Charles B. Carrington

Normal Chest Roentgenograms in Chronic Diffuse Infiltrative Lung Disease

We undertook this study to determine the prevalence of normal roentgenograms in chronic diffuse infiltrative lung diseases. Of 458 patients with such disorders histologically confirmed, 44, or 9.6 per cent, had normal pre-biopsy films. In this group with normal x-ray films, desquamative interstitial pneumonia, sarcoidosis and allergic alveolitis were the most frequent diagnoses. Dyspnea was the principal complaint, and fine rales were common. The vital capacity was reduced in 57 per cent, and the single-breath diffusing capacity in 71 per cent. In half, histological changes and functional impairment were moderately severe. Films may be normal in such cases because isolated foci are too small or too few, because diffuse interstitial or intra-alveolar disease may cast no discrete shadows or because the lesions primarily affect airways or blood vessels. Patients with normal chest roentgenograms and normal mechanics of breathing but with impaired gas exchange should have lung biopsy for early diagnosis and therapy.

Efficacy of Oophorectomy in Lymphangioleiomyomatosis and Benign Metastasizing Leiomyoma

PROLIFERATION of smooth muscle within the lung can occur as a nonspecific finding in a variety of chronic lung diseases; it can also be the major histologic manifestation in two clinical entities: ...

Follicular bronchitis/bronchiolitis

Nineteen open lung biopsies demonstrating follicular bronchitis/bronchiolitis were reviewed with special attention to clinical manifestations. Morphologically, follicular bronchitis/bronchiolitis was represented by coalescent reactive germinal centers adjacent to airways in the absence of clinical or pathologic evidence of chronic obstructive pulmonary disease or bronchiectasis. Three clinicopathologic groups were identified: 1) patients with collagen vascular diseases, especially rheumatoid arthritis and Sjögrens syndrome; 2) patients with a familial form of the disease or with immunodeficiency syndromes; and 3) a heterogeneous group of patients with frequent peripheral blood eosinophilia, suggesting a hypersensitivity reaction. Prognosis was related to age at the time of biopsy and, to some extent, to the clinical group. Steroid therapy had inconsistent effects in all groups identified. The differential diagnosis of lymphoid lesions in the lung is also discussed.

Sclerosing hemangioma of the lung: a clinicopathologic study of 51 cases.

ABSTRACT The clinical and pathologic features of 51 sclerosing hemangiomas of the lung are reviewed. This tumor is benign and occurs predominantly in women. It has a variegated histologic appearance characterized by an admixture of four major histologic patterns: solid, hemorrhagic, papillary, and sclerotic. Characteristic uniform round cells are found within the stroma in all patterns and are unique to this tumor. Sclerosing hemangioma is a distinct clinicopathologic entity and should be distinguished from other benign neoplasms or inflammatory lesions of the lung.

Pulmonary lymphomas simulating lymphomatoid granulomatosis

Twenty cases of malignant lymphoma presenting in the lung and 10 cases with secondary pulmonary involvement were studied. All cases shared the feature of prominent vascular infiltration by lymphoid cells, and in the 20 cases presenting with pulmonary involvement, this feature led to confusion with lymphomatoid granulomatosis. Both the primary and secondary lymphomas showed similar histologie features including vascular infiltration, extensive necrosis, and foci of a histologically polymorphous and benign infiltrate. The diagnosis of lymphoma was based on the identification of monomorphous foci of atypical lymphoid cells except in the cases of Hodgkins disease. The malignant cells were occasionally focal and microscopic and surrounded by an extensive histologically benign infiltrate. Examination of several blocks was often required in such cases before a diagnosis of lymphoma could be made. The clinical and radiologie findings at presentation were nonspecific. Radiologie findings included unilateral or bilateral nodules and infiltrates. The prognosis of the 20 patients who presented with pulmonary lymphoma was poor; half were dead in less than 2 years.

Pulmonary lymphomas: current concepts.

The shift from a clinical definition (aggressive behavior) to an immunologic definition (clonal proliferations of cells) of lymphomas has led to a reinterpretation of most pulmonary pseudolymphomas as indolent lymphomas. The recognition of the diverse histologic appearance of lymphomas and the acceptance of extranodal lymphomas support the view that most cases of lymphomatoid granulomatosis are malignant lymphomas. Criteria for the recognition and classification of pulmonary lymphoid lesions are discussed.

Pulmonary involvement in malignant histiocytosis. A clinicopathologic spectrum

We describe five patients in whom pulmonary malignant histiocytosis was histologically confirmed during life. Pulmonary symptoms dominated the clinical presentation in three patients, and one patient had a 5-year history of pulmonary malignant histiocytosis controlled by steroids. Radiologic features were nonspecific. Most patients had bilateral reticulonodular or fluffy infiltrates. Recurrent pulmonary histiocytosis in one patient was manifest by bilateral pulmonary nodules. Pathologically, pulmonary infiltration by malignant histiocytosis followed the normal lymphatic pathways of the lung along bronchovascular rays, in interlobular septa, and within the pleura. Unusual features included marked septal edema and fibrosis out of proportion to the degree of infiltration, and in one case, the marked predilection for the infiltrate to occlude small airways (“malignant histiocytosis bronchiolitis”). Three patients had microscopic nondestructive nodules adjacent to lymphatics. A pulmonary recurrence in one patient was composed of large monomorphous nodules with central necrosis and prominent vascular infiltration by malignant cells. The pulmonary infiltrate of malignant histiocytosis was often heterogeneous, and included variable numbers of lymphocytes and plasma cells intermingled with alveolar macrophages and metaplastic alveolar lining cells. The cytologic features of the infiltrate varied from benign to pleomorphic and obviously malignant. Histologic features which may obscure the correct diagnosis, as they did initially in three of our cases, include: malignant histiocytic bronchiolitis, marked septal edema and fibrosis; the heterogeneous cellular infiltrate; and in one case, benign cytologic features. The most valuable initial clue to the correct diagnosis was the tendency of the infiltrates to follow lymphatics of the lung.

Malakoplakia of the Lung

We have presented the clinical, radiologic and pathologic features of 2 patients with pulmonary malakoplakia. The histologic features, including diagnositc Michaelis-Gutmann bodies, were identical to those in the urinary tract where malakoplakia is recognized as an abnormal cellular response to chronic bacterial infection. Both patients were immunocompromised: one a cardiac transplant, the other a patient with Hodgkins disease. The lesions were focal and showed some response to antibiotic therapy, although other disease processes progressed in both patients. Malakoplakia should be added to the list of unusual infections occurring at unusual sites in compromised hosts.

Thoracic Surgical Problems in Asbestos-Related Disorders

Among 1,577 persons with asbestos exposure followed up from 3 to 30 years, 113 had thoracic surgical procedures for asbestos-related disorders. Twenty-six individuals suspected of having asbestosis with atypical features underwent open-lung biopsy; a different disease was revealed in 14. Most of the 29 patients with mesothelioma had a small thoracotomy for diagnosis only; chemotherapy in half of them proved entirely ineffective. Experience with 23 patients with bronchogenic carcinoma did not differ from that in persons not exposed to asbestos. Problems of causal relationship are discussed. Most of the 68 individuals with benign asbestos pleural effusion had no symptoms, but because of recurrence, 15 were operated on for decortication or for possible mesothelioma. Hyaline plaques often were mistaken for lung, rib, or diaphragmatic tumors, and sometimes mesothelioma was suspected. Operative intervention in the 24 patients with plaques could have been avoided by obtaining a more detailed occupational history and reviewing previous chest roentgenograms, which invariably showed identical or smaller plaques from 2 to 17 years earlier.

Intravascular Bronchioloalveolar Tumor (IV-BAT)

Intravascular bronchioloalveolar tumor (IV-BAT) is a recently described, histologically distinct, malignant, primary lung neoplasm. Originally it was believed to arise from type II alveolar cells which invade blood vessels within the lung, and hence its name. More recent ultrastructural studies suggest an origin from mesenchymal cells, and therefore the tumor may be more appropriately considered a sarcoma. The onset of the disease may be insidious, and its clinical course may vary from slow to rapid progression. A history is present of a young woman with slowly enlarging multiple ill defined pulmonary nodules. Open lung biopsy was diagnostic of IV-BAT. The clinical course, differential diagnosis and pathogenesis of this tumor are briefly discussed.