ppt cyst lung
TRANSCRIPT
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Namratha Ravishankar
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What is a cystic lesion in the lung?
Pathology
A cyst is a round circumscribed space surrounded by an epithelial or fibrous wall of variable thickness.
Hansell DM, Bankier AA, MacMahon H, et al. Fleischner Society: Glossary of terms for thoracic imaging. Radiology 2008;246(3):697-722.
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Namratha R
CYSTIC LESIONS OF THE LUNG
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Radiology
A cyst appears as a round parenchymal lucency or low attenuating area with a well defined interface with normal lung. The wall thickness is usually <4mm
No associated pulmonary emphysema
Usually contain air but may contain fluid or solid material
Hansell DM, Bankier AA, MacMahon H, et al. Fleischner Society: Glossary of terms for thoracic imaging. Radiology 2008;246(3):697-722. Accessed via Pubmed.com
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Cyst-Radiology
Also used to describe enlarged thin walled air spaces in lymphangioleiyomyomatosis and Langhan’s cell histiocytosis
Thick walled honeycomb lungs seen in end stage fibrosis
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Entity Imaging characteristics
Lung cyst Well-circumscribed, rounded, thin-walled air-filled structure within the lung parenchyma. Wall thickness of ≤3mm.
Cavity Air-filled space within the pulmonary parenchyma with thicker walls (>4 mm).
Emphysema Polygonal-shaped lucent area without definable walls.
Bronchiectasis Air-filled space within the lung parenchyma that branches and connects with the airway. Associated airway abnormalities including air trapping, bronchial wall thickening, and bronchiolar impactions.
Honeycombing Clustered subpleural airspaces with variable size and wall thickness. Other signs of pulmonary fibrosis: architectural distortion, traction bronchiectasis, and reticular opacities.
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Mechanisms of cyst formation They include bronchiolar check-valve mechanism, vascular
occlusion or ischaemia necrosis, and dilation of the bronchioles
Degradation of the connective matrix, especially by metalloproteinases, may play a further role particularly in LAM and PLCH
1. Kuhlman JE, Reyes BL, Hruban RH, et al. Abnormal air-filled spaces in the lung. Radiographics 1993; 13: 47–75.
2. Ichikawa Y, Kinoshita M, Koga T, et al. Lung cyst formation in lymphocytic interstitial pneumonia: CT features. J Comput Assist Tomogr 1994; 18: 745–748. 331.
3. Worthy SA, Brown MJ, Muller NL. Technical report: cystic air spaces in the lung: change in size on expiratory high-resolution CT in 23 patients. Clin Radiol 1998; 53: 515–519. 332
4. Lee KN, Yoon SK, Choi SJ, et al. Cystic lung disease: a comparison of cystic size, as seen on expiratory and
5. inspiratory HRCT scans. Korean J Radiol 2000; 1: 84–90.
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CHECK VALVE MECHANISM
The valve mechanism had been defined by BROOKE as ‘‘one in which the entrance from a bronchus into a lung cavity become obstructed in a valve-like manner, presumably with a piece of necrotic tissue, and thus allows the ingress of air during inspiration but prevents the egress during expiration’’.
Brooke B. Excessive spontaneous inflation of a lung cavity. Lancet 1931; 2: 240–241.
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Etiology
Focal or multifocal cystic lung diseaseCongenital Bronchogenic cysts Pulmonary sequestration Congenital cystic adenomatoid malformations
(CCAM)Infectious Pulmonary tuberculosis Coccidioidomycosis Pneumocystis carinii pneumonia Echinococcus granulosus or E multilocularisLymphocytic interstitial pneumonia (LIP)Desquamative interstitial pneumonia (DIP)
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Etiology
Diffuse cystic lung diseasePulmonary Langerhans’ cell histiocytosis (PLCH)Lymphangioleiomyomatosis (LAM)Honeycomb cystic lung disease Asbestosis Idiopathic pulmonary fibrosis Collagen vascular disease Hypersensitivity pneumonitis SarcoidosisMiscellaneous Cystic lung disease in Down’s syndrome118 119 Birt-Hogg Dube syndrome120–122 Trauma
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Cystic focal and multifocal disease
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Diffuse cystic lung disease
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Paediatric-Developmental
Bronchogenic cyst Pulmonary sequestration Congenital cystic adenomatoid
malformation Lobar emphysema Bronchial atresia Lymphangiectasia Plueropulmonary blastoma
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Non developmental
Pneumatocoele
Others Lymphatic cysts Enteric cysts Mesothelial cysts Simple parenchymal cysts
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Bronchogenic cyst
Shanti and Klein (2008) studied a series of 236 patients undergoing pulmonary resection for cystic lung lesions.
Bronchogenic cysts constituted 20% of this group. Of these 47 cases, 20 involved a lobar location, which required lobectomy, and 27 cases were extralobar and were treated with resection of the cyst.
Shanti CM, Klein MD. Cystic lung disease. Semin Pediatr Surg. Feb 2008;17(1):2-8.
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Bronchogenic cyst
Bronchogenic cysts are supernumery foregut buds disconnected and separated from the tracheobronchial tree to form a cystic mass during embryogenesis (between 4th - 6th weeks)
Most common site is middle mediastinum (65-90%)
Remote locations, including the interatrial septum, neck, abdomen, and retroperitoneal space.
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CLINICAL FEATURES
Most bronchogenic cysts are found incidentally.
In infants- compression of the trachea or bronchi and esophagus-wheezing, stridor, dyspnea, and dysphagia.
Intraparenchymal cysts may manifest with recurrent infection.
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Thin walled spherical unilocular masses –fluid filled, air filled or with air fluid levelsCalcification of cyst wall
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Bronchogenic cysts
Lined by secretory respiratory epithelium (cuboid or columnar ciliated epithelium)
Wall-cartilage, elastic tissues, mucous glands and smooth muscle
They do not usually communicate with the bronchial tree, and are therefore typically not air filled.
Contain fluid (water), variable amounts of proteinaceous material, blood products, and calcium oxalate
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DifferentialsMIMICS
Enteric cyst Posterior mediastinumGastric epithelium
Oesophageal cyst Squamous liningDouble muscle layer
Pericardial cyst Unilocular, Mesothelial lining
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Bronchogenic cyst
ComplicationsFistula formationUlceration of cyst wallSuperimposed infectionHaemorrhage
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Pulmonary sequestration
It is characterized by a portion of lung
that does not connect to the tracheobronchial tree and has a systemic arterial supply,usually from the thoracic or abdominal aorta
Newman B. Congenital bronchopulmonary foregut malformations: concepts and controversies.
Pediatr Radiol 2006;36(8):773–791.
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Sequestered lung
Two types of sequestration have been described: intralobar and extralobar.
The extralobar form has its own pleural investment and systemic venous drainage,
The intralobar form shares the pleural investment with the normal lung and usually (but not invariably) drains into the pulmonary venous system
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CLINICAL FEATURES
Intralobar sequestrationEarly childhood or adolesence with
recurrence lower lobe pneumoniaExtralobarUsually asymptomaticMay have cyanosis and feeding
difficultiesAssociated with diaphragmatic hernias,
cardiac malformations and foregut anomalies
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Pulmonary Sequestration Usually seen in the left lower lobe CT-homogenous soft tissue mass, cysts
containing air or fluid, focal emphysema or hypervascular focus of lung parenchyma
Lung tissue is poorly developed and cystically dilated
Cysts lined by columnar to cuboidal epithelium
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GROSS PATHOLOGY
Pleura thickened with adhesions Parenchyma-cysts upto 5cm in dia
with mucinous or purulent material and fibrosis.
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MICROSCOPY
Loose, spongy tissue with numerous small cystic spaces containing clear, mucoid fluid.
Dilated bronchi with mucous or purulent material Alveoli filled with foamy macrophages Thick walled vessels reflecting systemic vascular
drainage with elastic stains
1. DeParedes CG, Pierce WS, Johnson DG, Waldhausen JA. Pulmonary sequestration in infants and children: a 20-year experience and review of the literature. J Pediatr Surg. Apr 1970;5(2):136-47.
2. AFIP, Non neoplastic disorders of lower respiratory tract
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Congenital pulmonary airways malformation (CPAM)
A congenital pulmonary airways malformation (CPAM) (until recently described as a congenital cystic adenomatoid malformation (CCAM)) refers to a multi-cystic mass of segmental lung tissue with abnormal bronchial proliferation.
It is considered part of the spectrum of bronchopulmonary foregut malformations
Berrocal T, Madrid C, Novo S et-al. Congenital anomalies of the tracheobronchial tree, lung, and mediastinum: embryology, radiology, and pathology. Radiographics. 24 (1): e17.
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PATHOPHYSIOLOGY
Failure of normal broncho-alveolar development with hamartomatous proliferation of terminal respiratory units in a gland-like pattern (adenomatoid) without proper alveolar formation.
These lesions have intracystic communications and, unlike bronchogenic cysts, can also have a connection to the tracheobronchial tree
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Pathophysiology
The term congenital adenomatoid malformation of the lung was first used by Ch’in and Tang in 1949
Incidence of about 1 in 25,000 live births
Stocker described 3 types which were expanded to 5 types in 2005
Type 0 (Tracheobronchial) to type 4 (Alveolar)
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Congenital pulmonary airway malformation, type 0
CPAM, type 0, also known as acinar dysplasia or agenesis, is a rarely occurring and infrequently described malformation that is largely incompatible with life.
It is seen in term and premature infants who are cyanotic at birth and survive only a few hours
Associated with cardiovascular abnormalities and dermal hypoplasia
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Histology
Bronchial type airways with cartilage, smooth muscle and glands separated by abundant loosely vascularised mesenchyme
Ciliated pseudostratified cells with goblet cells
Mucous cells and cartilage in all cases
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CPAM, type 1-most common
CPAM, type 1, the large or predominant cyst type
First week to month of life, can be seen in older children and even young adults.
65% of cases ,amenable to surgery with a good prognosis.
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CT scan shows multiple large cysts (>2cm) involving the lower lobe of left lung. The cysts are air-filled, expand the lower lobe, cause mediastinal shift and hypoplasia of right lung
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Histology
Boundary between lesion and adjacent lobe sharply delineated
Cysts(2-10cm in diameter) lined by pseudostratified cilated columnar epithelium interspersed with rows of mucous cells(in 1/3rd of cases)
Polypoid or papillary appearance due to elastic tissue beneath the epithelium
Interspersed alveolar ducts,saccules and alveolae
Absent cartilage and inflammation
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BAL in CCAM type 1
Type 1 congenital cystic adenomatoid malformation (CCAM), the most frequent malformation of the lung, is the only type to present intracystic mucinous cell clusters, which may form beyond the cysts, extracystic mucinous proliferation resembling mucinous bronchioloalveolar carcinomas (BACs).
As mucinous BACs are increasingly described in the literature in young patients with CCAM, we hypothesized that type 1 CCAM mucinous cells could represent BAC precursors.
Mucinous Cells in Type 1 Pulmonary Congenital Cystic Adenomatoid Malformation as Mucinous Bronchioloalveolar Carcinoma Precursors
Lantuejoul, Sylvie MD, PhD; Nicholson, Andrew G. MD†; Sartori, Giuliana PhD; Piolat, Christian MD; Danel, Claire MD, PhD∥; Brabencova, Eva MD; Goldstraw, Peter MD; Brambilla, Elisabeth MD, PhD*; Rossi, Giulio MD
AJSP, June 2007 - Volume 31 - Issue 6 - pp 961-969 doi: 10.1097/01.pas.0000249444.90594.27
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MALIGNANCY
CCAM-Maturation defects at various points during organogenesis and maturation
Focal atypical goblet cell hyperplasia in 33% Bronchioloalveolar carcinoma in 1%. Mean age -26 years All mucinous in character Sheffield et al described premalignant
changes in type 1 CCAM Epithelial hyperplasia and malignant
change in congenital lung cysts Clin pathol 1987;40.61-14
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Bronchioalveolar carcinoma Mucous cell proliferation-hyperplasia Extension into adjacent alveoli- lepidic
growth pattern-Brochioloalveolar cell carcinoma
IHC:IL-3,IL4 and MUC-2 nuclear staining in atypical goblet cells and cytoplasmic and nuclear staining in adjacent epithelium
Chromosomal aberrations in the mucous cells similar to those in adenocarcinoma in non smokers
Good prognosis with exceptional metastasis
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PROGNOSIS
BAC in CCAM less aggressive disease than BAC in a structurally normal lung
Douglas West et al, Dept of histopathology and
cardiothorasic surgery,Glasgow uk The society of thorasic surgeons
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Congenital pulmonary airway malformation (CPAM), type 2.
CPAM, type 2, the medium cyst type, accounts for 10% to 15% of cases.
Seen within the first year of life Poorer outcome Grossly, cysts rarely more than
1.5 cm in diameter that tend to blend with the normal adjacent parenchyma.
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Areas of low attenuation consist of clusters of multiple, small and evenly spaced air cysts
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Histology
Multiple small cysts(0.5-2cm) Small relatively uniform cysts
resembling bronchioles separated by normal alveoli.
Cysts are lined by cuboid-to-columnar epithelium and have a thin fibromuscular wall.
No mucous cells or cartilage Solid pale tumor-like tissue with
striated muscle in 5%
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Congenital pulmonary airway malformation (CPAM), type 3.
First days to month of life Male predominance, and owing to its
large size Maternal polyhydramnios and fetal
anasarca, high mortality rate Grossly, the lesion is “noncystic”
and appears more like dense pulmonary parenchyma
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GROSS
Grossly a solid mass without obvious cyst formation
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Histology
Solid appearance Excess of bronchiolar structure
separated by small air spaces, with cuboidal lining resembling late fetal lung
Microscopic adenomatoid cysts
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CPAM, type 4
The peripheral acinar cyst type, appears to be a
hamartomatous malformation of the distal acinus.
This variant is seen equally in boys and girls, with an age range of newborn to 4 years and accounts for 10% to 15% of cases.
type 4 lesions may present with mild respiratory distress, sudden respiratory distress from tension pneumothorax, pneumonia.
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Grossly, large thin-walled cysts are present at the “periphery” of the lobe and appear to be lined by a smooth membrane.
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Histology type 4
Cysts(upto 10 cm) are lined by flattened epithelial cells (type I and II alveolar lining cells) over most of wall, with occasional low cuboidal epithelium seen.
The wall of the cyst is composed of loose mesenchymal tissue with prominent arteries and arterioles.
Loose mesenchyme must not be confused with similar features seen in the cystic type of PPB.
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MICROSCOPY
Focal stromal hypercellularity (50%)
Focal immature cartilage Associated pleuropulmonary
blastoma (bilateral type 4 CCAM with stromal cellularity)
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Pleuropulmonary blastoma Low-grade cystic PPB has been confused with large
cyst type 1 CCAM/CPAM and type 4 CPAM, and likely accounts for many, if not all, reports of malignancy arising in large cyst CCAM.
Low-grade cystic PPB can be distinguished histopathologically on the basis of the presence of a thin layer of primitive mesenchymal cells beneath the cyst wall
Hill DA, Jarzembowski JA, Priest JR, Williams G, Schoettler P, Dehner LP. Type I pleuropulmonary blastoma: pathology and biology study of 51 cases from the international pleuropulmonary blastoma registry. Am J Surg Pathol 2008;32(2):282–295.
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Associations
Type 2 CPAM has been noted in nearly 50% of cases of extralobar sequestrations.
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CCAM and PPB
Type I or purely cystic PPB is usually associated with larger cysts, more typical of type 4 CCAM.
Controversy exists as to whether the tumor develops within a CCAM or whether the cystic lesion represents PPB from the onset
In a report of 50 cases from the PPB registry, the authors propose that CCAM could be a precursor to PPB just as nephrogenic rests and nephroblastomatosis are to Wilms tumor
J.R. Priest, M.B. McDermott, S. Bhatia et al. Pleuropulmonary blastoma,A clinicopathologic study of 50 cases Cancer, 80 (1997), pp. 147–161
D.A. Hill, L.P. Dehner, L.V. Ackerman A cautionary note about congenital cystic adenomatoid
malformation (CCAM) type 4 Am J Surg Pathol, 28 (2004), pp. 554–555
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Pleuropulmonary blastoma Pulmonary blastomas are a relatively rare group
of primary lung neoplasms that are composed of immature malignant epithelial and/or mesenchymal tissues whose features may resemble early embryological lung tissues.
First described by Barnard in 1952.
Koss M, Travis W, Moran C. Pulmonary sarcomas,blastomas, carcinosarcomas and Teratomas. Spencer’sHistopathology of the Lung (5th edn). New York, NY:McGraw Hill, 1996:1092–100. Barnard WG. Embryoma of lung. Thorax 1952;7:299
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RADIOLOGY
Solid, mixed and cystic heterogeneous low attenuation, pleural effusion , contralateral mediastinal shift, and lack of chest wall
invasion .
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MICROSCOPY
Type 1-Multicystic Cysts separated by fibrovascular
septae lined with benign respiratory epithelium
Stroma-small round to spindle cells condensing to form a continuous cambium layer beneath the epithelium
Rhabdomyoblastic differentiation
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Congenital lobar emphysema
Congenital lobar emphysema (CLE) refers to an over inflation of one or more lung lobes presumably due to various factors including a possible obstructive check valve mechanism at a bronchial level .
Berrocal T, Madrid C, Novo S et-al. Congenital anomalies of the tracheobronchial tree, lung, and mediastinum: embryology, radiology, and pathology. Radiographics. 24 (1): e17.doi:10.1148/rg.e17
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Congenital lobar emphysema
Neonatal period or infancy Males>females Left upper lobe and right middle lobe
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Congenital lobar emphysema
Congenital lobar overinflation-Normal architecture with overdistention of the alveoli
No true emphysematous changes Emphysema: Permanent
distention of the airspaces distal to the terminal bronchiole with destruction of their walls
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Etiology
Etiology Not found in up to 50% Bronchial obstruction found in ~25% Allows collapse on exhalation (ball-
valve mechanism) Air trapping leads to alveolar
overinflation
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Etiology
1. Intrinsic obstruction (more common) Intramural: Defect in the bronchial wallDefective quantity or quality of cartilage Intraluminal: Lesion in the lumen of the
bronchus Redundant bronchial folds, mucous plugs1. Extrinsic obstruction Compression of the bronchus from a lesion
outside the bronchial wall Cardiovascular: PDA, vascular sling Mass: Lymph node, bronchogenic cyst, oncologic
mass
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Involvement
Upper lobes are predominantly involved
LUL: 42%RML: 35%RUL: 21%Lower lobes: <1%Bilateral involvement: ~20%
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CLINICAL FEATURES
Symptoms (in order of decreasing frequency)
1. Moderate respiratory distress (most)
2. Cyanosis (half)3. Mild respiratory distress (less than
half)4. Asymptomatic (infrequent)5. Severe life-threatening distress
(least common)
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Massive distention of alveolar spaces, but no tissue destruction
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CLE
It is necessary for pediatricians to evaluate associated anomalies because 14% of the cases of CLE have coexistent congenital heart disease
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Bronchial atresia (BA)
Bronchial atresia (BA) is a developmental anomaly characterised by focal obliteration of the proximal segment of a bronchus.
The bronchi distal to the atresia become filled with mucus and may form a mucocoele
The lung distal to the atretic bronchus develops normally but is overinflated due to collateral air drift with air trapping.
Most commonly occurs at the apico-posterior segment of the left upper lobe
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The bronchioles plugged by mucus and the surrounding alveoli are dilated. Many neutrophils and macrophages were found within the bronchi and surrounding lung parenchyma, indicating acute or chronic infection. Alveoli were enlarged, with a loss of alveolar walls.
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Primary pulmonary lymphangiectasia (PPL)
Primary pulmonary lymphangiectasia (PPL) is a rare disorder of unknown aetiology characterised by dilatation of the pulmonary lymphatics
Primary pulmonary lymphangiectasia in infancy and childhood
P.M. Barker, C.R. Esther Jr, L.A. Fordha, S.J. Maygarden, W.K. Funkhouser
European respiratory journal
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Lymphangiectasia
Full term infants with respiratory distress, pleural effusion(chylous)/generalised oedema
Pleural effusions with diffuse interstitial infiltrates
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Diffuse thickening of the interstitium, both of the peribronchovascular interstitium and the septa surrounding the lobules
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Dilated lymphatic spaces in the sub-pleural connective tissue, along thickened interlobar septa, and around bronchovascular axes
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Differential Diagnosis of Cystic Lung Disease
Developmental cystsNon-infectious: Blebs and bullae Pulmonary Langerhans’ cell histiocytosis (PLCH) Lymphangioleiomyomatosis (LAM) Honeycomb lungInfectious: Pneumatocoele Pneumocystis carinii pneumonia (PCP) Tuberculosis Hydatid cyst Coccidiodomycosis
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TUMOURS
Pleuropulmonary blastoma Cystic teratoma Multicystic mesothelioma Cystic mesenchymal hamartoma Metastases
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MIMICS
Cystic bronchiectasis
Hartman TE. CT of cystic diseases of the lung. Radiologic Clinics of North America. 2001;39(6):1231-43
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Disease Findings Distribution
Assoc. Findings
IPF Honeycomb cystsSubpleural, basilar predominance
Irregular lines of attenuation, ground-glass
PLCH Thin-walled cysts Random, spares bases
Nodules
LAM Thin-walled cysts Random, diffuse Chylous effusion
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Differential diagnosisTS Thin-walled cysts Random, diffuse Angiomyolipomas
of kidneys and liver
LIP Thin-walled cysts Basilar predominance
Ground-glass attenuation
Cystic Bronchiectasis
Cystic structures contiguous with bronchial tre
Diffuse or focal Signet ring sign: each cystic space has an attendant vessel
Adapted from: Hartman TE. CT of cystic diseases of the lung. Radiologic Clinics of North America 2001;39(6):1231-43.
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Blebs and bullae
CT Scan: Thin walled cystic air space contiguous with the pleura
Arbitrary distinction between bleb and a bulla is of little clinical significance
Hansell DM, Bankier AA, MacMahon H, et al. Fleischner Society: Glossary of terms for thoracic imaging. Radiology 2008;246(3):697-722.
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Bleb
The term bleb usually connotes a subpleural collection of air within the layers of visceral pleura caused by a ruptured alveolus.
The air dissects through the interstitial tissue into the thin, fibrous layer of visceral pleura where it accumulates to form a bleb.
Rupture of a bleb is often associated with the development of a spontaneous pneumothorax
Cystic and Bullous Lung Disease Robert R. Klingman, MD, Vito A. Angelillo, MD, and
Tom R. DeMeester, MD Departments of Surgery and Pulmonary Medicine, Creighton University School of Medicine, Omaha, Nebraska
Ann Tkorac Surg 1991;52:576-80)
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Bullae
An air filled space within the lung parenchyma resulting from deterioration of the alveolar tissue.
These lesions have a fibrous wall , trabeculated by the remnants of alveolar septa.
They can develop in a lung that is otherwise normal or in a lung in which the architecture has been destroyed by chronic obstructive disease.
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Blebs and Bullae
Bullae can reach substantial size and occupy an entire lobe
Usually seen in chronic obstructive pulmonary disease but also seen in normal young healthy individuals
Chronic obstructive pulmonary disease- no lobar predilection for the bullae
Asymptomatic patients, bullae - in the upper lobes and peripherally
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Bullae are large dilated airspaces that bulge out from beneath the pleura
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Bulla results from destruction of alveolar walls (paraseptal emphysema). The bleb results from rupture of alveolar air into the pleura
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Differences
Bullae in the substance of the lung
Blebs in the visceral pleura outside the inner elastic lamina
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Pulmonary Langerhans’ cell histiocytosis (PLCH)
PLCH is typically a disease of young adults which predominately affects the lungs and bones
Very strong association with smoking(90%) Interstitial lung disease Lung affected in isolation or in
association with organ systems
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Pulmonary Langerhans’ cell histiocytosis (PLCH)
Pulmonary disease in PLCH is characterized by peribronchiolar 1-10 mm nodules in the early stages
In later stages of PLCH, the major pulmonary finding is cysts (present in 80% of patients) and there may be no nodules present
Lung bases are relatively spared at all disease stages
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Cysts in pulmonary LCH
The abnormalities are diffuse and symmetrical.
The cysts in PLCH vary in size and shape, in contrast to the uniform appearance of cysts in lymphangioleiomyomatosis (LAM)
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Characteristic combination of diffuse cysts and centrilobular micronodules
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Cysts in PLCH
Cysts more pronounced later in the disease usually less than 10mm in diameter may measure up to 2 - 3 centimetres in size
Thin-walled, but on occasion may be up to a few millimetres thick
confluence of 2 or more cysts results in bizarre shapes : bilobed cloverleaf branching internal septations
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GROSS PATHOLOGY
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Histopathology
The earliest histologic lesion of PLCH consists of proliferation of Langerhans’ cells along small airways
These early cellular lesions expand to form nodules 1 to 5 mm in diameter.
The characteristic lesion is composed of variable numbers of Langerhans’ cells,eosinophils,plasma cells, lymphocytes, fibroblasts, and pigmented alveolar macrophages, which form a loosely aggregated granulomas
These granulomas are typically centered around distal bronchioles, where they infiltrate and destroy airway walls
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Histopathology
It is postulated that as these cellular granulomas evolve, peripheral fibrosis forms resulting in traction on the central bronchiole which becomes cyst-like
Evolution from nodule, through cavitating nodule and thick walled cysts, to the 'stable' thin-walled cysts
Electron microscopy may reveal characteristic Birbeck granule
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Lymphangioleiomyomatosis (LAM)
Lymphangioleiomyomatosis (LAM) is a disorder of smooth muscle proliferation.
Primarily affects women of childbearing age.
It also can present after menopause in women undergoing estrogen hormonal treatment.
This condition is indistinguishable from pulmonary involvement in tuberous sclerosis, which can also occur in men
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Pathophysiology
Characterized by the progressive proliferating and infiltrating smooth muscle like cells (lymphangioleiomyomatosis cells)
Cystic destruction of the lung parenchyma; obstruction of airways, blood vessels, and lymphatics
2 main forms:tuberous sclerosis complex (TSC)–associated LAM and sporadic LAM (S-LAM).
In tuberous sclerosis, type II pneumocytes form clusters termed multifocal micronodular pneumocyte hyperplasia that are unique to TSC and may occur in the absence of
LAM in these patients
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PATHOLOGY
Two phases of proliferation in lymphangiomyomatosis.
The early phase - proliferation of immature muscle cells which cover alveolar walls, bronchioles, pleura and vessels, including lymphatic routes.
Late phase - development of cystic spaces and wider proliferation of muscle cells throughout the lung.
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Cyst formation in LLAM
An immunohistochemical study of metalloproteinases (MMP) and their inhibitors suggested that MMP-2 and MMP-9 (both of which can degrade elastin as well as the collagens) are responsible for the connective tissue destruction and cyst formation in LAM
Hayashi T, Fleming MV, Stetler-Stevenson WG, et al. Immunohistochemical study of matrix metalloproteinases (MMPs) and their tissue inhibitors (TIMPs) in pulmonary lymphangioleiomyomatosis (LAM). Hum Pathol 1997; 28:
1071–1078.
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It shows thin-walled cysts of relatively uniform size diffusely distributed throughout all lung fields . The cysts may vary in size from 2 to 40 mm
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PATHOLOGY
Small clusters or nests at the edges of the cysts and along the alveolar walls, pulmonary blood vessels, lymphatics, and bronchioles .
Mitotic figures are rarely seen. Loss of alveoli is associated with cyst
formation
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LLAM
The proliferating LAM cells are morphologically heterogeneous and can be classified into 2 types: spindle-shaped cells and epithelioid cells.
Spindle-shaped cells are centrally located, whereas the epithelioid cells exist in the peripheral regions of the LAM cell nodules
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IHC
Lymphangioleiomyomatosis cells coexpress smooth muscle markers (such as smooth muscle actin and desmin) and melanocytic markers (such as HMB-45, Melan-A/MART-1, and microphthalmia transcription factor)
Coexpression of contractile proteins and melanocytic markers, LAM cells are suggested to be of perivascular epithelioid cell origin
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Immunohistochemistry
Demonstration of the presence of estrogen receptor (ER) and progesterone receptor (PR) in the epithelioid LAM cells (50%) who never received hormone treatment.
ER and PR are selectively expressed in epithelioid LAM cells and are down-regulated by hormone therapy
Matsui K, Takeda K, Yu ZX, et al. Downregulation of estrogen and progesterone receptors in the abnormal smooth muscle cells in pulmonary lymphangioleiomyomatosis following therapy: an immunohistochemical study.
Am J Respir Crit Care Med. 2000;161(3, pt 1):1002–1009.
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IHC
Recently, CD1a and cathepsin K were found to be positive in both spindle shaped and epithelioid LAM cells
Useful new markers for the diagnosis of pulmonary LAM and renal angioleiomyoma
Chilosi M, Pea M, Martignoni G, et al. Cathepsin-K expression in pulmonar lymphangioleiomyomatosis. Mod Pathol. 2009;22(2):161–166
Adachi Y, Horie Y, Kitamura Y, et al. CD1a expression in PEComas. Pathol Int. 2008;58(3):169–173
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Pneumatocoeles
Pneumatocoeles are intrapulmonary air-filled cystic spaces that can have a variety of sizes and appearances.
They may contain air-fluid levels and are usually the result of ventilator-inducted lung injury in neonates or post-pneumonic
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ETIOLOGY
Staphylococcus aureus: most common
Pneumocystis carinii Streptococcus pneumoniae Haemophilus influenzae Escherichia coli Group A streptococci Klebsiella pneumoniae Adenovirus Primary tuberculosis
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RADIOLOGY
Smooth inner margins Contain little if any fluid Wall (if visible) is thin and regular Persist despite absence of symtpoms
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PATHOLOGY
Arise from necrotic foci that develop early in disease, initially have irregular shapes and thick walls.
Exudate disappears, and walls thin. Necrotic material around the pneumatocele. Walls can contain organized inflammatory cells
with focal collections of multinucleated giant cells. In 1972, Boisset reported the presence of air
corridors between the bronchiolar lumen and the interstitial space
Boisset GF. Subpleural emphysema complicating staphylococcal and other pneumonias. J Pediatr. Aug 1972;81(2):259-66.
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Infectious cysts
True infectious cysts that persist despite resolution of the primary infection may occur with Pneumocystis carinii pneumonia or Echinococcosis (hydatid disease).
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Pnemucystis carinii pneumonia Cysts vary in size, shape, number, wall
thickness– Thin-walled (<3mm), usually air-filled– Usually multiple, bilateral– May be intraparenchymal or subpleural– upper lobe predominance Cystic disease now occurs in 10-34% PCP
cases Cysts in HIV patient are highly suggestive of
PCP
Boiselle, PM, Crans, CA and Kaplan, MA. The Changing Face of Pneumocystis carinii P in AIDS Patients. AJR 1999; 172: 1301-1309.
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Lung cysts are usually multiple, thin walled and bilateral, but range in size, shape and distribution
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Alveoli which are distended with honey- combed, foamy, brightly eosinophilic material . There is a scanty inflammatory infiltrate composed mainly of monocyte, occasional plasma cells and histiocytes.
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Grocott's silver stain shows black cysts in alveolar wall & exudates. It looks as round or indented (“new-moon” shape). )
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Tuberculosis
Tuberculosis may present with atypical manifestations in one-third of the cases, and multiple thin-walled cysts are one such rare manifestations of tuberculosis
Lee JY, Lee KS, Jung KJ et al. Pulmonary tuberculosis: CT and
pathologic correlation. J Comput Assist Tomogr 2000; 24:691-8.
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Mechanisms
Marked caseating necrosis of the bronchial walls cystic bronchiectasis
Granulomatous involvement of the bronchioles may lead to a check-valve mechanism leading to cyst formation
In isolated cases, isoniazid has been implicated
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Multiple large cysts (bilateral), thin walled, and involving all zones of the lung
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HYDATID CYST
Hydatid cysts may be solitary or multiple, the number depending mainly on the amount of ova ingested and the number of embryos filtered through the liver and lungs.
A centrally located cyst is said to be usually round, but may become oval or polycyclic
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Hydatid cyst
Inferior lobes most commonly affected
Intact:ruptured::3:1 The cysts may change shape on
maximum inspiration and expiration, which is known as the Escudero- Nimerov sign, but which is true also of any thin-walled water filled cyst
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Calcified unilocular hydatid cyst. Contrast material-enhanced CT scan shows a round lesion with water attenuation and a ringlike pattern of calcification (arrows). This pattern represents calcification of the pericyst and strongly suggests a diagnosis of hydatid cyst
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MICROSCOPY
Outer acellular laminated membrane Germinal membrane Protoscolices, attached and budding
from the membrane
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Coccidiodomycosis
When acute, cavities can be thick-walled or surrounded by dense consolidation.
Thin walled grape skin cysts can also be seen with acute infection or as a result of healing of the thick walled lesions
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large (up to 80 micron) spherules/sporangia, as shown in this case. These are filled with numerous spherical endospores. The sporangia and endospores can be within giant cells or extracellularly.
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Honeycomb Lung
The original usage was a gross pathological term employed at autopsy to describe lungs with a wormeaten or honeycomb appearance
II. HEPPLESTON, A. G. Pathology of honeycomb `lung. Thorax, 1956, II, 77-94.
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HONEYCOMB LUNG
Honeycombing represents destroyed and fibrotic lung parenchyma with numerous cystic airspaces with thick fibrous walls representing the late stages of lung diseases with complete loss of acinar architecture.
Variable wall thickness and lined by metaplastic bronchiolar epithelium
Hansell DM, Bankier AA, MacMahon H, et al. Fleischner Society: Glossary of terms for thoracic imaging. Radiology. 2008;246(3):697-722.
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Pathology
Essential change is the obliteration of bronchioles by fibrosis or granulomata and compensatory dilatation of neighboring bronchioles, which forms the honeycomb appearance
Heppleston AG. The pathology of honeycomblung. Thorax 1956; 11:77–93
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HONEYCOMBING
“Clustered cystic air spaces, typically of comparable diameters on the order of 3–10 mm but occasionally as large as 2.5 Cm.
Usually subpleural and characterized by welldefined walls”
However, “the cystic air spaces of honeycomb lung tend to share walls”
Hansell DM, Bankier AA, MacMahon H, McLoud TC, Muller NL, Remy J. Fleischner Society: glossary of
terms for thoracic imaging. Radiology 2008; 246:697–722Webb WR, Muller NL, Naidich DP. Standardized terms for
high-resolution computed tomography of the lung: a proposed glossary. J Thorac Imaging 1993; 8:167–175
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Idiopathic interstitial pneumonia
Honeycombing was identified in 41–100% of UIP, depending on the reported series .
Nonspecific interstitial pneumonia (NSIP) and desquamative interstitial pneumonia (DIP), which are the chronic interstitial pneumonias of IIP show honeycombing in 0–30% and 4.3–39%, respectively .
In acute interstitial pneumonia, the frequency is lower, ranging from 6% to 14%
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IDIOPATHIC PULMONARY FIBROSIS
Honeycomb cysts are a feature of idiopathic pulmonary fibrosis (IPF) and typically have a subpleural location
Walls of the cysts are clearly defined and thickened – a sign of fibrosis
Predominant in posterior and lower lobes This characteristic distribution distinguishes
UIP from other diseases with honeycomb lung.
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Diffuse ground glass opacities with cysts (arrow). (B) A high resolutionCT scan from the same patient more clearly shows cysts within ground glassopacities. Traction bronchiectasis is also present, suggesting that the ground glassopacities are secondary to fibrosis rather than an inflammatory process.
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Multiple thin-walled cysts occupying most of lobe. Note that some cysts contain mucous material
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Idiopathic pulmonary fibrosis showing traction bronchiectasis (white arrows). The adjacent bronchi and vasculature differentiates these structures from true cysts. End-stage lung fibrosis is evident with diffuse honeycombing (black arrow), reticulation and traction bronchiectasis.
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MICROSCOPY
Patchwork pattern, which is characterized by alternating zones of abnormal and normal lung side by side without transition zones
Small islands of residual normal or nearly normal lung interspersed among extensively scarred parenchyma
Combination of areas of honeycomb change and scars that replace normal alveoli
Honeycomb areas are characterized by enlarged airspaces lined by bronchiolar epithelium and often filled by mucin and variable numbers of inflammatory cells.
Small areas of active fibrosis (fibroblast foci) are present in the background of collagen deposition
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Desquamative interstitial pneumonia
It is a disease that is seen almost exclusively in current or former smokers
Accumulation of pigmented macrophages within the airspaces with a homogenous appearance and limited mononuclear infiltrate within the interstitium.
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The alveolar septa are thickened by a sparse inflammatory infiltrate that often includes plasma cells and occasional eosinophils, and they are lined by plump cuboidal pneumocytes.The intraluminal macrophages in DIP frequently contain dusty brown pigment .
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Cellular non-specific interstitial pneumonia (NSIP) pattern. On higher power, the septal widening is due to a mild to moderate infiltrate of lymphocytes with scattered plasma cells, with minimal associated fibrosis.
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Marked thickening of the alveolar septa due to interstitial edema, inflammatory cell infiltration, fibroblast proliferation (within the interstitium and airspaces), and type II cell hyperplasia, Hyaline membranes in focal areas along alveolar septa, Thrombi in small arteries
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Other causes
Honeycomb cystic lung disease Asbestosis Collagen vascular disease Hypersensitivity pneumonitis Sarcoidosis
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Bronchiectasis
Bronchiectasis, or the dilatation and distortion of bronchi and bronchioles, may be mistaken for cystic airspace disease when a dilated airway is viewed ‘‘en face’’
Bronchiectasis may be the result of either a chronic suppurative process or accompany lung fibrosis, when it is then referred to as traction bronchiectasis
Challenges in pulmonary fibrosis ? 3: Cystic lung disease
Gregory P Cosgrove, Stephen K Frankel, Kevin K BrownThorax 2007;62:820–829. doi: 10.1136/thx.2004.031013
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Bronchiectasis
Cystic bronchiectasis can be differentiated from true cystic lung disease by the continuous relationship of the cystic structure to bronchial tree
Approximately uniform, medium-sized cavities are typical of cystic bronchiectasis.
Valsalva and Mueller maneuvers produce rapid change in the size of cysts, which freely communicate with the airways; this change distinguishes cystic bronchiectasis from other conditions.
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Traction Bronchiectasis
Differentiated from cystic lung disease by the presence of an adjacent blood vessel suggesting a bronchovascular unit rather than a cystic air space.
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Mesenchymal cystic hamartoma
Mesenchymal cystic hamartoma (MHC) of the lung is a very rare disease with an indolent clinical course and might be easily misdiagnosed as pleuropulmonary blastoma and other uncommon cystic lung lesions
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HISTOLOGY
Bilateral multifocal cysts lined by normal or metaplastic respiratory epithelium resting on a cambium layer of mesenchymal cells
● Lesion is initially solid, but becomes cystic when approximately 1 cm in diameter● Slow growing
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Cysts were lined with normal respiratory epithelium. Beneath the epithelium were band-like layers of cells composed of primitive mesenchymal-like cells with dark oval nuclei, scanty cytoplasm, and very rare mitoses . Scattered or clustered mature fat cells were present in some areas of the cysts and nodules
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Benign multicystic mesothelioma
Rarely described in the pleura Single or multiple thin walled cysts Multiloculated cyst lined by
attenuated or cuboidal cells with atypia
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TERATOMA
Intrapulmonary teratomas typically range from 2.8 to 3 cm in diameter, and are cystic and multiloculated but may rarely be predominantly solid
In 42% of the cases, the cysts are in continuity with bronchi, and have an endobronchial component resulting in hemoptysis or expectoration of hair or sebum
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MICROSCOPY
Radiographically, lesions are typically cystic masses often with focal calcification.
Microscopically, mesodermal, ectodermal and endodermal elements are seen in varying proportions.
Pulmonary teratomas are mostly composed of mature, cystic somatic tissue
Mature elements often take the form of squamous lined cysts.
Thymic or pancreatic elements may be seen in mature teratomas
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CYSTIC LUNG METASTASES
The appearance of cystic lesions in the lung in malignancy is rare and predisposes to spontaneous pneumothoraces.
Multiple cystic lesions occur commonly in bronchus carcinoma and also sarcoma, bladder cancer and, less commonly, lymphoma
Both chemotherapy and immune suppression can induce cavitation in malignant lesions.
Tumour necrosis and tumour infiltration of air-containing spaces with a check-valve mechanism are postulated for causing these cystic lesions
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SARCOMAS
Spontaneous pneumothorax complicating sarcoma is associated with most cell types, recurrent in nearly half of the patients
The main cell types consisted of angiosarcoma (39%), leiomyosarcoma (15%) and osteosarcoma (15%)
Hoag JB, Sherman M, Fasihuddin Q, et al. A comprehensive review of spontaneous pneumothorax complicating sarcoma. Chest 2010; 138: 510–518
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Squamous cell carcinoma Metastases from the head and neck tended to
cavitate when small and to have thin walls, whereas metastases from squamous cell carcinomas of the bladder and genitalia generally cavitated when they were larger and had thickened walls.
Seminoma, Ewing sarcoma, myxosarcoma, Wilms tumor, osteogenic sarcoma, angiosarcoma, transitional cell carcinoma, teratocarcinoma
Multiple, Thin-Walled Cystic Lesions of the LungJ. David Godwin,w. Richard Webb, Charles J. SavocaGordon Gamsu, Philip C. GoodmanAJR 135:593-604, September 19800361 -803X/80/1 353-0593
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Rare cystic lung lesions
Pulmonary thromboembolism Neurofibromatosis Follicular bronchitis Pulmonary spread of laryngeal
papillomatosis Hodgkin’s lymphoma Rheumatoid arthritis with necrobiotic
nodules Birt Hogg syndrome Down’s syndrome