Roberta R. Miller

Glandular neoplasia of the lung. A proposed analogy to colonic tumors

In 62 consecutive resections for adenocarcinoma of the lung, 50 cases (81%) had single adenocarcinomas and 12 (19%) had multiple adenocarcinomas. In seven of these 12 patients, two adenocarcinomas were found. In the other five patients, the specimen contained a dominant adenocarcinoma and several 0.1‐ to 1‐cm nodules of similar histologic appearance. In four of the 50 single tumor patients and one of seven double tumor patients, 1‐ to 2‐mm nodules were found along with adenocarcinomas that we interpreted as being bronchioloalveolar tumors of uncertain malignant potential. An analogy is drawn between these four types of findings and single tumors of the colon, double tumors of the colon, polyposis syndromes, and tubular adenomas of the colon, respectively.

Orbital-Adnexal Lymphangiomas: A Spectrum of Hernodynarnically Isolated Vascular Harnartornas

A retrospective review of 13 cases of lymphangioma has led to a classification of these lesions into categories of superficial, deep, and combined types. The clinical manifestations, prognosis, and management directly correlate with the pathophysiology and the location of the lesions. Superficial lesions consist of isolated multicystic vascular abnormalities of cosmetic significance only. Deep orbital lymphangiomas present as spontaneous, acute proptosis due to retrobulbar hemorrhage. Combined lesions demonstrate both superficial and deep components and are also characterized by spontaneous hemorrhages. Histopathologically, lymphangiomas represent a spectrum of vascular hamartomas with a constellation of features that parallels the clinical progression and histology of similar lesions elsewhere in the head and neck. This may include the presence of diaphanous serous-filled vascular channels, a connective tissue stroma with lymphorrhages, features of old hemorrhage, dysplastic vessels, and random smooth muscle bundles. Both direct and indirect evidence suggests that these lesions are characterized by relative hemodynamic isolation.

Lingular and Right Middle Lobe Biopsy in the Assessment of Diffuse Lung Disease

It has been said that the lingula and right middle lobe should be avoided for open-lung biopsy because of nonspecific fibrosis and vascular changes. To determine if the diagnostic yields of lingular or right middle lobe biopsy specimens were unsatisfactory, we reviewed the results of open-lung biopsy in 73 adult patients; 26 were immunocompromised and 47, nonimmunocompromised. We found no evidence to suggest that these two sites were inherently inferior. In 20 of the nonimmunocompromised patients, computed tomography was performed prior to biopsy, and demonstrated no particular tendency for greater involvement of the lingula or right middle lobe. We conclude that lingular and right middle lobe biopsy is useful in the diagnosis of parenchymal lung disease and that these sites should not necessarily be avoided. Computed tomographic scanning prior to biopsy is helpful in guiding the surgeon to the appropriate sites from which to obtain biopsy specimens.

MRI of infiltrative lung disease : comparison with pathologic findings

Objective Our goal was to compare MRI with pathologic findings in patients with chronic infiltrative lung disease. Materials and Methods The study included 22 consecutive patients who had MRI and lung biopsy performed within 21 days (median 4 days). Fifteen patients had open lung biopsy: five with idiopathic pulmonary fibrosis, three with extrinsic allergic alveolitis, and seven with miscellaneous conditions. Seven patients had transbronchial biopsy: four with sarcoidosis and three with miscellaneous conditions. All patients had 1.5 T MRI with cardiac-gated Tl-, proton density-, and T2-weighted SE sequences. Results The predominant patterns of abnormality seen on MR included parenchymal opacification (n = 12), parenchymal opacification and reticulation (n = 2), reticulation (n = 3), nodularity (n = 3), and interlobular septal thickening (n = 1); normal findings were found in 1. The 14 patients with parenchymal opacification included 9 with ground-glass intensity and 5 with consolidation. In 12 of these 14 patients the parenchymal opacification represented an active inflammatory process including alveolitis, pneumonia, and granulomatous inflammation, while in 2 patients it represented fibrosis. Reticulation was shown to represent fibrosis in five of five cases. The three patients with nodules had sarcoidosis. Conclusion The MR findings correlate closely with those seen on lung biopsy. Parenchymal opacification on MR usually indicates the presence of potentially reversible disease, while reticulation usually indicates irreversible fibrosis.

Neuroendocrine carcinomas of the lung

N EUROENDOCRINE carcinomas of the lung are tumors related to the Kulchitsky cell, a neuroendocrine cell normally present in the bronchial mucosa.lV2 These tumors account for approximately 25% of all lung tumors and include three subtypes: classic carcinoid, atypical carcinoid, and small cell carcinoma. These three different subtypes share many common morphologic and biochemical features, but represent a spectrum of aggressiveness with some overlap of clinical, radiologic, and pathologic features.‘V3 A more extensive discussion of the pathology of these tumors is given in the article by Pietra in this issue. Classification into three subtypes is important because their treatment and prognosis are different.4 At one end of the spectrum is the carcinoid tumor, a low-grade carcinoma with low incidence of metastasis and good prognosis following surgical resection. At the other end of the spectrum is the small cell carcinoma, an extremely malignant tumor that metastasizes early in its course and is usually not amenable to surgical resection. The treatment consists of chemotherapy and radiotherapy. Atypical carcinoids are tumors of intermediate malignant potential and prognosis. They are usually treated by lobectomy or pneumonectomy with or without adjuvant chemotherapy and radiotherapy. Because of the differences in treatment among these tumors, accurate preoperative diagnosis is critical. However, because of the overlap between the three subtypes and their similar cytologic features, preoperative differential diagnosis is difficult and often misleading. Cytologic specimens obtained by sputum, bronchoscopy, or fine-needle aspiration biopsy are usually able to suggest the diagnosis of neuroendocrine carcinoma, but there is unavoidable error in distin-

Novel technique for isolation of human lung mast cells

A novel technique for isolation of human lung mast cells is developed. Human lung tissue was enzymatically digested and the cells were partially purified by centrifugation on Percoll density gradient. Cells obtained at the Percoll density of 1.05-1.09 g/ml were then subjected to a cell sorter equipped with a single argon laser beam (FACS 440). Using four criteria as density, granularity, size and autofluorescence, four major cell populations were identified. One of the major populations contained 70-95% mast cells with a mean and SE values of 88 +/- 11% purity, n = 18 as determined by the measurement of total histamine content, light microscopic observation of stained cells with toluidine blue and estrase, and surface-stained IgE fluorescence antibody. Approximately less than 10% mast cells were identified in the three other major cell populations. Mast cells isolated by FACS were found to be intact, viable (approximately equal to 90%) and functionally normal as determined by the release of histamine evoked after stimulation with ionophone A23187, or challenged with anti-human IgE.

Mediastinal lymph node necrosis: a newly recognized complication of mediastinoscopy.

Eight cases of partial mediastinal lymph node necrosis identified at thoracotomy two to 17 days after cervical mediastinoscopy are described. In 6 cases, the involved nodes were grossly abnormal at operation, requiring frozen section interpretation. In the first 2 patients, the areas of nodal infarction were misinterpreted as necrotic tumor. Permanent sections from all 8 patients showed no evidence of tumor in the infarcted nodes. Factors predisposing to nodal infarction included right-sided tumor, central tumor, and large mediastinoscopic biopsy specimens. In all instances, the infarcted nodes were subcarinal and/or main bronchial. In 2 patients, left recurrent laryngeal nerve palsy occurred after mediastinoscopy. Necrosis in distal nodal areas should be recognized as a complication of thorough mediastinoscopic sampling, presumably due to interruption of arteries supplying these nodes. Awareness of this phenomenon by surgeons and pathologists may avert falsely positive gross or microscopic diagnoses of metastatic malignancy at thoracotomy.