LUNGS PATHOLOGY

Professor MIRCEA BURUIAN MD,PhD

Chairman of the Department of Radiology & Imaging of the
Clinical County Emergency Hospital Tg.Mures
PNEUMONIA
 General features
• Epidemiology: pneumonia is 6th more common cause
of death, and the leading cause of death due to
infection

Factors responsible for this high mortality rate:

1. increasing elderly population
2. immunocompromised
3. hosts in greater numbers
4. new etiologic agents of pneumonia
5. antibiotic-resistant organisms
6. unusual organisms acquired from international
travel
 General features
• Portal of entry:

a)inhalation of airborne droplets

b)aspiration of nasopharyngeal organisms
c)hematogenous spread to the lungs from other extrathoracic
sources of infection
d)direct extension from a localized site of infection
e)infection from penetrating wounds
 General features
• Etiology:

– Streptococcus pneumoniae(50%)
– Viral pneumonia(20%)
– Mycoplasma pneumoniae(5%) CAP
– Legionella pneumophila

» Staphilococcus aureus
» Gram negative organisms
» Haemophilus influenzae(20%) HAP
» Chlamydia pneumonia(15%)

CAP = Community-Acquired Pneumonia

HAP = Hospital-Acquired Pneumonia
Presenting Signs and Symptoms

– Cough with sputum production

– Fever and chills
– Chest pain and dyspnea
 IMAGING METHODS
• Best imaging tool
– CXR for: Indications for CXR
• detection Fever
• assessing extent of disease Cough
Sputum production
• detect complications Coarse crackles
• evaluate treatment response

• Protocol advice
– CT INDICATIONS - problem solving tool for:
• Nondiagnostic CXR
• Unsloved pnumonia
• Evaluate treatement response
 Classification
• The pathologic classification of pneumonia is based on the
anatomic localization of the disease process

1. Lobar pneumonia

2. Bronchopneumonia

3. Acute interstitial pneumonia

 1. Lobar pneumonia
• Pathologic features:
– Results when inhaled organisms reach the subpleural zone of
the lung and produce alveolar wall injury with severe
hemorrhagic edema
AIR SPACE Consolidation Entire lobe
Segment
– Pattern commonly seen in pneumonia due to:
» S.pneumonia
» Klebsiella pneumonia
» L.pneumophila
» Mycoplasma pneumoniae
 Lobar pneumonia
• Radiographic features:
– CXR
• Confluent opacification
• Air bronchograms
– Involvement of entire
lobe is possible, but
sublobar form is the most common

– CT
• The CT features are similar to those seen on standard
radiograph
• The air bronchograms are often more easily visualized
Lung segmental anatomy
 Lobar pneumonia

• PA view shows RML pneumonia

• Note the indinstict borders, air bronchograms and the silhouetting of the right heart border
 2. Bronchopneumonia
• Pathologic features

– Results when the organisms are deposited in the epithelium of peripheral

airways (distal bronchi or bronchioli) resulting in:
• Epithelial ulcerations
• Peribronchiolar exudate
• The prebronchiolar alveoli become filled with pus and
edema

Radiologic features
– Patchy pattern, quilt pattern
– Confluent bronchopneumonia
 Bronchopneumonia
Small nodules <1cm
• Radiographic features:
– Multiple, ill defined, nodular opacities that are patchy, but that may
eventually become confluent and produce

– Consolidation with airspace opacification (multifocal, diffuse)

– Segmental and lobar opacification develops (similar to the pattern of

lobar pneumonia)

Necrosis Cavitation
 Bronchopneumonia

• PA view shows:

• bilateral, patchy, and

inhomogeneous opacities

• confluent in some areas

3. Acute interstitial pneumonia
• Pathologic features
– Viral organism (Influenza A and B, RSV, measles,
varicella)
– Edema and mononuclear cell infiltration arround
the bronchiolar walls and extend into the
interstitium

• Radiographic features
– Thickening of end-on bronchi and tram lines
– Reticullar pattern
 Acute interstitial pneumonia

• PA radiograph shows increased perihilar and basilar interstitial markings

representing viral pneumonia
 Complications of pneumonia
1. Cavitation
- Organisms:
Staphylococcus aureus
Streptococci
Gram-negative bacilli
Anaerobes
- Types:
Lung abscess: single, well defined mass often with air-fluid level
Necrotizing pneumonia: small lucencies or cavities
Pulmonary gangrene: sloughed lung
Complications of pneumonia
Complications of pneumonia
 Complications of pneumonia
2. Pneumatoceles
- Organism:
Staphylococcus aureus
- Occur in children
- Radiology: thin walls, multiple lesions
Complications of pneumonia

Pneumatocele:
radiograph of a patient with fulminant
staphylococcal pneumonia shows a
rounded lucency in the left lower lobe
 Complications of pneumonia
3. Pleural effusion and empyema
- Common (40%)
- Parapneumonic
- Empyema (bronchopleural fistula)
Complications of pneumonia

Parapneumonic effusion
(pneumococcal pneumonia)
A: the PA view shows a right upper
lobe consolidation
B: an oblique view 2 days later
demonstrates a right effusion
 Complications of pneumonia
4. Adenopathy
- Common with granulomatous infections
(fungi, tuberculosis)
- Uncommon with most bacterial and viral
infections
 Complications of pneumonia
• Other complications
– Acute respiratory distress syndrome (ARDS)
– Bronchiectasis
– Slow resolution
– Recurent pneumonias
 Pneumonia - Differential diagnosis
1.Cardiogenic Pulmonary Edema
•Cardiomegaly and pulmonary venous hypertension
•Edema will shift with position (gravitational shift test)
•Focal edema in right upper lobe common with mitral
regurgitation

2.Hemorrhage
•Patients usually anemic and often have hemoptysis

3.Aspiration
•May have predisposing condition such as esophageal
motility disorder
•Gravitational dependent location
 Differential diagnosis
4.Cryptogenic Organizing Pneumonia
• Patients often treated for pneumonia for variable length of
time
• Focal chronic bibasilar consolidation or interstitial thickening

5.Chronic Eosinophilic Pneumonia

• Typically chronic peripheral upper lobe consolidation
• Will not respond to antibiotics
 Differential diagnosis
6.Hypersensitivity Pneumonitis
• Often mistaken as pneumonia
• History of antigen exposure
• Chest radiograph often normal
• CT: Diffuse ground-glass opacities, centrilobular nodules, and geographic
hyperinflation of lobules

7.Pulmonary Infarction
• Resolution: Infarcts exhibit "melting snowball" sign, pneumonia in contrast
"fades" away like a ghost

8.Atelectasis
• Fissural displacement or other signs of air loss
 PULMONARY
TUBERCULOSIS
 1. Epidemiology
• Distinct differences in the epidemiology of TB are observed
between developing and industrialized nations.
• In countries where the standard of living is low and health
resources are scarce, the risk of recent infection is high and 80%
of cases involve persons in their productive years (15–59 years of
age)
• In economically developed countries where progressive declines
in the incidence of TB have been achieved, the annual risk of
infection is low.
• The majority of TB cases arise as a result of endogenous
reactivation of remote infection acquired when TB was more
prevalent; this results in disease rates highest in the elderly (65
years of age). Active disease manifesting in younger patients
usually arises in racial and ethnic minorities or in association
with human immunodeficiency virus (HIV) infection
 Tuberculosis
• Global emergence of multidrug-resistant (MDR) strains of M
tuberculosis in recent years has greatly complicated the
management and control of transmission of active cases

• Risk factors associated with drug resistance included:

– history of TB,
– foreign country of birth
– co-infection with HIV
 2. Pathogenesis

• Mycobacterium tuberculosis -
the infectious agent of TB, is a
thin, slightly curved bacillus
that is an obligate aerobe
 Transmission
– M tuberculosis is transmitted via airborne droplet nuclei that
are produced when persons with pulmonary or laryngeal TB
• cough
• sneeze
• speak
• sing
– Transmission occurs when another person inhales droplet
nuclei
– Transmission potential:
• The presence of acid-fast bacilli in sputum smear
• Positive sputum culture for M tuberculosis
• Presence of cavitation on the chest radiograph
• Presence of TB laryngitis
• High volume and watery respiratory secretions
 Radiology
1. Radiographic screening

– The purpose of screening chest radiographs is to identify persons

with active TB

– Tuberculin skin testing

– The CDC recommends that pregnant women in high-risk groups or

from areas with a high prevalence of both HIV infection and TB
undergo screening

– In a pregnant woman with a positive tuberculin skin test, a chest

radiograph with shielding of the abdomen should be performed
after the 12th week of gestation, or earlier if the woman has
symptoms suggestive of pulmonary TB
• 2. Disease manifestation

– Radiologic manifestations of pulmonary TB

are dependent on several host factors:
• including prior exposure to TB
• age
• underlying immune status

 Primary
 Postprimary disease (reactivation of primary
focus or continuation of the initial infection)
 Classification of tuberculosis into primary or
reactivation
phases is based on the radiographic appearance.
Primary tuberculosis
 Ranke complex
1. Ghon`s focus
2. Lymphadenopathy
3. Lymphangitis a) Bronchial
Simple 1. Adenobronchial fistula
4. Perifocal congestion
5. Serofibrinous pleurisy 2. Atelectasis
3. Hyperinflation
4. Extrinsic bronchial stenosis
b) Lymph nodes cavern
c) Pleural complications
Localized d) Pulmonary
1. Mechanical reflexes
2. Inflammatory
1. Caseous pneumonia
Primary complex 2. Primary cavern

a. Bronchogenic
i. Bronchopneumonia
1) Diffuse
2) Pseudolobar
3) Echisectorial
b. Lymphatic
c. Hematogen
1) Disseminated (granulitis)
Progressive 2) Localised
i. Pleural-septal fibrosis
Disseminated ii. Cirrhotic apex
iii. Diffuse disseminations
iv. Simon nodules
 Ranke complex
1. Ghon`s focus
2. Lymphadenopathy
3. Lymphangitis a) Bronchial
Simple 1. Adenobronchial fistula
4. Perifocal congestion
5. Serofibrinous pleurisy 2. Atelectasis
3. Hyperinflation
4. Extrinsic bronchial stenosis
b) Lymph nodes cavern
c) Pleural complications
Localized d) Pulmonary
1. Mechanical reflexes
2. Inflammatory
1. Caseous pneumonia
Primary complex 2. Primary cavern

a. Bronchogenic
i. Bronchopneumonia
1) Diffuse
2) Pseudolobar
3) Echisectorial
b. Lymphatic
c. Hematogen
1) Disseminated (granulitis)
Progressive 2) Localised
i. Pleural-septal fibrosis
Disseminated ii. Cirrhotic apex
iii. Diffuse disseminations
iv. Simon nodules
 PRIMARY TUBERCULOSIS

Ghon’s
focus

Adenitis
Lymphangitis

RANKE COMPLEX
 A. Simple primary complex
• Pulmonary focus constituted after
penetration of Koch bacillus in a normal
host

• Limited pulmonary focus most commonly

located at the basis of the lobes
– More vivid ventilation
– More abundant perfusion
 1.Ghon`s focus
• Exudative alveolitis focus mainly located in the lower lung
lobes
• Shape: round, polygonal, irregular
• Dimensions from 1mm to more than one segment
• In most cases the focus is unique
• Intensity: low intensity, subcostal
• Contur: wiped as most exudative foci
• Structure: homogenous, intensity decreases towards the
periphery
• In more than 50% of cases Ghon`s focus is missed to
radiological visibility- the diagnosis is suggested by the
lymphadenopathy
 Ghon`s focus
• Over time dynamics
– Restitutio ad integrum (resorption)
– Caseous transformation
– Fibrosis
– Encapsulation→ after caseous transformation
– Ulceration → primary caverne
 Ghon`s focus

• Limited pneumonic focus- basis of the

lungs
• More vivid ventilation
• More abundant perfusion
 2.Tuberculous lymphangitis
Ranke complex. Subpleural
fibrocalcific nodule (white arrows)
• Specific angiitis and and thickened, scarred lymphatic
periangiitis proces the vessel (red arrows)
lymphatic vessels
represent the
infectious process
vector from Ghon`s
focus to satellite
nodules
 Tuberculous lymphangitis

Perifocal inflamation
 3.Lymphadenopathy
• Lymphadenopathy is the radiologic hallmark of primary TB

• While enlarged nodes occur in 83%–96% of pediatric cases,

the prevalence of lymphadenopathy decreases with
increasing age

• The right paratracheal and hilar stations are the most

common sites of nodal involvement in primary TB, although
any combination, including bilateral hilar or isolated
mediastinal lymphadenopathy, may also occur
Lymphadenopathy

• Radiologic features:
– Opacity
– Round, oval
– mm→cm
– Uni or bilateral
– Same intensity as mediastinum
– Contour: net, polyciclic, oval
Lymphadenopathy
Lymphadenopathy
 4. Perifocal congestion

• Reaction process of the organism during the hypersensitivity period

due to Koch bacillus
5. Serofibrinous pleurisy
 Ranke complex
1. Ghon`s focus
2. Lymphadenopathy
3. Lymphangitis a) Bronchial
Simple 1. Adenobronchial fistula
4. Perifocal congestion
5. Serofibrinous pleurisy 2. Atelectasis
3. Hyperinflation
4. Extrinsic bronchial stenosis
b) Lymph nodes cavern
c) Pleural complications
Localized d) Pulmonary
1. Mechanical reflexes
2. Inflammatory
1. Caseous pneumonia
Primary complex 2. Primary cavern

a. Bronchogenic
i. Bronchopneumonia
1) Diffuse
2) Pseudolobar
3) Echisectorial
b. Lymphatic
c. Hematogen
1) Disseminated (granulitis)
Progressive 2) Localised
i. Pleural-septal fibrosis
Disseminated ii. Cirrhotic apex
iii. Diffuse disseminations
iv. Simon nodules
 Atelectasis

Trachea deviation

RUL

High position of the left

pulmonary artery

Radiographic features:
Systematized opacity
-Rresult from the obstruction or compression of a
Homogenous
bronchus
Retractile/Aspirative
- Will disappear after the repermeablization of the
bronchus
Inflammatory consolidation
• Primary tuberculous pneumonia
– Lung basis most common
affected but can affect any
lobe
– > ½ of cases lower lobe
– Any chronic consolidation
particularly in the lower
lobes may suggest
tuberculosis
– Cavitation: rare in primary
TB, more frequently reported
in adults then in children
with the primary form
disease
 Primary tuberculous pneumonia

• Posteroanterior (A) and lateral (B) views show primary tuberculous pneumonia.
• A patchy consolidation can be seen in the left lower lobe.
Secondary TB
 Reactivation tuberculosis

• Usually occurs:
– in apical and posterior segments of the upper lobes
and
– the superior segment of the lower lobes
 Reactivation TB features
1. Consolidation
2. Cavitation
3. Bronchogenic spread
4. Chronic pattern
5. Other
1. Miliary tuberculosis
2. Pneumothorax
3. Endobronchial tuberculosis
4. Tuberculoma
5. Tuberculous empyema
6. Bronchopleural fistula
 Reactivation TB features
1. Chronic patchy areas of consolidation
Consolidation
 Reactivation TB features
2. Cavitation :
• hallmark of reactivation TB
• Cavities result when areas of caseation necrosis erode
into the bronchial tree, expelling liquefied debris.
• CT is more sensitive than plain radiography in the
detection of small cavities
• They may have thick or thin walls, which can be
smooth or irregular
Cavitation
Cavitation
 Reactivation TB features
3. Bronchogenic spread:
• occurs when a cavity erodes into an adjacent airway and organisms
spread endobronchially to other parts of the lung
• ill-defined nodules that usually are 5 to 6 mm in diameter
• numerous and often bilateral

• On CT, the pattern of bronchogenic spread can easily be recognized

by a tree-in-bud pattern. This consists of centrilobular, branching,
linear opacities with or without the presence of centrilobular
nodules within 3 to 5 mm of the pleural surface or interlobular
septa. This pattern is best appreciated on high-resolution CT (HRCT)

• It is not specific for bronchogenic spread of tuberculosis and may

occur in other inflammatory diseases involving the peripheral
airways.
Bronchogenic spread of TB
Bronchogenic spread of TB
 Reactivation TB features
4. Chronic pattern
• Fibronodular
• Fibrocalcific
• Volume loss
• Bronchiectasis
Fibrocalcic TB
 Other radiographic features
1. Miliary tuberculosis
– Hematogenous dissemination
– Diffuse, 1- to 2-mm nodules
2. Pneumothorax
3. Endobronchial tuberculosis
– Lobar or segmental atelectasis
4. Tuberculoma
– Single or multiple
– Nodules larger than 1 cm
5. Tuberculous empyema
6. Bronchopleural fistula
Miliary TB
Miliary TB
Miliary TB
Tuberculoma
Loculated pleural effusion
Bronchiectasis
Other aspects
Differential diagnosis
BRONCHOCARCINOMA
 Epidemiology
• Lung cancer causes more death than the next
most common cancers combined:
- colon
- breast
- pancreas
- prostate
 Epidemiology
• Cigarette smoking – public enemy #1
• Lung cancer was a rare tumor in the early part
of 20th century (In 1912 Adler could find only
374 cases of lung cancer in the world autopsy
records)
• By the 1950`s it was the #1 cancer killer in men
• For ~40 years before 1987, brest cancer was #1
cancer killer in women
• In 1987 lung cancer became the leading cause
of cancer death in women and men
 Etiologies
1. Cigarette smoking (85% of lung cancer deaths
are due to smoking)
2. Passive (second-hand) smoking ~25% of lung
cancers in non-smokers
3. Genetic predisposition
4. Exposure to radon gas, asbestos, uranium
5. Underlying ILD (interstitial lung disease )
 Cigarette smoking
- public enemy number 1

• The cancer risk for smokers increases in

proportion to the degree and duration
of exposure to cigarette smoke

• Even 40 years after cessation of

smoking, the risk for lung cancer among
formersmokers remains elevated
compared with nonsmokers
 Classification

1. Small cell lung cancer (SCLC) Different:

- histologic features
2. Non-small cell lung cancer - treatment
1. Adenocarcinoma
2. Bronchioloalveolar carcinoma
3. Squamous cell carcinoma
4. Undifferentiated large cell carcinoma
 Bronchogenic carcinoma
• Common >95% • Uncommon <5%

1. Adenocarcinoma 50% – Carcinoid

2. Squamous cell carcinoma

– Adenoid cystic carcinomas
33%
(cylindroma)

3. Small cell lung carcinoma

15% – Mucoepidermoid carcinoma

4. Large cell lung carcinoma 2%

 1. Squamous cell carcinoma
- SCCA
• 33% of all bronchogenic carcinomas

• Strong association with smoking

• Most commonly CENTRAL(2/3)

• Most common to CAVITATE

• SLOWEST GROWTH of all lung Ca, so

least likely to have distant met at the
time of diagnosis

• Usually LARGE SIZE at time of

diagnosis
 Superior sulcus tumor =
PANCOAST TUMOR
• 3-5% of cancers are situated in the
superior sulcus
• Invades neighbourhood structures
– Chest wall
– Neck
– Brachial plexus
– Thoracic sympathetic ganglia
– Subclavian artery/vein
– Vertebral column/ribs
• SCCA is the most common cause of:
– PANCOAST sd.
– HORNER`S sd.
 Pancoast tumor
• Pancoast syndrome
– Shoulder pain
– Radicular pain in distibution of
C8/T1/T2
– Wasting of small muscles of
hand

• Horner`s syndrome
– Ptosis
– Miosis
– Hemifacial anhydrosis
 Pancoast tumor

• CT, MR
imaging is
recommanded
to evaluate
brachial plexus
involvement
 2. Adenocarcinoma
• 50% of al bronchogenic carcinomas

• Most common cell type in WOMEN

and NONSMOKERS

• EARLY METASTASES

• Subtype:
– Bronchoalveolar cell cancer(BAC)

• Weaker association with smoking

 adenocarcinoma
• Associated with
pulmonary fibrosis and
scars = SCAR carcinoma

• PERIPHERAL

• PLEURAL TAIL-thin linear

extension to pleura
 adenocarcinoma
• Of all bronchogenic
carcinomas, adenocarcinoma is
the most frequent associated
with CALCIFICATION:
whether an engulfed
preexisting calcification or
dystrophic calcification
 3. Large cell carcinoma
• 2% of all lung cancers
• Strong association with cigarette smoking
• LARGE PERIPHERAL TUMORS(>3cm diam)- NECROSIS
• RAPID GROWTH
• EARLY METASTASES
• Diagnosis of exclusion given to a primary lung tumor
lacking squamous, glandular or small cell differentiation
• By electron microscopy, these undifferentiated large
cell tumors may have features of adenocarcinoma or
scuamous cell carcinoma (SCCA)
 Large cell carcinoma
• LUL mass
– Occupying the
left apex
– heterogenous
→necrosis
– Invading
mediastinum
– Displacing of
the trachea
and
oesophagus
contralaterally
 4.Small cell lung cancer
- sclc
• 15% of all bronchogenic carcinoma
• 90% are CENTRALLY located
• Strongly associated with smoking
• RAPID GROWTH
• EARLY and WIDESPREAD METASTASES→ at the time of diagnosis

• Small blue cell of neuroendocrin origin

• SCLC is cosidered a systemic disease/

malignancy
• Surgery rarely performed chemotherapy
• Radiosensitive but poor prognosis
 sclc
58F at presentation 8 months later
 LUL SCLC with extensive mediastinal
disease
• Large hilar
mediastinal mass
compressing and
narrowing the
main left bronchus

• Displacement of
the right
pulmonary artery

• Circumferential
narrowing of the
left pulm art
 Staging of lung cancer
• Purpose of staging:
– Select patients who will benefit from:
• Surgery (the best chance for cure)
• Adjuvant chemotherapy or radioteraphy
– Prognosis
• Non–Small cell lung cancer : TNM staging
• Small cell lung cancer: limited/extended
Non-sclc
• Unresectable lung cancers:
– T4 – Invasion of the
mediastinum or involvement of
the heart, great vessels,
trachea, esophagus, vertebral
body, or carina; or neoplasia
associated with a malignant
pleural or pericardial effusion,
or satellite nodules in the same
lobe
– N3 – Metastasis to contralateral
mediastinal and hilar nodes,
ipsilateral or contralateral
scalene or supraclavicular
nodes
– M1 – distant metastasis present
 Sclc (small cell lung cancer)
• Limited: dissemination confined to hemitorax; no malignant effusion
– Can be treated within a single radiation port so it can
include controlateral mediastinal and supraclavicular
nodes
– RADIATION and CHEMOTHERAPY
– Median survival 14-30 months
– 20% cure rate (in limited stage)

• Extensive: beyond the hemitorax

– CHEMOTHERAPY. Any radiation is for palliation.
– Median survival 8-14 months. Cures are very rare.
 Bronchogenic carcinoma
• Overal 5 years survival remains
• ~ 10-15% for all lung cancers

• Best prognosis: focal BAC

• Next best prognosis: SCCA
• Worst prognosis: SCLC
 SVC syndrome
• Causes:
– SCLC the most common cause
– Mediastinal
invasion/metastases/lymphoma
– Granulomatous disease-
histoplasmosis, TB
– Venous thrombosis
• Signs:
– Facial fullness
– Proeminent veins in face/upper
chest
– Headache
– Upper extremity edema
 Paraneoplastic syndromes

• Systemic manifestation of primary

tumor unrelated to distant metastases

• Result from hormones/peptides

produced by tumors
 Paraneoplastic syndromes
1. Cachexia of malignancy
• Ectopic PTh- hypercalcemia-frequent assoc with SCCA

2. Clubbing and HPO

• ADH-SIADS hyponatremia- assoc with SCLC

3. Eaton-Lambert sd.
• Ectopic ACTH- Cushing sd. (weakness, hyperglycemia, hyperkaliemia,
metabolic alcalosis-assoc w carcinoid), acromegaly, gynecomastia- assoc
with SCLC

4. Migratory thrombophlebitis (Trousseau sd.)

CLINICAL CASES
 Left inf.post.acute
pneumonia

Acute left pneumonia-

alveolary congestion
Right Upper Lobe Acute Pneumonia
Right Upper Lobe Acute Bacterial
Pneumonia
Right Upper Lobe
Acute Bacterial
Pneumonia
Left basal pneumonia
Staphilococus pneumonia
Acute pneumonia with proteus
Pulmonary abscess after pneumonia
Left superior lobe peumonia
Right superior lobe pneumonia
 Pneumonia
with Betsonia
(ornitosis-
psitacosis)
Chronic pneumonia
ASPIRATION PNEUMONIA
CMV INFECTION
CMV INFECTION
LIPOID PNEUMONIA
LUNG ABSCESS
PULMONARY TB
PULMONARY TB
PULMONARY TB
THANK YOU FOR YOUR ATTENTION !