Color Atlas of Pulmonary Cytopathology

Springer New York Berlin Heidelberg Barcelona Hong Kong London Milan Paris Singapore Tokyo

Sudha R. Kini, MD Division Head Cytopathology Department of Pathology, Henry Ford Hospital Detroit, Michigan, USA

Color Atlas of Pulmonary Cytopathology

Foreword by Samuel P. Hammar, MD

With Contributions by Patricia Greenstreet and M. J ane Purslow

Illustrations by Pathology Images, Inc.

With 1312 Figures, 1302 in Full Color

Springer

Sudha R. Kini, MD Division Head Cytopathology Department of Pathology Henry Ford Hospital Detroit, MI 48202, USA skini I @hfhs.org

Cover illustrations: Front cover: Central, keratinizing squamous carcinoma cells in bronchial brushings (Fig. 6C-20A): right upper corner, adenosquamous carcinoma with malignant cells exhibiting both glandular and squamous differentiation (Fig. IOC-50) (used with permission from Lippincott-Williams and Wilkins); left lower corner, carcinoid tumor cells in bronchial brushings demonstrating uniform small cells with salt and pep­per chromatin (Fig. 8C-4); background, fine needle aspiration biopsy of a keratinizing squamous cell carcinoma of the lung (Fig. 6C-31).

Back cover: Adenosquamous carcinoma in bronchial brushings with malignant cells exhibiting both glandular and squamous differentiation (Fig. IOC-50) (used with permission from Lippincott-Williams and Wilkins); background, fine needle aspiration biopsy of keratinizing squamous cell careinoma of the lung (Fig. 6C-31).

Library of Congress Cataloging-in-Publication Data Kini, Sudha R.

Color atlas of pulmonary eytopathology / Sudha R. Kini. p. ; cm.

Includes bibliographie al referenees and index. ISBN 978-1-4419-2977-8 I. Lungs-Cytopathology-Atlases. 1. Title. [DNLM: I. Lung Diseases-Pathology-Atlases. 2. Cytological Techniques-Atlases.

3. Lung Neoplasms-Pathology-Atlases. WF 17 K55c 2002J RC756 .K564 2002 616.2'407-dc21 2001054920

Printed on aeid-free paper.

© 2002 Springer-Verlag New York, Inc. Softcover reprint ofthe hardcover Ist edition 2002

All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer-Verlag New York, Tnc., 175 Fifth Avenue, New York, NY 10010, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identified as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights. While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with re­spect to the material contained herein.

Production coordinated by Chernow Editorial Services, Ine., and managed by Lesley Poliner; manufacturing supervised by Jacqui Ashri. Typeset by Matrix Publishing Service, Inc., York, PA.

9 8 765 432 1

ISBN 978-1-4419-2977-8 ISBN 978-0-387-21641-6 (eBook) DOI 10.1007/978-0-387-21641-6

Springer-Verlag New York Berlin Heidelberg A member oi BertelsmannSpringer Science+Business Media GmbH

To my late husband, Ratnakar Kini, MD, whose enthusiasm and encouragement is always with me in spirit,

and to my daughters, Sarita and Sunita,

in appreciation of their support and encouragement

Foreword

Only once in a while does a pathology book arrive on the scene that all diagnostic pathologists should own. Color Atlas of Pulmonary Cytopathology, by Sudha R. Kini, MD, is such a book. It can best be described as concise yet detailed. There is more useful information packed into its 15 chapters than seen in most books three times its size. Thus it gives me a great pleasure to contribute this foreword.

As I reviewed the manuscript prior to writing this Foreword, I was impressed by many unique features that I would like to share with you. The chapter covering the standard cytopreparatory techniques, specimen procurement methodology, and stain­ing techniques contains detailed information that many pathologists once knew but have forgotten. It is a good refresher course and reference resource. Near the be­ginning of this chapter, Dr. Kini states a fact weil known to experienced diagnos­tic pathologists, namely that communication between pathologists and clinicians is essential. It is akin to a favorite saying of one of my partners that the best special stain in pathology is a telephone call to the appropriate clinician. This chapter also contains especially useful information on the expected diagnostic yield from vari­ous specimen types, for example, FNA, BAL, and wh ich type of specimen is most useful for making a specific diagnosis.

Another chapter discusses tli.e anatomy, histology, and cytology of the normal components of the lower respiratory tract. The tables in this chapter are represen­tative of the superb tables throughout this book. They are packed with detailed use­ful information and are easy to refer to.

One of my favorite chapters discusses nonneoplastic lesions. Perhaps this is be­cause as the longer one practices diagnostic pathology, the more one realizes the difficulties in differentiating reactive nonneoplastic cells and tissue process from malignant ones. This chapter should be required reading for all pathology residents and pathologists. It also illustrates the extensive experience of Dr. Kini has and her exceptional understanding of the morphogenesis of disease processes as weil as clin­ical features associated with such diseases. This chapter contains many pearls.

Several chapters dealing with the cytopathology of common and uncommon lung neoplasms have a standard format consisting of an introduction of the gross and his­tologie features of a given tumor followed by a detailed discussion of the cy­topathologic findings. Specimens most likely to obtain diagnostic cells are discussed.

The seetion on differentiating adenocarcinoma from epithelial mesothelioma is especially straightforward, detailed and honest. It provides the reader with a back­ground and puts the cytopathology aspects in perspective. There is extremely use­ful information in all these chapters about specificity and sensitivity of cytologic findings and differential diagnoses.

There is useful immunohistochemical and ultrastructural information throughout the book. The book contains detailed chapters on the histology and cytopathology

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of Iymphoproliferative lesions of the lung and an unusual amount of detail on metastatic neoplasms to lung.

This book contains so mush useful information that it could have been written without a single illustration. That is not the case however and, in fact, the color photographs are numerous and the quality is the best I have seen in any pathology book. As a result, this book will serve as a companion volume to another Springer­Verlag publication, Pulmonary Pathology, where due to size constraints, the chap­ter on pulmonary cytopathology had to be eliminated in current edition.

A Color Atlas of Pulmonary Cytopatholgy is a book that should not only be on the desk of all cytotechnologists/cytopathologists, but also on the desk of all pathol­ogists/surgical pathologists and pulmonologists. This atlas reveals what many di­agnostic pathologists already know, namely that cytopathology provides a superb insight into the morphology of neoplastic and nonneoplastic lung disease.

Samuel P. Hammar, MD Director

Diagnostic Specialities Laboratory Bremerton, Washington

Foreword

Preface

The purpose of this atlas is to provide a comprehensive, pictorial resource of pul­monary cytopathology. Although pulmonary cytopathology is enriched with myr­iad of individual case reports, review articles, seminars, and monographs on an in­dividual topic or topics, there is not currently a single text devoted entirely to all of its fractions with adequate illustrations. More than two decades have passed since the book Diagnostic Respiratory Cytology, by W.W. Johnston and W.J. Frable, was published, and more than one decade since D.L. Rosenthal's monograph, Cy­topathology of Pulmonary Diseases. Both are still excellent references. The last few years have seen several publications of atlases; however, they encompass only as­piration cytopathology of lungs and other thoracic organs. The chapters on pul­monary cytopathology in some of the newer textbooks are excellent but limited by the small number of illustrations. With major advances in our understanding of lung cancers, the addition of newer diagnostic entities, revised classifications of lung tu­mors, and newer diagnostic techniques, there appeared to be a need for all of this information to be under one cover.

I have compiled this atlas with that in mind by including the current information in both exfoliative and aspiration cytopathology, both of malignant neoplasms as weIl as of nonneoplastic lesions, infections, and pulmonary involvement in im­munodeficient and immunosuppressed patients, as weIl as pulmonary cytopathol­ogy in neonatal and pediatric age group. I have tried to provide liberal illustrations of common lung malignancies as weIl as of unusual and uncommon ones, so that the reader does not have to search the literature when confronted with an unusual case. Because I did not have many of these unusual cases in our files, I am im­mensely grateful to my professional colleagues-Iocally, within the United States, and globally-who readily responded to my request for glass slides or images. I have also focused on nonneoplastic entities, including noninfectious and infectious disease processes, that often demonstrate cytologic changes in respiratory speci­mens. Bronchoalveolar lavage has gained tremendous popularity because of its suc­cess in the detection of infectious agents, especially in immunocompromised pa­tients. Many of the nonneoplastic disease processes described in this text mandate that the final diagnoses be established by means other than cytology, and rightfully so. The cytologic changes, however, can often provide clues for further investiga­tions.

I have opted to discuss only primary intrapulmonary malignancies in this atlas, thereby excluding pleural diseases and tumors, specifically malignant mesothe­liomas. The decision was made because malignant mesothelioma could not be dis­cussed alone without devoting an entire chapter to pleuraliesions. I feIt this to be beyond the scope of the atlas; however, diffuse malignant mesothelioma has been discussed and illustrated in considerable detail in the differential diagnoses of ade-

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nocarcinomas. The sarcomatous variant is also discussed, along with spindie cellle­sions of the lung. I do hope that omission of a chapter devoted to mesothelial le­sions will not detract from the completeness of this atlas.

No publication in pathology is complete without discussions on diagnostic accu­racy and pitfalls. I have tried to emphasize the differential diagnoses in every chap­ter and attempted to highlight the cytologic differences in tables and in illustrations.

The chapter on cytopreparatory techniques is rather comprehensive. No one will disagree with the fact that proper cytologic evaluation and diagnostic interpretation is directly proportional to the quality of the prepared and stained smears. The il­lustrations in this atlas can attest to it. I hope that the information provided in that chapter will help those who are facing difficulties in cytopreparation. As far as choice of fixation and staining is concerned, Papanicolaou is fortunately the stan­dard method for exfoliative cytology and will not cause any debate. The preferred staining method for fine needle aspiration biopsies is a different issue. I have al­ways been a proponent of Papanicolaou stain, which explains why most of the im­ages presented in this atlas are wet-fixed and stained by Papanicolaou method.

The value of any atlas depends on the quality of its color images. The credit for these goes entirely to Ms. Jane Purslow for her excellence in photomicrography. Her enthusiasm knows no bounds. I will always be indebted to Jane for her encour­agement, support, and relentless energy, and for taking hundreds of photomicrographs. I am very pro ud of my cytopathology technical staff, both cytotechnologists and med­icallaboratory technicians, for the excellent quality of cytopreparation. Their dedica­tion is unsurpassed. I am very grateful to Dr. Irving Dardick of Pathology Images, Toronto, Canada, for the superb reproduction and color balance of the images. Work­ing with Dr. Dardick is always a very pleasant experience. The art and photography department staff at Henry Ford Hospital has been very gracious, helpful, and cooper­ative in taking several of the photographs related to cytopreparation. I am truly ap­preciative of their services. I gratefully acknowledge the secretarial assistance pro­vided by Ms. Laure Porzondek and Ms. Linda Brandt. Ms. Susan Dingler, the education coordinator of Henry Ford School of Cytotechology, was always willing to review the manuscript and offer helpful advice, especially in reference to students' needs. I have always kept the interest of cytotechology students in the back of my mind, and for that reason the text in some chapters is rather quite detailed.

It is my hope that this atlas will be a welcome addition to the field of cytopathology and be useful both to those who practice cytopathology as weil as to those practic­ing pulmonary medicine.

Sudha R. Kini, MD

Preface

Acknowledgments

Acknowledgments are due for the following copyrighted material:

Acta Cytologica for Fig. 6C-39B, from: Dugan MJ. Cytologic diagnosis of basal cell (basaloid) carcinoma of the lung. Acta Cytol 1995; 39:539-542.

Acta Cytologica for Figs. lOC-41-lOC-43. Nguyen GK. Aspiration biopsy cytol­ogy of benign clear cell ("sugar") tumor of the lung. Acta Cytol 1989; 33:511-515.

Acta Cytologica for Fig. lOC-99. Kumar PV, Monabati A. Bronchial oncocytoma diagnosed by brushing cytology. Acta Cytol 1998; 42:1056-1057.

Diagnostic Cytopathology for Fig. lOC-48. Weynand B, Collard PH, Galant C. Cy­topathological features of solitary fibrous tumor of the pleura. Diagn Cytopathol 1998; 18:118-124.

Diagnostic Cytopathology for Fig. 10C-1O. Machicao CN, Sorenson KL, Abdul­Karim FM, Somrak TM. Transthoraeie needle aspiration biopsy in inflammatory pseudotumor of the lung. Diagn Cytopathol 1989; 5:400-403.

Diagnostic Cytopathology for Fig. 4C-87 and 4C-88. Gordon SM, Gal AA, Hertzier GL, Bryan JA, Perlino C, Kanter KR. Diagnosis of pulmonary toxoplasmosis by bronchoalveolar lavage in cardiac transplant recipient. Diagn Cytopathol 1993; 9:650-654.

W.B. Saunders and Co. for Table 4-13. Bedrossian CWM, Mason MR, Gupta PK. Rapid cytologic diagnosis of Pneumocystis. Semin Diagn Pathol 1989; 6:245-261.

Springer-Verlag, Inc., for Table 4-2. Meyers JL, Colby TV; Yosem SA. Common pathways and patterns of injury, In: Dail DH, Hammer SP, editors. Pulmonary Pathology, second edition. New York: Springer-Verlag, 1993:59. For Table 5-1. Travis WD, Corrin B, Shimoshoto Y, Brambilla E. Histologie Classification ofLung and Pleural Tumors, third edition. New York: Springer-Verlag, 1999;21-24.

Armed Forces Institute of Pathology for Table 3-2. Colby TV, Koss MN, Travis WD. Tumors ofthe Lower Respiratory Tract, third edition. Washington, D.C.: AFIP, 1995:10.

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Mayo Clinic Proceedings for Table 12-1. Thompson GP, Utz lP, Rosenow EC, My­cred L, Swansen Sl. Pulmonary Iymphoproliferative disorders. Mayo Clin Pro 1993;68:804-817.

Lippincott-Williams and Wilkins for Figs. 4C-14B, 6C-13, 7C-I17A&B, 7C-127A&B, 7C-154A, 7C-155A&B, 7C-162A&B, 8C-37C, 8C-42, 8C-57A, lOC-3, lOC-7, lOC-9, lOC-25 , IIC-17A, IIC-23, 13C-84; 14C-7, 14C-8, and Tables 4-20, 6-4, 6-6, 7-8, and 8-11. From: Kini SR. Color Atlas of Differential Diagnosis in Exfoliative and Aspiration Cytopathology. Baltimore: Williams and Wilkins, 1999, And Figure IOC-50. From Kini SR. Thyroid, Second Edition. Baltimore: Lippincott Williams & Wilkins, Sudha R. Kini, MD, 1996.

Acknow ledgments

Contents

Foreword, by Samuel P. Hammar . . . . . . . . . . . . . . . . . . . . . . . . . . .. vii Preface ............................................... ix Acknowledgments ....................................... xi Color Plates ........................................... xv Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. XIX

Explanatory Notes ...................................... xxi

Part I Principles of Pulmonary Cytopathology

1 Introduction ............................. . . . . . . . . . . . . .. 3

2 Respiratory Specimen Types for Cytologic Diagnoses Specimen Procurement, Collection Methods, Specimen Submission, Cytopreparation, and Staining . . . . . . . . . . . . . . . . . .. 6 Patricia Greenstreet, M. Jane Purslow, and Sudha R. Kini

3 Anatomy, Histology, and Cytology of Normal Components of the Lower Respiratory Tract . . . . . . . . . . . . . . . .. 27

4 Nonneoplastic Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 38

5 Classification of Lung Tumors: An Overview of Lung Carcinomas ........................ 78

6 Squamous Cell Carcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 82

7 Pulmonary Adenocarcinoma ............................. 91

8 Pulmonary Neuroendocrine Tumors: Carcinoid Tumors, Atypical Carcinoids, Large Cell Neuroendocrine Carcinoma, and Small Cell (Undifferentiated) Carcinoma . . . . . . . . . . . . . . . . . .. lO3

9 Large Cell U ndifferentiated Carcinoma . . . . . . . . . . . . . . . . . . .. 117

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10 Uncommon Tumors and Tumorlike Lesions of the Lower Respiratory Tract and Tracheal Lesions ............. 123

11 Lung Cancer Metastatic to Other Body Sites ............... 141

12 Pulmonary Lymphoproliferative Disorders ................. 145

13 Metastatic Malignancy to the Lung . . . . . . . . . . . . . . . . . . . . . .. 151

14 Pulmonary Cytopathology in Neonatal and Pediatric Age Groups .............................. 165

15 Pulmonary Invo1vement in Immunocompromised Hosts . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 175

Part 11 Pulmonary Cytopathology: A Color Atlas

Index .............................................. 291

Color Plates

Plate 2-1 Plate 2-2 Plate 2-3 Plate 2-4 Plate 2-5 Plate 2-6 Plate 2-7 Plate 2-8

Plate 3-1 Plate 3-2 Plate 3-3

Plate 4-1

Plate 4-2 Plate 4-3 Plate 4-4 Plate 4-5 Plate 4-6 Plate 4-7 Plate 4-8 Plate 4-9 Plate 4-10 Plate 4-11 Plate 4-12 Plate 4-13 Plate 4-14 Plate 4-15 Plate 4-16

Plate 6-1

Plate 6-2 Plate 6-3 Plate 6-4 Plate 6-5 Plate 6-6

Ideal cytopreparations with Papanicolaou stain ........... 182 U nsatisfactory cytopreparation. Loop method ....... . . . .. 183 Methods for smear preparation ...................... 184 Smear for Romanowsky type stain . . . . . . . . . . . . . . . . . . .. 185 Saponin® technique for removing red blood cells ......... 186 HistoGeJTM method for preparing cell blocks ............ 187 Examples of unsatisfactory sputum sampIes ............. 188 Bronchial brushings, washings and BAL ............... 189

Normal constituents in respiratory tract specimens ........ 190 Normal constituents in respiratory specimens ............ 191 Non-cellular objects in respiratory specimens ............ 192

Bronchial epithelial cells with non-specific reactive changes (Irritation forms) .................... 193 H yperplasia of respiratory epithelium . . . . . . . . . . . . . . . . .. 194 Repair/regenerative changes in bronchial epithelium ....... 195 Reactive/hyperplastic alveolar type 11 pneumocytes . . . . . . .. 196 Amiodarone induced changes ....................... 197 Mycobacterial infections . . . . . . . . . . . . . . . . . . . . . . . . . .. 198 Actinomycosis .................................. 199 Viral infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 200 Mycotic infections ............................... 201 Mycotic infections ............................... 202 Parasitic infestations .. . . . . . . . . . . . . . . . . . . . . . . . . . . .. 203 Pneumocystis carinii infection . . . . . . . . . . . . . . . . . . . . . .. 204 Goodpasture's Syndrome. . . . . . . . . . . . . . . . . . . . . . . . . .. 205 Granulomatous inflammation in sarcoidosis ............. 206 Pulmonary alveolar proteinosis ...................... 207 Differential diagnoses of fluffy exudate ................ 208

Spectrum of preinvasive squamous lesions in respiratory epithelium . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 209 Preinvasive squamous lesions ....................... 210 Well differentiated keratinizing squamous cell carcinoma ... 211 Squamous cell carcinoma in bronchial washings . . . . . . . . .. 212 Squamous cell carcinoma in FNA .................... 213 Morphologic variants of squamous cell carcinoma . . . . . . . .. 214

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Plate 6-7

Plate 6-8

Plate 7-1 Plate 7-2

Plate 7-3 Plate 7-4 Plate 7-5 Plate 7-6

Plate 7-7 Plate 7-8 Plate 7-9

Plate 7-10 Plate 7-11

Plate 7-12 Plate 7-13

Plate 7-14

Plate 7-15

Plate 7-16

Plate 7-17 Plate 7-18 Plate 7-19

Plate 7-20

Plate 7-21

Plate 7-22

Plate 8-1 Plate 8-2 Plate 8-3 Plate 8-4 Plate 8-5 Plate 8-6 Plate 8-7 Plate 8-8 Plate 8-9 Plate 8-10 Plate 8-11 Plate 8-12 Plate 8-13

Differential diagnoses of weIl differentiated squamous cell carcinoma ................................. . Differential diagnoses of weIl differentiated squamous cell carcinoma ................................. .

Pulmonary adenocarcinoma cells in sputum ............ . Pulmonary adenocarcinoma cells in bronchial brushings and washings .................................. . Pulmonary adenocarcinoma cells in BAL .............. . Pulmonary adenocarcinoma cells in FNA .............. . Pulmonary adenocarcinoma cells in FNA .............. . Bronchioloalveolar carcinoma, non-mucinous type, ...... . in sputum Bronchioloalveolar carcinoma, non-mucinous type, in FNA .. Differential diagnoses of pulmonary adenocarcinomas ..... . Pulmonary adenocarcinoma versus hyperplasia of respiratory epithelium ............................ . Differential diagnoses of pulmonary adenocarcinomas ..... . Pulmonary adenocarcinomas versus reactive/hyperplastic type 11 pneumocytes ............................. . Sclerosing hemangioma versus pulmonary adenocarcinoma .. Pulmonary adenocarcinomas versus metastatic breast adenocarcinomas ............................... . Pulmonary adenocarcinomas versus metastatic papillary thyroid carcinomas .............................. . Pulmonary adenocarcinomas versus metastatic carcinomas from gastro-intestinal tract ......................... . Pulmonary adenocarcinomas versus adenoid cystic carCInoma .................................... . Diffuse epithelial type malignant mesotheliomas ......... . Malignant mesothelioma cells in pleural effusion fluid .... . Pulmonary adenocarcinomas versus diffuse epithelial type malignant mesotheliomas ......................... . Pulmonary adenocarcinomas versus diffuse epithelial type malignant mesotheliomas ......................... . Pulmonary adenocarcin<;>mas versus diffuse epithelial type malignant mesotheliomas in FNA specimens ........... . Ancillary studies in the diagnoses of pulmonary adenocarcinomas from diffuse epithelial type malignant mesotheliomas ......................... .

Carcinoid tumors of the lungs ...................... . Carcinoid tumors of the lung ....................... . Spindie cell carcinoid tumor ....................... . Differential diagnoses of spindie cell carcinoid .......... . Atypical carcinoid tumor .......................... . Large cell neuroendocrine carcinoma (LCNEC) ......... . Small cell (undifferentiated) carcinoma ............... . Small cell (undifferentiated) carcinoma ............... . Small cell (undifferentiated) carcinoma ............... . Small cell (undifferentiated) carcinoma ............... . Differential diagnoses of small cell carcinoma .......... . Differential diagnoses of small cell carcinoma .......... . Combined small cell carcinomas .................... .

Color Plates

215

216

217

218 219 220 221 222

223 224

225 226

227 228

229

230

231

232 233 234

235

236

237

238

239 240 241 242 243 244 245 246 247 248 249 250 251

Color Plates

Plate 9-1 Plate 9-2

Plate 9-3

Plate 9-4

Plate 9-5

Plate 9-6

Plate 10-1 Plate 10-2 Plate 10-3 Plate 10-4 Plate 10-5 Plate 10-6 Plate 10-7 Plate 10-8 Plate 10-9 Plate 10-10 Plate 10-11 Plate 10-12 Plate 10-13

Plate 11-1 Plate 11-2 Plate 11-3

Plate 12-1 Plate 12-2

Plate l3-1 Plate l3-2 Plate 13-3 Plate l3-4 Plate l3-5 Plate l3-6 Plate l3-7 Plate l3-8

Plate 13-9 Plate 13-10

Plate 13-11

Plate l3-12

Plate 14-1 Plate 14-2

Large cell undifferentiated carcinoma ................. . Large cell undifferentiated carcinoma in fine needle aspiration biopsies .............................. . Large cell undifferentiated carcinoma in fine needle aspiration biopsies .............................. . Differential diagnoses of large cell undifferentiated carcinoma ........................ . Differential diagnoses of large cell undifferentiated carcinoma ........................ . Differential diagnoses of large cell undifferentiated carcinoma ........................ .

Tumor-like lesions of the lungs ..................... . Amyloidosis ................................... . Inflammatory pseudopolyp ........................ . Pulmonary hamartoma ........................... . Sclerosing hemangioma ........................... . Benign clear "sugar" cell tumor of the lung ............ . Adenosquamous carcinoma ........................ . Giant cell carcinoma of the lung .................... . Carcinosarcoma ................................ . Pulmonary blastoma ............................. . Malignant fibrous histiocytoma ..................... . Hemangiopericytoma ............................ . Adenoid cystic carcinoma ......................... .

Metastatic squamous carcinoma of the lung ............ . Metastatic adenocarcinoma of the lung ................ . Metastatic small cell carcinoma ..................... .

Lymphoproliferative disorders Lymphoproliferative disorders

Metastatic breast adenocarcinoma to the lungs .......... . Metastatic thyroid carcinomas ...................... . Metastatic adenocarcinoma from the gastro-intestinal tract .. . Metastatic transitional cell carcinoma of the urinary bladder . Metastatic malignancies from uterus .................. . Metastatic malignant melanoma ..................... . Metastatic soft tissue tumors ....................... . Differential diagnoses of metastatic soft tissue tumors with spindIe cell pattern .......................... . Metastatic malignant lymphoma ..................... . Differential diagnoses of papillary carcinomas in ........ . lung FNAs Differential diagnoses of papillary carcinomas in ........ . pleural fluid Differential diagnoses of papillary carcinomas in ........ . pleural fluid Bronchopulmonary dysplasia in neonates .............. . Metastatic tumors to the lungs in FNA specimens ........ .

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253

254

255

256

257

258 259 260 261 262 263 264 265 266 267 268 269 270

271 272 273

274 275

276 277 278 279 280 281 282

283 284 285

286

287

288 289

Abbreviations

AIDS ARDS BAC BAL BALT BPD CDC CIS CMV CSF CT DAD EBV FFB FNA H&E HBV HCV HIV hpf HSV IASLC KS LCCA LCNEC UP MALT MFH MGB MIA NEC NHL NSCC PAP PCP PTLD RSV

acquired immunodeficiency syndrome adult respiratory distress syndrome bronchioloalveolar carcinoma bronchoalveolar lavage bronchus associated lymphoid tissue bronchopulmonary dysplasia Communicable Disease Center carcinoma in situ cytomegalovirus cerebrospinal fluid computed tomography diffuse alveolar damage Epstein-Barr virus flexible fiberoptic bronchoscope fine needle aspiration biopsy Hematoxylin and Eosin Hepatitis B virus Hepatitis C virus human immunodeficiency virus high-power field Herpes simplex virus International Association for Study of Lung Cancer Kaposi's sarcoma large cell carcinoma large cell neuroendocrine carcinoma lymphoid interstitial pneumonitis mucosa-associated lymphoid tissue malignant fibrous histiocytoma Michaelis-Guttmann bodies Mycobacterium avium intracellulare neuroendocrine carcinomas non-Hodgkin's lymphoma non-sm all cell carcinoma pulmonary alveolar proteinosis Pneumocystis carinii pneumonia posttransplant Iymphocytic disorder respiratory syncytial virus

XIX

xx Abbreviations

see small cell carcinoma TBFNA transbronchial fine needle aspiration biopsy TTFNA transthoraeie fine ne edle aspiration biopsy US ultrastructure WHO World Health Organization

Explanatory Notes

Stains

All cytologic preparations are wet-fixed and stained by Papanicolaou method. Any other stain used is so indicated.

Illustrations

All color images have the letter "C" after the number (e.g., 2C-). All black and white illustrations are numbered as to the chapter number and the

sequential number.

Magnification

Unless otherwise specified, the photomicrographs are taken at 40X (or high power). All other magnifications are noted in the legends (low power 4.5 X; medium power lOX).

All electron micrographs are taken on uranyl acetate and lead citrate preparation.

xxi