Lung Pathology

LUNG

KEY TOPICS IN LUNG PATHOLOGY FOR THE FRCPath PART 1 EXAM

Part 1 FRCPath (Histopathology) Simple advice from personal experience that may be helpful to consider: • Follow the instructions.

• Look through the whole paper v. quickly before starting – confirm how many questions, lay-out, idea of future questions may aid recall.

• Keep an eye on time and be aware of approximate time per question.

• answer each question and immediately complete the answer sheet.

• do not put answers on separate paper and transcribe at the end.

• complete the answer sheet very carefully.

• check answers at the end if time and complete any omitted.

• be very cautious changing answers at the end – if you are not sure, st your 1 impression may be correct.

Epithelial lung tumours Adenocarcinoma Small cell carcinoma Squamous cell carcinoma Large cell carcinoma Adenosquamous carcinoma Sarcomatoid carcinoma

Carcinoid tumours

Q. 73F. Pleural effusion. ?mass on CXR. Pleural fluid cell block performed. Cells positive for D2-40 and calretinin; negative for MOC31. Possible diagnoses based on IHC include: A. B. C. D. E. F.

Adenocarcinoma Squamous cell carcinoma Small cell carcinoma Reactive mesothelial cells Malignant mesothelioma Malignant melanoma

T/F T/F T/F T/F T/F T/F

Q. 73F. Pleural effusion. ?mass on CXR. Pleural fluid cell block performed. Cells positive for D2-40 and calretinin; negative for MOC31. Possible diagnoses based on IHC include: A. B. C. D. E. F.

Adenocarcinoma Squamous cell carcinoma Small cell carcinoma Reactive mesothelial cells Malignant mesothelioma Malignant melanoma

F F F T T F

Q. Primary lung adenocarcinoma is positive for which of the following markers? T/F A. B. C. D. E. F. G. H.

CDX2 CK7 CK20 MOC31 TTF1 Napsin A P63 AE1/AE3

Q. Primary lung adenocarcinoma is positive for which of the following markers? T/F A. B. C. D. E. F. G. H.

CDX2 CK7 CK20 MOC31 TTF1 Napsin A P63 AE1/AE3

F T F T T T F T

Q. Which of the following are epithelial markers that could be used for IHC in a pleural fluid sample in parallel with mesothelial markers? T/F A. B. C. D. E. F. G. H. I. J. K. L.

CDX2 AE1/AE3 Calretinin CK5/6 CK7 CAM5.2 BerEP4 CK20 MOC31 MNF-116 TTF1 34betaE12

Q. Which of the following are epithelial markers that could be used for IHC in a pleural fluid sample in parallel with mesothelial markers? T/F A. B. C. D. E. F. G. H. I. J. K. L.

CDX2 AE1/AE3 Calretinin CK5/6 CK7 CAM5.2 BerEP4 CK20 MOC31 MNF-116 TTF1 34betaE12

TRUE TRUE

Q. Which of the following are cytokeratins? T/F A. B. C. D. E. F. G. H. I. J. K. L.

CDX2 AE1/AE3 Calretinin CK5/6 CK7 CAM5.2 BerEP4 CK20 MOC31 MNF-116 TTF1 34betaE12

Q. Which of the following are cytokeratins? T/F A. B. C. D. E. F. G. H. I. J. K. L.

CDX2 AE1/AE3 Calretinin CK5/6 CK7 CAM5.2 BerEP4 CK20 MOC31 MNF-116 TTF1 34betaE12

T

T T T T T T

Q. The following are useful markers to distinguish malignant mesothelioma from adenocarcinoma:

A. B. C. D. E. F. G. H. I. J. K. L. M. N.

WT-1 AE1/AE3 Calretinin CK5/6 CK7 CAM5.2 BerEP4 CK20 MOC31 MNF-116 Thrombomodulin E-cadherin CEA EMA

Q. The following are useful markers to distinguish malignant mesothelioma from adenocarcinoma:

A. B. C. D. E. F. G. H. I. J. K. L. M. N.

WT-1 AE1/AE3 Calretinin CK5/6 CK7 CAM5.2 BerEP4 CK20 MOC31 MNF-116 Thrombomodulin E-cadherin CEA EMA

T T T T T

T T T T

Q. Which one of the following markers can help to distinguish between malignant mesothelioma and adenocarcinoma by differential subcellular staining:

A. B. C. D. E. F. G. H. I. J. K. L. M. N.

WT-1 AE1/AE3 Calretinin CK5/6 CK7 CAM5.2 BerEP4 CK20 MOC31 MNF-116 Thrombomodulin E-cadherin CEA EMA

Q. Which one of the following markers can help to distinguish between malignant mesothelioma from adenocarcinoma by differential subcellular staining:

N. EMA

BerEP4 MOC31 Calretinin CK5/6 WT1 Thrombomodulin D2-40

Epithelial marker Epithelial marker Mesothelial marker Mesothelial marker Mesothelial marker Mesothelial marker Mesothelial marker

BerEP4 MOC31 Calretinin CK5/6 WT1 Thrombomodulin D2-40 CEA CD15 E-cadherin EMA

Adenocarcinoma + + + +/+ + cytoplasmic

Mesothelioma + + + + + + membranous

Q. Which of the following markers may be useful to distinguish reactive mesothelial cells from malignant mesothelioma? T/F A. B. C. D. E. F. G. H. I. J. K. L.

Calretinin MOC31 AE1/AE3 Desmin p53 CEA D2-40 EMA CK7 p63 SMA vimentin

Q. Which of the following markers may be useful to distinguish reactive mesothelial cells from malignant mesothelioma? T/F A. B. C. D. E. F. G. H. I. J. K. L.

Calretinin MOC31 AE1/AE3 Desmin p53 CEA D2-40 EMA CK7 p63 SMA vimentin

T T T

Reactive mesothelial cells

Mesothelioma

Desmin

+ (83%)

- (28%)

EMA

- (15%)

+ (75%)

p53

- (9%)

+ (59%)

Q. Metastasis in lung or primary. Which primary tumours typically have this immunoprofile?

CK7-,CK20CK7+, CK20CK7+, CK20CK7-, CK20+

A. B. C. D. E. F. G. H. I. J. K.

Lung adenocarcinoma Colon adenocarcinoma Mesothelioma Pancreatic adenocarcinoma Small intestine adenocarcinoma Breast adenocarcinoma Prostate adenocarcinoma Ovarian mucinous adenocarcinoma Ovarian serous / endometrioid adenocarcinoma Bladder - transitional cell carcinoma Endometrial adenocarcinoma

CK7+/CK20 CK7+/CK20 CK7- / + CK20+

CK7-/CK20-

Lung

prostate

Ovary (mucinous)

Breast

Small intestine mesothelioma Bladder - TCC Ovary (serous, Pancreas endometrioid) Endometrial Thyroid

colorectal

RCC HCC

Q. In the subtyping of metastatic lung tumours, please match the tumours with the antigen that could aid diagnosis by IHC. Each tumour can have no antigen, one or more than one corresponding positive antigens. Each antigen can be used once, more than once or not at all.

A. Prostate adenocarcinoma B. Breast adenocarcinoma C. Endometrial adenocarcinoma D. Renal cell carcinoma E. Gastric adenocarcinoma F. Colorectal adenocarcinoma G. Pancreatic adenocarcinoma H. Seminoma 1) ER 2) Ki67 3) CDX2 6) SMAD4 7) PR 8) PAX8 11) pCEA 12)mCEA 13)PSA

4) SYTL5 9) PLAP

5) Vimentin 10) AR

14) EMA

15)PSAP

Q. In the subtyping of metastatic lung tumours, please match the tumours with the antigen that could aid diagnosis by IHC. Each tumour can have no antigen, one or more than one corresponding positive antigens. Each antigen can be used once, more than once or not at all.

A. B. C. D. E. F. G. H.

Prostate adenocarcinoma Breast adenocarcinoma Endometrial adenocarcinoma Renal cell carcinoma Gastric adenocarcinoma Colorectal adenocarcinoma Pancreatic adenocarcinoma Seminoma 2) Ki67 4) SYTL5

11) pCEA

12)mCEA

10) AR 13)PSA 11)PSAP 1) ER 7) PR 8) PAX8 1) ER 7) PR 8) PAX8 5) Vimentin 3) CDX2 3) CDX2 6) SMAD4 9) PLAP

14) EMA

Q. Which of the following conditions in the lung have a tendency to cavitate?

A. B. C. D. E.

Lung adenocarcinoma Tuberculosis Sarcoidosis Lung squamous cell carcinoma Lung small cell carcinoma

Q. Which of the following conditions in the lung have a tendency to cavitate?

A. B. C. D. E.

Lung adenocarcinoma Tuberculosis Sarcoidosis Lung squamous cell carcinoma Lung small cell carcinoma

T

T

Q.Which of the following markers help to distinguish between lung adenocarcinoma and lung squamous cell carcinoma?

A. B. C. D. E. F. G. H. I.

TTF1 MNF-116 CK5/6 Calretinin p63 p16 p40 CK14 CK8

Q.Which of the following markers help to distinguish between lung adenocarcinoma and lung squamous cell carcinoma?

A. TTF1 C. CK5/6 E. p63

G. p40 H. CK14

Squamous markers • • • •

p63 p40 CK5/6 CK14 Bishop JA, Teruya-Feldstein J, Westra WH, Pelosi G, Travis WD, Rekhtman N. p40 (ΔNp63) is superior to p63 for the diagnosis of pulmonary squamous cell carcinoma. Mod Pathol. 2012 Mar;25(3):405-15.

Lung squamous cell carcinoma • c. 45% primary lung tumours in men. c.25% in women.

• >90% in cigarette smokers • may cavitate • histological criteria • keratinisation • intercellular bridging • +/- dysplasia / CIS • variants – small cell, basaloid, papillary, clear cell, alveolar spacefilling peripheral variant

Lung Adenocarcinoma Adenocarcinoma in situ Minimally invasive adenocarcinoma Invasive adenocarcinoma Non mucinous (describe predominant pattern) Lepidic (formerly bronchioloalveolar) Acinar Papillary Micropapillary Solid Mucinous adenocarcinoma (describe predominant pattern) Mucinous (colloid) Fetal Enteric Signet ring

Clear cell

Lung adenocarcinoma • c.28% of primary lung tumours in men and c.42% in women.

• most occur in smokers but the most common type of lung cancer in non-smokers.

• identification of: • lepidic pattern (previously bronchioloalveolar pattern), acinar pattern (definite gland formation), papillary pattern, papillary nodules without stromal cores (micropapillary pattern) or intracellular mucin-containing vacuoles in more than five cells in two consecutive high power fields of an otherwise undifferentiated carcinoma (solid pattern).

• Recording of the predominant pattern of tumour is now recommended.

• identification of minimally invasive tumours (area of invasion less than or equal to 5 mm) • identification of adenocarcinoma-in-situ when the tumour is wholly lepidic (previously termed ‘bronchioloalveolar’) in pattern.

• CK7+, CK20-, TTF1+, NapsinA +

Napsin A, a New Marker for Lung Adenocarcinoma, Is Complementary and More Sensitive and Specific Than Thyroid Transcription Factor 1 in the Differential Diagnosis of Primary Pulmonary Carcinoma: Evaluation of 1674 Cases by Tissue Microarray Bradley M. Turner, Philip T. Cagle, Irma M. Sainz, Junya Fukuoka, Steven S. Shen and Jaishree Jagirdar Archives of Pathology & Laboratory Medicine Feb 2012, Vol. 136, No. 2 (February 2012) pp.

163-171 doi: http://dx.doi.org/10.5858/arpa.2011-0320-OA

• lung adenocarcinoma – peripheral tumour • arises in terminal bronchioles

Lung Adenocarcinoma

1. Lepidic (formerly bronchioloalveolar)

2. Mucinous Ca

Lung Adenocarcinoma

3. Papillary adenocarcinoma

4. Papillary adenocarcinoma

Lung Adenocarcinoma 5. Signet ring adenocarcinoma

Pulmonary Adenocarcinoma: The Expanding Spectrum of Histologic Variants Cesar A. Moran Archives of Pathology & Laboratory Medicine Jul 2006, Vol. 130, No. 7 (July 2006) pp. 958-962

Q. Characteristics of small cell lung carcinoma: T/F

A. B. C. D. E. F. G. H.

Finely granular chromatin Cytoplasmic vacuolation Dense cytoplasm on Pap staining Positive staining for synaptophysin Is generally treated by surgery Nuclear moulding Accounts for 45% of primary lung cancers Is distinguished from primary lung adenocarcinoma by its lack of staining for TTF1 I. Is a small round blue cell tumour J. Is strongly related to cigarette smoking K. Azzopardi effect

Q. Characteristics of small cell lung carcinoma: T/F

A. B. C. D. E. F. G. H.

Finely granular chromatin T Cytoplasmic vacuolation F Dense cytoplasm on Pap staining F Positive staining for synaptophysin T Is generally treated by surgery F Nuclear moulding T Accounts for 45% of primary lung cancers F Is distinguished from primary lung adenocarcinoma by its lack of staining for TTF1 F I. Is a small round blue cell tumour T J. Is strongly related to cigarette smoking T K. Azzopardi effect T

Lung small cell carcinoma • c. 20% primary lung tumours.

• strong association with cigarette smoking, usually central/hilar •Cells “small” with scant cytoplasm, round to spindled nuclei, fine chromatin. No conspicuous nucleoli.

• Nuclear moulding common.

• Crush artefact.

• High mitotic count - usually > 60 /10 HPF. • The Azzopardi effect: encrustation of blood vessels with nuclear basophilic material.

• +ve for NE markers – synaptophysin, chromogranin, CD56 • +ve for TTF1; dot-like pan-CK staining.

• EM – dense core neurosecretory granules 100-200nm • Associated with paraneoplastic syndromes.

• Df Dx – lymphoid infiltrates, lymphoma, other small round blue cell tumours (e.g. metastatic small cell ca / Merkel cell carcinoma CK20+, TTF1-; small cell variants of other tumours e.g. SCC, MM; etc), large cell neuroendocrine carcinoma, • Tx – chemotherapy (except few v. early stage tumours)

Small cell carcinoma – central tumour

Q. Which one of the following lung tumours are associated with haemorrhage including potentially fatal haemoptysis when treated with monoclonal antibody therapy (bevacizumab) : T/F A. B. C. D. E.

Squamous cell carcinoma Adenocarcinoma Small cell carcinoma Large cell neuroendocrine carcinoma Atypical carcinoid tumours

Q. Which one of the following lung tumours are associated with haemorrhage including potentially fatal haemoptysis when treated with monoclonal antibody therapy (bevacizumab) : T/F A. Squamous cell carcinoma • Bevacizumab is not licenced for SCC • SCC arises from large bronchi whereas adeno peripheral • Central tumours may invade major vessels

Q. Molecular pathology of lung tumours: Which one technique is favoured / forecasted in pathology to be the principal instrumental technique that will lead lung cancer molecular diagnostics in the future : T/F A. B. C. D. E. F. G.

miRNA analysis Genomic DNA sequencing Whole human genome expression arrays High throughput proteomics by MALDI mass spectometry Gene expression by multiplex qPCR Mitochondrial DNA mutation analysis Raman spectroscopy

Q. Molecular pathology of lung tumours: Which one technique is favoured / forecasted in pathology to be the principal instrumental technique that will lead lung cancer molecular diagnostics in the future : T/F A. miRNA analysis

B. Genomic DNA sequencing C. Whole human genome expression arrays D. High throughput proteomics by MALDI mass spectometry E. Gene expression by multiplex qPCR Mitochondrial DNA mutation analysis F. Raman spectroscopy Lorito A, Schmitt FC. (Cyto)Pathology and sequencing: next (or last) generation? Diagnostic Cytopathology 2011;40:459-61.

DNA sequencing for mutation analysis

• Sequenom massARRAY • based on MALDI TOFF mass spectometry • can be used for high-throughput DNA sequencing and mutation analysis

Q: Which of the following are important genes in lung cancer molecular testing? T/F A. B. C. D. E. F. G. H. I. J. K. L. M. N.

MIB1 p63 EGFR TTF1 EML7-ALK EML3-ALK EML4-ALK KRAS-ALK KRAS c-MYC MYBL1 BRAF p40 PDL1

Q: Which of the following are important genes in lung cancer molecular testing? T/F A. MIB1 B. p63 C. EGFR D. TTF1 E. EML7-ALK F. EML3-ALK G. EML4-ALK H. KRAS-ALK I. KRAS J. c-MYC K. MYBL1 L. BRAF M. P40 N. PDL1 Kerr KM. Histopathology 2012;60: 531-46

EGFR mutation testing in lung cancer

• Epidermal growth factor receptor • small molecular inhibitors of the tyrosine kinase domain of EGFR (ergotinib, gefitinib) are particularly effective in patients with specific EGFR mutations: • c. 85% of these are deletions in exon 19 or the L858R substitution mutation in exon 21 • most EGFR mutations occur in adenocarcinoma • EGFR mutations reported at 10-15% of cases in European / Caucasian studies (40-60% in East Asia).

Lung carcinoid tumours

• Histologic subtypes of pulmonary neuroendocrine tumours: typical carcinoids, atypical carcinoids, small cell carcinoma, and large cell neuroendocrine carcinoma TYPICAL CARCINOID TUMOUR • <5% of primary lung tumors ● Locally invasive ● Usually 40 years or below ● No gender predilection, not related to smoking ● May infiltrate or spread to local lymph nodes, but doesn’t affect prognosis ● Rarely produces carcinoid syndrome (flushing, diarrhoea, cyanosis) ● Nests or trabeculae of medium sized polygonal cells of low nuclear grade, round to oval finely granular nuclei and lightly eosinophilic cytoplasm. Nucleoli inconspicuous. ● No/minimal mitotic activity <2/10hpf or necrosis

Lung carcinoid tumours ATYPICAL CARCINOID TUMOUR • 2-10 mitoses/10HPF or necrosis

• both TC and AC are + for CK and NE markers.

• TTF1 + in c. 1/3 TC and up to ½ of AC (if +ve supports lung primary site)

Beasley MB. Diagnostic Histopathology. 2008; 14:10: 465

Q. Which of the following is classical of bronchiolitis obliterans organising pneumonia?

A. B. C. D. E. F.

Fibrosis Asbestos fibres Macrophages within alveoli Intrabronchiolar fibroblastic plugs Granulomas Hyaline membranes

Q. Which of the following is classical of bronchiolitis obliterans organising pneumonia?

D. Intrabronchiolar fibroblastic plugs

Bronchiolitis obliterans organising pneumonia

• Common response to infectious or inflammatory injury to lungs

• Requires Clinicopathological correlation • A clinicopathological syndrome that can be caused by various agents including drugs, infections, toxic inhalants and immune disorders.

• Histology – intrabronchioloar fibroblastic plugs (Masson plugs), interstitial inflammatory cells, lumenal macrophages.

Q. Aspergillus has the following features:

A. B. C. D.

45% branching of hyphae Non-septate Invasion of blood vessels Infection in immunocompetent patients

Q. Aspergillus has the following features:

A. B. C. D.

45% branching of hyphae Non-septate Invasion of blood vessels Infection in immunocompetent patients

T F T F

Q. Pneumocystis pneumonia: A. B. C. D. E.

jirovecii is the species that causes lung infection carinii is the species that causes lung infection motoso is the species that causes lung infection Is an opportunistic infection Histologically - alveolar spaces filled with eosinophilic foamy material containing fungi.

F. Is characteristed by non-branching septate hyphae G. Is characteristed by 4-6micron diameter cup-shaped cysts

Q. Pneumocystis pneumonia: A. jirovecii is the species that causes lung infection B. carinii is the species that causes lung infection C. motoso is the species that causes lung infection

D. Is an opportunistic infection E. Histologically - alveolar spaces filled with eosinophilic foamy material containing fungi F. Is characteristed by non-branching septate hyphae

G. Is characteristed by 4-6micron diameter cup-shaped cysts

Formerly known as P. carinii, a pneumocystis variant that occurs in animals; P. jiroveci is specific to humans ● Opportunistic yeast-like fungus present in bronchoalveolar lavage (BAL), sputum or biopsy ● Classical pneumonia in AIDS patients ● May also occur in otherwise immunocompetent patients with protein-calorie malnutrition, haematologic malignancies or undergoing chemotherapy or chronic corticosteroid treatment.

Q. In routine diagnostic practice, asbestos fibres can be counted using: A. B. C. D. E. F.

H&E sections Electron microscopy Perls staining Nitric acid digest and light microscopy Autofluorescence Unstained FFPE sections

Q. In routine diagnostic practice, asbestos fibres can be counted using: A. B. C. D. E. F.

H&E sections Electron microscopy Perls staining Nitric acid digest and light microscopy Autofluorescence Unstained FFPE sections

T T T T T

Q. Abestos bodies: A. B. C. D. E. F.

Are synonomous with feruginous bodies Are diagnostic of asbestosis The asbestos fibre count decreases over time in living patients lung tissue Are not found in hilar lymph nodes Are usually found in mesothelioma tissue Amphiboles are associated more than crysotiles with mesothelioma

Q. Abestos bodies: A. Are synonomous with feruginous bodies B. Are diagnostic of asbestosis

F F

C. The asbestos fibre count decreases over time in living patients lung tissue T D. Are not found in hilar lymph nodes E. Are usually found in mesothelioma tissue

F. Amphiboles are associated more than crysotiles with T mesothelioma

F F

Q. 36F. Heavy smoker. Progressive SOB. CXR – bilateral ground glass appearance. Lung biopsy – alveoli filled with histiocytes, hyperplasia or type 2 pneumocytes, lymphoplasmacytic infiltrate.

Diagnosis: A. B. C. D. E.

Bronchiolitis obliterans organising pneumonia Usual interstitial pneumonia Desquamative interstitial pneumonia Extrinsic allergic alveolitis Non-specific interstitial pnemonia

Q. 36F. Heavy smoker. Progressive SOB. CXR – bilateral ground glass appearance. Lung biopsy – alveoli filled with histiocytes, hyperplasia or type 2 pneumocytes, lymphoplasmacytic infiltrate. Diagnosis: A. Bronchiolitis obliterans organising pneumonia B. Usual interstitial pneumonia

C. Desquamative interstitial pneumonia D. Extrinsic allergic alveolitis E. Non-specific interstitial pnemonia

Desquamative interstitial pneumonia

• Usually adults • insidious onset of shortness of breath • M:F = 1:2 • usually one decade younger that UIP patients • 90% are current or past cigarette smokers • associated with collagen vascular disease • Patients who stop smoking +/- steroid therapy have good prognosis • Mean survival of 12 years, mortality 28% • Histology – accumulation of macrophages and type 2 pneumocyte hyperplasia.

• Diffuse collections of intraalveolar macrophages containing lipid and PAS+ granules (originally considered to be desquamated pneumocytes)

Further reading for the part 1

• Robbins pathology and MCQ book • RCPath datasets and documents • Check for screening programmes (NHS screening website) • immunohistochemistry vade mecum (Dr Paul Bishop) http://e-immunohistochemistry.info/web/histopathology_help.htm

Good luck in the exam