De pathologie achter de CT Bronkhorst colloquium 2013-2014 Interstitiële longziekten Katrien...
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Transcript of De pathologie achter de CT Bronkhorst colloquium 2013-2014 Interstitiële longziekten Katrien...
De pathologie achter de CTDe pathologie achter de CT
Bronkhorst colloquium 2013-2014Interstitiële longziekten
Katrien Grünberg, klinisch [email protected]
VoorbereidingVoorbereiding
• De opzet van de lezing is om u kennis te laten maken met een aantal histopathologische afwijkingen en patronen. Tijdens de cursus zal verder worden ingegaan op de vertaling van de histologie naar CT.
• Om de histologische afwijkingen van de longen te kunnen herkennen, is kennis van de normale microscopische anatomie essentieel. Neem de volgende dia’s door als U uw kennis wilt opfrissen.
• Vervolgens kunt U zelf aan de slag met 3 casus. Na enkele inleidende dia’s, vindt U de links naar gescande coupes.
Even opfrissenEven opfrissen
• Om de histologische afwijkingen van de longen te kunnen herkennen, is kennis van de normale microscopische anatomie essentieel. Neem de volgende dia’s door als U uw kennis wilt opfrissen.
Alveolar surface area: 143 m2 Capillary surface area: 140 m2
90% Air-blood interface surface area: 126 m2 (70 times skin: 1.8 m2)
Blood content 0.2 L
RBC passes through capillary bed in 0.75 seconds
Lungs are for gas exchangeLungs are for gas exchange
The alveolar-capillary membraneThe alveolar-capillary membrane
CO2
O2
0.6 m
The alveolar-capillary membraneThe alveolar-capillary membrane
O2
CO2
LungsLungs
Core businessCore business• Gas exchange
Infrastructure and LogisticsInfrastructure and Logistics• Conducting airways• Conducting vessels• Innervation• Defence
Alveolar duct – terminal bronchioleAlveolar duct – terminal bronchiole
BronchioliBronchioli
lumen
epithelium
airway smooth muscle
alveoli
pulmonary artery
Bronchovascular bundle
Airway epitheliumAirway epithelium
2 - 3 days
AlveoliAlveoli
Surfactant producing cells:Surfactant producing cells:Type II pneumocytes and Clara cellsType II pneumocytes and Clara cells
Barry R. Stripp et al. Am. J. Respir Cell Molec Biol. 2002;. 27: 170-8
Alveolar surface area: 143 m2
Tracheobronchial liningTracheobronchial lining
Seromuc. Glands
Goblet cell s
surfactant
Lung vasculatureLung vasculature
Alveolar surface area: 143 m2 Capillary surface area: 140 m2
90% Air-blood interface surface area: 126 m2
Blood content 0.2 L
RBC passes through capillary bed in 0.75 seconds
Arteries and veinsArteries and veins
Interlobular septum
Axial artery
Bronchiole Vein
Lymph vessel
ArteriesArteries
• Elastic artery (> 1 mm )– bronchi
• Muscular artery (50-1000 m)– bronchioli
• Arterioles (< 50 m)– Alveolar parenchyma
Bronchus-associated lymphatic tissue Bronchus-associated lymphatic tissue (BALT)(BALT)
Lymph vesselsLymph vessels
D-240
• Around p. arteries• In interlobular septa
The secondary lobuleThe secondary lobule
Pulm artery
Vein
Lymph vessel
Airway
Interlobular septum
Inleiding in histopathologie van ILDInleiding in histopathologie van ILD
ILD is about patternsILD is about patterns
• Type of lesions– Fibrosis– Inflammation
• Distribution
Fibrosis: distributionFibrosis: distribution
• Intersitial or airspace• Centrilobular or subpleural• Basal fields vs upper fields
Lymphatic Centrilobular distribution
InflammationInflammation
• Composition– lymphocytic, plasmacell, neutro/eosinophilic– granulomatous
• Distribution– Interstitial (centrilobular/diffuse) – Bronchiolitis– Vasculitis
InflammationInflammation
CluesClues
• Necrosis• Hyaline membranes (as in diffuse alveolar
damage)• Pigmentation
– Iron (bleeding)– Inhaled stuff
• Funny looking cells and such
Case 1Case 1
• Fibrosis? – Distribution (centrilobular or subpleural?)
• Inflammation?– Type?
• Clues?
• Descriptive diagnosis – Summary of pattern of fibrosis and inflammation, clues
• DD
Case 1Case 1
pleura
→ fibroblast foci
Old and young fibrosis:
temporal heterogeneity
Case 2Case 2
• M 71 yr. History of myocardial infarction.
• Fibrosis? • Inflammation?• Distribution?• Airspaces?
• Pattern• DD
Fibrosis. Where?
Nodular fibrosis. Where? And some infiltrate. Where?
Nodular fibrosis in alveolar spaces: Masson bodies
Lymphocytic infiltrate in alveolar septa (interstitial pneumonitis)
Funny looking alveolar macrophages (foamy)
PatternPattern
• Organizing pneumonia• Mild pneumonitis• Clue: foamy macrophages
General DifferentialsGeneral Differentials
• Infection• Infection
• Vasculitis• Collagen vascular disease / AID / IgG4 • Occupational/recreational toxic stuff (inhaled) • Drugs (iv, otherwise)• Idiopathic fibrosis• Other (inborn)
ClueClue
• Patient used amiodarone
• OP, pneumonitis, foamy macrophages all fit with amiodarone-induced ILD
• http://www.pneumotox.com
Case 3Case 3
• M 75 yr • Fibrosis? (EvG this staining shows fibrosis in red, elastin in black)
– Specifics
• Inflammation?– Specifics
• Distribution?• Pattern• DD
Inflammation, bronchiolocentric
bronchiolocentric inflammation: lymphocytes (T cells)
Clues
Giant cells in poorly formed granulomas
PatternPattern
• Minimal fibrosis• Bronchiolocentric interstitial pneumonia• Clue: poorly formed granulomas
Differential DxDifferential Dx• …
ClueClue
• Patient kept pigeons
EAA – hypersensitivity pneumonitisEAA – hypersensitivity pneumonitis
• Bird fancier's lung • Also called bird breeder's lung, pigeon
breeder's lung, and poultry worker's lung
• Bagassosis• Cephalosporium HP• Cheese-washer's lung• Chemical worker’s lung - Isocyanate HP• Chemical worker's lung[9] - Trimellitic
anhydride (TMA) HP• Coffee worker's lung• Compost lung• Detergent worker's disease• Familial HP• Also called Domestic HP• Farmer's lung• Hot tub lung• Humidifier lung• Japanese summer house HP Also called
Japanese summer-type HP• Laboratory worker's lung• Lycoperdonosis
• Malt worker's lung• Maple bark disease• Metalworking fluids HP• Miller's lung• Mollusc shell HP• Mushroom worker's lung• Peat moss worker's lung• Pituitary snuff taker's lung• Sauna worker's lung• Sequoiosis• Streptomyces HP• Suberosis• Tap water HP• Thatched roof disease• Tobacco worker's lung• Wine-grower's lung• Woodworker's lung
How to bluff your way through interstitial lung diseaseHow to bluff your way through interstitial lung disease
EAA HPUIPNSIPSR-ILD(C)OP(BO)OPDIPRB-ILDDAD
═ Extrinsic allergic alveolitis ═ Hypersensitivity pneumonitis═ Usual interstitial pneumonia═ Non-specific interstitial pneumonia═ Smoking-related interstitial lung disease═ (Cryptogenic) Organizing Pneumonia═ (Bronchiolitis Obliterans) Organizing Pneumonia═ Desquamative interstitial pneumonia═ Respiratory bronchiolitis - ILD═ Diffuse alveolar damage (≈ ARDS)