. 3.3). It takes only 24 h
for hemosiderin-laden macrophages to present in
the lung. If they are accompanied by clotted fibrin
in the alveolar space, blood vessels should be scru-
tinized for evidence of vasculitis.
Intra-alveolar Macrophages
It is a frequent finding in many conditions to the
point that it is almost nonspecific on a small
biopsy if the background disease is not readily
recognized. Smokers and patients with pulmo-
nary edema or pneumonia or any type of fibrosis
or condition that causes the lung to lose its elas-
ticity are likely to result in numerous macro-
phages in the alveoli.
Pseudolipoid Artifact
Occasionally air bubbles in the alveolar spaces
could assume a rounded configuration that is
similar to fat globules noted in exogenous lipoid
3 Types of Biopsies
Fig. 3.4 Pseudolipoid artifact showing air bubbles with
globular shape similar to that of fat globules in lipoid
pneumonia
pneumonia (Fig. 3.4). The difference is that in true
lipoid there are foamy macrophages surrounding
the fat globules. Other features of aspiration pneu-
monia could be seen like multinucleated giant
cells and vegetable matter.
Carcinoid Tumorlets
Nests of neuroendocrine cells growing around the
bronchial walls could occur in patient with chronic
obstruction. They are characterized as tumorlets as
long as the largest dimension is less than 0.5 cm.
Tumors beyond this size are considered as carci-
noid tumors, either typical or atypical type. These
are usually discovered incidentally in lobectomy or
wedge biopsy specimens obtained for other rea-
sons. The morphology is usually bland with uni-
form cells and round or oval nuclei. The chromatin
is usually granular with “salt and pepper” pattern.
There is nesting of the cells with peripheral pali-
sading of the cells (Fig. 3.5). The stroma could be
scant or could show sclerosis and even calcifica-
tions. The cells are positive for neuroendocrine
markers such as chromogranin A and synaptophy-
sin [11]. The mitotic activity should be less than
2/10 HPF, and the Ki 67 proliferative should be
extremely low (less than 2 %). They can be mis-
taken for metastatic carcinoma to the lungs [12].
25
Fig. 3.5 Carcinoid tumorlets are small nests of cells with
neuroendocrine differentiation as noted by the “salt and
pepper” chromatin and the amphophilic cytoplasm. They
are located directly around the endobronchial wall
Minute Meningothelial-Like
Nodules
Other incidental findings on large biopsies and
lobectomy specimens are the following: They
are usually located within the parenchyma
(to differentiate from carcinoid tumorlets).
Their morphology is akin to that of meningothe-
lial whorls. They have spindle cells with fre-
quent pseudoinclusions, and they could be
positive for EMA and vimentin immunohisto-
chemical stains (Fig. 3.6a, b). Although ultra-
structural evidence was presented to show
similarity to meningothelial cells, which resulted
in a change of the name from chemodectoma to
meningothelial-like nodules, on the genetic level,
they were not similar to meningioma; hence, their
origin is uncertain [13].
Corpora Amylacea
This is another frequent finding in the lungs of old
patients and those with massive pulmonary
edema. They are seen in the alveolar spaces
assuming the rounded deposits of concentrically
lamellate bodies with eosinophilic color. They
may represent degenerative by-products, and they
have no clinical significance.
26 M.M. Fraig

Fig. 3.6 Low-magnification images of so-called chemodectoma or minute meningothelial-like nodules (left, a) and
higher magnification (right, b) showing the characteristic spindle cells with their pseudoinclusions

Fig. 3.7 Multilobated megakaryocyte with dark smudgy Fig. 3.8 Astroid body is a frequent finding in the setting
chromatin is entrapped in the alveolar lining and could be of sarcoidosis, but it is not pathognomonic of the disease
confused with viral cytopathic effect or radiation effect and could be found in other conditions

Mineralization and Ossification

Megakaryocytes of Bronchial Cartilage

The lung is a very vascular organ with massive
circulation of blood going through it every min-
ute. Megakaryocytes frequently get trapped in
the fine capillaries of the lung, and they some-
times appear in the alveolar lining (Fig. 3.7).
They could be mistaken for viral cytopathic
effect or the degenerative smudgy cells from che-
motherapy or radiation therapy. They are numer-
ous in septic conditions and metastatic tumors.
Mineralization or calcification of the bronchial
cartilage is a frequent finding in older patients
that has no clinical significance. They could also
have oncocytic change of the seromucinous
glands in the wall of the bronchus. Ossification of
the cartilage could also occur.
Other insignificant or incidental findings
include smooth muscle nodules, dystrophic calci-
fication, and astroid bodies (Fig. 3.8).
3 Types of Biopsies
Practical Approach to Small Lung
Biopsy
1. It is very important to be familiar with the
clinical history and/or the imaging studies of
the patients to maximize the diagnostic yield
from these biopsies.
2. On scanning magnification, try to see if the
process is mainly bronchocentric or parenchy-
matous in the alveolated areas.
3. Look for acute lung injury pattern with the
characteristic fibroblastic plugs and swirls of
fibroblasts. If that is the case, look for hyaline
membrane, and then look for viral inclusions
or acute pneumonia to discern the etiology of
either bronchiolitis obliterans/organizing
pneumonia or diffuse alveolar damage.
4. Granulomas are the next item, and they could
be subtle and especially the poorly formed
ones. The carrot-shaped nuclei with haphaz-
ard orientation in a thickened area should be a
tip-off. Follow the algorithm for our radio-
logic correlation chapter as to what the type of
lesion is. It is important to recognize the dif-
ference between airspace lesions and nodular
or diffuse processes.
5. Fibrin in the alveoli should denote leaking
vessels and prompt closer scrutiny of the
blood vessels.
6. Sometimes it is what you can rule out from the
biopsy rather than what you are able to diag-
nose that could help the pulmonologists to
narrow their differential diagnosis.
7. Do not be afraid to say “unremarkable endo-
bronchial wall and alveolated lung” instead of
listing all nonspecific findings that confuse
the clinician.
References
1. Fruchter O, Fridel L, El Raouf BA, Abdel-Rahman N,
Rosengarten D, Kramer MR. Histological diagnosis
of interstitial lung diseases by cryo-transbronchial
biopsy. Respirology. 2014;19:683–8.
27
2. Colt HG, Russack V, Shanks TG, Moser KM.
Comparison of wedge to forceps videothoracoscopic
lung biopsy. Gross and histologic findings. Chest.
1995;107:546–50.
3. Schwartz LE, Aisner DL, Baloch ZW, Sterman D,
Vachani A, Gillespie C, Haas A, Litzky LA. The diag-
nostic efficacy of combining bronchoscopic tissue
biopsy and endobronchial ultrasound-guided trans-
bronchial needle aspiration for the diagnosis of malig-
nant lesions in the lung. Diagn Cytopathol. 2013;41:
929–35.
4. Logrono R, Wojtowycz MM, Wunderlich DW, Warner
TF, Kurtycz DF. Fine needle aspiration cytology and
core biopsy in the diagnosis of alveolar soft part sar-
coma presenting with lung metastases. A case report.
Acta Cytol. 1999;43:464–70.
5. Priola AM, Priola SM. Computed tomography-guided
needle biopsy of lung lesions: is fine needle aspiration
really more accurate than core needle biopsy? Acta
Radiol. 2013;54:1150–1.
6. Yamagami T, Iida S, Kato T, Tanaka O, Nishimura T.
Combining fine-needle aspiration and core biopsy under
CT fluoroscopy guidance: a better way to treat patients
with lung nodules? Am J Roentgenol. 2003;180:811–5.
7. Babiak A, Hetzel J, Krishna G, Fritz P, Moeller P,
Balli T, Hetzel M. Transbronchial cryobiopsy: a new
tool for lung biopsies. Respiration. 2009;78:203–8.
8. Casoni GL, Tomassetti S, Cavazza A, Colby TV,
Dubini A, Ryu JH, Carretta E, Tantalocco P, Piciucchi
S, Ravaglia C, Gurioli C, Romagnoli M, Gurioli C,
Chilosi M, Poletti V. Transbronchial lung cryobiopsy
in the diagnosis of fibrotic interstitial lung diseases.
PLoS One. 2014;9:e86716.
9. Pajares V, Puzo C, Castillo D, Lerma E, Montero MA,
Ramos-Barbon D, Amor-Carro O, Gil de Bernabe A,
Franquet T, Plaza V, Hetzel J, Sanchis J, Torrego A.
Diagnostic yield of transbronchial cryobiopsy in inter-
stitial lung disease: a randomized trial. Respirology.
2014;19:900–6.
10. Sakairi Y, Sato K, Itoga S, Saegusa F, Matsushita K,
Nakajima T, Yoshida S, Takiguchi Y, Nomura F,
Yoshino I. Transbronchial biopsy needle rinse solution
used for comprehensive biomarker testing in patients
with lung cancer. J Thorac Oncol. 2014;9:26–32.
11. Aubry MC, Thomas Jr CF, Jett JR, Swensen SJ,
Myers JL. Significance of multiple carcinoid tumors
and tumorlets in surgical lung specimens: analysis of
28 patients. Chest. 2007;131:1635–43.
12. Darvishian F, Ginsberg MS, Klimstra DS, Brogi E.
Carcinoid tumorlets simulate pulmonary metastases
in women with breast cancer. Hum Pathol. 2006;37:
839–44.
13. Torikata C, Mukai M. So-called minute chemodec-
toma of the lung. An electron microscopic and immu-
nohistochemical study. Virchows Arch A Pathol Anat
Histopathol. 1990;417:113–8.
 Airspace-Occupying Diseases
Mostafa M. Fraig
Acute Pneumonias
Acute pneumonias could be divided into infec-
tious, which include bacterial, fungal, and viral
ones, and noninfectious which include aspiration,
lipoid, and allergic ones. In most cases of bacterial
or viral pneumonia, a biopsy is not needed to make
the diagnosis as other microbiological studies or
empirical treatment is instated based on the clini-
cal picture and imaging finding. Only in cases that
do not respond to antibiotics or because of other
compounding factor like in immunocompromised
patients, a biopsy is obtained, and the infectious
process is evident through the presence of numer-
ous neutrophils with or without a mucopurulent
exudate as in Fig. 4.1a, b.
On a small biopsy, the presence of acute inflam-
mation and/or necrosis is a fortuitous finding.
It tends to be sporadic or focal judging from the
autopsy material. Usually, by the time a patient is
scheduled for a biopsy, the most common finding is
the organizing pneumonia which will be discussed
later under the acute lung injury pattern.
Viral pneumonia could present in different
ways. Adenovirus infection could be subtle and
shows only as dark smudgy nuclei in the alveolar
M.M. Fraig, M.D. (*)
Department of Pathology and Laboratory Medicine,
School of Medicine, University of Louisville,
530 South Jackson Street, Louisville, KY 40202, USA
e-mail: m.fraig@louisville.edu
M.M. Fraig (ed.), Diagnosis of Small Lung Biopsy: An Integrated Approach,
DOI 10.1007/978-1-4939-2575-9_4, © Springer Science+Business Media New York 2015
4
lining or with viral cytopathic effect showing
ground-glass nuclei. On the other hand, influenza
virus and herpes simplex virus (HSV) tend to
cause areas of necrosis and some neutrophilic
infiltrate similar to that of bacterial pneumonia.
The clue to the viral etiology would be based on
the presence of viral cytopathic changes with
nuclear inclusions in case of the HSV and ground-
glass nuclei in the influenza virus. These findings
could be present in the background of diffuse
alveolar damage (DAD), and recognizing the viral
etiology or other etiologies in general is important
in the treatment of these cases. Cytomegalovirus
induces only chronic inflammation and is charac-
terized by the enlarged cells with basophilic
nuclear inclusions. The virus usually infects alveo-
lar lining cells and endothelial cells.
Acute Lung Injury Pattern
The clinical definition of acute lung injury has
evolved over the years. In its latest iteration, it is
defined as the ratio of the partial pressure of the
arterial oxygen relative to that pressure in inspired
air. A ratio of <300 is considered indicative of
acute lung injury, and a ratio <200 confirms respi-
ratory failure due to acute respiratory distress
syndrome (ARDS) [1].
From the histopathologic point of view, the
acute lung injury pattern is one that is predomi-
nantly of organizing fibrosis mainly by fibroblastic
proliferation and a recent myxoid background.
29
30
Fig 4.1 Low magnification view of the fibrinopurulent
exudate in the alveolar space with thickening of the inter-
alveolar septa in (a). A higher magnification of the same
The fibrosis is of the recent type without dense
collagen deposition or distortion of lung architec-
ture as would be highlighted by a reticulin stain.
The main two entities of this pattern are DAD
which is the majority of cases of ARDS. The
idiopathic variant of DAD is acute interstitial
pneumonia (AIP) or Hamman-Rich disease. The
other entity is bronchiolitis obliterans/organizing
pneumonia (BOOP) with its idiopathic variant
called cryptogenic organizing pneumonia (COP)
[2]. There is a substantial overlap in the histo-
morphologic features between BOOP and DAD.
In both of these entities, there are commonly:
1. Thickening of the interalveolar septa with
mild chronic inflammatory infiltrate and fibro-
blastic proliferation. The septa could also
demonstrate intercellular edema exaggerating
the thickness of the septa and making it appear
as a reticular pattern.
2. Proliferation of type II pneumocytes lining the
alveolar spaces.
3. Proliferation of the fibroblasts forming polyp-
oid and fascicular bundles filling up the alveo-
lar spaces to be called “fibroblastic plugs.”
The latter could plug the alveolar air spaces or
the bronchial lumens.
The lung will turn into a consolidated mass
with sporadic air spaces in predominantly fibro-
elastic mass comprised by the thick septa and
fibroblastic plugs [3]. This in turn hinders gas dif-
fusion and hence results in the shortness of breath
and hypoxia when measuring blood gases.
M.M. Fraig
pattern shows the neutrophilic infiltrate in the alveoli as
well as in the interstitium in (b)
Bronchiolitis Obliterans/Organizing
Pneumonia
It is by far the most common pattern seen on a lung
biopsy. Several reasons account for that; BOOP
could be encountered as a reaction to the primary
lung injury. This would include post-infectious
pneumonia, inhalational injury, post radiation,
aspiration pneumonia, and in the setting of colla-
gen vascular disease. In addition, BOOP could be
present around mass lesions in the lung such as
tumors or granulomas. In the latter situation, if
there is familiarity with imaging finding and if
there is suspicion for a mass lesion, it is important
to communicate to the clinician that the presence
of BOOP could be a nonspecific finding, which
does not account for the mass lesion seen on imag-
ing. The other scenario where BOOP can be pres-
ent is as a minor component of other disease
entities such as hypersensitivity pneumonia or
nonspecific interstitial pneumonia [4].
Histopathologic Features
BOOP usually appears as polypoid structures
bulging into the air spaces in the peribronchial
areas with a short stalk embedded in the intersti-
tium (Fig. 4.2a, b). Some fascicles of elongated
fibroblasts could be seen extended in parallel to
the interalveolar septa. Using collagen stains
4 Airspace-Occupying Diseases
Fig. 4.2 Low power magnification of a small biopsy
showing the pale areas with the myxoid fibroblastic plugs
and the cellular infiltrate in the thickened interalveolar
Fig. 4.3 Another example of a polypoid fibroblastic plug filling up the alveolar space (a), and another one is almost
obliterating the bronchial lumen (b)
such as Movatt stain, the highlighted light green
color of recent organizing fibrosis pattern appears
as a tree of cauliflower extending throughout
the lung parenchyma in the area of biopsy [5].
The polypoid masses used to be called “Masson’s
bodies.” The interstitial cellular infiltrate is usu-
ally comprised by a mixture of lymphocytes,
plasma cells, macrophages, and neutrophils
(Fig. 4.3a, b). The presence of lymphoid aggre-
gates or lymphoid follicles with germinal centers
should raise the possibility of a more chronic pro-
cess such as hypersensitivity pneumonia (HP) or
collagen vascular disease. The presence of poorly
formed granulomas and eosinophils would make
the first more likely, and the history and serologic
testing would confirm the latter.
31
septa. The air spaces are markedly reduced by the infil-
trate (a). The polypoid plug with its stalk is shown with
swirling bands of fibroblasts (b)
Whereas, in most cases, the histomorphologic
features do not provide the underlying etiology of
BOOP, it is important to not ignore some of the
easily recognizable etiologies. Finding a frothy
material in the alveolar space in an immunocom-
promised patient would suggest Pneumocystis
jiroveci pneumonia. In addition, looking for viral
inclusions or smudgy nuclei characteristic of
adenovirus infection would elicit the causing
agent in some cases.
Sometimes, it is difficult to rule out DAD
based on a small biopsy, and because of the sig-
nificant overlap between BOOP and DAD, an
umbrella term such as “acute lung injury pattern”
may be a useful first step in characterizing the
lesion in the lung. DAD usually has an interstitial
32
pattern with less fibroblastic plugs and more
fascicles of fibroblasts and of course the hallmark
of hyaline membrane. These could be sporadic
and not included in the small transbronchial
biopsy, but the use of acute lung injury pattern
could cover both entities as they share common
therapeutic and management pathways.
Another term that is usually confused with
BOOP is obliterative bronchiolitis or constric-
tive bronchiolitis. Many in the lung transplant
community refer to it as “bronchiolitis obliter-
ans” which is the opposite of BOOP clinically
and histopathologically. Obliterative bronchiol-
itis most commonly occurs as a late complica-
tion of transplant rejection and is mainly a small
airway disease. The lung parenchyma is almost
normal, and the main problem is the presence of
an annular band of fibrosis constricting the
lumen of the small airways [6]. Movatt stain is
helpful in highlighting the fibrosis.
Idiopathic BOOP is usually a problem on
imaging and clinically. As the name suggests,
there is no prior incident to suggest the presence
of a sole area of consolidation or ground-glass
opacity in the lung, and suspicion of malignancy
is in the differential diagnosis, especially for ade-
nocarcinoma in situ, which used to be called
bronchioloalveolar carcinoma. This particular
type was recognized as a separate clinicopatho-
logic entity and given the name COP. However,
from the histopathologic standpoint, it is similar
in every aspect to BOOP [7].
Diffuse Alveolar Damage and Adult
Respiratory Distress Syndrome
DAD is characterized by an insidious onset and a
rapid course of respiratory failure requiring
mechanical ventilation in most cases. In clinical
terminology, this is recognized as ARDS.
However, there are several etiologies that could
result in ARDS but fail to show the characteristic
findings of DAD in histopathologic examination.
For instance, acute silicosis could result in mas-
sive pulmonary edema that results in ARDS, but
the pathology of course is not that of DAD. All
cases of DAD are considered part of ARDS but
not all cases of ARDS would result in DAD.
M.M. Fraig
The list of potential causative agents is long and
variable. The list includes infection, toxic inhal-
ants, drugs, radiation and chemotherapy, trauma
and shock, burns, and certain ingested material
like kerosene.
Pathologically, the disease goes through two
stages:
Exudative phase: usually in the first week of pre-
sentation and is characterized by presence of
patchy areas of pulmonary edema and plasma pro-
teins in the alveolar spaces. There are mild or focal
areas of thickening of the interalveolar septa.
Organizing phase: usually sets in the second
week and usually when the patient is stable
enough to be biopsied. They are usually the find-
ings discussed above. In later stages the hyaline
membrane would start to disappear leaving
behind a small fragment of fibrin or hyaline
membrane embedded within the interstitium.
This is a result of the sticky surfaces of opposing
hyaline membrane-coated alveolar linings fusing
together and taking with them the hyaline mem-
brane in what would appear as the interstitium. In
this stage the presence of organized fibrin thrombi
in small blood vessels could be used in lieu of the
hyaline membrane to diagnose DAD.
Histopathologic Features
The biopsy from a patient with DAD shares many
similarities with those from BOOP. However,
certain points need to be understood to recognize
the difference between these two entities:
1. DAD is a combination of an epithelial injury
as well as endothelial injury. As such, the
endothelial injury will result in leakage from
the small vessels and the formation of intra-
vascular thrombi, and plasma proteins will be
present in the alveolar spaces. When the
degeneration and necrosis by-products mix
with the fibrin from the plasma proteins, they
form a slurry-like material that paints the
alveolar lining layer as what we recognize as
the hyaline membrane (Fig. 4.4a, b). The lat-
ter makes gas diffusion more difficult than
even in BOOP. For this and other reasons,
4 Airspace-Occupying Diseases
Fig. 4.4 Organizing diffuse alveolar damage with the
loose myxoid background and diminished air spaces simi-
lar to that in BOOP without the polypoid fibroblastic plugs
Fig. 4.5 An intravascular thrombus blocking the lumen of medium-sized blood vessels (a). The area distal to these
blood vessels showed pulmonary infarction with subsequent squamous metaplasia and atypical mitotic figures (b)
patients with DAD usually require mechanical
ventilation and have worse prognosis than
those with BOOP [8].
2. The presence of intravascular thrombi in
larger vessels could lead to areas of lung
infarctions. These could ultimately result in
the squamous metaplasia with atypia. These
areas could include abnormal mitotic figures
and areas of necrosis. It is very important to
be very cautious in interpreting fine needle
aspiration material or bronchoalveolar lavages
(BALs) from patients suspected of having
DAD or who are on ventilators. The metaplas-
tic squamous epithelial cells along with the
33
(a). The well-defined hyaline membrane is lining the alveo-
lar spaces with a continuous undulating pattern and the
thick interalveolar septa with intercellular edema (b)
necrotic debris could lead to an erroneous
diagnosis of squamous cell carcinoma
(Fig. 4.5a, b).
3. Most patients with DAD get biopsied by the
second week of presentation where the orga-
nizing phase is the predominant phase.
However, some patients may be biopsied
earlier. In the latter case, pulmonary edema
and an eosinophilic material representing the
leaked plasma proteins could be copiously
present without the characteristic hyaline
membrane or the areas of fibroblastic prolif-
eration. Some authors called this “acute fibrin-
ous and organizing pneumonia” (AFOP) [9].
34
Fig. 4.6 Low magnification view of the slightly thick-
ened interalveolar septa, lined by type II pneumocytes and
showing an eosinophilic material in the alveolar spaces
Some investigators thought it belongs to a
form of BOOP; others thought it represents an
early phase of DAD (Fig. 4.6a, b). In practice
the distinction is not important as the treat-
ment would follow the patient’s performance
status and the picture would be of an acute
lung injury pattern.
4. The idiopathic form of DAD is also a distinct
entity called “acute interstitial pneumonia”
(AIP) or Hamman-Rich disease after the two
physicians who first described the disease
occurring in relatively young patients and
resulting in an accelerated course of respiratory
failure and a characteristic form of fibrosis on
autopsy.
5. DAD could be superimposed on cases of usual
interstitial pneumonia (UIP), and in that case it
is called “accelerated phase of UIP.” If the
patient has been previously diagnosed with
UIP or there is a radiologic evidence of UIP as
would be discussed later, the presence of a
DAD picture along with the honeycomb
changes in the lung would point to that diagno-
sis. If there are several biopsies from different
lobes, one might show UIP without DAD [10].
6. A subset of patients with AIP may come with
a protracted history of respiratory symptoms
that does require mechanical ventilation only
to show histopathologic evidence of DAD on
the biopsy.
M.M. Fraig
(a). A closer view shows the lack of hyaline membrane
and fibroblastic proliferation seen in the later organizing
phase (b)
Intra-alveolar Hemorrhage
As a general rule the diagnosis of hemorrhage in
the lungs requires the presence of hemosiderin
macrophages. The mere presence of blood within
the biopsy is not enough evidence for intra-
alveolar hemorrhage as blood from the biopsy
procedure is usually the culprit for such
hemorrhage.
Intra-alveolar hemorrhage in its primary form
is a diffuse process involving all areas of the
lung. The potential etiology is usually an autoim-
mune disease such as Goodpasture syndrome
[11]. In this case a small portion of the biopsy
should be snap frozen for immunofluorescence
studies. Other common causes would include
vasculitides such as capillaritis syndrome in
microscopic polyangiitis and Henoch-Schonlein
purpura. Other primary diseases are associated
with toxic inhalants and drugs. An idiopathic
form also exists.
In Goodpasture syndrome, there is an associ-
ated renal lesion, and immunofluorescence with
linear deposits along the basement membrane is
diagnostic. There is a marked accumulation of
hemosiderin-laden macrophages with their char-
acteristic chunky refractile material with an
orange or brown discoloration. They can also be
deposited within the lung parenchyma. Iron stain
4 Airspace-Occupying Diseases
Fig. 4.7 Intra-alveolar hemorrhage with hemosiderin-
laden macrophages containing chunky crystals brown to
yellow hemosiderin (a). In a case of vasculitis, there are
leaking vessels due to inflammation of the wall by the
usually is not needed to highlight hemosiderin as
it is easy to identify on H&E stain (Fig. 4.7a, b).
In cases of a vasculitis, a similar picture is
present with the additional finding of fibrin in the
alveolar spaces with the evidence of the vasculitis
also present in the blood vessels.
In cases of idiopathic pulmonary hemosidero-
sis, the diagnosis is by exclusion as in any idio-
pathic case. The chronic bleeding may lead the
marked deposits of hemosiderin to encrust the
medial wall of the blood vessels resulting in what
is called “endogenous pneumoconiosis.”
In secondary alveolar hemorrhage, the causes
include infections especially necrotizing ones.
Systemic diseases that affect the coagulation
mechanisms such thrombocytopenia and coagu-
lation defects, uremia, and renal failure are the
most common ones.
Localized hemorrhage could be the result of a
focal lesion or disease that causes bleeding in one
or several small blood vessels. This includes vaso-
invasive fungi such as aspergillus or narcotizing
tumors. The bronchial wall could have lesions
eroding through the wall and the accompanying
vessel. The significance of identifying these
lesions is to justify the resection that could be per-
formed to stop the bleeding. Sometimes the
pathologist is left with this task after the operation
is performed, and if there is no lesion or an obvious
culprit, the fear is that it could happen again.
35
lymphocytic infiltrate of this case of lymphatoid granulo-
matosis with concomitant fibrin deposits in the alveoli.
Notice the lack of neutrophilic infiltrate (b)
Pulmonary Alveolar Proteinosis
Pulmonary alveolar proteinosis (PAP) is a rare
disease that could be idiopathic, secondary, or
congenital. In most cases the idiopathic or
acquired form affects middle-age adults in 90 %
of the cases. The secondary form (5–10 % of
cases) is mainly due to inhalational exposure to
industrial material such as silica, cement dust,
aluminum, or titanium oxide. The rare congenital
form affects children in the neonatal period.
There is a controversy as whether it is a true PAP
condition; however, the prognosis is invariably
poor. The etiology of the primary type is poorly
understood. It is thought to be a mutation that
affects the function of GM-CSF, an important
factor in surfactant homeostasis and an essential
regulator in immune defense [12]. An increased
level of GM-CSF autoantibodies was found in
patients with primary PAP. Most patients present
with dyspnea and nonproductive cough. Less
common symptoms include low fever, weight
loss, fatigue, and chest pain.
Imaging studies show areas of lung opacities
sparing the apices and costophrenic angles on a
chest X-ray. On CT scan the characteristic
“crazy-paving” pattern is recognized. It is a com-
bination of ground-glass opacities with reticular
(septal) lines that involve any area of the lung but
36
Fig. 4.8 General view of PAP showing the characteristic
amorphous material in the alveolar space with needle-
shaped cholesterol clefts (a). A higher magnification view
tend to spare the costophrenic angles. Even
though the CT findings are highly suggestive,
they are still nonspecific, and a lung biopsy is
needed to confirm the diagnosis.
Histomorphologic Features
An eosinophilic amorphous material with choles-
terol needle-shaped clefts is seen filling the alve-
oli. The alveolar walls are not usually affected by
the process, but there could be a focal increase in
the wall thickness that is filled by an inflamma-
tory infiltrate. Small eosinophilic globules that
stain positive with periodic acid-Schiff stain with
diastase digestion are also present (Fig. 4.8a–c).
The interlobular septa are also widened and show
abnormally dilated lymphatics.
M.M. Fraig
of the D-PAS-positive globules in PAP (b). Contrasting
view of pulmonary edema with a homogeneous material
and several macrophages floating in the fluid (c)
The main differential diagnosis is with pulmo-
nary edema where the edema leaves little strands
of proteins or faint powdery material. Plasma
proteins leaking in the alveolar space assume a
homogeneous eosinophilic material that shows
scalloping near the alveolar walls. The D-PAS-
positive globules are also absent by special stains.
Another differential is with the frothy material
seen in Pneumocystis jiroveci. The latter is an
infection in immunocompromised patients and as
such usually shows widening of the interalveolar
septa, and the material is frothy rather than gran-
ular with no cholesterol clefts or D-PAS-positive
globules.
The treatment in these cases usually is by
repeated BAL. The prognosis is usually good and
few patients might need to have a repeat BAL
within few months.
4 Airspace-Occupying Diseases
Pneumoconiosis
Most of pneumoconiosis results in an interstitial
disease. The old entity of giant cell interstitial
pneumonia or GIP was considered part of the
idiopathic interstitial pneumonia till it was found
to harbor many of the exogenous materials from
industrial exposure. However, some of these
agents can manifest in the alveolar spaces as
numerous macrophages and giant cells contain-
ing the offending agent. The determination of the
agent requires careful clinical history and tissue
analysis of crystals and other materials in spe-
cialized laboratories.
Pulmonary Edema
Pulmonary edema is a common finding in hospi-
talized patients who undergo intravenous infu-
sion, and they end up with circulatory overload.
Patients with congestive heart failure, hypopro-
teinemia, or cirrhosis are prone to have pulmo-
nary edema. The edema fluid can be serous with
very few solutes or proteins, and this will appear
as thinly reticular mesh or crisscrossing strands
or powdery material in the alveolar spaces.
If plasma proteins are admixed, they appear as a
homogenous eosinophilic material. Corpora
amylacea, which are concentrically lamellated
eosinophilic bodies in the alveolar spaces, are
usually seen especially in older patients. They are
nonspecific findings in those patients and in
autopsy cases.
37
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D’Alessio FR, Kubo K. Acute lung injury review.
Intern Med. 2009;48:621–30.
2. Cordier JF. Organising pneumonia. Thorax. 2000;55:
318–28.
3. Epler GR. Bronchiolitis obliterans organizing pneu-
monia: definition and clinical features. Chest. 1992;
102:2S–6S.
4. Epler GR, Colby TV. The spectrum of bronchiolitis
obliterans. Chest. 1983;83:161–2.
5. Capdevila E, Banus E, Domingo C, Ferrer A, Mata JM,
Marin A. [Bronchiolitis obliterans organizing pneumo-
nia: the usefulness of the transbronchial biopsy as a
diagnostic technic]. An Med Interna. 1994;11:449–51.
6. Myers JL, Colby TV. Pathologic manifestations of
bronchiolitis, constrictive bronchiolitis, cryptogenic
organizing pneumonia, and diffuse panbronchiolitis.
Clin Chest Med. 1993;14:611–22.
7. Azzam ZS, Bentur L, Rubin AH, Ben-Izhak O, Alroy
G. Bronchiolitis obliterans organizing pneumonia.
Diagnosis by transbronchial biopsy. Chest. 1993;104:
1899–901.
8. Blennerhassett JB. Shock lung and diffuse alveolar
damage pathological and pathogenetic considerations.
Pathology. 1985;17:239–47.
9. Beasley MB, Franks TJ, Galvin JR, Gochuico B,
Travis WD. Acute fibrinous and organizing pneumo-
nia: a histological pattern of lung injury and possible
variant of diffuse alveolar damage. Arch Pathol Lab
Med. 2002;126:1064–70.
10. Kaarteenaho R, Kinnula VL. Diffuse alveolar damage:
a common phenomenon in progressive interstitial
lung disorders. Pulm Med. 2011;2011:531302.
11. Boyce NW, Holdsworth SR. Pulmonary manifestations
of the clinical syndrome of acute glomerulonephritis
and lung hemorrhage. Am J kidney Dis. 1986;8:31–6.
12. Frazier AA, Franks TJ, Cooke EO, Mohammed TL,
Pugatch RD, Galvin JR. From the archives of the
AFIP: pulmonary alveolar proteinosis. Radiographics.
2008;28:883–99; quiz 915.
 Interstitial Lung Diseases in Small
Lung Biopsies
Mostafa M. Fraig
Interstitial Lung Diseases
Liebow and Carrington through their work in the
1970s were the first to classify and organize the
entity of interstitial lung disease [4]. Their land-
mark work resulted in a classification schema that
recognized usual interstitial pneumonia (UIP) as a
distinct entity and not just a common pathway to
end-stage lung disease. In addition they identified
desquamative interstitial pneumonia (DIP) as
another entity even though the name was found to
be incorrect later on. They added lymphocytic and
giant cell interstitial pneumonias (LIP and GIP,
respectively) to the category. These were found to
represent cases of low-grade lymphoma in the
case of the first and cases of pneumoconiosis in
the latter. The entity of bronchiolitis obliterans
interstitial pneumonia (BIP) was added as it
represented to them an acute phase of the other
fibrosing conditions (Table 5.1).
Later, Katzenstein and Askin refined this clas-
sification and added other entities such as nonspe-
cific interstitial pneumonia (NSIP) and respiratory
bronchiolitis-interstitial lung disease (RB-ILD).
LIP and GIP were removed from the classifica-
tion as they were considered no longer idiopathic
M.M. Fraig, M.D. (*)
Department of Pathology and Laboratory Medicine,
School of Medicine, University of Louisville,
530 South Jackson Street, Louisville, KY 40202, USA
e-mail: m.fraig@louisville.edu
M.M. Fraig (ed.), Diagnosis of Small Lung Biopsy: An Integrated Approach,
DOI 10.1007/978-1-4939-2575-9_5, © Springer Science+Business Media New York 2015
5
diseases. BIP was also removed because it related
to the acute lung injury pattern which eventually
resolves and leaves no residual effects on the lung
(Table 5.2).
The most recent attempt in classifying these
entities has been through the combined effort of
the American Thoracic Society and the European
Respiratory Society with two schemas in almost
a decade [5–7].
As more knowledge accumulated, the classifi-
cation became more refined, and criteria for diag-
nosis and subset of patients were recognized as
different in prognosis and response to treatment.
For example, patients with UIP associated with
CVDs were found to represent a subset that fares
better than the idiopathic UIP one [8]. The use of
high-resolution CT and the experience of radiol-
ogist in diagnosing UIP made the requirement for
surgical biopsy in many cases redundant.
Clinical and Radiological Findings
of UIP
It is important before looking at the biopsy from
interstitial lung disease to be familiar with the
clinical and radiological findings. UIP usually
presents in the fifth and sixth decades of life with
an insidious onset of progressive dyspnea and
shortness of breath. Patients have bilateral crack-
les on auscultation with a characteristic “Velcro
type.” The pulmonary function tests (PFTs) have
a restrictive pattern.
39
40 M.M. Fraig

Table 5.1 Liebow classification of interstitial lung

disease, 1975
Usual interstitial pneumonia (UIP)
Bronchiolitis obliterans interstitial pneumonia (BIP)
Desquamative interstitial pneumonia (DIP)
Lymphoid interstitial pneumonia (LIP)
Giant cell interstitial pneumonia (GIP)

Table 5.2 Current classification by Katzenstein, 1995

Usual interstitial pneumonia (UIP)
Desquamative interstitial pneumonia (DIP)
Acute interstitial pneumonia (AIP)
Nonspecific interstitial pneumonia (NSIP)
Fig. 5.1 Patch fibrosis with broad areas with collagen
deposition alternating with areas with reticular fibrosis in
Radiologically, by high-resolution CT, there is UIP. In the center there is a fibroblastic focus
a bilateral fibrosis accentuated in the lower por-
tion of the lung and in the lung periphery with
occasional honeycomb pattern in those areas.
Ground-glass opacities are frequent findings in
all of interstitial lung disease. The picture could
be so characteristic that along with the clinical
findings, in half the cases the diagnosis could be
made without obtaining a biopsy.

Histopathologic Findings

Open lung biopsy used to be the gold standard for

diagnosing idiopathic interstitial disease. In this
biopsy several areas of the lung would be sam-
pled preferably with a sample from each lobe tar-
geting involved areas guided by the CT scan
image. In the affected areas there is a patchy
process of fibrosis and mild to moderate chronic
inflammatory infiltrate. UIP could be called
“peripheral fibrosis of the lung.” The process is
usually more pronounced in the periphery of the
lung with honeycomb changes in those areas and
also in the periphery of the lung lobules with the
center of the lobule less affected by fibrosis than
the periphery. The fibrosis takes place by dense
collagen deposition with a mild inflammation
within those areas (Fig. 5.1). Fibroblastic foci are
areas of recent fibrosis that show a recent type of
fibrosis with myxoid background and small
fascicles of fibroblasts within the interstitium
juxtaposed immediately to areas of dense fibrosis,
Fig. 5.2 The fibroblastic focus is under higher magnifica-
tion showing the streaming fibroblasts in a myxoid back-
ground. The focus is only slightly bulging from the
interstitium and is next to an area with dense fibrosis, in
contrast to the polypoid fibroblastic plugs seen in BOOP
a feature that helps differentiating it from the
fibroblastic plugs of cryptogenic organizing
pneumonia in which the age of fibrosis is uniform
and plugs assume a polypoid configuration
(Fig. 5.2). The inflammation is never severe, but
lymphoid aggregates could be present, and when
there are several of them, a possibility of UIP
associated with CVD should be raised to be con-
firmed by serological testing. The latter group of
patients usually has a better prognosis than the
one with idiopathic UIP [8]. Features that indi-
cate chronic irritation of the lung could be seen in
5 Interstitial Lung Diseases in Small Lung Biopsies
Fig. 5.3 An area of bronchial metaplasia with many alve-
olar spaces lined by columnar epithelium and inspissated
mucous filling bronchial lumens
Fig. 5.4 An area with honeycomb changes under the
pleural surface which corresponds to areas of accentuated
fibrosis in the periphery of the lungs on high-resolution
CT scan images
the same setting. These would include type II
pneumocytes proliferation, bronchial metaplasia,
and smooth muscle cirrhosis (Fig. 5.3).
Honeycomb changes representative of those seen
on CT are also present in the periphery under the
pleura (Fig. 5.4). Foamy and pigmented macro-
phages could be seen in the alveolar spaces, but
their significance and contribution to the diagno-
sis are limited. Rare granulomas or other inciden-
tal findings could be seen, but their significance
and detraction from the diagnosis should be
weighed against the other evidence of UIP.
41
Table 5.3 Revised American Thoracic Society/European
Respiratory Society classification of idiopathic interstitial
pneumonias: multidisciplinary diagnoses [7]
Major idiopathic interstitial pneumonias
Idiopathic pulmonary fibrosis
Idiopathic nonspecific interstitial pneumonia
Respiratory bronchiolitis-interstitial lung disease
Desquamative interstitial pneumonia
Cryptogenic organizing pneumonia
Acute interstitial pneumonia
Rare idiopathic interstitial pneumonias
Idiopathic lymphoid interstitial pneumonia
Idiopathic pleuroparenchymal fibroelastosis
Unclassifiable idiopathic interstitial pneumonias
An important caveat to the diagnosis is the
location of the biopsy as the tips of the lobes are
notorious for harboring many of the features of
chronic irritation of the lung with a sudden transi-
tion to the completely normal lung away from the
very tip of the lobe. Caution should be exercised
and correlation with high-resolution CT should
be performed.
Recently, several reports of the possibility of
making the diagnosis of UIP from transbronchial
biopsy have surfaced [1]. However, the diagnos-
tic yield of such biopsies is still low (specificity
of 26–32 %) [3]. Another promising type of
biopsy is the cryobiopsy which offers better size
and less artifacts to make the diagnosis more reli-
able [3].
In the latest ATS/ERS schema for the diagno-
sis of UIP, the histopathologic findings were
divided to definite, probable, possible, and not
UIP based on the presence or absence of certain
criteria summarized in Table 5.3.
Clinical Course
Many UIP patients succumb to the condition
known as “accelerated phase of UIP” where the
patients go quickly into respiratory failure requir-
ing mechanical ventilation. Histologically, the
findings are similar to organizing diffuse alveolar
damage superimposed or alternating with areas
of characteristic UIP pattern. Hyaline membrane
formation and fibroblastic proliferation along
42 M.M. Fraig

with edema and fibrin deposits are present along

with interstitial dense fibrosis and evidence of
chronic lung irritation.
Unfortunately, UIP presents a problem for
understanding the underlying pathogenesis and
also treatment. Immunosuppressive drugs failed
to make any significant difference in the lives of
these patients. Just recently, there are reports that
pirfenidone, an anti-fibrogenic drug, shows some
promising results in clinical trials [9]. Lung
transplant is currently the only available hope for
these patients.

Fig. 5.5 Uniform fibrosis and moderate interstitial inflam-

Nonspecific Interstitial Pneumonia mation with uniform age of the fibrosis are all criteria for the
diagnosis of nonspecific interstitial pneumonia (NSIP)
It used to be reserved for non-classifiable cases
that did not quite fit any of the idiopathic intersti-
tial pneumonia category. However, in a landmark
paper, Katzenstein et al. after analyzing a cohort
of these cases reached to the conclusion that they
represent a distinct group from UIP and other
entities, even though they share similar features
with UIP patients [10, 11].

Clinical and Radiological Findings

of NSIP

These patients are usually a decade younger than

those of UIP, and the male to female ratio is almost
equal. They usually present with an insidious onset
of dyspnea and shortness of breath. They have the
same pattern of restrictive changes on the PFTs.
Radiologically, there is a reticular pattern of fibro-
sis and ground-glass opacities on high-resolution
CT. The characteristic peripheral attenuation seen
in UIP is usually lacking, and honeycomb changes
are not a standard feature. The picture is usually
more prominent in the lower lobes though, which
helps in the differential diagnosis with hypersensi-
tivity pneumonia [12].
There is a frequent association with CVD,
especially rheumatoid arthritis and scleroderma.
NSIP could be the presenting disease in the lung
of CVD. The prognosis of NSIP is much better
than that of UIP with an overall 5-year survival
between 75 and 90 % [11].
Fig. 5.6 NSIP showing the same type of uniform fibrosis
and areas with markedly cellular infiltrate that lack the
variegated pattern and fibroblastic foci seen in UIP
Histopathologic Features
The main distinguishing feature of NSIP from
UIP, an important and crucial differential diagno-
sis, is the temporal and architectural uniformity of
the fibrosis. There is a thickening of interalveolar
septa by increased fibrosis and a chronic inflam-
matory infiltrate (Fig. 5.5). The amount of the lat-
ter could range from marked to sparse. Based on
that, the NSIP patterns could be divided into cel-
lular NSIP on one extreme and fibrotic NSIP with
a possible third pattern of mixed NSIP when
there are alternating patterns of both (Fig. 5.6).
5 Interstitial Lung Diseases in Small Lung Biopsies
Fig. 5.7 NSIP with cellular interstitial chronic inflamma-
tion and uniform fibrosis
The fibrotic pattern imparts a worse prognosis
and has been lumped with cases of UIP in the
past. The key difference from UIP is the lack of
fibroblastic foci and the lack of variegated pattern
of fibrosis (Fig. 5.7). Microscopic foci of BOOP
could be encountered in the biopsy, and these
should not draw away from the diagnosis. The
presence of granulomas or marked eosinophilia
should point to other granulomatous diseases
instead of NSIP.
Clinical Course
While many clinicians wondered about the clini-
cal entity of NSIP from the standpoint of clinical
presentation, the fact remains that it is mostly a
treatable disease and has a good response to cor-
ticosteroids, and it pays to distinguish it from
other idiopathic interstitial pneumonias, espe-
cially UIP. As to what NSIP really represent, sev-
eral speculations were put forward, including a
possibility of CVD presenting in the lung with
these manifestations in this group of patients,
similar with what these diseases present in the
kidney. Another possibility is that some cases
could represent cases of hypersensitivity pneu-
monia where the insulting antigen has not been
identified. Another possibilities are cases of
slowly resolving BOOP or acute pneumonia and
lastly cases of inadequately sampled UIP [13].
The entity is expanding, as will be discussed
43
later, and the presence of macrophages, whether
foamy or pigmented ones, should not detract
from the diagnosis.
Desquamative Interstitial
Pneumonia and Respiratory
Bronchiolitis-Interstitial Lung
Disease
In the original classification of Liebow, DIP was
thought of as a disease where the epithelial cells
slough off and fill the alveolar spaces and hence
the name, DIP. However, later studies revealed
these cells to be pigmented macrophages from
smoking. The close association with smoking
history made this disease and others like it more
smoking related rather than idiopathic pneumo-
nia. Respiratory bronchiolitis (RB) is a disease
with few symptoms that was reported in smokers
based on an autopsy study by Niewoehner et al.
[14]. These cases were reported to have a peri-
bronchial pattern of fibrosis with the accumula-
tion of pigmented macrophages in the same
areas, which is different from the diffuse pattern
seen on imaging and on biopsies of DIP. Patients
with RB did not have their PFTs measured, and
the presence of clinical evidence of interstitial
lung disease was not documented. Recognition of
the occurrence of restrictive pattern of changes
on PFTs led to the designation of this subset of
patient as RB-ILD, a diagnosis that would require
the performance of PFTs and knowledge of the
restrictive pattern. It was thought then that the
two entities, DIP and RB-ILD, represented two
ends of the spectrum. The presence or absence of
the peribronchial pattern of fibrosis became
almost irrelevant in making the diagnosis of
RB-ILD. Some pathologists shied away from
making this diagnosis without knowing this
information which in most cases is not provided
with the biopsy. However, there is more overlap
in the clinical presentation, radiologic imaging,
and histopathologic features that makes the dis-
tinction between the two entities almost arbitrary.
DIP with the classic marked fibrosis described in
the original reports is more akin to NSIP than to
RB-ILD [15]. The reason of this distinction is the
44 M.M. Fraig

effect of cessation of smoking and corticosteroid

therapy on one group that might not be enough to
alter the disease in the other one. Another obser-
vation is the presence of pigmented macrophages
in sheets whenever the lungs are fibrosed for any
other reason, like in cases of asbestos exposure or
bleomycin treatment, which could result in a sec-
ondary phenomenon of DIP-like reaction (see
below) in the setting of fibrosis and not the pri-
mary disease.

Clinical Presentation of RB-ILD

and Smoking-Related Diseases Fig. 5.8 RB-ILD showing clusters of lightly pigmented
macrophages in the alveolar spaces. There is air duct in
Dyspnea and shortness of breath with dry cough the center assuming a slightly curved line and an inter-
lobular septum on the right side
are the most common symptoms in these patients.
The history of smoking is very common in
90–100 % of cases. Males are more affected than
females and the mean age is a decade younger
that of UIP. As in all interstitial lung diseases,
there are restrictive changes on the PFTs.
Radiologically, there are diffuse ground-glass
opacities with fine reticular fibrosis in the lungs.
The lung images could be normal in some cases.
Usual emphysematous changes encountered in
smokers are not seen in these patients, so air
trapping and cyst formation are not features of
the disease.
Fig. 5.9 A loose cluster of pigmented macrophages is in
the alveolar space. Notice the mild fibrosis in the interal-
Histopathologic Findings veolar septa

The diagnosis of RB-ILD and DIP has been con-
troversial as was outlined in the introduction. The
degree of fibrosis is an important parameter. In
RB-ILD, mild fibrosis should be used as one
important criterion of the diagnosis as cases with
marked and broad fibrosis or interstitial scarring
are not going to improve unless these are spo-
radic and constitute as a small portion of the lung
(Fig. 5.8). The pigmented macrophages are usu-
ally dispersed in the alveolar spaces and only
small clusters are noted. Small sheets of these
macrophages can be seen under the pleural sur-
face. The macrophages are usually tan or light
brown and contain small dark powdery particles
in the cytoplasm (Fig. 5.9). They can be easily
differentiated on routine stains from the
hemosiderin-laden macrophages of alveolar
hemorrhage where the cytoplasm contains a
chunky refractile material. In fact, iron stain can
be confusing as it would be positive in both types
of macrophages with only the degree of positivity
separating the two entities. The macrophages
should be in every alveolar space.
A newly described entity called “smoking-
related interstitial fibrosis (SRIF)” that was
described in patients with resected lung for lung
cancer is similar to RB-ILD except for a few dif-
ferences which include fibrotic interstitial scar-
ring and the presence of emphysematous changes
(Fig. 5.10) [16]. Since these patients presented
5 Interstitial Lung Diseases in Small Lung Biopsies
Fig. 5.10 An area of fibrosis and chronic inflammation in
the interstitium with clusters and single pigmented macro-
phages. Torn interalveolar septa with terminal clubbing
consistent with emphysematous changes can be seen. This
latter finding is not seen in RB-ILD or DIP. It is a feature
of smoking-related interstitial fibrosis (SRIF)
with their lung cancer signs and symptoms, it is
hard to identify any distinguishing clinical pic-
ture to expect in patients with this condition.
Other investigators are calling the entity
“smoking-related interstitial lung disease
(SR-ILD)” or “combined pulmonary fibrosis and
emphysema syndrome” [17]. The presence of
nodules on radiologic imaging and in the biopsy
should raise the possibility of Langerhans cell
histiocytosis (LCH), which presents in the same
population of patients but at a younger age and
with spontaneous pneumothorax. On examining
the histologic sections, there is a characteristic
stellate shaped lesion with a collection pale areas
containing the abnormal histiocytes that stain
positive by CD1a immunostain (Fig. 5.11).
DIP-Like Reaction
An important reason to correlate with the CT
findings is to avoid overcalling areas with excess
pigmented macrophages, which are usually local-
ized, as one of the smoking-related diseases.
This phenomenon is usually associated with
45
Fig. 5.11 A collection of abnormal histiocytes with convo-
luted nuclei and pale cytoplasm admixed with lymphocytes,
plasma cells, and eosinophils in the background. This is the
hallmark of Langerhans cell histiocytosis (LCH)
focal obstruction of the lung due to the presence
of mass lesion like a large granuloma or tumor
masses. Areas distal to these masses usually have
post-obstructive pneumonia with the accumulation
of foamy as well as pigmented macrophages.
It could also occur whenever the structure of
the lung is stiffening by fibrosis and the lung
loses its elasticity.
Acute Interstitial Pneumonia
Acute interstitial pneumonia (AIP) is similar in
many aspects to DAD. It is also similar to the
condition described by both Hamman and Rich.
So the name Hamman and Rich disease is syn-
onymous with AIP. The only differentiating fac-
tor from DAD is that AIP is idiopathic and there
is no known underlying etiology.
Clinical Presentation of AIP
Rapid respiratory failure unexplained by any pre-
cipitating factor is the most common presentation.
Patients usually require mechanical ventilation
and supportive measures. Imaging would show
diffuse ground-glass opacities and consolidation
of the lungs. The patients could be of any age.
The prognosis is similar to that of DAD and is
46 M.M. Fraig

Fig. 5.12 Widening of the interalveolar septa with fibro- Fig. 5.13 Hyaline membrane is lining the alveolar space
blastic proliferation in the background of myxoid matrix in AIP and plump type II pneumocytes next to it
is a feature seen in acute interstitial pneumonia (AIP).
There is also type II pneumocyte proliferation indicating
an epithelial injury

variable from one series to another. The treat-

ment is by supportive measures and corticoste-
roid therapy. The mortality rate is between 40 and
70 % within a few months. The disease could
recur in those who survive the first episode.

Pathologic Findings
The findings are very similar to those from orga-
nizing DAD. Typically, there is widening of the
interalveolar septa by recent fibroblastic prolifera-
tion and moderate chronic inflammatory infiltrate
(Fig. 5.12). The hyaline membrane can be noted
coating the alveolar walls (Fig. 5.13). Remnants
of the hyaline membrane could be seen dispersed
within the interstitium. Intravascular thrombi
could be seen at different stages of organization
with areas of squamous metaplasia present wher-
ever intermediate blood vessels are involved
(Fig. 5.14). In general, the picture is that of an
acute lung injury and is different from that of UIP
or NSIP. There is no dense fibrosis and areas simi-
lar to BOOP are more dominant than those in
NSIP. The presence of hyaline membrane and its
remnants is diagnostic.
Fig. 5.14 Areas of squamous metaplasia in AIP. Caution
should be exercised in interpreting these cells in the bron-
choalveolar lavage from these patients as an erroneous
diagnosis of malignancy could be rendered
Hypersensitivity Pneumonia (HP)
HP is a very common differential diagnosis with
the entities included in idiopathic ILD. There are
several clinical similarities as well as radiological
and pathologic overlapping features that warrant
a discussion here. The disease is also known as
extrinsic allergic alveolitis and is immunologi-
cally mediated. The response is both humoral and
cell mediated. Several antigens and agents present
a potential to invoke such reaction with differing
potencies. Many of these have been characterized
5 Interstitial Lung Diseases in Small Lung Biopsies
over the decades and recognized by their specific
names from the bird fancier’s lung, farmer’s lung,
humidifier’s lung, and several others.
Clinical Presentation
HP can present in an acute, subacute, or chronic
form depending on the amount and duration of
antigen exposure. In the acute form the patient
would suffer an acute onset of severe dyspnea,
high fever, and chills that will subside within 12 h.
On imaging there will be ground-glass opacities
and small nodules. As the relationship between
the exposure and the symptoms is clearly evident,
these patients will be diagnosed clinically and
rarely that a biopsy would be needed.
In the subacute and chronic forms, patients are
exposed to smaller amounts of antigen over a
more protracted period of time. The subacute con-
dition lasts for weeks to months where the chronic
one is a prolonged process and takes years with
more prominent changes resulting in an irrevers-
ible damage to the lungs. Sometimes, there is no
clear relationship to an antigen, and a lung biopsy
provides the first clue to the diagnosis. On high-
resolution CT imaging, there are ground-glass
opacities and linear attenuation with traction
bronchiectasis and reticular fibrosis indicating
honeycomb changes. There will be small nodules
corresponding to lymphoid aggregates scattered
in the mid to upper portion of the lungs [18]. This
picture is very important in the differential diag-
nosis with both UIP and NSIP where the disease
usually dominates in the lower lobes and there are
no nodules. However, a significant overlap could
occur, and because of the chronic nature of the
disease, HP is the most common disease in the
differential diagnosis of UIP and NSIP [19].
Histopathologic Findings
The changes follow the route of the antigen to
have a bronchocentric pattern. There are areas of
fibrosis with marked cellular infiltrate by lym-
phocytes and plasma cells and some eosinophils
47
Fig. 5.15 Low-magnification view of hypersensitivity
pneumonia (HP) showing interstitial fibrosis and marked
cellular infiltrate with occasional lymphoid aggregates
in the mix. Epithelioid histiocytes could be present
in aggregates, and lymphoid follicles with germi-
nal centers are frequently present. Poorly formed
granulomas with multinucleated giant cells are
present usually near or around the bronchial wall
(Fig. 5.15). Areas of BOOP are also present, and
these create a mixed picture of acute and chronic
lung injury that could be confused with UIP or
accelerated phase of UIP. However, the marked
cellularity and absence of patchy fibrosis and
fibroblastic foci should help rule that out. In addi-
tion the presence of granulomas should rule out
idiopathic interstitial lung disease altogether
(Fig. 5.16a, b). Difficult cases can present as
fibrosing HP where there are more pronounced
fibrosis and features of chronic irritation of the
lung such as bronchial metaplasia and smooth
muscle cirrhosis with less cellular infiltrate.
The presence of poorly formed granulomas and
frequent lymphoid follicle could help in the dif-
ferential diagnosis [20].
Lymphoid Interstitial Pneumonia
This is a controversial entity as some authors
consider these cases to belong to NSIP if they are
not part of the low-grade lymphoproliferative
disorders. Others think some of these cases repre-
sent a separate entity as in the case of patients
48
Fig. 5.16 (a) A poorly formed granuloma from a case of
HP showing histiocytes and multinucleated giant cells,
but no foreign material is seen. (b) A foreign material
with Sjogren’s syndrome. Diffuse lymphocytosis
and lymphoid follicles with germinal centers in
the background of areas with broad fibrosis and
dense collagen deposition are the hallmarks of
the disease [21].
Summary
Idiopathic interstitial lung diseases are a group of
diseases with different outcomes and with signifi-
cant management differences. The integration of
the clinical, radiological, and pathologic findings
is crucial to making the diagnosis and avoiding
diagnostic pitfalls. The role of smaller biopsy
especially cryobiopsy is evolving and might
increase the number of biopsies as a tool not only
to establish the diagnosis but also to follow up on
the effect of treatment. Under those circumstances,
it is important to use all the information available
to try to reach a definitive diagnosis. However, in
the absence of information, applying a strict set of
criteria in making the diagnosis should be fol-
lowed. There are difficult cases and even with all
available data, are still hard to categorize. In those
cases, a descriptive diagnosis is warranted, and an
explanatory note as to what is present and what is
absent and where the pathologist is standing from
all the possible diagnoses could be helpful. In
many cases it is an evolving process, and the dis-
ease might manifest itself better on follow-up.
M.M. Fraig
from a bird fancier’s lung surrounded by a foreign-body
giant cell reaction
The more information is available, the better the
chance for a proper diagnosis. Teamwork is impor-
tant, and switching venues with scattering infor-
mation in different institutions and with different
care providers should be discouraged.
References
1. Berbescu EA, Katzenstein AL, Snow JL, Zisman
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 Diagnosis of Granulomatous
Disease and Vasculitis in Small
Lung Biopsies
Sanjay Mukhopadhyay
Introduction
A granuloma is a compact (organized) aggregate
of histiocytes [1]. Granulomas are a common
pathologic finding in transbronchial, endobron-
chial, and needle biopsies of the lung in routine
practice [2]. Although sarcoidosis and infec-
tions (mycobacterial or fungal) account for the
majority of these lesions, several other entities
enter the differential diagnosis [1, 3]. The aim of
this chapter is to discuss clinical, radiologic,
and histologic findings that help to arrive at a
specific diagnosis using small lung biopsies.
A common problem faced by pathologists is that
organisms cannot be demonstrated even on spe-
cial stains, and there are no pathognomonic fea-
tures of specific noninfectious entities. The
approach to such cases is discussed. Finally,
selected vasculitic diseases are reviewed since
some of these overlap substantially with granu-
lomatous lung diseases.
The diagnostic approach to granulomas in the
lung has been described in considerable detail,
including an algorithmic approach [1, 4]. The key
steps are as follows:
S. Mukhopadhyay, M.D. (*)
Department of Anatomic Pathology, Cleveland
Clinic, Robert J. Tomsich Pathology and Laboratory
Medicine Institute, 9500 Euclid Avenue/L25,
Cleveland, OH 44195, USA
e-mail: mukhops@ccf.org
M.M. Fraig (ed.), Diagnosis of Small Lung Biopsy: An Integrated Approach,
DOI 10.1007/978-1-4939-2575-9_6, © Springer Science+Business Media New York 2015
6
Determine whether the granulomas are necrotizing
or non-necrotizing. Identification of necrosis is a
key step in narrowing the differential diagnosis
since it influences the likelihood of finding an
organism. The majority of necrotizing granulomas
of the lung are caused by mycobacterial or fungal
infections, while sarcoidosis is the most common
cause of non-necrotizing granulomas [1, 3]. Some
entities, such as Cryptococcus infections and par-
ticulate matter aspiration, do not fit neatly within
this paradigm, in that necrosis is present in some
cases but absent in others. These entities are dis-
cussed separately in “Causes of Granulomatous
Inflammation with Variable Necrosis” section.
1. Try to ascertain whether granulomas are
located within the airspaces (alveolar spaces)
or interstitium (alveolar septa) and whether
they show a predilection for peribronchiolar
or perivascular parenchyma. This further nar-
rows the differential diagnosis.
2. Look carefully for organisms on hematoxylin–
eosin (H&E)-stained slides before ordering
special stains. Most organisms that cause
pulmonary granulomas are visible on H&E,
especially at high magnification. Notable
exceptions are mycobacteria and Histoplasma
(in histoplasmomas) [5–7].
3. Obtain “special” stains for microorganisms. It is
prudent to have a low threshold for ordering
stains, especially in the following situations:
• Necrotizing granulomas. Abundant necro-
sis should prompt a rigorous search for
organisms.
51
52
• Loose, vaguely granulomatous histiocytic
infiltrates. Such infiltrates may contain
numerous organisms.
• The patient is immunocompromised.
• The clinician is particularly suspicious of
infection.
Ziehl–Neelsen (commonly referred to as
AFB, which stands for acid-fast bacteria) and
Grocott methenamine silver (GMS) are the best
stains. Periodic acid–Schiff (PAS) is less sensi-
tive than GMS, especially for Histoplasma,
which is the only fungus that cannot be visual-
ized without special stains.
4. Look for organisms only within the granulo-
matous inflammatory infiltrate, using the cor-
responding H&E-stained slide for orientation.
Organisms are usually found in the necrotic
center of the granuloma, but may also be found
in the granulomatous rim within histiocytes or
multinucleated giant cells [7–9]. Searching
randomly is unproductive.
5. Organisms may be visible at low magnifica-
tion if they are large, darkly staining, or numer-
ous. However, mycobacteria and some fungi
(e.g., Histoplasma) can be missed unless the
search includes painstaking examination at
high magnification. A thorough search with a
40× objective is usually sufficient, but myco-
bacteria can be so rare that a meticulous search
in a large area of necrosis can take up to a half
hour to find a single AFB. Constant adjustment
of fine focus is useful when hunting for AFB,
and an oil immersion lens can also be helpful
in difficult cases.
6. Look for specific histologic features of nonin-
fectious granulomatous diseases (described
below) [1].
Causes of Necrotizing
Granulomatous Inflammation
Tuberculosis
Clinical and Radiologic Findings
Worldwide, tuberculosis is the most common
cause of necrotizing granulomas in the lung. This
is not true in the United States, however, where
S. Mukhopadhyay
fungal infections are a more common cause of
pulmonary granulomas, especially in endemic
areas [3]. It is important for pathologists to
remember that tuberculosis is a clinical, radio-
logic, and/or microbiologic diagnosis, not a histo-
logic one. The diagnosis may be confirmed by
growth of M. tuberculosis in cultures of sputum,
bronchial washings, or biopsied lung tissue. In the
appropriate clinical setting, a positive blood inter-
feron-gamma release assay or a positive purified
protein derivative (PPD) test may provide sup-
portive evidence. In most cases, the role of the
pathologist is to exclude alternative diagnoses,
identify granulomatous inflammation, and detect
mycobacteria (AFB). Although differentiation of
M. tuberculosis from non-tubercular mycobacte-
ria such as M. avium complex (MAC) is impor-
tant for therapy, these organisms cannot be
distinguished histologically. Pathologists should
be prepared to explain to clinicians that mycobac-
terial speciation is best performed by microbio-
logic cultures. Cultures are often positive even
when special stains on histologic specimens are
negative [3]. If, as is often the case, tissue was not
submitted for cultures, or cultures are negative,
polymerase chain reaction (PCR) assays for M.
tuberculosis and non-tubercular mycobacteria can
be used on formalin-fixed paraffin-embedded tis-
sue. In practice, however, these assays are unavail-
able for clinical use in most laboratories, and their
yield is low in cases with small numbers of organ-
isms. In a recent study, PCR for M. tuberculosis
on formalin-fixed paraffin-embedded tissue did
not detect even a single additional case of tuber-
culosis in pulmonary necrotizing granulomas in
which histologic special stains and microbiologic
cultures were negative [10].
Histologic Findings in Small Biopsies
Necrotizing granulomatous inflammation is the
hallmark of tuberculosis [11]. Although non-
necrotizing granulomas may occur alongside
necrotizing granulomas, pure non-necrotizing
granulomatous inflammation is rare [1]. The
granulomas of tuberculosis are often described
as “caseating,” an outdated term that refers to the
cheese-like macroscopic (gross) appearance of the
necrosis. The necrosis of tuberculous granulomas
6 Diagnosis of Granulomatous Disease and Vasculitis in Small Lung Biopsies
Fig. 6.1 Tuberculosis. Transbronchial lung biopsy from
an elderly individual with cough and weight loss. Cultures
grew M. tuberculosis. (a) This ill-defined histiocytic
is in fact quite variable histologically, ranging
from pink (eosinophilic, corresponding to the so-
called caseous necrosis) to “dirty” (basophilic
due to necrotic nuclear debris) to frankly suppu-
rative (neutrophil rich). Pink necrosis is the most
common, but this “caseation” is entirely nonspe-
cific since it can be seen in virtually any granulo-
matous mycobacterial or fungal infection [10].
Necrosis in tuberculosis is usually abundant. The
granulomatous infiltrate can be ill defined or
vague, and necrosis may not be sampled, espe-
cially in small biopsies (Fig. 6.1a, b). There are
no histologic features that differentiate tubercu-
losis from other infectious granulomatous lung
diseases.
Detection of AFB is a key responsibility of the
pathologist. AFB are tiny rod-shaped structures
that stain red (in a blue background) on acid-fast
stains such as Ziehl–Neelsen or Fite (Fig. 6.1a, b).
53
infiltrate is vaguely granulomatous. Compare with
Fig. 6.2a. (b) Ziehl–Neelsen stain shows several acid-fast
bacteria
As stated above, M. tuberculosis and non-
tubercular mycobacteria cannot be differentiated
histologically. Although some cases may show
large numbers of organisms, AFB are often very
few and difficult to find in immunocompetent
individuals. Screening with a 20× objective
(or lower) may miss organisms if they are few in
number. Examination with a 40× or 100× (oil
immersion) objective lens for several minutes is
required in most cases. Mycobacteria are most
commonly found within the necrotic center of
necrotizing granulomas, although (unlike
Histoplasma) they can also be found in the gran-
ulomatous rim. Each necrotic area in the slide
should be examined meticulously with constant
adjustment of fine focus so as not to miss organ-
isms that may be visible in only one plane. Areas
other than the necrotic center and the granuloma-
tous rim virtually never contain organisms.
54
Non-tubercular Mycobacterial
Infection
Clinical and Radiologic Findings
Tuberculosis is such a well-recognized cause of
pulmonary granulomas that few pathologists think
of non-tubercular mycobacteria (mycobacteria
other than M. tuberculosis) as a cause of granulo-
matous inflammation in the lungs. Clinicians and
pathologists are most familiar with these organ-
isms in the setting of acquired immunodeficiency
syndrome (AIDS), in which low CD4 counts pre-
dispose to uncontrolled proliferation of these
organisms within macrophages. It is not widely
recognized that infections with these organisms
frequently involve immunocompetent patients
[12]. In fact, in the United States, non-tubercu-
lar mycobacteria are now more commonly iso-
lated than M. tuberculosis, a trend that is
reflected in lung specimens seen by pathologists
[3, 12]. For unclear reasons, there is a curious
predilection for the right middle lobe and lin-
gula of middle-aged women (“middle lobe syn-
drome” or “Lady Windermere syndrome”) [13,
14]. However, these infections can occur at any
age and involve both genders. The most typical
radiographic picture is multifocal bronchiecta-
sis with multiple small nodules, but cavities and
infiltrates are also common. The diagnosis is
most often made by identifying non-tubercular
mycobacteria in microbiologic cultures of respi-
ratory tract specimens. The most common organ-
ism is Mycobacterium avium–intracellulare
(MAI), currently known as MAC. Other species
such as M. kansasii, M. abscessus, M. fortuitum,
and M. chelonae are occasionally isolated. Since
non-tubercular mycobacteria are common in the
environment (especially in water), a common
clinical dilemma is whether the organisms are
truly responsible for the patient’s symptoms or
are merely contaminants. There is no easy answer
to this question, but clinical criteria to differenti-
ate true infections from saprophytic growth have
been proposed [12]. As with tuberculosis, the role
of surgical pathologists is to exclude malignancy,
identify granulomas, and find mycobacteria on
acid-fast stains.
S. Mukhopadhyay
Histologic Findings in Small Biopsies
The histologic findings of non-tubercular myco-
bacterial infections are highly variable. They
include necrotizing granulomas identical to
tuberculosis, non-necrotizing granulomatous
inflammation associated with organizing pneu-
monia (“organizing granulomatous pneumonia”),
and other nonspecific findings such as bronchiec-
tasis and chronic bronchiolitis [10, 15, 16].
Sheets of foamy macrophages or ill-defined gran-
ulomatous infiltrates—rather than well-formed
granulomas—are characteristic of infections in
immunocompromised hosts, most typically
patients with AIDS. The macrophages in such
patients are usually packed with large numbers of
AFB (Fig. 6.2a, b). The finding of granulomas
within airspaces (alveolar spaces and the lumens
of small bronchioles) is a clue to non-tubercular
mycobacterial infection (see “Hot Tub Lung”
section) [15]. AFB may be found in some cases
in immunocompetent individuals, but many are
negative because of limited sampling or small
numbers of organisms. In such cases, cultures
may yield organisms even in the face of negative
histologic special stains [3, 10]. Therefore, clini-
cians and pathologists must ensure that results of
cultures are negative before an active mycobacte-
rial infection is excluded—this can take up to
several weeks. Cultures are the only definitive
means for differentiating tuberculosis from non-
tubercular mycobacterial infection. For a discus-
sion on examination of acid-fast stains and
mycobacterial speciation, see the preceding sec-
tion on tuberculosis.
Histoplasmosis
Clinical and Radiologic Findings
Histoplasmosis is the most common endemic fun-
gal infection in the United States. It occurs in sev-
eral central, midwestern, and southern states along
the Ohio and Mississippi river valleys, and also in
regions on both sides of the St. Lawrence Seaway,
which runs between Canada and the northeastern
United States. The infection is also endemic in
several countries in Central and South America.
6 Diagnosis of Granulomatous Disease and Vasculitis in Small Lung Biopsies
Fig. 6.2 Non-tubercular mycobacterial infection in an
immunocompromised patient. Transbronchial lung
biopsy. Cultures grew M. avium. (a) Histiocytic infiltrate,
The most common circumstance in which
pathologists encounter Histoplasma is a biopsy of
a lung nodule to rule out malignancy (Fig. 6.3a, b).
The majority of such nodules are incidentally
detected on radiographs performed for unrelated
reasons. The term “histoplasmoma” has been
applied to such nodules when they are shown his-
tologically to be necrotizing granulomas contain-
ing Histoplasma organisms [6, 9, 17, 18]. Several
studies have demonstrated that the organisms in
the majority of these lesions are nonviable and
culture negative [3, 7, 10, 19]. The suffix “-oma”
is applied because these lesions can mimic many
features of malignant lung nodules. Clinicians
and radiologists are trained to recognize small,
stable (nongrowing), calcified, non-spiculated
nodules in nonsmokers as benign [20], but lesions
55
vaguely granulomatous. Such lesions often contain greater
numbers of organisms than well-formed granulomas. (b)
Innumerable acid-fast bacteria on a Ziehl–Neelsen stain
that stray from this norm may be considered
suspicious for malignancy. Thus, a solitary lung
nodule in a smoker or a nodule that is spiculated,
noncalcified, enlarging in size, or positron emis-
sion tomography (PET) positive is liable to be
biopsied. Since each of these features has been
documented in pulmonary histoplasmomas, his-
tology is the only modality that can definitively
determine the nature of such nodules. This type
of nodule is usually peripheral and is best sam-
pled with a needle biopsy [2, 18, 21]. Surgical
pathologists see histoplasmomas in institutions
where core needle biopsies of lung nodules are
performed, whereas in centers where fine needle
aspiration is the preferred approach to peripheral
lung nodules, this lesion falls into the domain of
the cytopathologist.
56
Fig. 6.3 Histoplasmoma. (a) Chest CT showing solitary
lung nodule (arrow). (b) Core needle biopsy of the nodule
shows a necrotizing granuloma. Necrosis is at the top
Rarely, transbronchial or needle biopsy of the
lung may be performed in patients with a poten-
tially fatal, progressive form of histoplasmosis
known as disseminated histoplasmosis [5]. Such
patients are usually immunocompromised and
develop disseminated disease that may second-
arily involve the lungs, analogous to miliary
tuberculosis. In a few cases, clinical and radio-
logic evidence of extrapulmonary involvement is
absent at presentation, making the diagnosis of
disseminated disease challenging. Clinical clues
suggestive of disseminated disease include the
immunosuppressed state of the patient com-
bined with the presence of fever, thrombocyto-
penia, elevated transaminases, multiple lung
nodules, and/or bilateral reticulonodular lung
infiltrates [5].
S. Mukhopadhyay
(arrow) and granulomatous inflammation is at the bottom
left (arrow). No organisms are visible on H&E
Histologic Findings in Small Biopsies
Histologically, a histoplasmoma is a necrotizing
granuloma, the tissue reaction being indistin-
guishable from the so-called caseating granu-
loma of tuberculosis (Fig. 6.3a, b) [6, 9]. The
lesion is characterized by a large necrotic center
surrounded by a relatively thin granulomatous
rim composed of a few layers of epithelioid his-
tiocytes, occasionally accompanied by a few
multinucleated giant cells. Since the majority of
the lesion consists of necrosis, the latter is often
the most prominent finding in needle biopsies
[2, 18, 21]. The necrosis may be pink (“caseous”)
or may contain nuclear debris (“dirty”) or ghosts
of necrotic alveoli (“infarct like”). Histoplasma
yeasts are present within the necrosis, but are
almost never visible on H&E, a diagnostically
6 Diagnosis of Granulomatous Disease and Vasculitis in Small Lung Biopsies 57

Fig. 6.4 Histoplasma yeasts on GMS. (a) When organisms are numerous, narrow-based budding is likely to be present
(arrow). (b) Scarce organisms (arrows) may be missed, especially at low magnification

valuable feature that differentiates Histoplasma
from other fungal yeasts that cause pulmonary
granulomas, all of which are visible on H&E
[1, 6, 7, 9]. GMS staining is required to demon-
strate Histoplasma organisms within the necro-
sis, where they appear as small (3–5 μm),
uniform, oval, round, or tapered yeasts (Fig. 6.4a, b)
[1, 18]. Organisms can vary from numerous to
rare [5]. The size, shape, and uniformity of the
yeasts, as well as their non-visibility within
necrosis on H&E, are the key diagnostic fea-
tures, aiding to distinguish them from
Cryptococcus and Pneumocystis, which are the
fungi most likely to cause diagnostic difficulties
[1, 22]. Narrow-based budding is a helpful fea-
ture, but is also seen in Cryptococcus, and may
not be present when organisms are few in num-
ber. Potential explanations for the non-visibility
of Histoplasma in histoplasmomas on H&E
include the relatively few organisms, necrotic
background, extracellular location, and non-
viability of the organisms [5].
Histoplasma must also be differentiated from
tiny, lightly basophilic microcalcifications, which
are often visible within necrosis on H&E, but are
nonuniform in shape and GMS negative. Dust
particles, which are GMS positive, can mimic
Histoplasma, but they are smaller and less uni-
form and lack the typical oval or tapered shapes
of this organism. Conversely, if GMS-stained
slides are examined only at low magnification,
Histoplasma yeasts can be misinterpreted as dust
particles.
The histologic features of the disseminated
form of histoplasmosis, which can involve the lung,
are highly suggestive of aggressive, widespread
disease and serve as a histologic surrogate marker
of immunosuppression. They include filling of
58
Fig. 6.5 Disseminated histoplasmosis in a transbronchial
lung biopsy. The patient was an immunocompromised
renal transplant recipient. (a) Numerous histiocytes are
present within the airspaces (short arrow) and alveolar
septa (long arrow). Organisms are readily visible within
the cytoplasm of the histiocytes on H&E. There are no
airspaces and alveolar septa by numerous histio-
cytes engorged by large numbers of yeasts that
are easily visible on H&E (Fig. 6.5a, b) [5, 23].
Granulomas are usually absent, although necro-
sis may be present. The visibility of the organ-
isms within viable macrophages on H&E is in
sharp contrast to the morphology of the far more
common histoplasmomas described in the pre-
ceding paragraphs.
Coccidioidomycosis
Clinical and Radiologic Findings
Coccidioidomycosis is a fungal infection
endemic in the southwestern United States
including southern Arizona, southern California,
S. Mukhopadhyay
granulomas. (b) Morphologic details are best appreciated
under oil immersion. Histoplasma yeasts are round to oval
and ring like, with an eccentric purple dot or crescent.
This is the form of histoplasmosis that was described by
Samuel Darling in 1906
New Mexico, Nevada, Utah, and western Texas,
as well as in northern Mexico and other areas in
Central and South America. Cases are occasion-
ally encountered outside these areas in individu-
als who visit or move to other states after being
infected in an endemic area. In endemic areas,
acute exposure causes a flu-like illness known as
acute coccidioidomycosis or valley fever (a dis-
ease named for the San Joaquin Valley in
California). Healed and/or contained infections
can cause lung nodules or cavities that mimic
malignancy, analogous to histoplasmomas (see
“Clinical and Radiologic Findings” section of
histoplasmosis). In some series of solitary pul-
monary nodules in endemic areas, coccidioidal
granulomas are more common than malignan-
cies. Only a minority of patients with nodular/
6 Diagnosis of Granulomatous Disease and Vasculitis in Small Lung Biopsies
Fig. 6.6 Coccidioides in a necrotizing granuloma. Core
needle biopsy of a lung nodule. (a) The main finding in
this biopsy is necrosis. Granulomatous inflammation was
present elsewhere in the biopsy. Large round fungal
cavitary disease are immunocompromised. The
majority have negative results by serology. Thus,
a small lung biopsy can be a valuable nonopera-
tive means of establishing a definitive diagnosis.
Histologic Findings in Small Biopsies
Coccidioidomycosis can be diagnosed on needle
biopsies [18], although the yield is considered to
be poor. Histology is often diagnostic despite
negative cultures [3, 24]. In immunocompetent
individuals, coccidioidomycosis manifests as
necrotizing granulomas with pink (“caseating”)
necrosis identical to tuberculomas or histoplas-
momas [9] or suppurative necrosis similar to
blastomycosis. Eosinophils can be numerous
within the necrotic centers of the granulomas as
well as in the surrounding lung, and this can be a
valuable clue to the diagnosis [25]. However,
59
organisms are visible on H&E, even at low magnification.
(b) Thick-walled Coccidioides spherules, filled with
endospores. The presence of these structures is
diagnostic
eosinophils are absent in some cases. Definitive
diagnosis rests on the identification of “spher-
ules,” which are large (20–100 μm) round struc-
tures with a thick cell wall (Fig. 6.6a, b) [18, 24].
Spherules may be filled with several small yeast-
like “endospores” or may be ruptured, frag-
mented, collapsed, or empty [8]. It has been
proposed that the morphologic diagnosis of coc-
cidioidomycosis should require at least one
endospore-filled spherule [26]. Both spherules
and endospores are visible on H&E, but spher-
ules are easier to recognize because of their large
size [9]. They may be found either within the
necrotic center of the granuloma or within multi-
nucleated giant cells, even in small biopsies.
Budding is absent. Hyphae may occasionally be
found. The main organism in the differential
diagnosis is Blastomyces, which can usually be
60
distinguished by the presence of broad-based
budding and nuclear material. However, in some
cases, Coccidioides and Blastomyces cannot be
reliably differentiated on histologic grounds.
Blastomycosis
Clinical and Radiologic Findings
Blastomycosis is an uncommon fungal infection
that usually involves immunocompetent individu-
als. In North America, most reported cases have
been from states bordering the Great Lakes, the
St. Lawrence Seaway, the Lower Mississippi
valley, and the southeast United States, a geo-
graphic distribution similar to histoplasmosis [27].
Cough and fever are common symptoms. Patients
may present with a flu-like illness, a bacterial
pneumonia-like picture, or acute respiratory dis-
tress syndrome (ARDS). Chest imaging can
show infiltrates, pneumonia-like consolidation,
nodules, or masses with or without cavitation.
Extrapulmonary disease can occur, the major sites
being the skin, genitourinary tract, and bone [27, 28].
The sensitivity of serology is low. Cultures may
take 3–4 weeks to become positive.
Histologic Findings in Small Biopsies
Blastomycosis can be diagnosed in small lung
biopsies [21, 28]. Histology can be positive in
culture-negative cases [29]. Of the major fungal
yeasts that infect the lung, Blastomyces forms the
most distinctive granulomas. The granulomas are
characteristically “suppurative,” i.e., they have
neutrophil-rich centers resembling abscesses.
They are frequently mistaken for abscesses and
are referred to in the older literature as “pyogranu-
lomatous.” The periphery of the granulomas is
composed of epithelioid histiocytes and variable
numbers of multinucleated giant cells. Organisms
can be found both in the suppurative center and
the granulomatous rim [2, 21]. Blastomyces yeasts
are large (8–15 μm) with a thick double-contoured
cell wall. A characteristic feature is the presence
of basophilic nuclear material. The organisms are
visible on H&E as well as GMS. Although GMS
highlights far more organisms than are apparent
on H&E, it also obscures the nuclear material.
Blastomyces characteristically forms a single
S. Mukhopadhyay
broad-based bud, a key feature in the differential
diagnosis with other morphologically similar
fungal yeasts, including Cryptococcus and
Coccidioides [1].
Aspergillosis
Clinical and Radiologic Findings
Fungal hyphae such as Aspergillus usually do not
cause granulomatous inflammation in the lung.
However, a minority of pulmonary infections with
these fungi are associated with a granulomatous
response, which appears to be a marker of limited
tissue invasion. The best-known clinical entity in
which granulomatous inflammation occurs is
chronic necrotizing pulmonary aspergillosis, also
known as semi-invasive aspergillosis [30, 31].
The condition was described as a chronic progres-
sive infection characterized by persistent or enlarg-
ing lung cavities in individuals without preexisting
cavitary lung disease. Subsequent studies have
shown a predilection for men and individuals with
emphysema or compromised immunity.
Histologic Findings in Small Biopsies
Most instances of this entity are characterized by
necrotizing granulomatous inflammation similar
to tuberculosis or histoplasmosis [32]. The diag-
nosis rests on demonstration of fungal hyphae
within the granulomas, usually in the cavitary
center. Aspergillus cannot be reliably differenti-
ated from other morphologically similar fungal
hyphae without microbiologic confirmation.
Wegener’s Granulomatosis
(Granulomatosis
with Polyangiitis/ GPA)
Clinical and Radiologic Findings
Wegener’s granulomatosis is a form of vasculitis
that classically affects the lungs, kidneys, and
upper respiratory tract. It is the most common
type of vasculitis seen in lung biopsies. Patients
usually present with cough, hemoptysis, dyspnea,
renal failure, sinusitis, and/or epistaxis.
Radiographic findings include bilateral cavitary
nodules or infiltrates. Some patients present with
6 Diagnosis of Granulomatous Disease and Vasculitis in Small Lung Biopsies
Fig. 6.7 Granulomatosis with polyangiitis (Wegener’s
granulomatosis). Core needle biopsy. (a) “Dirty” necrosis
is basophilic due to abundant nuclear debris. (b)
Necrotizing vasculitis. The wall of this medium-sized
blood vessel is focally infiltrated and destroyed by an
clinical and radiologic features of diffuse alveolar
hemorrhage. Most cases are positive for anti-
neutrophil cytoplasmic antibodies (ANCA).
Positive immunofluorescence for cytoplasmic
ANCA (c-ANCA) with antibodies against pro-
teinase 3 has high specificity for Wegener’s gran-
ulomatosis. However, it is well documented that
Wegener’s granulomatosis can present with local-
ized pulmonary involvement and that such cases
are significantly more likely to be ANCA negative
than those with multisystem disease. It is such
cases that cause the greatest diagnostic difficul-
ties. Radiologically, these cases may present with
bilateral lung nodules. However, Wegener’s gran-
ulomatosis presenting as a solitary lung nodule
has also been described [33]. Biopsies are most
often performed when the clinical setting is
unusual. Pathologists must therefore be prepared
to recognize the histologic features of Wegener’s
61
inflammatory infiltrate consisting of neutrophils and his-
tiocytes (long arrow). Note that the left side of the vessel
is relatively spared (short arrow is in lumen). This type of
“eccentric vasculitis” is typical of Wegener’s
granulomatosis
granulomatosis in atypical settings and should not
be deterred by the absence of multisystem involve-
ment or a negative ANCA. Patients with localized
pulmonary necrotizing granulomas can subse-
quently develop extrapulmonary vasculitis and
become ANCA positive on follow-up [10].
Histologic Findings in Small Biopsies
The classic histologic findings of Wegener’s
granulomatosis are necrotizing granulomatous
inflammation and necrotizing vasculitis. This
combination is required for a definitive pathologic
diagnosis of Wegener’s granulomatosis. Unfortu-
nately, it is often difficult or impossible to demon-
strate since the affected vessels may be completely
destroyed. The necrosis of Wegener’s granuloma-
tosis is often described as “dirty” due to its baso-
philic hue, which is caused by nuclear debris
derived from necrotic neutrophils (Fig. 6.7a, b).
62
Suppurative (neutrophil rich) necrosis may also
be present. “Geographic” necrosis, characterized
by necrotic areas with irregular contours, cannot
be appreciated in a small biopsy. Tiny microab-
scess-like granulomas with suppurative centers
may be a clue to the diagnosis. They consist of
aggregates of a few multinucleated giant cells
surrounding a minute cluster of neutrophils [34].
Multinucleated giant cells with prominent hyper-
chromatic nuclei may accompany the necrotizing
granulomas. When demonstrable, necrotizing
vasculitis manifests as a mixed neutrophilic–his-
tiocytic infiltrate within vessel walls, often
accompanied by small, subtle foci of fibrinoid
necrosis. The infiltrate frequently involves only
one side of the affected vessel (“eccentric vascu-
litis”) (Fig. 6.7a, b). Karyorrhectic nuclear debris
is often present. Findings that should not be mis-
interpreted as necrotizing vasculitis include vas-
cular inflammation comprised entirely of
lymphocytes and plasma cells, granulomas in the
vessel wall, and necrotic vessels within areas of
parenchymal necrosis. In virtually all cases, there
is a background of severe nonspecific acute and
chronic inflammation containing neutrophils,
lymphocytes, and plasma cells. Organizing pneu-
monia (plugs of fibroblasts within airspaces) may
be present. The presence of hemosiderin-laden
macrophages in and around the inflammatory
process is another clue to the correct diagnosis.
Wegener’s granulomatosis occasionally pres-
ents with diffuse pulmonary hemorrhage, the
histologic correlate of which is “capillaritis,” a
destructive vasculitis affecting alveolar septal cap-
illaries [35–37]. It is characterized by a mixed neu-
trophilic–histiocytic inflammatory infiltrate that
destroys alveolar septa and is accompanied by
intra-alveolar hemorrhage consisting of variable
combinations of fresh blood (red blood cells),
fibrin, and hemosiderin-laden macrophages. The
neutrophils invariably spill into the adjacent air-
spaces, causing acute bronchopneumonia to enter
the differential diagnosis.
Transbronchial lung biopsies may occasionally
show suggestive but nonspecific findings such as
acute inflammation mixed with granulomatous
inflammation or granulomas with dirty necrosis
[38]. In such cases, a definitive diagnosis cannot
be made by histology alone and requires correla-
tion with ANCA serologies.
S. Mukhopadhyay
Churg–Strauss Syndrome
(Eosinophilic Granulomatosis
with Polyangiitis/EGPA)
Clinical and Radiologic Findings
Churg–Strauss syndrome is a rare disease of
asthmatic individuals characterized by tissue and
blood eosinophilia, granulomatous inflammation,
and vasculitis. Patients typically present with
fever, weight loss, striking peripheral (blood)
eosinophilia, and transient or migratory pulmo-
nary infiltrates. Imaging features include
ground-glass opacities, centrilobular nodules, and
airspace consolidation [39]. Many patients have
extrapulmonary manifestations such as cutaneous
lesions or neuropathy. Perinuclear ANCA
(p-ANCA) is positive in approximately two-thirds.
Many cases are diagnosed without biopsy or with
a biopsy of a site other than the lung.
Histologic Findings in Small Biopsies
The most consistent histologic feature of Churg–
Strauss syndrome is the presence of increased
numbers of eosinophils within the affected tis-
sues. The full spectrum of diagnostic findings,
which consists of a combination of necrotizing
vasculitis, granulomatous inflammation with
eosinophils, and eosinophilic pneumonia [4], is
rarely seen, especially in transbronchial biopsies
[40]. However, pathologists should recognize
that any of these features—especially in combi-
nation with numerous eosinophils—raises the
possibility of Churg–Strauss syndrome in the
appropriate clinical context.
Rheumatoid Nodule
Clinical and Radiologic Findings
Rheumatoid nodules typically present as multiple
pulmonary nodules in patients with known
rheumatoid arthritis [10]. Most patients are sero-
positive at the time of diagnosis, and some have
concomitant subcutaneous rheumatoid nodules.
Histologic Findings in Small Biopsies
It is impossible to make this diagnosis with cer-
tainty on a small biopsy since it is partially a
diagnosis of exclusion that rests on the finding of
necrotizing granulomatous inflammation without
6 Diagnosis of Granulomatous Disease and Vasculitis in Small Lung Biopsies
evidence of organisms or necrotizing vasculitis in
patients with known rheumatoid arthritis. The
histologic findings are not distinctive. The role of
pathology is to exclude alternative possibilities,
the most important being infection and Wegener’s
granulomatosis.
Rare Infectious Causes of Pulmonary
Granulomas
A handful of other organisms cause granuloma-
tous inflammation in the lungs, but are very
unlikely to be seen in routine practice, especially
in small lung biopsies. These include fungi such
as Sporothrix, which typically causes suppurative
granulomas in the skin but can also involve the
lungs [41], and Pneumocystis, which usually
causes a frothy intra-alveolar exudate but can
rarely be associated with granulomatous inflam-
mation [22], and parasites such as Dirofilaria,
which causes granulomas with infarct-like necro-
sis due to embolization from the right side of the
heart into pulmonary arteries [42].
Necrotizing Granulomas of Unknown
Etiology
It is common for necrotizing granulomas to be
found in lung specimens with no histologic evi-
dence of a definite etiology, infectious or other-
wise. This is especially true in small biopsies,
which do not sample the entirety of the lesion.
Diagnostic findings such as organisms or vasculi-
tis are therefore easily missed. The problem is
greater than mere sampling error. Studies have
demonstrated that even when entire necrotizing
granulomas are resected surgically, an etiology
cannot be found in a significant percentage of
cases [7, 10]. There is substantial evidence to
support the notion that such lesions are “burnt-
out” mycobacterial or fungal infections in which
organisms have been destroyed or removed by
the granulomatous inflammatory response.
What can pathologists do if the etiology of a
granulomatous process is not apparent and spe-
cial stains are negative? [4, 43] Of the several
steps that can reveal an etiology in such cases, the
63
most important one is to carefully reexamine the
histologic findings, especially the GMS-stained
slides. Waiting for results of cultures may be pro-
ductive since some organisms, especially myco-
bacteria, grow in cultures even though special
stains may be negative. Finally, clinical informa-
tion, specifically radiologic findings, results of
ANCA tests, and a history of rheumatoid arthritis,
can help in making a specific diagnosis in some
cases. The best way to communicate these issues
to the clinician is in a comment, instead of
encumbering the diagnostic line with a wordy
description. The diagnosis can then simply be
“necrotizing granulomatous inflammation (see
comment).”
Causes of Non-necrotizing
Granulomatous Inflammation
Sarcoidosis
Clinical and Radiologic Findings
The diagnosis of sarcoidosis depends on a com-
bination of clinical context and pathologic find-
ings [44]. Yet, details of clinical and radiologic
findings are rarely, if ever, provided to patholo-
gists at the time of the initial diagnosis. However,
pathologists with access to electronic medical
records should be familiar with key findings that
indicate whether the clinical context is appropri-
ate for sarcoidosis. Typical patients with sarcoid-
osis are young individuals of either gender, with
a peak in the 30s and 40s [45]. Cases have been
well documented in the elderly but are infrequent
[46]. The most common radiologic finding is
bilateral hilar or mediastinal adenopathy.
Bilateral hilar adenopathy in an asymptomatic
young person is considered highly suspicious for
sarcoidosis [44]. In the lungs, radiologic findings
may be absent or may consist of bilateral infil-
trates or nodules. Patients may be asymptomatic,
the radiologic findings having been discovered
incidentally, or they may present with cough and
dyspnea. Sarcoidosis is a multisystem disease
and may involve virtually any other organ.
Patients can present with a wide variety of symp-
toms referable to involvement of these sites, such
as erythema nodosum (skin) and uveitis (eye).
64
Fig. 6.8 Non-necrotizing granulomas consistent with
sarcoidosis in a transbronchial lung biopsy. (a) Multiple
non-necrotizing granulomas are present within the inter-
stitium (arrows). An important finding is the presence of
Clinical findings that argue against sarcoidosis
include unilateral infiltrates, a unilateral mass,
bronchiectasis, predominant airspace opacities,
lack of response to steroids, and absence of hilar
or mediastinal adenopathy. Needless to say, posi-
tive cultures for mycobacteria or fungi exclude
the diagnosis. Unfortunately, culture results are
seldom available at the time of biopsy [47].
Therefore, the pathologic diagnosis, and often
the clinical diagnosis, is usually made before an
infection can be definitively excluded.
Histologic Findings in Small Biopsies
In western countries, sarcoidosis is by far the
most common cause of granulomas in transbron-
chial biopsies [3]. Endobronchial ultrasound
(EBUS) with transbronchial needle aspiration is
increasingly used to demonstrate granulomas in
S. Mukhopadhyay
normal lung away from the granulomas (arrowhead, bot-
tom right). (b) Same biopsy, high magnification. The
granulomas are well formed and surrounded by hyalinized
fibrosis
hilar lymph nodes [48]. The histologic hallmark
of sarcoidosis is the non-necrotizing (“noncaseat-
ing”) granuloma [1, 20]. However, non-
necrotizing granulomas are also found in other
lung diseases [47], making it important for
pathologists to recognize histologic features that
are consistent with sarcoidosis and those that
exclude or argue against the diagnosis [1].
Pathologists are well served to remember that
one of their key responsibilities is the exclusion
of alternative diagnoses, including infection,
malignancy, and other causes of granulomatous
lung disease.
In transbronchial biopsies, the granulomas of
sarcoidosis are found in the bronchial mucosa or
in the alveolar septa (interstitium) (Figs. 6.8a, b
and 6.9a, b) [4, 47]. In classic cases, they are
plump, well formed, and surrounded by layers of
6 Diagnosis of Granulomatous Disease and Vasculitis in Small Lung Biopsies
Fig. 6.9 Non-necrotizing granulomas consistent with
sarcoidosis. Transbronchial lung biopsy. (a) Non-
necrotizing granuloma within bronchiolar wall. An inclu-
sion is present within a giant cell (arrow). (b)
Non-necrotizing granuloma within the interstitium. The
granuloma is small and ill defined. A giant cell in the
concentric hyalinized fibrosis (Fig. 6.8a, b).
Multiple small granulomas may fuse into larger
nodules. Necrosis can occur but in most cases is
minimal, tends to have a degenerated or fibrinoid
quality, and usually involves only a few granulo-
mas [49]. Nonspecific inclusions of various
kinds, including pink spider-like structures
(asteroid bodies), basophilic concentric calcifica-
tions (Schaumann bodies), and calcium oxalate
crystals, may be found within the granulomas
(Fig. 6.9a, b) [1, 47, 49]. These are thought to be
endogenous products of macrophage metabolism
and are not specific for sarcoidosis. The classic
lymphangitic (lymphatic) distribution of sarcoid
granulomas—along the pleura, interlobular
septa, and bronchovascular bundles—is a valu-
65
granuloma contains an inclusion (arrow). There is no hya-
linized fibrosis. Lung parenchyma away from the granu-
loma is normal. Although the findings are consistent with
sarcoidosis, they are less typical than the case illustrated
in Fig. 6.8. Also compare with hypersensitivity pneumo-
nitis (Figs. 6.10, 6.11, and 6.12)
able diagnostic feature in surgical lung biopsies
but for obvious reasons cannot be appreciated in
transbronchial biopsies. Special stains for
microorganisms should be performed in all cases.
Histologic features that argue against sarcoid-
osis—and suggest an alternative diagnosis—
include extensive necrosis, suppurative or “dirty
necrosis,” organizing pneumonia (fibroblast
plugs within the airspaces), and foreign particles
(vegetable particles, talc, microcrystalline cellu-
lose, or crospovidone) [4]. An important histo-
logic feature of sarcoidosis is that chronic
inflammation, when present, is localized to the
area surrounding the granulomas (Fig. 6.9a, b).
The lung away from the granulomas is normal.
This feature helps to differentiate sarcoidosis
66
from hypersensitivity pneumonitis, in which
interstitial chronic inflammation is found even in
lung parenchyma away from granulomas [1, 50, 51].
Needless to say, identification of mycobacterial
or fungal organisms on H&E or special stains
excludes sarcoidosis. On the other hand, negative
special stains do not “confirm” a diagnosis of
sarcoidosis, since these can be negative in infec-
tions [47].
For practical purposes, the information in the
preceding paragraphs must be distilled into a diag-
nosis on a pathology report. The most conservative
approach on transbronchial biopsies is to simply
state “non-necrotizing granulomas” in the diagnosis
and put the “soft findings” in the comment, which
can include a description of the granulomas, the
presence of typical or atypical findings, and the
extent to which the histologic findings are consis-
tent with sarcoidosis. When findings are minimal
and equivocal, it is appropriate to state this in the
comment. On the other hand, histologically classic
granulomas are occasionally encountered in the
appropriate clinical context. In such cases, the
diagnosis could state “non-necrotizing granulo-
mas consistent with sarcoidosis.” The final diagno-
sis of sarcoidosis is a clinical one and ideally takes
into consideration clinical, radiologic, pathologic,
and microbiologic findings. The difficulties of
making a clinical diagnosis of an entity that lacks
a gold standard and is largely a diagnosis of exclu-
sion have been well described [44].
Hypersensitivity Pneumonitis
Clinical and Radiologic Findings
Hypersensitivity pneumonitis (also known as
hypersensitivity pneumonia and referred to in the
past as extrinsic allergic alveolitis) is a form of
interstitial lung disease caused by inhalational
exposure to organic antigens in susceptible and
sensitized individuals [52, 53]. The disease is
often difficult to diagnose because there is no
universally accepted gold standard. The symp-
toms are similar to other interstitial lung diseases,
the most common being cough with or without
dyspnea [52, 54]. Most patients are nonsmokers.
Worsening of symptoms upon exposure to the
S. Mukhopadhyay
offending antigen is a classic feature, but cases
that come to biopsy usually do lack an obvious
exposure. Perhaps the best-known form of hyper-
sensitivity pneumonitis is “farmer’s lung,” a con-
dition resulting from exposure of sensitized
individuals to thermophilic actinomycetes such
as Saccharopolyspora rectivirgula, a bacterium
found in moldy hay [51, 54, 55]. The most common
source of exposure identified in biopsy-proven
cases is avian antigens derived from pet birds
such as parakeets (including budgerigars), cocka-
tiels, finches, doves, canaries, macaws, pigeons,
and parrots (“bird fancier’s lung”) [50, 56–58].
Other relatively common sources of exposure are
household mold, hot tubs, humidifiers, and
feather duvets. The proportion of cases of well-
documented hypersensitivity pneumonitis in
which an inciting antigen cannot be found is
quite high, varying from 25 to 63 % [53, 57, 58].
Radiologic findings are not specific, although
they may be suggestive [55]. The most common
findings are bilateral ground-glass infiltrates, tiny
centrilobular nodules/opacities, and mosaic atten-
uation, the last being a consequence of air trapping
due to small airway (bronchiolar) involvement.
The findings are usually more prominent in the
upper lobes. However, one or more of these find-
ings may be absent, and any lobe can be involved.
Long-standing cases can progress to fibrosis and
honeycomb change.
Histologic Findings in Small Biopsies
Hypersensitivity pneumonitis is occasionally
encountered in transbronchial lung biopsies,
although less often than sarcoidosis. Although it
is included in this chapter on granulomas, it is
important to remember that the hallmark of this
disease is diffuse interstitial chronic inflamma-
tion and that the predominant cell in the inflam-
matory infiltrate is the lymphocyte [50, 51, 53,
54, 59]. Granulomatous inflammation is usually
subtle and is absent in a significant proportion of
cases (30 % in most series) [51, 52]. Contrary to
what one might expect from the name of the con-
dition, eosinophils are absent or at best occa-
sional [51–54].
The main finding in small biopsies is a diffuse
chronic inflammatory infiltrate that expands the
6 Diagnosis of Granulomatous Disease and Vasculitis in Small Lung Biopsies
Fig. 6.10 Hypersensitivity pneumonitis in a woman with
a pet bird (macaw). Transbronchial lung biopsy. (a)
Diffuse interstitial chronic inflammation with slight
accentuation around a respiratory bronchiole (arrow). A
giant cell is present within the interstitium in the lower
alveolar septa (interstitium) (Figs. 6.10a, b and
6.11a, b) [52, 59]. Granulomas, when present,
are interstitial, tiny, and poorly formed, often
consisting of no more than a few loosely aggre-
gated histiocytes or isolated multinucleated giant
cells (Figs. 6.10a, b; 6.11a, b; and 6.12a, b) [60].
In many cases, the “granulomas” are actually
single multinucleated giant cells scattered within
the interstitial inflammatory infiltrate, containing
a variety of nonspecific endogenous inclusions
such as cholesterol crystals/clefts, Schaumann
bodies, or calcium oxalate crystals (Figs. 6.11a, b
and 6.12a, b). Some of these inclusions are
birefringent and may be misinterpreted as “for-
eign material.” The differences between these
structures and true foreign particles have been
67
half of the picture. The location of the giant cell adjacent
to a small artery suggests a peribronchiolar location. (b)
Multinucleated giant cell at high magnification. Note the
cholesterol crystal/cleft, a common inclusion in this
condition
illustrated elsewhere [1]. Foamy macrophages
are often present within the airspaces in hyper-
sensitivity pneumonitis. They are a nonspecific
manifestation of small airway involvement/
obstruction, but their presence can be a tip-off to
the diagnosis.
Classic cases of chronic hypersensitivity
pneumonitis show a characteristic “histologic
triad,” which is important to recognize because it
allows pathologists to suggest the diagnosis even
in the absence of clinical or radiologic informa-
tion. Interestingly, the triad is defined differently
in different publications. Most authors define it
as a combination of cellular bronchiolitis, inter-
stitial chronic inflammation, and scattered, small
interstitial non-necrotizing granulomas [52, 53].
68
Fig. 6.11 Hypersensitivity pneumonitis in a transbron-
chial lung biopsy. (a) Cellular chronic interstitial pneumo-
nia characterized by alveolar septal chronic inflammatory
infiltrate (arrows). The area at the top right is in the vicin-
ity of an alveolar duct (see scattered smooth muscle fibers,
However, a slightly different triad consisting of
interstitial chronic inflammation, granulomas, and
organizing pneumonia has also been described.
This latter triad is present in 42 % of surgical
biopsies but only 9 % of transbronchial biopsies,
highlighting the difficulties in diagnosis intro-
duced by sampling error in small biopsies [56].
Hot Tub Lung
Clinical and Radiologic Findings
Hot tub lung is a hypersensitivity-like granulo-
matous reaction to non-tubercular mycobacteria in
aerosolized water derived from hot tubs and other
sources such as showerheads and swimming
S. Mukhopadhyay
long arrows). Note the tiny, poorly formed granuloma
(short arrow), shown at high magnification in (b). (b)
Poorly formed granuloma typical of hypersensitivity
pneumonitis. Note the inclusion (Schaumann body)
within a multinucleated giant cell
pools [59, 61–63]. The clinical presentation is
similar to that of hypersensitivity pneumonitis.
Women are more commonly affected than men.
The most common symptoms are dyspnea,
cough, and fever. Imaging shows bilateral inter-
stitial infiltrates often described as nodular, retic-
ulonodular, or ground glass, with centrilobular
nodules and air trapping [64, 65]. A history of hot
tub use is essential for the diagnosis.
Histologic Findings in Small Biopsies
The most characteristic histologic finding is the
presence of well-formed granulomas within the
lumens of alveolar ducts and respiratory bron-
chioles [1, 4, 66]. The granulomas are typically
non-necrotizing, but necrotizing granulomas
6 Diagnosis of Granulomatous Disease and Vasculitis in Small Lung Biopsies
Fig. 6.12 (a, b) Inclusions in hypersensitivity pneumoni-
tis. These concentric calcifications (Schaumann bodies)
are typically found within multinucleated giant cells and
may also be seen. Interstitial granulomas and
interstitial chronic inflammation are often present.
The histologic features overlap considerably
with hypersensitivity pneumonitis, but the granu-
lomas of hot tub lung are usually larger, better
formed, and occur within the airspaces [1].
Additionally, organizing pneumonia is more
prominent in hot tub lung than in hypersensitivity
pneumonitis. The presence of organizing pneu-
monia and airspace granulomas helps to distin-
guish hot tub lung from sarcoidosis. The
possibility of hot tub lung can be raised on the
basis of histologic findings, but definitive diagno-
sis requires a history of hot tub use. AFB are
demonstrable in lung biopsies in some cases.
Cultures of respiratory specimens and/or the con-
taminated hot tub water may yield mycobacteria,
mainly MAC [63–65].
69
are thought to be endogenous products of macrophage
metabolism. They should not be mistaken for exogenous
(foreign) particles
Talc Granulomatosis
Clinical and Radiologic Findings
“Talc granulomatosis” is one of many terms used
to describe a distinctive pulmonary perivascular
foreign-body granulomatous reaction seen in
individuals who inject pills intended for oral con-
sumption [67]. The practice differs from usual
forms of intravenous drug abuse in that it involves
injection of pills or tablets rather than better-
known drugs of abuse such as heroin or cocaine.
The pills are typically crushed, dissolved in an
aqueous solution, and injected intravenously,
hence the term “mainline granulomatosis” [68].
The pills contain psychoactive substances such as
methadone, pentazocine, methylphenidate, and
tripelennamine, oral medications that produce a
greater and more immediate stimulant effect
70
Fig. 6.13 Talc granulomatosis. Transbronchial lung
biopsy. (a) Foreign-body granulomas within alveolar
septa. Arrow indicates granuloma shown at high magnifi-
cation in (b). (b) Foreign-body granuloma containing
when injected [68–71]. The active ingredient in
the pills is soluble, but excipients (“fillers” or
“binders”) such as talc, microcrystalline cellu-
lose, and crospovidone whose function is to pro-
vide bulk and other physical properties to pills
are insoluble [72]. These insoluble excipients
travel via the venous circulation and the right side
of the heart to the pulmonary circulation, where
they are trapped within alveolar septal capillar-
ies. Subsequently, they extrude out of the capil-
laries into the interstitium and elicit a foreign-body
giant cell reaction. The vascular occlusion can be
associated with thrombosis, pulmonary hyperten-
sion, and right heart failure [69, 70]. Radiologic
findings include bilateral micronodular or miliary
lung nodules. Examination of the retina can be
helpful in supporting the diagnosis in some cases.
Since patients seldom admit to such illicit
S. Mukhopadhyay
multinucleated giant cells surrounding pale-staining for-
eign particles (arrows). Note that the foreign particles and
giant cells are located adjacent to a capillary (arrowhead)
activity, the pathologist is often the first to sug-
gest the diagnosis.
Histologic Findings in Small Biopsies
Although most cases have been reported in
autopsies and surgical lung biopsies, the diagno-
sis can be made on transbronchial lung biopsy.
The main finding is the presence of foreign-body
granulomas located adjacent to capillaries within
alveolar septa. The granulomas can be numerous,
prominent, and obvious or few, tiny, and subtle.
They usually consist of multinucleated giant cells
that surround and engulf foreign particles, which
are usually found adjacent to capillaries rather
than within their lumens (Fig. 6.13a, b). The most
common foreign particles are microcrystalline
cellulose, talc, and crospovidone (Fig. 6.14a, b).
Microcrystalline cellulose and talc are pale and
6 Diagnosis of Granulomatous Disease and Vasculitis in Small Lung Biopsies
Fig. 6.14 Foreign material in talc granulomatosis,
same case as Fig. 6.13. (a) H&E. Foreign particles sur-
rounded by multinucleated giant cells. The pale material
is microcrystalline cellulose (arrow); the purple coral-like
colorless on H&E but strongly birefringent under
polarized light. Crospovidone is purple or baso-
philic and has a distinctive coral-like shape on
H&E, but is not birefringent [72]. Microcrystalline
cellulose and crospovidone are often found
together in the same biopsy. The Movat penta-
chrome stain can be helpful in distinguishing
between microcrystalline cellulose and talc [73].
Microcrystalline cellulose stains yellow on
Movat, while talc stains light blue. The main
entity in the differential diagnosis is aspiration
pneumonia caused by aspiration of gastric con-
tents that include pill fragments. In contrast to
talc granulomatosis, aspiration of pill fragments
is characterized by organizing pneumonia and
peribronchiolar granulomas that may also contain
aspirated vegetable fragments [74].
71
material is crospovidone (arrowhead). (b) Movat penta-
chrome stain. Microcrystalline cellulose stains yellow
(arrow); crospovidone is green (arrowhead)
Chronic Beryllium Disease (Berylliosis)
Clinical and Radiologic Findings
Chronic beryllium disease is often mentioned in
standard textbooks as a mimic of sarcoidosis, but
is rarely seen in practice. The diagnosis is heavily
dependent upon a history of exposure to beryl-
lium. The diagnosis can be confirmed by a blood
test known as the beryllium lymphocyte prolif-
eration test (BeLPT). In a recent study, 34 of 121
patients with a diagnosis of sarcoidosis reported
a history of exposure to metals, including 17 who
reported exposure to beryllium [75]. However,
none of the 34 had a positive BeLPT, suggesting
that even a history of beryllium exposure does
not necessarily equate to a definitive diagnosis of
chronic beryllium disease.
72
Histologic Findings in Small Biopsies
Although the histologic features of chronic beryl-
lium disease are said to consist of non-necrotizing
granulomas mimicking sarcoidosis, the published
literature describes findings that have more in
common with hypersensitivity pneumonitis
[76, 77]. In practice, the diagnosis is seldom
entertained in the absence of an appropriate
exposure history.
Causes of Granulomatous
Inflammation with Variable
Necrosis
Cryptococcosis
Clinical and Radiologic Findings
In contrast to other fungal yeasts that cause
pulmonary granulomas, Cryptococcus occurs
worldwide without an endemic area. It can infect
the lung in immunocompromised as well as immu-
nocompetent individuals. The former circum-
stance is more familiar to clinicians and
pathologists, especially in the setting of AIDS
[78]. However, infections in immunocompetent
individuals are also well documented and in most
cases present as lung nodules, which may be soli-
tary or multiple, solid or cavitary, and PET posi-
tive. In this setting, a neoplasm is usually the main
clinical concern. Such nodules are usually sam-
pled by needle biopsies, but transbronchial biop-
sies may also be used to sample accessible lesions.
Cultures of infected tissue are often positive.
Histologic Findings in Small Biopsies
As with other fungal organisms, the tissue reac-
tion to Cryptococcus depends on the immu-
nologic status of the host. Immunocompetent
individuals develop a granulomatous inflamma-
tory response, which most commonly consists
of large numbers of multinucleated giant cells
scattered in a background of histiocytes and lym-
phocytes, the entire lesion forming an ill-defined
granulomatous mass rather than discrete granu-
lomas. Organizing pneumonia, characterized by
plugs of fibroblasts in a pale-staining matrix,
may be a prominent finding, occasionally con-
S. Mukhopadhyay
taining embedded granulomas or multinucleated
giant cells. Cryptococcus yeasts are scattered
within the cytoplasm of the histiocytes and giant
cells (Fig. 6.15a, b). Some cases show areas of
“dirty” necrosis, whereas others manifest as nec-
rotizing granulomas similar to tuberculosis or
histoplasmosis. Organisms may be found both
within the necrosis and in the granulomatous rim
(Fig. 6.16a, b). Immunocompromised patients
may show identical findings, or they may show
large numbers of organisms within alveolar
septa, airspaces, and capillaries with minimal or
no granulomatous inflammation [78, 79].
Cryptococcus is a small (4–7 μm) round yeast
that is faintly visible on H&E within necrosis as
well as in the cytoplasm of histiocytes and multi-
nucleated giant cells [1, 4]. The cell wall is usu-
ally light staining and difficult to see at low
magnification, but a clue to the presence of
Cryptococcus is a “bubbly” appearance within
the cytoplasm of the histiocytes. Multiple organ-
isms are often present in clusters within the same
cell. On H&E, the engulfing cell characteristi-
cally retracts from the ingested yeast, resulting in
the formation of a halo around individual organ-
isms or clusters of organisms. The thin wall of the
yeast stains pale gray, and the center is colorless.
Narrow-based budding may be seen, similar to
Histoplasma. In contrast to Histoplasma, how-
ever, the yeasts are round rather than oval or
tapered, and there is significant variation in size.
GMS stains the yeasts well and often reveals far
more organisms than are apparent on H&E. The
size variation is also better appreciated on GMS,
and fragmented forms may be seen (Fig. 6.15b).
Although mucicarmine is often touted as the
stain of choice for this organism, in practice it is
rarely positive in pulmonary cryptococcal granu-
lomas (Fig. 6.17a, b). Since mucicarmine stains
the capsule of the organism, it has been proposed
that the lack of staining with mucicarmine implies
the lack of a capsule (“capsule-deficient
Cryptococcus”). Some have found the Fontana–
Masson stain to be a helpful marker of
Cryptococcus in this situation [80–83]. In most
cases, however, the combination of H&E and
GMS is sufficient for accurate identification of
the organisms by histology. The main fungal
6 Diagnosis of Granulomatous Disease and Vasculitis in Small Lung Biopsies
Fig. 6.15 Cryptococcus. Core needle biopsy of a lung
nodule. (a) H&E. The bubbly appearance is a clue to the
presence of the organisms. The yeasts are visible on H&E,
although they stain lightly and can easily be missed. A
characteristic halo is seen around some of the yeasts
yeast in the differential diagnosis is Histoplasma,
which can usually be distinguished by its non-
visibility on H&E and the lack of significant size
variation [1].
Aspiration Pneumonia (Due
to Aspiration of Particulate Material)
Clinical and Radiologic Findings
Aspiration pneumonia is traditionally thought to
be a bacterial bronchopneumonia with a predilec-
tion for the right lower lobe, caused by aspiration
of oral flora into the lungs. Patients are considered
to be at risk for aspiration if they are debilitated
and have obvious risk factors such as stroke, sei-
zures, head trauma, alcoholism, or major surgery.
73
(arrow). The appearance of Cryptococcus on H&E is dis-
tinctive and virtually pathognomonic, even more so than
its morphology on GMS. (b) GMS highlights more organ-
isms than were evident on H&E. Note the size variation
compared to Histoplasma (Fig. 6.4a)
Aspiration of gastric acid in persons with seizures,
stroke, or head trauma is also a well-recognized
aspiration syndrome. Finally, clinicians are also
familiar with aspiration of relatively large foreign
objects into the tracheobronchial tree, usually in
infants and children.
In recent years, an under-recognized form of
aspiration pneumonia has been described, char-
acterized by dyspnea, fever, cough, or recurrent
pneumonias caused by aspiration of particulate
material derived from gastric contents (mainly
food/vegetable particles but occasionally pill
fragments) [74]. A similar process has been
described as diffuse bronchiolar disease due to
chronic aspiration [84]. Chest imaging shows
infiltrates or nodules that may involve any lobe in
either lung. Risk factors for aspiration, present in
74
Fig. 6.16 Necrotizing granuloma containing Cryptococcus.
Core needle biopsy of lung nodule. (a) Low magnification.
The necrotic center of the lesion is at the top right (arrow),
and the granulomatous rim is at the bottom left (arrowhead).
approximately half of such patients, include
esophageal or gastric causes such as carcinoma,
prior surgery, achalasia, hiatal hernia, or gastric
outlet obstruction, neurologic causes such as sei-
zures and multiple sclerosis, and the use of drugs
such as cocaine or narcotics. The diagnosis is
often overlooked clinically.
Histologic Findings in Small Biopsies
The initial tissue response to aspirated food
particles consists of acute bronchopneumonia,
followed by a granulomatous response charac-
terized by suppurative and foreign-body granu-
lomas, with prominent multinucleated giant
cells containing vegetable and food particles.
This may be accompanied by organizing pneu-
monia, which consists of fibroblast plugs within
S. Mukhopadhyay
(b) At high magnification, the organisms within the necrosis
appear as round yeasts with a light-staining wall (arrow).
Fungal yeasts are also present within the granulomatous
component (arrowhead)
peribronchiolar airspaces. In later stages, orga-
nizing pneumonia and foreign-body granulomas
containing foreign material may be the only
findings. Finally, remote aspiration may show
only rare eosinophilic vegetable particles that
are usually degenerated and difficult to identify.
The particles are usually present in lung paren-
chyma adjacent to bronchioles. The tissue reac-
tion at this stage may be limited to a few
histiocytes surrounding the degenerated vegeta-
ble material. One or several of these findings
may be identified in small lung biopsies, the
diagnostic finding being the presence of particu-
late foreign matter (Fig. 6.18a, b). The morpho-
logic features of the tissue reaction and the
diagnostic vegetable particles in lung biopsies
and resections have been illustrated in several
6 Diagnosis of Granulomatous Disease and Vasculitis in Small Lung Biopsies
Fig. 6.17 Mucicarmine and Fontana–Masson staining in
a cryptococcal pulmonary necrotizing granuloma. Same
biopsy as Fig. 6.16. (a) Mucicarmine stain. As is often the
publications [1, 4, 74, 85–89]. It is important to
remember that—unlike foreign material derived
from pill fragments—most vegetable particles
are not birefringent.
Pulmonary Vasculitis
Goodpasture Syndrome
Clinical and Radiologic Findings
Goodpasture syndrome is a vasculitis that is a
classic example of a pulmonary–renal syndrome
[90]. It affects young individuals who present
with hemoptysis due to diffuse alveolar hemor-
rhage and acute renal failure caused by rapidly
progressive (crescentic) glomerulonephritis.
There is a predilection for young male smokers.
75
case, mucicarmine is negative (arrows). Negative staining
should not deter pathologists from the diagnosis. (b)
Fontana–Masson. The organisms stain positive (arrow)
The hemorrhage may be massive and life
threatening. Diffuse alveolar hemorrhage is usu-
ally characterized by extensive bilateral airspace
consolidation [91]. The serologic hallmark of
Goodpasture syndrome is the anti-glomerular
basement membrane antibody.
Histologic Findings in Small Biopsies
The most consistent finding is intra-alveolar hem-
orrhage characterized by varying proportions of
fresh blood (red blood cells), fibrin, and
hemosiderin-laden macrophages. Most cases show
no other significant findings. There is no granulo-
matous inflammation or parenchymal necrosis.
Capillaritis has been reported, but it has been
described as occasional and mild [92, 93].
Definitive pathologic diagnosis requires demon-
stration of linear staining in pulmonary capillaries
76
Fig. 6.18 Particulate matter aspiration. Transbronchial
lung biopsy. (a) Foreign-body granuloma containing neu-
trophils. This type of granuloma is a clue to the diagnosis.
for anti-glomerular basement membrane antibodies
by immunofluorescence. Immunofluorescence for
anti-glomerular basement membrane antibodies
can be performed on renal biopsies, but it has also
been shown to be a feasible technique in trans-
bronchial lung biopsies [94]. It is important for the
physician who performs the biopsy to submit two
tissue samples, one in formalin and the other in a
medium appropriate for immunofluorescence
(such as Michel’s).
Other Causes of Pulmonary Vasculitis
Other causes of pulmonary vasculitis include
Wegener’s granulomatosis and Churg–Strauss
syndrome, which have been discussed above in
the section on granulomatous diseases. Systemic
lupus erythematosus (SLE) can rarely manifest in
S. Mukhopadhyay
(b) Particulate material within multinucleated giant cells
(short arrows). The granulomas are embedded within a
background of organizing pneumonia (long arrow)
the lungs as diffuse alveolar hemorrhage and
capillaritis, but ANCA-related vasculitides are
far more common in this setting [36, 95].
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 Benign Tumors of the Lung
in Small Lung Biopsies
Mostafa M. Fraig
Benign Tumors of the Lung
Endobronchial Wall-Related Tumors
This group of tumors arises in the trachea or one of
the major bronchi. They tend to produce symptoms
of obstruction like wheezing, difficulty in breath-
ing, or post-obstructive pneumonia. As they are
easily accessible by bronchoscopic instrumenta-
tion and subsequently amenable to forceps-assisted
biopsy, good material could be obtained for histo-
pathologic examination and immunohistochemical
staining if needed. Cytologic specimens such as
brushings and washings are usually not productive
when mucosal surface is intact, but they can cor-
roborate the benign nature of the lesion by exclud-
ing the presence of malignant cells. Nevertheless,
lesional material should be obtained to confirm the
benign nature of the lesion; otherwise, the speci-
men is considered nondiagnostic.
Squamous Papilloma
Squamous papilloma of the lower respiratory tract
follows many of the characteristics of its counter-
part in the head and neck region as in its relation-
M.M. Fraig, M.D. (*)
Department of Pathology and Laboratory Medicine,
School of Medicine, University of Louisville,
530 South Jackson Street, Louisville, KY 40202, USA
e-mail: m.fraig@louisville.edu
M.M. Fraig (ed.), Diagnosis of Small Lung Biopsy: An Integrated Approach,
DOI 10.1007/978-1-4939-2575-9_7, © Springer Science+Business Media New York 2015
7
ship to HPV exposure and potential for malignant
transformation, albeit to a much lower extent.
They can be exophytic or endophytic (inverted).
They can also be solitary or multifocal [1].
Clinically they present as pedunculated
masses with a papillary or smooth surface or a
slight bulge in the endobronchial wall depending
on the growth pattern.
On microscopic examination, the surface has
bland squamous epithelium with the eosinophilic
glassy cytoplasm and small dark nuclei of the
metaplastic squamous epithelium. In the case of
the papillary variant, delicate fibrovascular cores
are seen within the papillary fronds. On the other
hand, the inverted type has islands of squamous
epithelium that seem to be embedded in the
underlying stroma. In the latter case, there is usu-
ally an inflammatory infiltrate near the surface
with some degenerative vacuoles. Mitotic fig-
ures, especially atypical ones, when they are
present above the basal layer along with the pres-
ence of cytologic atypia indicate the presence of
dysplasia [2]. It is important to mention this dys-
plasia as in cases where the lesions are multifo-
cal, subsequent lesions will appear, and follow-up
screening for these lesions is warranted. These do
not represent recurrences but rather multifocal
disease or inadequately excised lesions. In rare
examples, invasive squamous cell carcinoma has
been reported [3]. One of the caveats is to be
careful when the scar from a previously biopsied
lesion is interpreted as desmoplastic reaction and
sequestered squamous epithelium is interpreted
81
82
as an invasive component. The association with
HPV is well documented and koilocytic effect is
usually present in those cases with dysplasia.
This of course is different from flat lesions where
carcinoma in situ arises in metaplastic squamous
epithelium secondary to smoking or other carci-
nogenic exposure. The cytologic atypia in the lat-
ter is significant and is prerequisite on cytologic
and small biopsy specimens to diagnose
malignancy.
Pleomorphic Adenoma
Pleomorphic adenoma (PA) or benign mixed
tumor of the salivary gland can arise in the sero-
mucinous glands that is present around the tra-
cheobronchial tree of the lung. In fact many of the
salivary gland tumors occur in this area of sali-
vary gland analog [4]. The tumor can occur in
young adults as well as older population with a
slight predilection to females. The lesion usually
presents as a bulging mass with smooth intact
mucosal surface. On imaging, the lesion is usually
centrally located or in close relationship to the
bronchial tree with a well-circumscribed outline.
On histopathologic examination, there are the
usual myoepithelial cells with plasmacytoid fea-
tures with interspersed myxoid or cartilaginous
matrix. The chondroid matrix is less common in
the lung’s PA than in the salivary gland ones. In
cytologic material, the presence of magenta-
colored fibrillary matrix with the plasmacytoid
“hyaline cells” is the very characteristic on modi-
fied Giemsa stains. Small biopsy material may
present a challenge with the differential diagno-
sis including adenoid cystic carcinoma, mucoepi-
dermoid carcinoma, and sarcomatoid carcinoma.
Staining for myoepithelial marker such as cyto-
keratin and smooth muscle actin could help in
those instances, and the lack of cytologic atypia
or mitotic activity should eliminate the more
aggressive malignant tumors like sarcomatoid
carcinoma. Malignant transformation in those
tumors is extremely rare, and there is a no histo-
morphologic feature to predict this type of bio-
logic behavior.
M.M. Fraig
Schwannoma
Schwannoma or neurilemmoma is a benign
peripheral nerve sheath tumor that could occur
anywhere in the body where there are peripheral
nerves. It arises from the coating sheath of the
peripheral nerves, hence the name. It can occur as
a sporadic tumor or as part of Von Recklinghausen’s
disease neurofibromatosis, type I. In the latter
instance, it can attain the plexiform type where
the tumor follows nerve twigs and appears as
infiltrative. Malignant transformation in the lung
is extremely rare [4].
Classically, the tumor is comprised of the two
patterns, compact spindle cells (Antony A) alter-
nating with areas of less cellular loose and myxoid
areas (Antony B). Infiltration by eosinophils or mast
cells can be noted. The blood vessels are thick and
there are areas of collagen deposition with cells
palisading around recognized as Verocay bodies.
There are variants such as cellular one where the
tumor is mostly comprised of wavy spindle cells
with no loose areas. Another is the “ancient
schwannoma” where the cells show atypical mor-
phology with enlarged hyperchromatic nuclei as a
sign of degeneration which could be mistaken for
malignant transformation. Immunohistochemical
stains for S100, EMA, GFAP, and Ki67 could con-
firm the neuronal nature of the lesion, and the latter
reveals the indolent nature of its behavior. Negative
staining for cytokeratin could rule out sarcomatoid
carcinoma if such a differential is entertained.
Granular Cell Tumor
These tumors could occur anywhere in the body
and they are believed to be of schwannian origin.
As such they tend to follow nerve twigs creating
islands of tumor cells on the cut surface that
could be mistaken for an infiltrative tumor.
Clinically and radiologically, they present in
the lumen of the tracheobronchial tree as peduncu-
lated masses with smooth surface. They can attain
a large size up to 5.0 cm in maximum diameter.
Under microscopic examination, the tumor is
comprised of uniform cells with abundant finely
7 Benign Tumors of the Lung in Small Lung Biopsies
Fig. 7.1 Granular cell tumor with polygonal cells, granu-
lar eosinophilic cytoplasm, and uniform small nuclei is
usually located under the bronchial mucosa within the
endobronchial wall
granular eosinophilic cytoplasm and uniform cen-
trally located nucleus (Fig. 7.1). The cytoplasm is
believed to be full of lysosomes as proven by
ultrastructural studies and also evidenced by
immunoreactivity to CD 68, a macrophage
marker. The tumor shares some of the immuno-
histochemical profile with schwannoma and as
such is positive for S100, CD56, and CD57
immunostains. The polygonal cells with their
characteristic granular cytoplasm are relatively
easy to recognize on fine-needle aspiration mate-
rial. Obtaining material for immunohistochemical
stains to rule out neuroendocrine tumors such as
carcinoid is helpful in those situations. None of
these tumors have ever been reported to transform
to malignant ones [5].
Parenchymatous Tumors
While most of these tumors occur within the
peripheral parenchyma of the lung, they are not
restricted to these areas. Most of them are silent
and only discovered incidentally during work-up
for other diseases or screening for lung cancer.
Some of them, like hamartoma, have characteris-
tic radiologic features to make the diagnosis very
accurate; others require tissue sampling to rule
83
Fig. 7.2 Low-magnification view of a small biopsy illus-
trating the mixture of fat, connective tissue, and cartilage
in a pulmonary hamartoma
out malignancy, especially in cases with concur-
rent malignancies. Whenever there is limited
material to make the diagnosis, the use of adjunct
information from clinical and radiologic findings
becomes paramount to avoid making the wrong
diagnosis in these cases.
Pulmonary Hamartoma
This is a benign neoplasm composed of a mixture
of mesenchymal elements such as cartilage, fat,
connective tissue, and smooth muscle with
entrapped epithelium. They present as incidental
finding on imaging studies in older patients in the
sixth decade. They are more common in males
than females. They can be identified as such on
imaging where they can be recognized as coin
lesions with a “soap bubble” or “popcorn” appear-
ance and with occasional calcification. They can be
in the endobronchial wall producing symptoms of
obstruction and rarely hemoptysis due to the tumor
impinging on the endobronchial wall vessels [6].
Histologically, they are represented by lobules
of cartilage and intervening fat and entrapped
epithelium. In cytologic preparations, the
material is usually represented by fragments of
cartilage with scant other elements (Fig. 7.2).
84
The aspirator will usually report that the lesion is
hard and is well circumscribed. On modified
Giemsa stain, the cartilaginous material can be
appreciated with its magenta color.
On small biopsies, the presence of two mesen-
chymal elements helps in establishing the diag-
nosis. The presence of fat in close proximity to
the cartilage in small biopsy should be enough to
make the diagnosis. The lack of cytologic atypia
and pleomorphism, along with the radiologic
findings, should aid in establishing the benign
nature of the lesion.
Alveolar Adenoma
Alveolar adenoma (AA) is a well-circumscribed
lesion within the lung parenchyma. They are com-
prised of uniform cells of alveolar derivation. The
size can be large (up to 6.0 cm), but the circum-
scription and slow rate of growth if interval radio-
logic evaluation is applied should reveal the
benign nature of the lesion [7]. When the lesion is
completely removed, the microscopic examina-
tion reveals cystic spaces lined with what would
appear as type II pneumocytes. On a small biopsy
specimen, the differential diagnosis would include
adenocarcinoma in situ, adenocarcinoma with lep-
idic pattern, and pneumocytoma (sclerosing hem-
angioma). Immunoreactivity to TTF-1 and napsin
A does not help in discerning the malignant or
benign nature of the lesion [8]. Awareness of the
radiologic findings and bland natures of the cells is
important in working up these cases. Cystic spaces
could be interpreted as emphysematous changes
on a small-needle core biopsy. Again reviewing
the radiologic findings is very helpful.
Papillary Adenoma
This is another tumor with a well-circumscribed
outline and is an incidental finding in most cases.
Radiologic imaging reveals a mass within the
lung that could be in the differential diagnosis
with malignant tumors.
On microscopic examination, the presence of
papillary fronds is alarming for papillary
carcinoma on cytologic material or needle core
M.M. Fraig
Fig. 7.3 Papillary carcinoma of the lung showing the
delicate fibrovascular cores within the tumors and high-
grade nuclear features. Large pleomorphic nuclei with
prominent nucleoli are seen in a disordered pattern lining
the fronds in contrast to Fig. 7.4
biopsies. It is important to pay close attention to
the bland cytologic features, which contrasts with
those of true papillary carcinoma of the lung
where the nuclei have much more malignant fea-
tures with vesicular nuclei having an irregular
nuclear membrane and very prominent nucleoli
[9] (Fig. 7.3). Papillary carcinoma of the lung is
one of the most aggressive tumors among the
adenocarcinoma subtypes. The papillary frond
usually has an appreciable fibrovascular core,
and there is no tertiary structure where the cells
are piling up without a fibrovascular core
(Fig. 7.4a, b).
Immunohistochemical stains of this lesion
would follow the alveolar histogenesis with posi-
tive staining with TTF-1, napsin A, and CK7.
There could be variable staining for CEA which
may complicate the diagnosis of a benign entity
[10, 11].
Pneumocytoma “Sclerosing
Hemangioma”
This is a tumor that was first described as an analog
to a skin lesion because of the presence of blood
lakes and hemosiderin within the tumor [12].
7 Benign Tumors of the Lung in Small Lung Biopsies
Fig. 7.4 (a, b) The fibrovascular cores of papillary ade-
noma are larger, and the lining cells have low-grade
nuclear features with a streaming pattern. In (b) under
Later on, the histogenetic origin was proved to be
from alveolar cells. The name has been controver-
sial for decades, and recently Shimosato sug-
gested the name pneumocytoma to correctly
represent the cell of origin of this tumor as an
uncommitted cell of the alveolar lining [13]. The
tumor can occur at any age but it has a predilec-
tion to women with male to female ratio of 1:5. It
can occur anywhere in the lung but usually it is in
the periphery. It appears as a coin or oval lesion
and it could be surrounded by a crescent or a rim
of air around the lesion. It seldom shows any clin-
ical symptoms and is discovered incidentally.
On microscopic examination when the tumor
is completely resected, the circumscription is
appreciated and there are two types of cells: one
is similar to type II pneumocytes lining the alve-
olar spaces and the papillary fronds within the
tumor (Fig. 7.5a, b). The others are a group of
cuboidal cells representing the stroma or the
interstitium within the lesion. Both types are
polygonal or cuboidal in shape with uniform
nuclei and a fair amount of cytoplasm. Clusters
of foamy histiocytes or calcifications could be
seen within the solid areas or within the papil-
lary fronds. Hemosiderin could be seen deposited
85
higher magnification, the cells show apical snouts and fre-
quent pseudoinclusions
within the tumor or the area immediately next to
it [14].
The problem is usually encountered either on
frozen section or small biopsies and fine-needle
aspiration biopsies. In these examples the differ-
ential diagnosis with adenocarcinoma in situ can
be problematic. Correlation with history of smok-
ing and imaging studies can avoid the overcall. It
is also important to pay close attention to the
cytologic morphology. The nuclei are rounded
and the N/C ratio is low to moderate. The pres-
ence of nuclear pseudoinclusions should not be
interpreted as a sign of malignancy because it is
frequently encountered even in benign reactive
type II pneumocytes.
The cells follow the same pattern of those
derived from alveolar lining, being positive for
TTF-1 and napsin A, CK7, and EMA. The tumor
is negative for mesothelial markers WT-1, cal-
retinin, and CK5/6. It is also negative for the neu-
roendocrine markers, synaptophysin,
chromogranin, and CD56 [15].
Rarely, these tumors could metastasize to
draining lymph nodes. However, even when they
do, the course is indolent and the patient has been
reported not to die from the disease.
86
Fig. 7.5 (a, b) Pneumocytoma or the so-called sclerosing
hemangioma shows a combination of lining cells and
solid areas between cystic spaces (a). Blood lakes are
Solitary Fibrous Tumor
Solitary fibrous tumors of the lung and pleura
have been confused with mesothelioma because
of the old name of “localized fibrous mesotheli-
oma.” Later work proved these tumors to be of
multipotent fibrous derivation from the subpleu-
ral fibrous tissue. They are considered of low
malignant potential due to the fact that they can
attain some features associated with malignancy
like hypercellularity, increased mitotic activity
(>4/10 HPF) with associated hemorrhage, and
necrosis. In addition they can be locally aggres-
sive and recur after excision.
Radiologically, they range from 1.0 to 36 cm
in their greatest dimension. They are usually
closely associated with the pleura or embedded
within the lung parenchyma with a pedicle attach-
ing it to the overlying pleura. Areas of calcifica-
tion or hemorrhage can be seen on imaging [16].
On small biopsies these tumors show as fibro-
blastic proliferation with bland nuclei and a “pat-
ternless pattern” of growth. The ropey collagen
described in resected tumors is usually not appre-
ciated in small biopsies. The well-defined borders
M.M. Fraig
noted in the spaces. Sclerotic areas are also present in (b),
and in all instances the cells are similar in morphology
and histogenesis
and rounded or globoid outline should alert the
pathologist to the benign nature and attempts to
obtain material for immunohistochemical stains.
Immunostains show the tumor cells to be posi-
tive for CD34, CD99, and bcl-2. They are nega-
tive for pan cytokeratin, excluding sarcomatoid
carcinoma and mesothelioma. They are also nega-
tive for EMA, arguing against synovial sarcoma.
They are negative for S100, desmin, and smooth
muscle actin, ruling out neuronal as well as
smooth muscle tumors, which are in the differen-
tial diagnosis. Rare tumors such as hemangioperi-
cytoma, which solitary fibrous tumors have been
claimed to be representative of, are usually posi-
tive for vascular tumor markers such as CD31. As
with any spindle cell neoplasm, obtaining optimal
material for immunohistochemistry is crucial for
proper characterization of these lesions.
Clear Cell Tumor
Clear cell tumor of the lung which was also
known as “sugar tumor” due to the presence of
glycogen in the cytoplasm of these cells is a
7 Benign Tumors of the Lung in Small Lung Biopsies
member of the perivascular epithelioid cell
tumors or PEComas. These include angiomyoli-
poma, lymphangioleiomyomatosis (LAM), and
rare tumors of the falciform ligament. They share
the immunohistochemical profile of having a
melanocytic and occasionally smooth muscle
markers. They are positive for MART-1, HMB45,
and MITF-1 [17].
Clear cell tumors of the lung usually present
as well-circumscribed lesions in the periphery of
the lung. They occur in patients >40 years of age
and are 1–5 cm in maximum diameter.
Microscopically, they are characterized by
polygonal cells with clear to eosinophilic cyto-
plasm and small uniform nuclei. There are deli-
cate fibrovascular cores traversing among nests
of clear cells. Normal structures of the lung could
be entrapped within the tumor.
On small biopsies the clear eosinophilic cyto-
plasm would invoke a wide differential diagnosis
including metastatic tumors like clear cell carci-
noma from the kidney, clear cell melanoma, and
clear cell sarcoma. The tumor cells are positive
for PAS stain without diastase digestion due to
the rich glycogen content. They are also positive
for additional markers, CD117 and vimentin,
besides the melanocytic ones as mentioned
above. The negative reactivity to epithelial mark-
ers such as EMA and cytokeratin excludes clear
cell carcinomas in general. Positive staining for
actin and cytoplasmic staining with Myo-D1
should help in differentiating this tumor from
melanocytic tumors.
Inflammatory Myofibroblastic Tumor
In the past these were described as inflammatory
pseudotumors as they were rich in inflammatory
cells and what thought to be an organizing reac-
tive fibroblastic proliferation. Extensive studies
in the 1990s proved the presence of clonal expan-
sion and the presence of a neoplastic process.
These tumors present mostly at a young age in
half the cases, but they can be seen in any age
group and can produce symptoms if they extend
in the airways. They can be associated with para-
87
neoplastic syndrome which can manifest with
fever, weight loss, anemia, and hyperglobulin-
emia. They can be clinically silent and reveal
themselves only during screening for other
conditions.
Histologically, they are characterized by a
fibroblastic proliferation with vague fascicles of
spindle cells traversing the mass with a loose
myxoid background. The latter is considered the
classic “tissue culture” pattern. Another one is
quite cellular and shows even sclerotic collage-
nous stroma with sparse spindle cells. Cellular
pleomorphism and mitotic figures can be seen.
The outline of the tumor shows the interface with
the remainder of the lung to be irregular in
resected specimens [18].
In small biopsies the tumor tends to have vari-
able areas of fibrous proliferation admixed with
inflammatory cells. The latter include lympho-
cytes, macrophages, neutrophils, and eosinophils.
As in any spindle cell neoplasm, immunohis-
tochemistry is very essential in characterizing
these lesions.
In the case of inflammatory myofibroblastic
tumors, they are positive for smooth muscle actin
and calponin. They are negative for desmin and
CD34. In about 40 % of cases, they are positive
for ALK antibodies, which were first identified as
a marker for anaplastic lymphoma and for p80
protein [19, 20]. As in all spindle cell neoplasms
of the lung, sarcomatoid carcinoma is an impor-
tant differential diagnosis, and lack of reactivity
to cytokeratin and other epithelial markers is
very helpful in this regard.
Mucinous Cystadenoma
Mucinous cystadenoma of the lung is similar to
other tumors arising in other organs in the GI
tract and gynecologic locations. It is a cystic neo-
plasm characterized by proliferation of a layer of
mucinous epithelium lining a cyst with pools of
viscid mucin. They present in the periphery of the
lung or next to one of the terminal bronchi. The
fibrous shell is characteristic and is helpful on
frozen section diagnosis.
88
Radiologic imaging shows these as well-
circumscribed lesions in the periphery with a cys-
tic center.
These are tumors which can have an aggres-
sive behavior. The latter fact explains why they
are considered borderline tumors [21].
Small biopsy from these tumors can be difficult
to sort out without the clinical and radiologic cor-
relation as most malignant mucinous lesions of the
lung could have bland mucinous epithelium.
Other Tumors
Some other tumors can exist in the lung, but they
are either too small for biopsy and they are only
encountered in resected specimens. Minute
meningothelial-like nodules are an example of
those small lesions. Mature cystic teratoma,
chondroma, and heterotopic intrapulmonary thy-
moma can rarely present in the lung. In these
examples where the morphology is not typical
and characteristic, a generic diagnosis of a neo-
plastic process and additional tissue could lead
eventually to the proper characterization of the
lesion. The important rule in all of these lesions is
to avoid using malignant terms to describe them
unless one is absolutely sure of the diagnosis.
The lung is a vital organ that is needed for the
optimal quality of life, especially in old age. Loss
of function from any lobes of the lung can com-
promise this quality of life. Removing a lobe of
the lung when there is a sizable irreversible dis-
ease, tumor or when the lobe nonfunctioning can
be justified on it own merits but for a small benign
nodule, it can be quite tragic. Using the clinical
and radiologic imaging data is crucial to avoid
this type of mistake.
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62–70.
 Malignant Tumors of the Lung
in Small Lung Biopsies
Mostafa M. Fraig
Background
The first classification of lung tumors was pub-
lished in 1967 by the International Association for
the Study of Lung Cancer under the auspices
of the World Health Organization. It was updated
for the first time in 1981. The third edition of the
same classification was published in 1997. The
last published WHO classification was in 2004.
The WHO adopts a policy of making any clas-
sification based on methods and criteria that are
easy to apply and reproduce in any setting any-
where in the world. For histopathologic diagnosis,
hematoxylin and eosin (H&E)-stained histologic
sections are the standard type of morphology that
is followed for classification. The role of ancillary
studies such as immunohistochemistry (IHC) or
molecular markers should be to confirm not to
make the diagnosis. Differentiation along the epi-
thelial versus mesenchymal types of tissue would
serve as a basis to differentiate most carcinomas
from sarcomas. Within the epithelial category, car-
cinomas would be distinguished according to their
further differentiation along glandular or squa-
mous lineage. Undifferentiated carcinoma and
neuroendocrine differentiation are reserved for
M.M. Fraig, M.D. (*)
Department of Pathology and Laboratory Medicine,
School of Medicine, University of Louisville,
530 South Jackson Street, Louisville, KY 40202, USA
e-mail: m.fraig@louisville.edu
M.M. Fraig (ed.), Diagnosis of Small Lung Biopsy: An Integrated Approach,
DOI 10.1007/978-1-4939-2575-9_8, © Springer Science+Business Media New York 2015
8
small carcinoma with specific clinical and molecular
implications. Combined or mixed differentiation
could also occur.
The majority of tumors in the lung are carcino-
mas (90–95 %), with the remainder 5 % represent-
ing bronchial carcinoid and 2–5 % representing
mesenchymal or other miscellaneous tumors.
Adenocarcinoma
This is a malignant epithelial tumor with glandular
formation or mucin production. It is the most
common type of lung cancer, especially in women
and nonsmokers. The glandular differentiation
could take the forms of acinar, papillary, solid, or
micropapillary formations.
On imaging, the tumor could present as a
speculated nodule, ground-glass opacities or
pneumonia-like picture, or multiple nodules with
central lucency (cheerios pattern).
Grossly the tumors are soft white-tan with
close proximity to the pleural surface or with
pleural puckering when the pleura is involved by
the tumor or the tissue reaction around it. Areas of
necrosis could be seen as well as carbon pigments
if the patient has been a smoker.
Sampling these lesions became very versatile in
recent years with the advent of electromagnetic
navigational biopsy where a probe could be
directed to the periphery of the lung using a
bronchoscopic approach, and a sizable biopsy
can be obtained for diagnosis and molecular testing
91
92 M.M. Fraig

Fig. 8.1 Adenocarcinoma in situ at the interface with
normal lung shows an abrupt transition, unlike reactive
type II pneumocytes where they blend gradually with nor-
mal type I. The cytologic atypia is higher than that seen in
reactive epithelium, and there is no evidence of invasion
or host response (lymphocytic infiltrate)
Fig. 8.2 Invasive adenocarcinoma of the lung on a small
biopsy showing acini of tumor with lumen formation infil-
trating into the lung parenchyma. Blue mucin can be seen
easily into lumens

if needed. In addition, fiduciary markers can be

inserted for future radiotherapy if indicated.
CT-guided fine needle aspiration and core biopsy
have achieved high rate of diagnostic yield and
gained popularity in community settings.
Microscopically the tumor could present with a
“lepidic pattern,” an expression used to describe
birds sitting on a fence, where the tumor cells line
the alveolar spaces without invading or invoking
much of host response (Fig. 8.1). This type of ade-
nocarcinoma of the non-mucinous type is consid-
ered an adenocarcinoma in situ (AIS), as the
prognosis of these tumors is considered 100 %
survival at 5 years on complete resection. Once the
tumor invades, and as long as the focus of invasion Fig. 8.3 Papillary carcinoma of the lung is comprised of
is less than 5 mm, the prognosis is still close to papillary fronds with delicate fibrovascular cores and loss
100 % survival at 5 years. In the latter case, the of polarity of the nuclei. High-grade nuclear features are
tumor is called adenocarcinoma with minimal the norm. Sometimes the feature is partially present in
another pattern
invasion (AMI) [1]. The distinction between the
last two entities on a small biopsy can be extremely
difficult in the absence of architectural changes to and those with ground-glass attenuation suggestive
suggest invasion and the ability to estimate the size of lepidic pattern [2]. Any invasion beyond 5 mm
of invasion. However, radiological image has makes the tumor an invasive adenocarcinoma.
achieved a high level of accuracy in predicting The subtyping of this tumor is based on the pre-
the size of invasion in these tumors based on the dominant pattern, acinar (Fig. 8.2), solid with mucin
difference between areas of high optical density production, papillary (Fig. 8.3), and micropapillary,
8 Malignant Tumors of the Lung in Small Lung Biopsies 93

and these carry with them an increasing risk of

worse prognosis, respectively.
Diagnosis on small biopsies of well-
differentiated adenocarcinoma is fraught with
several difficulties; distinguishing this tumor
from reactive type II pneumocytes, especially in
areas around fibrosis and chronic inflammation,
is one that is underappreciated in lung pathology.
Looking for cilia and cytologic features is very
important before making the diagnosis of cancer.
The history of smoking, recent weight loss, and
the radiologic findings are some of the helpful
findings to support the diagnosis of malignancy
in those cases.
A tumor formerly known as mucinous bron-
chioloalveolar carcinoma is now called muci-
nous adenocarcinoma as these tumors have a Fig. 8.4 Mucinous adenocarcinoma in a small biopsy is
different presentation and immunohistochemical difficult to recognize because of the overlap with bron-
and molecular profile than AIS. These tumors chial epithelium exhibiting goblet cell hyperplasia.
could present as a multifocal disease, pneumonia- Lack of cilia and the network of mucinous epithelium
along with the tufting seen here are strong evidence to
like pattern, or as a solitary irregular area of con- the nature of the lesion, especially in the setting of large
solidation on imaging studies. They are mass in the lung
characterized by a copious amount of secreted
mucin which patients would cough out. The cells
usually have enlarged nuclei with irregular
nuclear contours but are basally located with an
abundant amount of columnar cytoplasm
(Fig. 8.4). They differ from non-mucinous type
in their reactivity to CK20 and variable staining
with CK7 and TTF-1; the latter two are consis-
tently positive in AIS. Mucinous adenocarci-
noma has high level of Kras mutations as it is
also associated with history of smoking [3]. For
those reasons, the biology and prognosis of
mucinous adenocarcinoma are thought to repre-
sent a different entity from AIS even though they
were previously lumped together under the term
bronchioloalveolar carcinoma.
Mucinous adenocarcinoma should always be
differentiated from metastatic counterparts from
other organs such as breast colloid carcinoma, pan- Fig. 8.5 Minute fragment of mucinous adenocarcinoma
creas, and colon in addition to gynecologic tumors in a needle core biopsy of the lung showing tufting of the
with similar morphology. Reactivity to such mucinous epithelium and lack of cilia
markers as CDX2 is helpful in this regard, but the
clinical correlation with lesions or history of carci- irregularity on cytologic material are helpful
noma in these organs is always helpful [4, 5]. features to make such diagnosis (Fig. 8.5).
Small biopsies from mucinous adenocarci- Mucinous carcinoma in situ is extremely rare and
noma can be difficult to diagnose. However, the most of mucinous carcinomas of the lung are
presence of tufting and nuclear membrane invasive by the time they are being diagnosed.
94
The majority of patients with adenocarcinoma
are smokers, but the occurrence of AIS is com-
mon in nonsmokers. The lesion starts as a small
precancerous lesion known as atypical adenoma-
tous hyperplasia (AAH) where atypical cells with
early molecular genetic aberration similar to those
in AIS appear in the lung. Their size is usually less
than 5 mm in diameter and could be encountered
in resected lungs for any other reason, and they
are considered as “field defect.”
By immunohistochemistry the majority of
adenocarcinomas react positively to thyroid
transcription factor (TTF-1) in about 80 % of
cases. Another marker is napsin A, which stains
surfactant producing cells as it also stains other
tumors from the kidney, thyroid, and others [6].
These two markers are very useful in differenti-
ating poorly differentiated adenocarcinoma from
poorly differentiated squamous cell carcinoma,
along with other markers for squamous cell dif-
ferentiation as p63 and/or CK5/6. Recently,
cocktails of these markers using different chro-
mogens have been used in performing the stains
on limited material. TTF-1 and napsin A could
be combined using alkaline phosphatase (brown
color and nuclear pattern) combined with horse-
radish or victor red (red color and cytoplasmic).
Both could stain the same cells concurrently.
The same could be done with p40 (nuclear) and
CK5/6 (cytoplasmic) [7]. Mucin stain could also
be used as a cheap and quick method in identify-
ing intracellular mucin secretion and as a proxy
for glandular differentiation.
On the molecular level, adenocarcinomas
express higher frequency of Kras mutation, espe-
cially in smokers (30 %) as compared to non-
smokers (5 %).
The revolutionary discovery of epithelial growth
factor receptor (EGFR) mutation in patients with
adenocarcinoma (especially women nonsmokers
from Asian descent) and the introduction of tyro-
sine kinase inhibitor chemotherapy made it imper-
ative to identify patients with adenocarcinoma and
to test these patients for the mutation. Other muta-
tions such as EML 4-ALK mutation which is
encountered less frequently than EGFR ones
opened the door for more molecular testing and
targeted therapy to these patients [8].
M.M. Fraig
Squamous Cell Carcinoma
This is the second most common carcinoma in
the lung. It is characterized by squamous differ-
entiation with keratinization and formation of
intercellular bridges corresponding to desmo-
somes on the ultrastructural level.
Over 90 % of squamous cell carcinomas occur
in smokers. They are usually preceded by squa-
mous metaplasia and dysplasia of the bronchial
lining epithelium before progressing to squa-
mous cell carcinoma in situ and finally into inva-
sive squamous cell carcinoma. The tumor is
usually centrally located; however, peripherally
located tumors occur in a minority of cases.
On imaging, the central location of tumor and
proximity to relatively large bronchi and bronchi-
oles are associated with obstruction and occlu-
sion with the resultant collapse or atelectasis of
lung segments distal to the tumor. These tumors
could also extend to the hilar or mediastinal
lymph nodes appearing as masses in those areas.
Squamous cell carcinoma is the most common
tumor to cavitate resulting in a thick-walled cav-
ity with areas of central lucency. When they
occur in the superior sulcus of the lung, they are
called Pancoast tumor. They could erode into
the posterior ribs and could cause Horner’s
syndrome.
Grossly, the tumor is white or gray with black
carbon pigments throughout. They may show
necrotic center with stellate-shaped periphery.
There may be central necrosis or polypoid growth
pattern, especially when the tumor extends into
the bronchial lumen.
Microscopically, the tumor shows keratin for-
mation, the amount of which is proportionate to
the degree of differentiation; more differentiated
tumors have more keratinization. The cells have
large dark nuclei and a moderate amount of waxy
eosinophilic cytoplasm. Sometimes the cells
have a smaller amount of cytoplasm with dark
and amphophilic color and peripheral palisading
similar to that of basal cell carcinoma of the skin,
which invoked the name basaloid variant of
squamous cell carcinoma (Fig. 8.6). When the cells
show cytoplasmic clearing, this would indicate
8 Malignant Tumors of the Lung in Small Lung Biopsies
Fig. 8.6 Basaloid squamous cell carcinoma with periph-
eral palisading of the basal layer, which has darker nuclei
and high N/C ratio. These cells can look similar to small
cell carcinoma on cytologic material
Fig. 8.7 Squamous cell carcinoma with clear cell pattern.
There is an island of squamous differentiation in the
middle
clear cell change and the name clear cell variant
is used (Fig. 8.7). When the cells still get smaller
but with distinct borders, prominent nucleoli, and
intercellular bridges, small cell variant is rendered
in the diagnosis. This needs to be distinguished
from small cell carcinoma or combined small cell
carcinoma and squamous cell carcinoma based
95
on the presence or absence of neuroendocrine
differentiation.
Immunohistochemistry is very helpful in
differentiating poorly differentiated squamous cell
carcinoma from other types of carcinomas.
Squamous cell carcinoma is usually positive for
pancytokeratin, high molecular weight cytokeratin,
and CEA. Two specific markers that are frequently
used in practice for squamous differentiation are
p63 and CK5/6. A more specific clone of p63
came into use recently and is known as p40 [7].
On the molecular level, squamous cell carci-
noma harbors EGFR, in about 84 % of cases.
Expression of Her-2/neu is more frequent in ade-
nocarcinoma but rare in squamous cell carcinoma
as is the case with Kras activation.
Small Cell Carcinoma
It is a malignant epithelial tumor characterized
by small cells (two times the size of a resting
lymphocyte) with scant cytoplasm, ill-defined
borders, and granular chromatin and absent or
inconspicuous nucleolus. Extensive necrosis is
usually present and mitotic activity is high.
The cells exhibit nuclear molding where the
nuclei are set together as a cobblestone pattern.
The tumor shows a central location as in squa-
mous cell carcinoma with early spread to hilar or
mediastinal lymph nodes. The tumor spreads
early to distant locations in the liver, adrenal
glands, bone marrow, and possibly brain. It is fre-
quently associated with superior vena cava
obstruction and paraneoplastic syndrome.
On imaging, the tumor is usually associated
with lung obstruction, atelectasis, and collapse of
lung segments. Early spread to regional lymph
nodes could manifest as hilar or mediastinal
masses. Since these tumors are metabolically
active, they are strongly positive on FDG-PET
scanning.
Grossly the tumors are white-tan, soft, and
friable. Extensive areas of necrosis could be noted
within the tumor. A minority of tumors (about
5 %) could present as peripheral coin lesions.
Microscopically the tumor presents as sheetlike
growth with small nuclei and very scant amounts
96
Fig. 8.8 Small cell carcinoma with extensive necrosis
and small blood vessels in the middle demonstrating
Azzopardi effect (smearing of blood vessels with released
DNA). The cells show remarkable nuclear molding and
very high N/C ratio
of cytoplasm around them. The chromatin is
finely granular with absent or inconspicuous
nucleoli. The mitotic activity is very high and
extensive areas of necrosis could be seen. The
smearing of loose DNA material around the walls
of blood vessels is known as Azzopardi effect
(Fig. 8.8). The combination of small cell carci-
noma with other types of non-small cell carcino-
mas could be encountered. For this diagnosis to
be made, there should be at least 10 % of the
other components along with the small cell
tumor. On small biopsy, the areas of necrosis and
marked mitotic activity might not be represented.
However the cytologic features are very charac-
teristic in that there is nuclear molding and high
N/C ratio and lack of nucleoli in spite of the high
grade of the tumor (Fig. 8.9).
By immunohistochemistry, small cell carci-
noma is positive for neuroendocrine markers
such as CD56, chromogranin A, and synaptophy-
sin in a majority of cases. Less than 10 % of all
small cell carcinomas are negative for all neuro-
endocrine markers. This possibility makes the
diagnosis a morphologic one [9]. On the other
hand, other non-small cell carcinomas such as
adenocarcinoma and large cell carcinoma could
M.M. Fraig
Fig. 8.9 Small cell carcinoma in a small biopsy lacking
the areas of necrosis but showing the same nuclear features
as in Fig. 8.8
express one or more of the neuroendocrine
markers. Small cell carcinoma is also positive for
TTF-1 in up to 90 % of cases.
Small cell carcinoma should be differentiated
from other neuroendocrine tumors as well as
small round blue cell tumors. The neuroendo-
crine category includes large cell neuroendocrine
carcinoma, atypical carcinoid, and typical carci-
noid. In cases of carcinoid tumors, the mitotic
activity is much lower (less than 10/2 mm2) with
lack of areas of necrosis and the presence of
organoid pattern. Large cell neuroendocrine car-
cinoma usually shows prominent nucleoli and
more abundant cytoplasm than that of small cell
carcinoma; otherwise the areas of necrosis and
the immunohistochemical profile would be simi-
lar [10]. Small round blue cell tumors such as
primitive neuroectodermal tumors (PNET) are
mitotically active than small cell carcinomas, and
they mark with CD99 and not for cytokeratin or
TTF-1. Merkel cell carcinoma when it is meta-
static to the lung can be difficult to distinguish
from small cell carcinoma on morphology alone.
Positivity for CK20 and lack of TTF-1 positivity
are helpful in distinguishing these two tumors
from each other.
On the molecular level, small cell carcinoma
is usually associated with a higher rate of p53
8 Malignant Tumors of the Lung in Small Lung Biopsies
mutation than other non-small cell carcinomas,
as well as amplification of MYC and methylation
of caspase-8, a key antiapoptotic gene.
Large Cell Carcinoma
This is an undifferentiated carcinoma that lacks
either squamous or glandular differentiation on
light microscopic evaluation. It has been used as
a diagnosis by exclusion or a wastebasket group.
In the era of targeted chemotherapy, this group of
carcinoma is expected to decrease significantly in
number as more testing is being performed to
classify this group to either a squamous or adeno-
carcinoma category [11].
These tumors usually present anywhere in the
lung and share their consistency and color with
other lung cancers.
Microscopically, the cells are large (larger than
two resting lymphocytes) and they grow in sheets
with no specific configuration to suggest either
squamous or glandular differentiation. The nuclei
are large and vesicular with prominent nucleoli.
Mitotic activity is usually high and areas of tumor
necrosis could be seen (Fig. 8.10).
Fig. 8.10 Large cell carcinoma is by definition a poorly dif-
ferentiated carcinoma with no morphologic evidence of either
squamous or glandular differentiation; the cells have larger
nuclei and lower N/C ratio that in small cell carcinoma.
Attempts should be made to categorize these tumors as either
adenocarcinoma or squamous cell carcinoma using IHC
97
Specific subtype of large cell carcinoma is
large cell neuroendocrine carcinoma which is
characterized by cells growing in organoid nest-
ing, trabecular or rosette-like and palisading pat-
terns. The cells have an amphophilic cytoplasm
and the nuclei have prominent nucleoli as opposed
to small cell carcinoma. Areas of tumor necrosis
and high mitotic count are also characteristic fea-
tures of this tumor. The tumor cells react posi-
tively to neuroendocrine markers such as
chromogranin A, synaptophysin, and CD56.
Carcinoid Tumors
Carcinoid tumors are neuroendocrine tumors of
low malignant potential. They arise around air-
ways as small tumorlets which are nests of neuro-
endocrine cells measuring less than 5.0 mm in
diameter. Those are usually discovered in resection
specimens performed for other reasons.
Carcinoid tumors are those measuring more
than 5 mm in diameter. They are usually well cir-
cumscribed in close proximity to major airways.
They may bulge into the bronchial lumen causing
partial obstruction of those airways. They remain
under an intact smooth mucosa and less likely to
produce erosion or necrosis. In these locations,
they are amenable to biopsy and a forceps-
assisted biopsy can provide a generous biopsy for
morphologic evaluation and IHC.
Under the microscope, they have polygonal
cells with fine granular or amphophilic cyto-
plasm. The nuclei are rounded with absent or
inconspicuous nucleoli (Fig. 8.11). The mitotic
activity is less than 2/10 HPF. There is usually an
organoid pattern of some sort. The cells can form
nests, trabecula, or festoons with peripheral pali-
sading of the cells. On cytologic preparations,
the cells are discohesive and many of them
would come as single cells, while others may
show rosettes and pseudoglandular pattern. The
background is usually clean with no evidence of
necrosis or apoptosis. Peripheral carcinoid
tumors are notorious for showing a spindle cell
pattern that could be confused with mesenchy-
mal tumors as well as sarcomatoid carcinoma.
The nesting pattern and the granular type of
98
Fig. 8.11 Carcinoid tumor can assume several patterns.
In this example, the cells show cytoplasmic clearing but
maintain their uniformity and nesting or “organoid” pattern,
when try to form a specific pattern like nests, trabecula, or
even pseudoglandular patterns
Fig. 8.12 Spindle cell carcinoid with nesting and nuclei
having the characteristic “salt and pepper” pattern. This is
different from smooth muscle tumors, which usually runs
in fascicles and continuous bundles
chromatin “salt and pepper pattern” are clues to
the nature of the tumors (Fig. 8.12).
IHC helps in elucidating the nature of these
tumors. They are typically positive for neuroen-
M.M. Fraig
Fig. 8.13 Large cell neuroendocrine carcinoma is show-
ing a slight nuclear molding but more abundant cytoplasm
and prominent nucleoli than seen in small cell carcinoma.
Frequent mitotic figure and areas of necrosis are usually
present
docrine markers such as synaptophysin, chromo-
granin A, CD 56, NSE, and leu 7 (CD57).
The strong diffuse positivity for chromogranin
A is in contrast to the weak or focal pattern in
small cell carcinoma. The proliferative index as
illustrated by the Ki67 labeling is low.
Atypical carcinoid is characterized by the
presence of single cell necrosis and partial loss of
the organoid pattern. The mitotic activity is
between 2 and 10/10 HPF. They present with
more aggressive behavior and higher potential
for metastasis. It is important to recognize the
difference between these entities on a small
biopsy and routinely perform Ki67 immunostain-
ing on all neuroendocrine tumors [12].
At the other end of the spectrum is large cell
neuroendocrine carcinoma with extensive areas
of necrosis and large cells forming rosettes. The
cells have more cytoplasm than is seen in small
cell carcinoma and the nucleoli are more evident
and an amphophilic cytoplasm characteristic of
neuroendocrine tumors [13] (Fig. 8.13). It is
important to remember that large cell carcinoma
is biologically different and is treated differently
from small cell carcinoma, notwithstanding the
8 Malignant Tumors of the Lung in Small Lung Biopsies
overlap on morphologic and immunophenotypic
features. One of the important differential diag-
noses is basaloid squamous cell carcinoma, espe-
cially on cytologic preparation and small biopsy.
Immunostains for squamous epithelial markers
such p40, p62, and CK5/6 should help in ruling
out this possibility.
Sarcomatoid Carcinoma
Sarcomatoid carcinoma of the lung is comprised
of areas of clear epithelial differentiation along
squamous, adenocarcinoma, or merely poorly dif-
ferentiated carcinoma admixed with either spin-
dle cell carcinoma or giant cell carcinoma. Each
of the latter components should account for at
least 10 % of the tumor, which is difficult to
appreciate on a small biopsy. Immunostains for
epithelial markers such as pancytokeratin or EMA
are important to make the distinction from carci-
nosarcoma where the mesenchymal elements fail
to react with such markers.
Metastatic Tumors
As the lung is a vast vascular organ and a large
pool of blood goes through the lung with every
heartbeat, it has an ability to trap circulating
tumor cells and develop metastasis more fre-
quently than other organs. The most common
tumors are those of melanoma, breast, and
ovarian cancer. The colon, pancreas, liver, and
gynecologic organs are all capable of metasta-
sizing early to the lung when they possess the
aggressive grade and critical volume to do so.
Checking the history for any previous cancer
or any concurrent lesion helps in quickly sort-
ing out the question of metastatic vs. primary
lung tumors. The presence of multiple nodules
in the lung would favor a metastatic tumor over
a primary. Characteristic patterns like renal
cell carcinoma of the clear cell type or mela-
noma with plasmacytoid nuclei and nuclear
pseudoinclusions should prompt investigation
and performance of IHC.
99
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 Index

A peribronchial fibrosis and chronic inflammation,

Acquired immunodeficiency syndrome (AIDS), 54, 72 23, 24
Acute fibrinous and organizing pneumonia (AFOP), 33 practical approach, 27
Acute interstitial pneumonia (AIP) pseudo-atelectasis, 24
clinical presentation, 45–46 pseudolipoid, 24–25
idiopathic form, DAD, 34 Aspergillosis
pathologic findings, 46 clinical and radiologic findings, 60
Acute lung injury pattern, 29–30 histologic findings, 60
Acute pneumonias, 29, 30 Aspiration pneumonia
Acute respiratory distress syndrome (ARDS), BOOP, 30
29, 30, 32, 60 clinical and radiologic findings, 73–74
Adenocarcinoma histologic findings, 74–76
atypical adenomatous hyperplasia (AAH), 94 Atelectasis, 15, 16, 94
abrupt transition, 92 Atypical adenomatous hyperplasia (AAH), 94
diagnosis, 93 Azzopardi effect, 96
EGFR, 94
electromagnetic navigational biopsy, 91
imaging, 91 B
immunohistochemistry, 94 Basaloid squamous cell carcinoma, 94, 95
invasive, 92 Benign tumors
lepidic pattern, 92 alveolar adenoma (AA), 84
mucinous, 93 clear cell tumor, 86–87
pleural surface/puckering, 91 endobronchial wall-related tumors, 81
types, 91 granular cell tumor, 82–83
Adenocarcinoma minimal invasion (AMI), 92 inflammatory myofibroblastic tumor, 87
AFOP. See Acute fibrinous and organizing pneumonia mucinous cystadenoma, 87–88
(AFOP) PA, 82
AIDS. See Acquired immunodeficiency syndrome papillary adenoma, 84
(AIDS) parenchymatous tumors, 83
Airspace disease, 14 pneumocytoma “sclerosing hemangioma”, 84–86
Air trapping, 14–15 pulmonary hamartoma, 83–84
Alveolar adenoma (AA), 84 schwannoma, 82
AMI. See Adenocarcinoma minimal invasion (AMI) solitary fibrous tumor, 86
Architectural distortion, 15 squamous papilloma, 81–82
ARDS. See Acute respiratory distress syndrome Blastomycosis
(ARDS) clinical and radiologic findings, 60
Artifacts and nonspecific findings histologic findings, 60
bronchial cartilage, 26 BOOP. See Bronchiolitis obliterans/organizing
carcinoid tumorlets, 25 pneumonia (BOOP)
chemodectoma, 25, 26 Bronchial cartilage, 26
corpora amylacea, 25 Bronchiectasis, 15, 16
fresh blood, 24 Bronchiolitis obliterans/organizing pneumonia (BOOP)
intra-alveolar macrophages, 24 air spaces, 30, 31
megakaryocytes, 26 alveolar space, 31
minute meningothelial-like nodules, 25, 26 bronchioloalveolar carcinoma, 32, 93

M.M. Fraig (ed.), Diagnosis of Small Lung Biopsy: An Integrated Approach, 101
DOI 10.1007/978-1-4939-2575-9, © Springer Science+Business Media New York 2015
102 Index

Bronchiolitis obliterans/organizing pneumonia Cryptococcosis

(BOOP) (cont.) clinical and radiologic findings, 72
DAD, 31–32 clusters, 72
description, 30 differential diagnosis, 72–73
etiology, 31 fibroblasts, 72
lung transplant community, 32 fungal organisms, 72
Bronchioloalveolar carcinoma, 32 granulomatous rim and necrosis, 72, 74
Bronchopneumonia, 14, 62, 73, 74 histiocytes and giant cells, 72, 73
immunocompromised patients, 72
mucicarmine and Fontana–Masson staining, 72, 75
C Cryptogenic organizing pneumonia (COP),
Carcinoid tumorlets, 25 9, 30, 32, 40
Carcinoid tumors CT. See Computed tomography (CT)
atypical, 98
differential diagnoses, 99
large cell neuroendocrine carcinoma, 98 D
nesting/organoid pattern, 97, 98 DAD. See Diffuse alveolar damage (DAD)
neuroendocrine, 97, 98 Desquamative interstitial pneumonia (DIP)
spindle cell, 98 histopathologic findings, 44–45
Caseating granuloma, 56 peribronchial pattern, fibrosis, 43
Caseous necrosis, 53 post-obstructive pneumonia, 45
Cavitation, 18 RB, 43
Centrilobular nodules, 16 smoking history, 43
Chemodectoma, 25, 26 smoking-related diseases, 45
Chest radiograph, 13 Diffuse alveolar damage (DAD)
Chronic beryllium disease (berylliosis) and AIP, 30, 45–46
clinical and radiologic findings, 71 and ARDS, 30, 32
histologic findings, 72 histopathologic features, 32–34
Churg–Strauss syndrome interstitial pattern, 31–32
clinical and radiologic findings, 62 DIP. See Desquamative interstitial pneumonia (DIP)
histologic findings, 62
Clear cell tumor, 86–87
Coccidioidomycosis E
differential diagnosis, 59–60 EBUS. See Endobronchial ultrasound (EBUS)
fungal infection, 58 EGFR. See Epithelial growth factor receptor (EGFR)
necrotizing granulomas, 59 Emphysema, 16
needle biopsy, 59 Endobronchial ultrasound (EBUS), 6, 7, 22, 64
spherules, 59 Endobronchial wall-related tumors, 81
Computed tomography (CT) Endogenous pneumoconiosis, 35
airspace disease, 14 Epithelial growth factor receptor (EGFR), 23, 94, 95
branching endobronchial nodules, 17
“crazy-paving” pattern, 35
cystic fibrosis, 15 F
description, 13 Fiberoptic bronchoscopy (FOB), 1–2
18F-FDG PET/CT, 14 Fibroblastic plugs, 30
ground-glass opacification, 9 Fine needle aspiration biopsy, 22
high-resolution, 13, 40, 41 Flexible fiberoptic bronchoscopy, 1–2
honeycomb changes, 41 Flow cytometry, 23
needle aspiration and core biopsy, 92 FOB. See Fiberoptic bronchoscopy (FOB)
smooth interlobular, 16 Focal and diffuse infiltrative diseases
solitary lung nodule, 56 COP, 9
subpleural/perilymphatic nodules, 17 cryobiopsy, 7–8
TSCT, 14 endobronchial cryotherapy, 7
Consolidation, 16 extrinsic allergic alveolitis, 7
COP. See Cryptogenic organizing pneumonia (COP) granulomatous lung diseases, 6
Core biopsy, 1, 22, 84, 92 hpersensitivity pneumonitis (HP), 7
Corpora amylacea, 25 HRCT, 8
Crazy-paving pattern, 16 IPF, 8
Cryobiopsy, 7–8, 22–23, 41, 48 NSIP, 8
Index 103

organizing pneumonia, 9 Hamman–Rich disease, 30, 34

pulmonary function testing, 8–9 High-resolution computed tomography (HRCT), 8
routine transbronchial lung biopsy, 6 Histoplasmosis
sarcoidosis, 7 caseating granuloma, 56
smoking-related inflmatory reaction, 8–9 characterization, 56
surgical lung biopsy, 6–7 chest CT and core needle biopsy, 55, 56
transbronchial lung biopsy, 6, 7 disseminated, 58
VATS, 8 endemic fungal infection, 54
Focal solid parenchymal lesions histologic features, 57
lung masses, 5 Histoplasma organisms, 57
lymphangitic metastases, 6 solitary lung nodule, 55
metastatic malignancies, 6 surgical pathologists, 55
solitary pulmonary nodules, 6 transbronchial/needle biopsy, 56
Fungal infections Honeycombing, 16
blastomycosis, 60 Horner’s syndrome, 94
coccidioidomycosis, 58–60 Hot tub lung
granulomatous mycobacterial, 53 clinical and radiologic findings, 68
histoplasmosis, 54–58 histologic findings, 68–69
mycobacterial, 51 HRCT. See High-resolution computed tomography
(HRCT)
Hypersensitivity pneumonitis (HP)
G cholesterol crystals/clefts, 67
Goodpasture syndrome clinical and radiologic findings, 66
clinical and radiologic findings, 75 clinical presentation, 47
histologic findings, 75–76 diffuse interstitial chronic inflammation,
Granular cell tumor 66–67
cytoplasm, 83 extrinsic allergic alveolitis, 46
endobronchial wall, 83 foamy macrophages, 67
microscopic examination, 82–83 granulomatous inflammation, 66
pedunculated masses, 82 histologic triad, 67–68
Granulomas. See Pulmonary granulomas histopathologic findings, 47, 48
Granulomatosis with polyangiitis (GPA). See Wegener’s lymphocyte, 66
granulomatosis lymphoid interstitial pneumonia, 47–48
Granulomatous inflammation transbronchial lung biopsy, 67, 68
aspergillosis, 60
aspiration pneumonia, 73–75
blastomycosis, 60 I
Churg–Strauss syndrome, 62 Idiopathic pulmonary fibrosis (IPF), 8
coccidioidomycosis, 58–60 Immunohistochemical staining, 23
cryptococcosis, 72–73 Inflammatory myofibroblastic tumor
diagnostic approach, 51 anaplastic lymphoma, 87
histoplasmosis, 54–58 characterization, 87
necrotizing granulomas, 63 neoplastic process, 87
non-tubercular mycobacterial infection, 54 paraneoplastic syndrome, 87
pathologic finding, 51 small biopsies, 87
pulmonary granulomas, 63 spindle cell neoplasms, 87
rheumatoid nodule, 62–63 Interlobular septal thickening, 16–17
tuberculosis, 52–53 Interstitial lung diseases
Wegener’s granulomatosis, 60–62 AIP, 45–46
Granulomatous lung diseases autoimmune, 8
HP, 7 classification, 39, 40
sarcoidosis, 7 DIP, 39, 43–45
Ground-glass nodule, 18 HP, 46–48
Ground-glass opacity, 16 NSIP, 42–43
RB-ILD, 43–45
UIP (see Usual interstitial pneumonia (UIP))
H Intra-alveolar hemorrhage, 34–35
Halo sign, 18 Intra-alveolar macrophages, 24
Hamartoma. See Pulmonary hamartoma IPF. See Idiopathic pulmonary fibrosis (IPF)
104
L idiopathic form, 8
Large cell carcinoma, 97
Lipoid pneumonia, 24–25
Lung biopsy
endobronchial diseases diagnose, 2–4
FOB, 1–2
nonsurgical approaches, 1, 9
parenchymal diseases diagnosis, 4–9
Lymphoid interstitial pneumonia (LIP), 47–48
M PA. See Pleomorphic adenoma (PA)
Malignant tumors
adenocarcinoma, 91–94
carcinoid, 97–99
histopathologic diagnosis, 91
large cell carcinoma, 97
metastatic, 99
sarcomatoid carcinoma, 99
small cell carcinoma, 95–97
squamous cell carcinoma, 94–95
Masson’s bodies, 31
Mediastinum
anterior, 19
middle, 19
posterior, 19
pulmonary interstitium, 19
Megakaryocytes, 26
Metastatic tumors, 99
Microbiology studies, 22–23
Miliary pattern, 17
Minute meningothelial-like nodules,
25, 26
Molecular testing, 23
Mosaic attenuation, 17
Mucinous adenocarcinoma, 93
Mucinous cystadenoma, 87–88
Mycobacterial. See Non-tubercular mycobacterial
infection
N stroma/interstitium, 85
Navigational bronchoscopy, 2, 6
Needle core biopsies, 22
Neurilemmoma, 82
Non-necrotizing granulomatous inflammation
chronic beryllium disease (berylliosis),
71–72
hot tub lung, 68–69
hypersensitivity pneumonitis, 66–68
sarcoidosis, 63–66
talc granulomatosis, 69–71
Nonspecific interstitial pneumonia (NSIP)
cellular, mixed and fibrotic, 42
celular interstitial chronic inflammation, 43
clinical and radiological findings, 42
clinical course, 43
ground-glass opacification, 8
histopathologic features, 42–43
Index
and UIP, 47
uniform fibrosis, 42, 43
Non-tubercular mycobacterial infection
AIDS, 54
histologic findings, 54, 55
multifocal bronchiectasis, 54
NSIP. See Nonspecific interstitial pneumonia (NSIP)
P
Pancoast tumor, 94
PAP. See Pulmonary alveolar proteinosis (PAP)
Papillary adenoma
fibrovascular cores, 84, 85
immunohistochemical stains, 84
microscopic examination, 84
Papilloma. See Squamous papilloma
Parenchymal diseases
categorization, 4, 5
focal and diffuse infiltrative diseases, 6–9
focal solid parenchymal lesions, 5–6
Parenchymatous tumors, 83
Part-solid nodule, 18
Peribronchovascular nodule, 17
Perilymphatic nodule, 17
PFTs. See Pulmonary function tests (PFTs)
Pleomorphic adenoma (PA)
benign mixed tumor, 82
chondroid matrix, 82
differential diagnosis, 82
histopathologic examination, 82
salivary gland tumors, 82
Pleura, 19–20, 41, 86, 91
Pneumoconiosis, 37, 39
Pneumocytoma
blood lakes and hemosiderin, 84
clusters, 85
frozen section, 85
polygonal/cuboidal, 85
types, cells, 85, 86
Practical approach, 27
Pseudo atelectasis, 24
Pseudolipoid artifact, 24–25
Pulmonary alveolar proteinosis (PAP), 35–36
Pulmonary edema, 25, 32, 37
Pulmonary function tests (PFTs), 39, 42–44
Pulmonary granulomas, 54, 57, 63
Pulmonary hamartoma
benign neoplasm, 83
cartilage and intervening fat, 83
small biopsies, 84
soap bubble/popcorn, 83
Pulmonary interstitium. See also Pulmonary
parenchyma
mediastinum, 19
structure, 18
Index 105

Pulmonary nodule Schwannoma

bronchoscopy, 6 cellular loose and myxoid areas, 82
cavitation, 18 immunohistochemical stains, 82
definition, 17–18 neurilemmoma, 82
ground-glass nodule, 18 Sclerosing hemangioma, 84–86
halo sign, 18 Secondary pulmonary lobule, 16
part-solid nodule, 18 Small cell carcinoma
reversed halo sign, 18 Azzopardi effect, 96
solid nodule, 18 characterization, 95
Pulmonary parenchyma chromatin, 96
airspace disease, 14 cytologic features, 96
air trapping, 14–15 extensive areas, necrosis, 95
architectural distortion, 15 imaging, 95
atelectasis, 15 immunohistochemistry, 96
bronchiectasis, 15, 16 neuroendocrine tumors, 96
centrilobular nodules, 16 Solid nodule, 6, 18
consolidation, 16 Solitary fibrous tumor
crazy-paving pattern, 16 fibroblastic proliferation, 86
emphysema, 16 immunostains, 86
ground-glass opacity, 16 lung parenchyma, 86
honeycombing, 16 mesothelioma, 86
infiltrate, 16 vascular tumor markers, 86
interlobular septal thickening, 16–17 Spindle cell carcinoid, 98
miliary pattern, 17 Squamous cell carcinoma
mosaic attenuation, 17 basaloid, 94, 95
opacity, 17 characterization, 94
peribronchovascular nodule, 17 clear cell pattern, 95
perilymphatic nodule, 17 imaging, 94
traction bronchiectasis, 16 immunohistochemistry, 95
tree-in-bud opacities, 17 keratin formation, 94
Pulmonary vasculitis metaplasia and dysplasia, 94
Goodpasture syndrome, 75–76 pancoast tumor, 94
Wegener’s granulomatosis, 76 small cell variant, 95
Squamous papilloma
characteristics, 81
R cytologic atypia, 81, 82
Respiratory bronchiolitis-interstitial lung disease dysplasia, 81, 82
(RB-ILD) microscopic examination, 81
clinical presentation, 44 Sugar tumor, 86–87
description, 43
histopathologic findings, 44–45
Reversed halo sign, 18 T
Rheumatoid nodule Talc granulomatosis
clinical and radiologic findings, 62 clinical and radiologic findings, 69–70
histologic findings, 62–63 crospovidone, 71
foreign material, 70, 71
microcrystalline cellulose stains, 71
S movat pentachrome stain, 71
Sarcoidosis transbronchial lung biopsy, 70
clinical and radiologic findings, 63–64 Thin section CT (TSCT), 14–16, 18
conservative approach, 66 Traction bronchiectasis, 16
EBUS, 64 Transbronchial biopsy, 5–7, 21–23, 41
granulomas, 65 Tree-in-bud opacities, 17
histologic features, 65 TSCT. See Thinsection CT (TSCT)
histologic hallmark, 64 Tuberculosis
microorganisms, 65 acid-fast stains, 53
transbronchial lung biopsy, 64, 65 caseating, 52
Sarcomatoid carcinoma, 99 clinical and radiologic findings, 52
106
Tuberculosis (cont.)
mycobacteria, 53
screening, 53
transbronchial lung biopsy, 53
U Wegener’s granulomatosis
Usual interstitial pneumonia (UIP)
accelerated phase, 34
clinical course, 41–42
ground-glass opacities, 40
histopathologic findings, 40–41
HRCT findings, 8
PFTs, 39
Index
V
Video-assisted thoracoscopy (VATS), 8
W
Wedge biopsy, 21, 23, 25
capillaritis, 62
clinical and radiologic findings, 60–61
multinucleated giant cells, 62
polyangiitis, 61
transbronchial lung biopsies, 62