j0305257 Systemic pathology The respiratory tract j0305257 Histology of respiratory tract 02_06 j0305257 Cellular components of bronchial mucosa 02_07 j0305257 The respiratory membrane respmemb j0305257 Chronic polypous rhinitis û chronic proliferative inflammation û û aetiology: ð chronic irritation ð ð allergy ð ð repeated acute inflammations j0305257 Polypous chronic rhinitis û Gross: ð mucosal polyps, often multiple ð variable size (mm – 2 cm) ð û Micro: ð oedematous mucosal connective tissue ð lymphoplasmocytic reactive infiltration, admixture of eosinophils, event. neutrophils ð mucinous hyperplasia ð covered by hyperplastic respiratory epithelium, squamous metaplasia possible j0305257 Polypous chronic rhinitis 1 Epithelium with squamous metaplasia 2 Thickened basal membrane 3 Oedematous stroma with eosinophilic and plasma cell infiltration, dilatated lymphatic vessels 1 2 3 j0305257 Polypous chronic rhinitis 1 Ciliated epithelium 2 Oedematous stroma with inflammatory infiltrate 1 2 j0305257 Polypous chronic rhinitis polyp4002 1 Congested capillary 2 Eosinophils 3 Oedematous stroma 1 2 3 j0305257 Asthma bronchiale ûrecurrent attacks of bronchospasm with exspiratory dyspnoea û status asthmaticus: ð increased frequency of attacks – permanent bronchospasm ð may be lethal ûetiology: ðHypersenzitivity I.type û variants: ðExtrinsic (environmental factors): •Atopic, IgE → mast cells degranulation…, bronchioloconstriction, increased vascular permeability and mucus secretion + eosinophils activation • ð Intrinsic: •hyperreactive URT, non-atopic j0305257 Asthma bronchiale û Gross (patients who died during status asthmaticus): ð acute emphysema ðmucus plugs in peripheral bronchi and bronchioles ð û Micro: ð intraluminal: • mucus, eosinophils, Charcot-Leyden crystals, cellular detritus • ð bronchial wall: • oedema of the mucous membrane • thickening (collagenisation) of the sub-basement membrane tissue • mucous glands hypertrophy, eosinophil-rich inflammatory infiltrate ð j0305257 Asthma bronchiale asma copy j0305257 Bronchiectasis û permanent abnormal dilatation of bronchi û arising from the weakening of the walls or changes in air pressure û morphology: ð cylindrical ð saccular ð fusiform j0305257 Bronchiectasis û aetiology: ð congenital/hereditary conditions: • incomplete development of bronchial wall • Kartagener syndrome – primary ciliary dysgenesis • ð acquired: • chronic inflammations • changes of the pressure – chronic pulmonary collapse – j0305257 Bronchiectasis û complications: ð inflammations: • chronic purulent bronchitis • bronchopneumonia including abscess formation • ð ð fibrosis, pulmonary hypertension and cor pulmonale ð ð secondary AA amyloidosis j0305257 Bronchiectasis image00110 BRONCHIECTASIA kopie j0305257 Bronchiectasis Image011 j0305257 Pulmonary emphysema û regressive change (atrophy) û û abnormal permanent enlargement of the airspaces in pulmonary û tissue û û aetiology (combination of several factors): ð smoking ð deficiency of α1-antitrypsin û û types: ð alveolar: • acute • chronic ð ð interstitial – airway rupture (trauma) û j0305257 Alveolar emphysema û acute: ð alveolar septa are not destroyed ð rather pulmonary hyperinflation or distention ð û chronic: ð permanent enlargement of airspaces distal to terminal bronchioles ð destruction of alveolar walls ð part of COPD (chronic obstructive pulmonary disease) • combination of chronic bronchitis and chronic emphysema ð j0305257 Alveolar emphysema û types: ð centrilobular (centriacinar): • upper lobes – apex, more in males, • most commonly seen in smokers without congenital a1-antitrypsin deficiency (but + chronic bronchitis), possible professional disease - dust • ð panacinar: • often lower lung zones; significant microscopic changes; a1-antitrypsin deficiency, old age • ð distal acinar (paraseptal): • adjacent to pleura, upper lobes foci of fibrosis, formation of cystlike structures – bullae (pneumothorax risk) • ð irregular: • associated with scarring, usually postinflammatory j0305257 Alveolar emphysema û Gross: ð enlarged, voluminous lungs, light, pale, dry, emphysematous bullae ð û Micro: ð thinning and destruction of alveolar walls ð ð deformation of bronchiolar walls ð ð chronic inflammatory changes j0305257 Emphysema û pathogenesis and complications: û thinning of alveolar walls and capillaries → ðreduced blood supply → ðcomplete destruction of alveolar walls → ðdifficult expiration + decreasing of lung capacity → ðhypoxemia → ðvasoconstriction → ðsecondary pulmonary hypertension → → ðcor pulmonale ð j0305257 Emphysema Image013 j0305257 Normal lung and pulmonary emphysema j0305257 Bullous emphysema j0305257 Panacinar emphysema 1 Enlargement of airspaces with thinning and destruction of alveolar septa 2 Bronchiole with mucous secretions 1 2 1 2 j0305257 Hemorrhagic pulmonary infarction û aetiology: ð thrombembolism of a. pulmonalis branches in the setting of compromised cardiovascular status (passive venous congestion) û typically hemorrhagic ð û often in lower lung lobes adjacent to pleura û û often multiple û û healing: ð granulation tissue, later formation of fibrous scar ð j0305257 Hemorrhagic pulmonary infarction û Gross: ð wedge-shaped focus of tissue with sharp borders ð dark red-blue (new), yellowish-grey (older) ð variable size ð solid consistency ð û Micro: ð coagulative necrosis of lung parenchyma ð large extravasations of erythrocytes ð formation of abscess at secondary infection ðreactive acute fibrinous pleuritis ðhealing – scarring + emphysema (diff.dg. x tumor) ð ð j0305257 Hemorrhagic pulmonary infarction infarkt plic 20x 01 1.Necrotic focus 2.Lung parenchyma 1 2 j0305257 Hemorrhagic pulmonary infarction infarkt plic 100x 01 Necrotic lung parenchyma j0305257 Chronic pulmonary venous congestion û associated with chronic left-sided cardiac insufficiency ð etiology: • ischemic heart disease, systemic hypertension, valvular disorders, cardiomyopathy • û clinically („asthma cardiale“): ð cough • rusty sputum ð shortness of breath (dyspnoea) • ortopnoea • paroxysmal nocturnal dyspnoea – relieved by sleeping with elevated head („additional pillows needed“) û û j0305257 Chronic pulmonary venous congestion û Gross: ð slightly enlarged lungs ð solid consistency ð rusty-brown color • rusty/cyanotic lung induration • û Micro: ð congestion of alveolar capillaries ð alveolar hemorrhage with siderophages: • histiocytes with cytoplasmic granules of hemosiderin ð fibrotization of alveolar walls j0305257 Chronic pulmonary venous congestion chron venostáza plíce 1. Oedematic fluid 2. Enlarged hyperemic septa 3. Siderophages 1 2 3 j0305257 Chronic pulmonary venous congestion chron venostáza plíce- detail 1. Oedematic fluid 2. Enlarged hyperemic septa 3. Siderophages 1 2 3 j0305257 Chronic pulmonary venous congestion Perls‘ reaction – iron pigment hemosiderin colored blue j0305257 Alveolar oedema û fluid accumulation in alveoli û û clinically: ð expectoration of bubbly watery pinkish sputum ð û patogenesis: ð ↑ vascular permeability (injury to the alveolar-capillary wall) ð ↑ vascular hydrostatic pressure ð ↓ intravascular osmotic pressure ð lymphatic drainage obstruction û j0305257 Alveolar oedema û Gross: ð lungs enlarged, heavy, conested ð bubbly fluid flowing out of the tissue +/- present in bronchi ð û Micro: ð alveoli filled with pink, homogenous fluid + air bubbles ð dilatation and hyperemia of alveolar wall capillaries ð û j0305257 Alveolar oedema edem plic 100x 1. Oedematic fluid 2. Dilated septa 3. Dilated capillary 1 2 3 j0305257 Amniotic fluid aspiration û minor aspiration usual during birth ð clinically insignificant ð û massive aspiration associated with fetus asphyxia ð umbilical cord or placental disorders ð û clinic: ð changes in fetal heart rate – immediate medical intervention necessary! j0305257 Amniotic fluid aspiration û Micro: ð keratin masses in bronchi and alveoli ð amniotic cells ð lanugo (thin primary hairs) ð meconium bodies (from fetus intestinal content) ð infected amniotic fluid → fetal death, adnate pneumonia û j0305257 Amniotic fluid aspiration, keratin in bronchiole 12x200 1 Masses of keratin 2 Bronchial epithelium 3 Multinuclear cell 1 2 3 j0305257 Amniotic fluid aspiration, keratin in alveoli 12x400x2 1 Masses of keratin 2 Meconium 3 Alveolar wall 1 2 3 j0305257 Pulmonary inflammations - classification û superficial: ð lobar pneumonia ð bronchopneumonia ð û interstitial ð purulent (abscess, gangrene) ð non-purulent • infectious (acute) – atypical pneumonia • non-infectious (chronic) j0305257 Lobar pneumonia û superficial diffuse fibrinous inflammation û affecting major part / entire lobe of a lung ð similar histological features in the same time ð older/immunocompromised patients → lethal without antibiotic therapy û untreated – 4 stages: ð congestion (+ oedema) ð red hepatization (inflammatory infiltrate + congestion) ð grey hepatization (fibrin) ð resolution (resorption) j0305257 Lobar pneumonia û healing: ð ad integrum ð complications: • empyema • abscess • carnification • sepsis • metastatic purulent inflammation – e.g.leptomeningitis, pericarditis, endocarditis… û j0305257 Lobar pneumonia, red hepatization j0305257 Lobar pneumonia, grey hepatization j0305257 Lobar pneumonia plíce 40x 1. Alveolar walls 2. Alveoli fulfilled with fibrinous exsudate 1 2 2 j0305257 Lobar pneumonia HE 40x 1. Alveolar walls 2. Alveoli fulfilled with fibrinous exsudate 1 2 2 j0305257 Lobar pneumonia HE 100x 1. Alveolar walls 2. Fibrinous exsudate with fibroblasts 1 2 2 j0305257 Bronchopneumonia û superficial type of pneumonia characterized by multiple foci of isolated, acute consolidation, affecting one or more pulmonary lobules û û inflammation spreads from bronchi û û aetiology: ð streptococcus, staphylococcus, haemophilus, klebsiella ð legionella – micro: • fibrinous purulent bronchopneumonia associated with fibrinous pleuritis û possible secondary confluent inflammation, overlap patterns û inflammatory complications: ð pleuritis ð abscess ð sepsis j0305257 Bronchopneumonia û Gross: ð oedema, hyperemic tissue with small grey-yellow foci û Micro: ðtypes of exsudate: • serous • fibrinous • suppurative (purulent) ð abscessing form – suppurative destruction of alveolar walls û j0305257 Bronchopneumonia brpn1 brpn2 copy j0305257 Abscessing bronchopneumonia plíce povrch abscesy plíce řez abscesy j0305257 Purulent bronchopneumonia BP 200x 1. Alveolar walls 2. Alveoli filled with neutrophils 1 2 j0305257 Abscessing bronchopneumonia BP 100x 1. Alveolar walls 2. Abscess with destruction of alveolar walls 1 2 2 j0305257 Infectious interstitial pneumonia û Etiology: ð viruses (incl. rubeola, varicella) ð mycoplasma, chlamydia, coxiella, etc. ð pneumocystis û Symptoms: ðfever, dyspnoea, dry cough, auscultation may be normal (empty alveoli), x massive changes on X-ray û Healing: ð ad integrum ð secondary bacterial pneumonia ð cryptogenic organizing pneumonia possible j0305257 Infectious interstitial pneumonia û Micro: ð 1) common histological features: • oedema and dilatation of alveolar walls • interstitium with mononuclear infiltrate (lymphocytes, macrophages, plasma cells) • possible ARDS - „hyaline membranes“ formation – necrotic pneumocytes and fibrin – eosinophilic material lining the lumen of alveoli j0305257 Infectious interstitial pneumonia ð 2) inclusion pneumonia: • typical inclusions and cytopatologic changes of pneumocytes • CMV: – large pneumocytes with basophilic intranuclear inclusions • Varicella, adenovirus: – intranuclear inclusions • Measles: – giant cell pneumonia – multinucleated cells in alveoli and bronchioli (Warthin-Finkeldey cells) • Pneumocystis pneumonia û j0305257 Pneumocystis pneumonia û etiology: ð Pneumocystis jirovecii •(opportunistic fungal infection, immunocompromised patients) ð û Micro: ð widened alveolar septa, intraalveolar bubbly eosinophilic material: • pneumocystis capsules ð special histological stains: • Groccott silver impregnation (black) • Giemsa (blue) • PAS j0305257 Pneumocystis pneumonia HE 100x 1. Alveolar walls filled with monocellular infiltration 2. Bubbly eosinophilic material 1 2 j0305257 Pneumocystis pneumonia HE400x 1 2 1. Alveolar walls filled with monocellular infiltration 2. Bubbly eosinophilic material j0305257 Neinfekční intersticiální pneumonie û Klasifikace: ð Kryptogenní fibrotizující alveolitida (idiopatická intersticiální pneumonie) • Běžná • Nespecifická • Deskvamativní • Obrovskobuněčná • ð Extrinzická fibrotizující alveolitida (hypersenzitivní pneumonitida) j0305257 Idiopathic pulmonary fibrosis û û usual interstitial pneumonia“ (UIP): ð70% of all of idiopathic interstitial pneumonias ð etiology: • in some collagenosis or in association with abnormalities of serum proteins •smoking • unclear ð dismal prognosis: lung transplantation ðMikro: •subpleural and a paraseptal foci of fibroblasts/fibrosis and chronic inflammatory infiltrate, cystic spaces - honeycombing • irregular distribution of histological features – temporal heterogeneity • j0305257 Idiopathic pulmonary fibrosis û non-specific interstitial pneumonia (NSIP): ðcommonly women, without link with smoking ð ð better prognosis • treated with corticosteroids • ð Micro: • chronic interstitial inflammation +/- fibrosis • no honeycombing • regular distribution of changes • • û j0305257 Usual interstitial pneumonia 15x20 1 Fibrosis 2 Compressed alveoli 1 1 2 2 j0305257 Usual interstitial pneumonia 15x100 1 Thickened septa 2 Vessels 3 Hyperplastic epithelium 4 Neutrophils in alveoli 1 2 3 4 j0305257 Usual interstitial pneumonia 1 Hyperplastic alveolar epithelium 2 Thickened alveolar walls with chronic inflammatory infiltration 3 Neutrophils in alveoli j0305257 Pneumoconiosis û an occupational and restrictive lung disease caused by the inhalation of specific dust û û sequels: inert (simple), fibrous, allergic, neoplastic û û high fibrogenicity of cristalline silica dust and asbestos û û 3 basic types: û ð coal-worker`s pneumoconiosis ð silicosis ð asbestosis j0305257 Silicosis û Chronic progressive pneumoconiosis û Silicone dioxide particles (0,2-2μm) toxic to macrophages – focal necrosis + release of fibrogenic factors - fibrosis ûX-ray – reticular fibrosis, nodules, diffuse fibrosis û lung insufficiency û cor pulmonale û û û ð j0305257 Silicosis û Gross (stages): ð reticular fibrosis ð ð silicotic nodules ð ð progressive massive fibrosis ð û Micro: ð nodules with concentric arrangement of hyalinized fibers and necrosis ð ð anthracophages in the periphery of the nodule ð ð emphysema in adjacent pulmonary tissue ð ð particles seen under polarized light j0305257 Silicotic nodule - lung silikosa 1. Fibrotic centre of the nodule 2. Emphysema 1 2 2 j0305257 Pulmonary silicosis Silica particles under polarized light j0305257 Diffuse alveolar damage (Acute Respiratory Distress Syndrome) û DAD (ARDS, RDS) û clinical: ð progressive respiratory insufficiency associated with shortness of breath and hypoxia, high mortality ð û Etiology: ð Primary ARDS: • lung inflammation/infection, aspiration of gastric content, mechanical trauma incl. chest contusion, fat embolism, near-drowning, ionizing radiation, inhaled irritants (smoke, chemicals), ð Secondary ARDS: • trauma (head) or sepsis • acute pancreatitis • renal insufficiency (uremia) • burns • hematologic conditions – DIC, multiple transfusions •chemical injury (heroin overdose, acetylsalicylates, …) • • j0305257 Diffuse alveolar damage (Acute Respiratory Distress Syndrome) û Gross: ð heavy lung ð dark red color ð boggy ð û Micro: ð exsudative phase: • capillary congestion, oedema, hyaline membranes formation within 48 hours • ð proliferative phase: • epithelium regeneration (type II. pneumocytes) • hyaline membranes ingested by macrophages • proliferation of fibroblasts in alveolar walls -> pulmonary fibrosis possible û j0305257 Diffuse alveolar damage (Acute Respiratory Distress Syndrome) ARDS 1. Hyaline membranes 2. Hyperemic septa 1 1 2 j0305257 Diffuse alveolar damage (Acute Respiratory Distress Syndrome) ARDS-detail 1 2 1. Hyaline membranes 2. Hyperemic septa j0305257 6.3 DAD, proliferative phase - fibrotic stage – distinctly thickened interalveolar septa with a chronic inflammatory infiltrate. j0305257 Granulomatous inflammations - Tuberculosis ûaetiology ðMycobacterium tuberculosis, M. bovis û ðspecial Ziehl-Neelsen stain •PCR more sensitive • ûdelayed-type hypersensitivity û (type IV. hypersensitivity) ðT cells-mediated immune memory response to TBC antigens (granulomas) j0305257 Tuberculosis – morphological features ûtbc granuloma – proliferative form ðhost resistance ðspecific granulation tissue: epithelioid macrophages + Langhans giant cells ð ûtbc exsudate – exsudative form (meningitis) ðallergy ðserofibrinous exsudate + Orth cells (macrophages) û +caseification ðcheese-like, caseous necrosis – sensibilization? û +colliquation (liquefaction) ðafter release of proteolytic enzymes by neutrophils û +calcification j0305257 Tbc granuloma 1caseous necrosis 2epithelioid macrophages 3Langhans giant cells 4lymphocytes 5 1 2 2 3 4 3 j0305257 Langhans giant cells j0305257 Caseous necrosis poprašková nekróza, 400x.jpg j0305257 Sarcoidosis û chronic granulomatous inflammatory disease of unknown aetiology û û affected tissue: ð mediastinal lymph nodes, lungs, skin, eye ð granulomas can affect any organ ð û small regular granulomas similar to TBC granulomas, but without caseous necrosis, fibrosis usually more pronounced û cytoplasmic bodies of Langhans giant cells, not specific: ð asteroid inclusions ð Schaumann bodies û û dg. per exclusionem – necessary elimination of TBC, fungal infection etc. j0305257 Sarcoidosis sarkoidóza-plíce1, 100x.jpg j0305257 Pulmonary chondrohamartoma û hamartoma? benign tumor? û û incidental X-ray finding û û differential diagnosis x malignant tumors important! û j0305257 Pulmonary chondrohamartoma û Gross: ð whitish yellow ð well demarcated ð lobular structure ð û Generally formed of mixture of homologous non-organised afunctional tissues : ð cartilage ð connective tissue ð fat ðtubular structures with epithelium û j0305257 Pulmonary chondrohamartoma chondrohamartom 20x 01 1.Cartilage 2.Fat tissue 3.Tubular structures with respiratory epithelium 1 2 3 j0305257 Pulmonary chondrohamartoma chondrohamartom 100x 02 Chondrocytes j0305257 Pulmonary chondrohamartoma chondrohamartom 100x 03 1. Cartilage 2. Fat tissue 3. Connestive tissue 4. Tubular structures 1 2 3 4 j0305257 Bronchogenic carcinoma û incidence: ð in CZE males 100/100 000 (the most common malignancy of men), ð females 25/100 000 (the 3rd most common malignancy of women, ↑ tendency) ð û aetiology: ð smoking • generally 20X higher risk in smokers • 20 cigarettes/day = 20 years, 40 cigarettes/day = 10 years... • magic threshold 200000 cigarettes ð asbestos, Hg, Ni, As ð ionization ð radioactive radon ð dust particles ð familial predisposition û j0305257 Bronchogenic carcinoma û Most common primary malignancy û 5 year survival 5 – 7 % û 4 – 7 decenium, more commonly males û Clinical symptoms: ðweight loss, chronic cough, haemoptysis, dyspnoea, chest pain, paraneoplastic syndromes (ACTH, ADH, PTH) û j0305257 Bronchogenic carcinoma û local complications: ð depends on the localization of the tumor: •lung collapse, bronchiectasis, bronchopneumonia, gangrene •Jeros cavern –destruction of vascular wall by necrotic mass of tumor –fatal bleeding – ðparaneoplastic syndromes •Aberrant production of peptide hormones (ACTH,ADH,PTH,..) ûclinical types: ð small cell lung carcinoma (SCLC) ð non-small cell lung carcinoma (NSCLC) j0305257 Small cell lung carcinoma û undifferentiated (high grade) neuroendocrine tumor û û 20 % of all bronchogenic carcinomas û û associated with smoking û û localized in lung hilus û û early metastatic spread, widespread dissemination ð lymphatic and hematogenous (LN, liver, brain, bones, kidney, adrenals, …) û j0305257 Small-cell lung carcinoma û histologic types: ðsmall cell („oat cell carcinoma“) ð intermediate (now included into small cell type) ðcombined ð û Micro: ð small cells with scant cytoplasm (size < 3 lymphocytes) ð small round - elongated dark blue nuclei without obvious nucleoli (oat cell carcinoma) ð solid growth ð neurosecretory granules in cytoplasm • chromogranin, synaptophysin j0305257 Small-cell lung carcinoma 1 1 1 14_02 1 Peribronchial and perivascular infiltration 2 Infiltration of lymph nodes in hilus 3 Bronchus 4 Vessels 1 1 2 3 4 j0305257 Small-cell lung carcinoma malobb ca 100x 1. Solid small cell infiltration 2. Necrosis 3. Fibrous stroma 3 1 2 j0305257 Small-cell lung carcinoma malobb ca 200x 1. Solid small cell infiltration 2. Fibrous stroma 2 1 j0305257 Non-small cell lung carcinoma û squamous cell carcinoma û adenocarcinoma ð adenocarcinoma in situ ð minimally invasive: • non-mucinous • mucinous • mixed ð invasive: • lepidic • acinar • papillary • micropapillary • solid û large cell lung carcinoma û other, incl. mixed j0305257 Squamous cell carcinoma û male 40%, female 20% û strongly associated with smoking û typical perihilar localisation (central>peripheral) û commonly slow progression from squamous metaplasia – dysplasia – ca in situ ðlate metastases û Micro: ð squamous cell carcinoma of common type • polygonal shaped cells in solid nests, keratin pearls, cell junctions ð variable differentiation j0305257 Squamous-cell lung carcinoma 11_01L 11_01R 1. Segmental bronchus 2. Tumor 1 1 2 2 j0305257 Squamous cell lung carcinoma 1103S2 11_03 1. Tumor localized in the periphery 2. Central necrosis 1 2 1. Tumor in bronchus 2. Segmental bronchus 2 1 j0305257 Squamous cell carcinoma spinaliom02 1.Solid nests of malignant keratinocytes 2.Keratin pearls 3.Stroma of the tumor 1 2 3 j0305257 Squamous cell carcinoma 02444-1 1.Tumor foci 2.Monocellular keratinization 1 2 j0305257 Squamous-cell carcinoma spinaliom04 1.Cell junctions 2.Nucleus with prominent nucleoli 1 2 j0305257 Adenocarcinoma û male 20%, female 40%; û û most cases in smokers, but the most common type in non-smokers û û typically localized in the periphery, subpleural ð late symptoms !!! Commonly accidental finding on X-ray/CT ð û formerly used term: ð bronchioloalveolar adenocarcinoma (BAC) no more in use (but still present in WHO classification of lung tumors) j0305257 Adenocarcinoma û classification: ð Adenocarcinoma in situ - AIS (size ≤3 cm): • non/mucinous (earlier BAC), • mucinous • mixed • no stromal/vascular/pleural invasion present • ð Minimally invasive ACA (size ≤3 cm and ≤ 5 mm invasion): idem • apart of lepidic growth other types of spread (papillary, solid….) or stromal invasion present • no vascular/pleural invasion present – ð Invasive ACA: • Lepidic • Acinar • Papillary • Micropapillary • Solid j0305257 Adenocarcinoma 12_01 1 Tumor localized in apex of the lung 2 Pigmentation inside the tumor 3 Emphysematous parenchyma 1 2 3 j0305257 Adenocarcinoma j0305257 Adenocarcinoma P0008 1. Structures of adenocarcinoma 2. Normal pulmonary parenchyma 1 2 j0305257 Adenocarcinoma P0009 1 2 1. Structures of adenocarcinoma 2. Normal pulmonary parenchyma j0305257 Adenocarcinoma P0001 1 2 1. Structures of adenocarcinoma 2. Normal pulmonary parenchyma j0305257 Adenocarcinoma P0002 Structures of an acinary and papillary formed adenocarcinoma j0305257 Adenocarcinoma P0010 Cytology of malignant cells - anisocytosis and anisokaryosis j0305257 Adenocarcinoma P0003 Cytology of malignant cells - anisocytosis and anisokaryosis j0305257 AIS/minimally invasive ACA non/mucinous (earlier BAC) 20x100 1 Normal alveolar walls 2 Alveolar walls with tumor cells 1 2 j0305257 AIS/minimally invasive ACA non/mucinous (earlier BAC) 20x400 1 Alveolar septum 2 Tumor 3 Malignant cells 1 2 3 j0305257 Large cell lung carcinoma û undifferentiated non-small cell carcinoma û û Micro: ð atypical pleomorphic cells ð ð absent features of small cell carcinoma, adenocarcinoma or squamous cell carcinoma j0305257 Large cell lung carcinoma 15_02 1 Necrosis 2 Bronchus 1 1 2 j0305257 Large cell lung carcinoma P0006 1. Pleomorphic tumor cells 2. Necrotic area 1 2 2 j0305257 Large cell lung carcinoma P0007 1. Pleomorphic tumor cells with prominent nucleoli 2. Necrotic area 2 1