Pulmonary Gross Examination

What is a transbronchial bx?

Bronchoscope accesses left/right primary bronchus

Samples unusual tissue

What is a CT-guided (percutaneous) lung bx?

Needle guided by CT for peripheral lesions

What is a wedge resection?

Staple-line excision of peripheral nodule

Triangular piece of lung parenchyma

Usually for non-tumor reasons

What is a lobectomy?

Removal of a single lobe with:

• Vascular

• Bronchial

• Staple-line margins

What is a bilobectomy?

Removal of two lobes

• Right lung only: Upper + middle, OR middle + lower

What is a pneumonectomy?

Removal of entire lung

• Includes:

  • Main bronchus

  • Hilar structures

What is a sleeve lobectomy?

Lobectomy with extended bronchial segment to spare parenchyma

What is a chest wall excision?

En bloc resection include:

• Ribs

• Soft tissue

Which lung is this?

Right

• PA more anterior to bronchus

What is this?

Anthracosis

• Caused by pollution

  • “Normal” in the lung

Which primary lung tumors are staged using the AJCC TNM system?

Non-small cell lung carcinoma (NSCLC)

• Squamous cell carcinoma

• Adenocarcinoma

Small cell carcinoma

Pulmonary carcinoid tumors

Which lung cancer is usually central?

Squamous cell carcinoma

Small cell carcinoma

Which lung cancer is usually peripheral?

Adenocarcinoma

What are the major pulmonary specimens received for gross examination?

Transbronchial biopsy

CT-guided (percutaneous) needle biopsy

Wedge resection

Lobectomy

Bilobectomy (right lung only)

Pneumonectomy

Sleeve lobectomy

Chest wall resection

Pleurectomy/decortication

Extrapleural pneumonectomy (EPP)

What should ALWAYS be reviewed before performing a pulmonary frozen section?

Clincal hx

Why is the clinical history especially important?

The lesion may represent tuberculosis or another infectious process

What is the protocol for some infectious specimens regarding frozen sections?

Some institutions decline frozen sections on infectious specimens

• Should discuss policy with surgeons in advance

Why should freeze spray never be used on suspected infectious lung specimens?

It may aerosolize infectious organisms

What PPE should be worn when tuberculosis is suspected?

N95 mask

What are the two most common reasons surgeons request a pulmonary frozen section?

Confirm malignancy

Evaluate margins

(Confirm purpose BEFORE cutting)

How is a parenchymal margin evaluated during frozen section?

Remove staple line

Ink underlying parenchyma

Submit perpendicular sections

Which lung carcinoma most commonly has positive parenchymal margins?

Squamous cell carcinoma (because it is usually central)

How can you distinguish the left lung?

Left lung:

• Two lobes

• Pulmonary artery superior to bronchus

How can you distinguish the right lung?

Right lung:

• Three lobes

• Pulmonary artery anterior to bronchus

What is a pleural peel (decortication)?

Surgical removal of fibrous rind from pleural surface

What is the purpose of a pleural peel (decortication)?

Restore lung expansion restricted by thickened pleura (emphysema, mesothelioma, effusions)

In a pleural peel (decortication), is the visceral pleura a true surgical margin?

No, it is NOT a true surgical margin

BUT its involvement is important for staging

What should always be documented for a pleural peel (decortication)?

Always know clinical hx BEFORE grossing

Document:

• Pleural thickness

• Extent of involvement

• Any associated lung parenchyma changes

What are the procedure ranges for a pleural peel (decortication)?

From partial pleurectomy to extrapleural pneumonectomy (EEP)

• EPP = En block resection

What is included in an EPP?

En bloc removal of:

• Lung

• Pleura

• Pericardium

• Diaphragm

What is the normal lung weight for a male?

Right: ~680 g

Left: ~600 g

What is the normal lung weight for a female?

Right: ~480 g

Left: ~420 g

Why is the lung perfused with formalin overnight before sectioning?

To inflate alveoli and better preserve architecture

(Perfused though bronchus with formalin)

Why are post-perfusion measurements more accurate?

They better reflect the lung's in vivo size

What areas are inked on lung resection specimens?

Staple-line parenchymal margin

Pleural areas with retraction/puckering

Which margin is assessed in a wedge resection?

Staple-line (parenchymal) margin

• Should ink underlying parenchymal margin

How should the staple margin be sectioned on a wedge resection?

Perpendicular

What should always be documented for a pulmonary mass on a wedge resection?

Size

Color

Consistency

Borders

Distance to pleura

Distance to margin

Pleural puckering/retraction

When is a perpendicular margin section mandatory on a wedge resection?

Tumor <2 cm from the margin

Which sections should always be submitted from a wedge?

Staple line parenchymal margin (perpendicular)

Tumor to pleura

Tumor to uninvolved lung

One block of uninvolved lung

What are the three critical margins in a lobectomy?

Bronchial (en face)

Vascular (en face)

Staple line/Parenchymal — THIS IS A MARGIN

Which margins are usually submitted en face?

Bronchial

Vascular

When should bronchial or vascular margins be submitted perpendicular in a lobectomy?

If tumor is within 2 cm

What pleural findings should always be documented in a lobectomy?

Retraction

Puckering

Plaques

Adhesions

Anthracosis

How should a lobectomy be sectioned?

Superior → inferior (best correlates with CT imaging)

Why are lungs sectioned at ≤0.5 cm intervals?

To detect small satellite nodules

What should always be described in uninvolved lung?

Spongy

Emphysematous

Consolidated

Fibrotic

Which lymph nodes should be searched for?

Hilar

Lobar

Peribronchial

Intrapulmonary

How should tumors be described in lung?

Size

Color

Consistency

Borders

What are some tumors descriptors in lung?

Spongy vs. solid

Cavitation

Necrosis

Central vs. peripheral

Bronchial involvement

What additional findings must be evaluated in pneumonectomy?

Main bronchus

Carina distance

Adjacent organ invasion

(All lobectomy steps apply as well)

Why is distance from the carina important?

Carinal involvement is pT4

Which structures should be examined for invasion especially in bilobectomy/pneumonectomy?

Pericardium

Diaphragm

Chest wall

Pleura

Phrenic nerve

Why is invasion across a fissure important?

It affects staging

True or False: Submit sections of uninvolved lung from each lobe present

True

What is a tumor bed?

Area of fibrosis/treated tumor remaining after therapy

What should be done to a tumor bed prior to cassette submission?

Photograph full-face cross section of tumor bed

What should always be documented in treated lung tumors?

Percent necrosis

How are tumor beds ≤3 cm handled?

Submit entirely

How are tumor beds >3 cm handled?

Full-face map

Additional relevant sections

What is the most common lung cancer?

Adenocarcinoma

What is the gross appearance of adenocarcinoma?

Gray-yellow

Solid

Pleural retraction

Ground-glass component possible

Which lung cancer is most common in women and nonsmokers?

Adenocarcinoma

What is AIS?

Adenocarcinoma in situ

What is the gross appearance of AIS?

Soft, gray area

Indistinct

Ground-glass

Often multifocal

What defines a minimally invasive adenocarcinoma (MIA)

≤3 cm total tumor

≤0.5 cm invasion

Why must AIS and MIA be entirely submitted?

To accurately measure invasion

Where does SCC usually arise?

Central bronchi

• Can show exophytic endobronchial invasion

What risk factor is strongly associated with SCC?

Smoking (tobacco exposure)

What is the gross appearance of SCC?

Gray-white

Firm

Cavitary

Necrotic

Hemorrhagic

What secondary changes result from bronchial obstruction?

Atelectasis

Obstructive pneumonitis

Which lung carcinoma commonly invades mediastinal structures?

Squamous cell carcinoma

What is a Pancoast tumor?

Apical SCC → involves cervical sympathetic plexus

What syndrome results from a Pancoast tumor?

Horner syndrome

What are four findings of Horner syndrome?

Ptosis

Anhidrosis

Miosis

Enophthalmos

What is the typical location of small cell carcinoma?

Central

Why is surgery uncommon for small cell carcinoma?

Early metastasis

Which lung cancer has the STRONGEST smoking association?

Small cell carcinoma

What is the gross appearance of small cell carcinoma?

Soft

Tan-gray

Necrotic

Extensive hilar involvement

What is the gross appearance of a carcinoid tumor?

Well circumscribed

Homogeneous

Fleshy

What classifiies a central carcinoid?

Polypoid endobronchial masses

What classifies a peripheral carcinoid?

Gray-yellow peripheral nodules

What differentiates tumorlets from carcinoids?

Tumorlets are <0.5 cm

(Gray, spongy; Single or multiple in parenchyma)

What cells give rise to mesothelioma?

Mesothelial cells

What risk factor is strongly associated with mesothelioma?

Asbestos

What is the typical latency of mesothelioma?

20-40 years

What is the gross prognosis of mesothelioma?

Plaque → Multinodular → Rind encasing lung

What procedures are covered with mesothelioma?

Partial pleurectomy

Pleurectomy/decortication (P/D)

Extended P/D

Extrapleural pneumonectomy (EPP)

What is visceral pleura?

Covers the lung surface (including fissures)

What is parietal pleura?

Lines the chest wall

How is the parietal pleura divided?

Costal pleura (chest wall)

Mediastinal pleura

Diaphragmatic pleura

What is the pleural cavity?

Space between visceral and parietal layers

What is the costomediastinal recess?

Angle between costal and mediastinal pleural

For EPP, what does the entire surface of the specimen also equal?

Surgical margin

• Dissection of tumor from thoracic wall

What is the typical gross descriptors of mesothelioma?

Gray-white to tan (variegated)

May diffusely coat parietal and/or visceral pleura

Consistency: firm, fibrous, or friable depending on histologic subtype

May extend into:

• Mediastinal fat

• Chest wall soft tissue

• Diaphragm

• Pericardium

What should always be documented for mesothelioma specimens?

Pleural thickness

Percent pleural involvement

Number of nodules

Lung invasion

Diaphragm invasion

Pericardial invasion

How are pleural nodules described for mesothelioma?

Few (<5)

Many (6–20)

Innumerable (>20)