The following is a medical media production from WRC TV. Well, what is a pseudo tumor? Is it really a tumor? Why do we say pseudo this is an entity which has long since been described at this institution described in the fifties and was considered to be an organizing residual of infl inflammation. It looks very much like a tumor on a radio graph. It has various appearances which will try to enumerate with several examples in this discussion. But the important thing about it is that it may very well be taken for a neoplasm and they exist as benign entities and we should know about them. They are fairly uncommon when you look at a general hospital practice, they're seen very seldom or at least not recognized as such. And one wonders why if it, it really is an organizing inflammation, why there should be so few of them? Certainly, inflammations of the lung are very common. They seem to result from resolving abscesses or organizing abscesses, organizing pneumonias. And the question is why do some people do this? And most people do not? And it may very well be and we have detected some of these so called pseudo tumors. It might be better to say that they are tumors in the true sense of the word a tumor is a mass. And we might be able to say pseudo neoplasm. Well, these pseudo tumors or pseudo neoplasms may be a surprise to us when we hear that some of them actually grow before it was always thought that this would be an organization of a post inflammatory lesion which then of course, ought to get smaller as it organized and become fibrous. But some of them have been detected growing. And the question is what grows and organizing fibrous mash shouldn't grow it. Some people posted well, maybe more of the lung was involved. And as the organization took place, we became aware of more area of involvement. But others said, no, they apparently grow and it's been thought now that proliferating cells may start again. And this always leads us in the direction of possible immunological effects where an antigen again causes an antigen antibody reflex and complex to form. And this might cause the proliferation of plasma cells and lymphocytes. And certainly a great number of our pseudo tumors or pseudo neoplasms are plasma cell in type and lymphocytic in type. There are others that are called fibroma fibrocyte tomas and these may not show very many lymphocytes and plasma cells. So we're not quite sure about that premise that these may grow since there may be a recrudescence of an immunological problem this is speculation and no one really knows what causes a pseudo neoplasm or pseudo tumor, inflammatory tumor to grow or what they, what really caused in the first place. But let's have a look at these. They exist and under the microscope, they've received this label. So I think radiologists has to be aware of it. But the important, the real value of discussing this topic is to show the range of masses of the lungs, what could be taken for these. And therefore, we'll discuss a differential diagnosis of fairly well defined masses of the lungs. This is a plasma cell granuloma type of inflammatory pseudo tumor. Notice that the boundary is extremely sharp, slightly lobulated. There's nothing on the inside of this mass. It we see lung markings over it. You may even wonder about calcification. But in in this one, there is nothing. It's just a solitary, mostly fibrous mask but loaded with plasma cells. And so we talk about a plasma cell granuloma, plasma granuloma is by far the most common lesion in Children of this type. But they are also seen in adults. In fact, most of the pseudo tumors in Children are apt to be plasmas. Here is another a a very young person notice the size that these can attain and it must be rather perplexing to understand that this is presumably an organizing fibrous mass. It's hard to imagine it's being so sharp. It really looks like a tumor, doesn't it like a growing tumor. They can be very tiny as well. Here's one that is certainly less than the diameter of the rib rather sharply defined and could be almost anything and preoperatively, we would not be able to make the diagnosis, but our investigation was said to be an inflammatory pseudo tumor. They can be big as volleyballs and then they're very young, they're allowed to be grama, which this was again, notice that it's large enough that the lung markings are stretched and draped around it. It's very sharp. Some of them are not so sharp. We will see them occasionally when they're not. But this one certainly is in all dimensions. As we see on this lateral view, this plasma granuloma. Here's one that begins to get us into an area where differential diagnosis is possible with those other masses. There's a whole list of things that they might be since they were quite round and sharp. And we will look at that list in a moment, but this one is elongate, it almost looks like a potato shape. And when anything takes on this shape, you can exclude a lot of things because many, many things that represent large, sharper defined masses in the lung field. Many of them are always round metastasis. For example, usually around hamartomas are usually roundish, even many of the bronchogenic primary carcinomas that are sharply defined out in the lung fields. Many of those are around. Although there we might get a little departure but usually never this incredible long shape. So if we see that we might give some idea, some consideration to inflammatory tumor and then we get bizarre shapes in these organizing fibrous masses. Notice this one is almost like a dumbbell, peculiar shape following presumably on Bronchia. Here's one that has a calcification that's very characteristic. This is again a great big potato shaped mass, not round, like so many large defined lesions along would be. And we'll consider that list later, this calcification should not be confused with hamartoma tomas. Of course, are important when you're talking about calcification contained within a mass or granuloma. But the hamartoma calcification is like cartilage, calcification. It looks like burst popcorn as someone said, and it really looks like convocation calcium of chondroid. But this one doesn't, this has a demining border as you can see a rather nicely organized border de limiting a zone of necrosis or dystrophy. So this is dystrophic calcification, not calcification and cartilage. And it's demining areas that are sometimes necrotic almost in like in in area. And so when we see calcification in these, we can sometimes get this characteristic of a de limiting rim. And this helps us toward making the diagnosis at least of inflammation or necrotic areas within a inflammatory mass. Obviously, we also see calcification in granulomas, but granulomas for the most part are very tiny. Uh once in a while we see a large granuloma two or three centimeters sometimes, but that's about it. It almost never. Would you see granuloma this size unless you want to call this a grandma. If we do give it the label plasma cell granuloma, it is a plasma cell granuloma type of inflammatory. So the tumor that's organized here is another which again is peculiar shape, almost like a potato sitting on its side with scattered areas of delimiting zones of calcification. Sometimes it might be difficult to see the characteristics of that calcification and it might require tomography to really see it. Well, here's another that's calcified and a quite lobulated mass. We did do tomography on this one so that we see the scattered calcium and this one is a little more difficult to judge. We might make out a border here. And perhaps if we had better technique in tomography, this is linear tomography. Perhaps if we did the hyper cyclo motion, we might get a little more information to see the calcium. Well, because this looks scattered around enough that it might consider this a Hamartoma and Hamas are roundish like this one is and Hamartomas are also quite lobulated. So I A Ham Tu of lung could easily fit this description with this marked lobulation and with the scattered calcium. So it behooves us to use good technique. And if we don't have it ourselves to let someone else do a slice on these, for us to really try to pin down the calcium because usually they do not look like the calcification of hamartoma and the calcification of the pseudo tumor, uh pseudo tumors will calcify unfortunately, in a not too high a percentage, four or 5%. So it doesn't help us too often anyway. Now, we may see microscopic calcification quite a few more than four or 5%. Hamartoma calcify radiologically in 15 to 20% of cases and microscopically in 35 to 40%. So they calcify more than the pseudo tumors considerably more. And of course, the calcification usually is different. Now, theoretically, a pseudo tumor would begin something like this. This patient in his fifties had pneumonia and he had all the symptoms of pneumonia came in with those symptoms and was treated, but his pneumonia was stubborn and would not resolve. And when a person who is a little older, particularly there's a smoker has a unresolving pneumonia, you must consider malignancy until proven otherwise for the safety of the patient. So they, they stayed with this one. The border was no longer as, as uh ill defined as in acute stages of his pneumonia, but it still was a little ill defined and here was the massive area of infiltration. They watched him because he was, he was not resolving as fast as they wanted him to. It was 27 September. Then by 11 October, his mass had become smaller and a little more sharp but still not resolved. And when this went on until this point at the end of October when he was still not resolving everything, but going down, they became a little concerned about this individual. They asked themselves a question they should have. And that is here is an older person who smokes. He's got unresolving pneumonia. Let's take a look at this man and let's consider him a bronchogenic carcinoma with a stubborn obstructive pneumonitis until proven otherwise. So they did all these procedures and they found nothing. So they decided to go right after this thing. Uh, even though that sometimes would not be very rewarding because if you had a tumor obstructing a bronchus and had a constructive pneumonia, all you're going to find in the biopsy is pneumonia. No tumor out there. The tumor is somewhere in the bronchus obstructing and causing obstructive pneumonia. But they thought, well, maybe it's an adenocarcinoma in the periphery that's got pneumonia with it and we've cured the pneumonia, but we've still got the adnoc carcinoma and that's why I won't resolve. And that question is, has come up. Well, they went ahead and they look, took a piece of, and they took a piece of the lung and did this biopsy and when it came back, it was called organizing pseudo tumor, inflammatory fibrosing, inflammatory pneumonitis was organizing. And I suppose if they had not interfered at this point and just watched him, which of course is not good policy, this might have sharpened up into one of those sharp masses we saw before, if we had let it go. So that's the presumption in these lesions when they're seen by the surgeon, even at, even when they, they've delivered that lobe of the lung and they've cut through the tumor. This has been cut in two halves. Uh It still looks like a tumor very sharply defined when it's that ripe. Presumably, they're very sharply defined if they've been there a long time and they have been organizing and Scots and have come down to a sharp nodule. The same thing that happens with a fungus infection at the beginning, it's ill defined. Then finally, it organizes and then we get a nodule that we call a granule or histoplasma or whatever. But if we had, if we had been there with our X ray machine at the beginning of a histoplasma, you would have seen pneumonia which then organized and became a histoplasma. This is what happens in, in a fungus infection. So obviously, this may be the same, we may be in the same ballpark here, starting out with a pneumonic area, infiltrated area which then organizes down to a sharp mass. And if we come along and see it for the first time when it's a sharp mass, it looks like a tumor and it does look like a tumor in the gross. And until a bite is taken, like it's been taken here and submitted for microscopic study, we may not be aware of what this is. Now, when you cut them in, in cross section, they look very sharp at the border. Now, oftentimes they form a so called pseudo capsule, which is not a real capsule but a capsule made up of fibrous tissue organization. In other words, we develop over a period of time, the inflammatory products scar up and we get a sheath of fibrous tissue around it, which then finally, the lung separates from it a little bit. Or the surrounding lung settles down and we stabilize and it looks like a capsule and it really, it's just a pseudo capsule and they're very solid looking sometimes quite fibrous. And until we get under the microscope and then realize it. Now, if we come along, on the other hand, at a time in the history of the pseudo tumor of this inflammatory response, at a time when it's still organizing and is not organized but organizing, then we might see borders that are still stormy as in this case. And the stormy borders will be reflected radiographically as rather ill defined borders just like we would see the same stormy borders in a Histoplasma. If we came along at the right time or tuberculoma, it depends on when the radiologist puts his beam through the disease. What stage of the disease is at will depend radiographic signs. So this is an inflammatory pseudo tumor two, but this one has a lot of storms still in the surrounding el walls so that there's no sharp interface between surrounding lung and mass and so on the radiograph, you'll have a fuzzy border. This is the kind of fuzzy border we just saw in that person, that older person with unresolving pneumonia. It wasn't really sharp yet, it was still fuzzy. And this is the reason probably. Now if we look at these on the microscope, we can see lots of fibrous tissue and great swirls lots of it and thousands of nuclei of chronic inflammatory cells, all those little black dots which you can see in great profusion here, especially out here, but they're seen all everywhere. This kind of thing is the kind of thing we see in the inflammatory tumor. It doesn't look neoplastic at all. There's no, there's no problem about confusion. In most cases, it's easy to see that it's post inflammatory on the microscope. And the surrounding lung may still show some infiltration of chronic inflammatory cells. But that quiets down in time during the syco organization that will quiet down and the surrounding lung may even get a little bit emphysema. We call it perifocal emphysema around a syco mass. And then occasionally the septa like this one. A septum may get caught up in this fibrous reaction and pulled in toward the mass of pseudo tumor. Other septum may be involved too and they will simply get fibrosed and made part of the pseudo capsule at the interface between the tumor, the inflammatory mass and the lung. Obviously, we have to go a little higher power to see what's going on. For example, this is a very mixed population of cells. It might be called a histoid pseudotumor. Although there are plenty of plasma cells and lymphocytes and there is of course, a little bronchial here which as you can see, has not been invaded or destroyed. If this were a tumor would have invaded and destroyed that little thing. That's a tiny bronchial and it's just surrounded by this reaction, but it's not destroyed. And we see evidences here of little vessels that are not destroyed. And we see lots of cells, some of them small, some of them large, some of them are histo sites. And it looks like a P cell population we'd see in an organizing inflammatory residual, there are a few giant cells scattered around here too, which will be seen better later on. And if the basic background of the pseudo tumor is fibrous for the most part as this is. But of course, you see lots of inflammatory cells here too. But in addition to that, if some of our fibroblasts pick up fat and become macrophage for fat and breakdown around inflammatory breakdowns, we often have a good deal of fat. And so we call this the fibro xanthoma type of pseudotumor fab an type. This is the same kind of thing that you'll see in the kidney with xantho granuloma pylori. It's the same idea. In other words, masses of fat in which some of the fibroblasts have become macrophages and scooped up the fat. And you'll see globs of little masses of fat strewn in amongst the fibrous tissue and the inflammatory cells. The fibros anto type. Now close up shows lots of Fibroplastic activity here. In addition to inflammatory cells and giant cells which remind you of what you see in a granuloma, you see the same giant cells in granuloma infections. So there's no question that the cell population, the appearance is that of an organizing inflammatory response. Now this is full of plasma cells. In this particular case, plasma cells completely dominate the landscape. There are a few histo sites, a few lymphocytes but it's the plasma cell that dominates here, see a few fibroblasts here. But notice that practically everything else they are plasma cells and this would be called a plasma cell granuloma. Notice right here is an interesting little cell with a great big fat body with a nucleus pushed to the side. This is called a Russell body. And when you see those, the astrologist knows when he sees Russell bodies that he's dealing with inflammatory plasmacytosis, not neoplastic plasmacytosis. The Russell body is his safety valve. Sometimes pseudo tumors are multiple, not very commonly, except in one type. In one type. The lymphocytic type, they may be multiple quite often. But in the plasma cell granulomata in the fibrous anthros type, they are rarely multiple usually one but the order of the day in lymphocytic types is to see multiple ones and often not too well defined shaggy like this. So the multiple ones that are shaggy are most likely to be lymphocytic pseudo tumors or so called pseudo lymphoma. Now, if we were to study our file and give you a report, it would go like this. We picked out 100 that had good radiographs. We have, we have at least twice that many in the files here. But 100 is a good report since most reports are two or three or four and you can rely on this pretty well notice the age range is fairly young overall, approximately 40 and the youngest can be very young and the oldest very old. Although these are exceptions since the range is around 40 the the average but notice by cell type how different they are. The lymphoid type is the older person and the fibromatoid type. But look how young we are when we have the plasma cell type and the fibrosus type, no one can really speculate about why this may be. It may be that it takes the younger person to respond to plasma cell. We know that most of the pseudo tumors in Children are plasma cell in type. But we don't really know why this is. Now, it may be also that there's some kind of breakdown in the immunological system that causes lymphoid aggregations. And this gets us into an older age group as an average. Ok. Size is another thing we should think about. I showed you a terrific range of size and you can see the range 1 to 13 you saw, you saw that range right there, but the average overall is not very large. If they were all much larger or much smaller, it might be a little easier to deal with them, particularly if they're much larger. You saw some big ones and I don't want to mislead you to think that that's the order of the day. You saw those big potatoes with calcium and the big volleyball and so on. But they are not the order of the day. The order of the day is 3 to 4 centimeters. And when you consider that 50% of them are even less than three centimeters or less, three CRS or less that makes them not too large overall. So maybe they are more the size of granulomas, except granulomas are usually less than 1 to 2 centimeters. Location, 60% are in the lower and 40% in the upper lung fields and 2 to 1 on the right side. Now, some of you will recognize that this is about the statement we would make about the location of pneumonias. Quite the opposite is of course true of real tumors. The neoplasms of the lung, two thirds are in the upper lobes. So it's just the opposite of this display here. We've got 60% of the lower lobes and this of course, ties in with pneumonia. Notice that surprisingly 5% are endobronchial. 5% are plural based. 4% are media style or higher in appearance. They're not really media ST higher, but they look like it. There are really lesions of the prana except the endobronchial ones which and the plural ones which might actually arise from bronchial infection or plural of fusion, organizing the common lobes are the lobes of pneumonia. In other words, right, lower lobe, right, upper lobe, left, lower lobe. Now, if we see a large mass like this or even maybe not so large, maybe 346 centimeters somewhere in there, then we're going to think of these entities. Remember our premise is that most of them are sharply defined, but they're not all you saw some pseudo tumors that were not sharply defined. Others were sharp. And how do we make differential diagnosis of these things? Obviously, pseudo tumors are fairly rare in the population as a whole. So there's a lot more chance that these are going to be our candidates than pseudo tumors. But we must consider all this at the same time since they all look alike. In many cases. By far, the most common cause of an isolated lesion out the lung fields is bronchogenic carcinoma. Unfortunately, close behind is a solitary metastasis. Three and four are rather uncommon. Five is not too common. These are not too common. 345 primary sarcomas are sarcomas of lung meeny, like the fibrous tissue of the lung or the muscle tissue of the lung or even the chondroid. In other words, Lima fibroma, om myosarcoma, fibrosarcoma, chondroma, sarcoma tissues inherent in the long bed that become sarcoma since they're mesenchymal. But they're not too common. Hamartomas are not too common either and these presumably are developmental defects in which normal lung tissue, the tissue indigenous to the area is involved but doesn't organize properly and becomes a form frost of that organ. In other words, the elements of the lung are in the amma, but they're all mixed up in a jumble and they're not too common. And interestingly enough, the hamartomas occur in later age groups. You'd think they would occur earlier, but they don't, the average age of pick up is in the fifties and sixties. These other things may be seen at any age group. Solid term tai bronchogenic course from later age groups, of course. But the nurse is not complete until we go through these. The bronchial Anoma or carcinoid is not usually an extra bronchial lesion, usually it's endobronchial, but some of them iceberg out in their growth instead of growing in toward the lumen, they rise deep in the wall of the bronchus instead of growing into the lumen, they may grow out against the lung and become a large white mass. So we have to include that and they're not too uncommon. So this is a pretty important member of the list if we're in the right part of the world, obviously, this has to be thought about too. Now, there are only a few granulomas that retain the size of the inflammatory tumor. One of them of course is the tario or cryptococcus that will retain the attain that size. So we put that on our list, we see these sometimes up to 6 to 8 centimeters. Now, the other granu moments such as histoplasmosis, sarcoidosis, tuberculoma, syphilid guma, and so on. They usually are small. Although an exception is a syphilitic guma, which of course, you almost never see anymore. That can be fairly large and pretty well organized inflammatory PSE tumor is in this list, of course. And then why do I have mesothelium in this list? After all? That's a plural based lesion. It could be in the interlobar fissure. And unless you're careful, it might simulate an inter pulmonary mass as you saw before. And as I'll show you again. Now, this is a little different from an inflammatory tumor, but it could easily be one because it's some elongate kind of a potato. It's lobulated and sharp. It could easily be an inflammatory pseudo tumor. You can, you can say that from what you've seen, but this is a bronchogenic carcinoma squamous cell squamous cell, bronchogenic carcinoma. And it is said over several surveys where these large masses were, were challenged by several authors particularly right of England that in our, in our own material. This is true also that bronchogenic carcinoma that are primary and appear as masses in the lung. And about 40% of all bronchogenic carcinoma do appear as masses in the lung. 40% appear as a mass that you can see out in the lung field. In bronchogenic primary carcinoma, they are not always round, sometimes they are, but quite often, they're funny, they're kind of a square around or void in appearance. And so when we see unusual shapes, we can think of bronchogenic primary carcinoma. And this is one, of course, this is epidermoid, bronchogenic carcinoma. However, quite often we are helped when we see these peculiar shags around the border of a bronchogenic carcinoma. This is quite common also and this represents invasion of surrounding lung by the carcinoma along lymphatics along septa or the collapse of a little lung unit, which looks like a line when it's collapsed. All these things can happen around the bronchogenic carcinoma and particularly if they're fairly well, fairly poorly differentiated and invade, so they can get quite a shaggy border from all these events. And this is uh something that could occur in a pseudo tumor, particularly if you caught it when it was still organizing. As you remember, we talked about that. But that way they could be confused. This could be an organizing infraction for that matter. If you call it just the right time, you might see even an infraction that's organizing rather than disappearing, organizing inflammation, infarction, pseudotumor or even bronchogenic carcinoma. So, it's not always easy to make diagnosis. But statistically bronchogenic carcinoma would be by far the most common cause of this pattern. If you saw it in the lung field and you would have to examine it somehow. You might have to brush biopsy it or needle it. If you're not going to do a thot, you have to come to grips with it because you don't know what it is. But these are interesting and this is quite a common appearance in primary bronchogenic carcinoma. Sometimes the margin will be poorly defined and not speculated but sort of fading off in the periphery like a mnemonic patch. And that can happen with inflammatory pseudo tumor organizing early. It could happen with an infarct organizing early or it could happen, of course, with carcinoma just beginning to involve the surrounding lung. And that's what this is. This is squamous cell carcinoma, but squamous cell Carma may be caught when they're sharp as we see in this one, in its lateral view. Look how sharp it is. That certainly could be one of the members of that gamut. Now, we looked at the gamut, we mentioned 10 things. Now, when we're talking about shaggy borders, we're not talking about metastasis or bronchial Anoma or cyst or Hamartoma, they don't have shaggy borders. So you see if we can work with that list they're always sharp, bronchial carcinoid, bronchial Anoma are always sharp. Hamartomas are always sharp bordered, they may be lobulated but they're sharp. Sarcomas and benign lesions of the lung are usually sharp, sell them over. Are they the sarcoma? The Lioy sarcoma, the fibro sarcoma sala ever has a shaggy motor. So when we see shaggy borders, it narrows it way down, we still have a problem. It could be an organizing, infarct, organizing inflammation. It could be a bronchogenic carcinoma beginning to invade around the surrounding lung. We still have a problem but it's narrowed down considerably. When we get sharp borders like this, we open the whole list. Again, this could be any one of the 10 members on the list except his position would be a little discouraging for in, in, in pulmonary or inter lowbar fiser mesothelioma that should not bother us because it's in the wrong position. Yeah, here is the margin of a well differentiated squamous cell carcinoma. Now, that's what that was. This is a well differentiated squamous cell carcinoma. Quite different from the, from the two I showed you before. And the reason for it is that it's a well differentiated one. As we can see by the cellular quality here, looks like the skin here even has carrot, but the border usually doesn't invade when it's well differentiated, grows slowly and keeps a sharp interface, the lung. However, if you get a pointy differentiated one like this one, then there's invasion at the border. And when we get that kind of interaction between the tumor and the surrounding lung, we start to get the shaggy irregular border. Now, here is a nicely Sharpe nicely sharp border, a little bit lobulated in a lesion, which could easily have been that first pseudo tumor I showed you same thing. But this one is an adnoc carcinoma of lung primary. And the reason it looks so sharp is it's very well differentiated and grows slowly. This one has lots of mucus in it, which is part of its differentiation. And because it grows slowly, it doesn't cause a lot of invasions surrounding lung. This is a growing about the same speed as a bronchial Anoma might grow a carcinoid that too would look like just like this because it grows slowly. When we see this in the flesh, we see a nicely sharp, sharply defined border. We see some lobulation, a solid tumor that does not invest the lung but simply grows slowly and crowds the lung aside and that's why it looks sharp. However, there are some carcinoma of the lung which instead of growing as a solid mass will grow along the scaffolding of the lung right from the beginning like bronchial cell carcinoma. This one has not done that. This adenocarcinoma has been a slow solid growth. This is a space occupying mass that pushes lung aside as it grows. It doesn't invest the lung. We call this growth hil ic when it's solid and expands as a solid mass and simply push his lung aside. We call it, on the other hand, if we have a mass, a, a tumor of the lung, which instead of growing as a solid mass tends to grow along the Elvira walls, the septa, then we call that lipi lep ID IC. These are two Greek words, the one means the solid mass growing concentrically like layers, pushing along the side. The second one, the means fish scale. And you'll see why in a minute, we use that word fish scale. And it means that the tumor cells grow along like scales, one after another along the walls of the lung and they never look solid as you'll see in a moment, this is a solid tumor and this is a broncho carcinoid, bronchial Anoma. Of course, we don't use the word Anoma anymore. We use the word carcinoid now because we don't think these are adenomas. They used to be thought that they were carcinoid type of adenomas. But we realize now that they're probably neurogenic tumors arising from neuro crust cells just like the ones in the gut do. The carcinoid is the gut and the carcinoid of the lung are apparently the same thing. It's sharply defined, little bit lobulated, of course, more lobulated than most actually, but it is sharply defined and it is ice breaking out of a main bronchus is a rising deep in a bronchial wall. But it's growing out against the lung. It's quite a, quite a large one. They can get quite large because the patient doesn't know he has them, they grow very slowly and he knows he has them early if they grow inside the Broncos, because then they'll block the bronchus and he'll get distal pneumonia or bronchitis or even worse. Whereas when they grow outside the bronchus, he doesn't have peripheral signs and he may not know he has it until he gets very large. So this one has gotten quite large. Now, here's another one looks just like, it looks like a pseudo tumor too, very sharply defined. And this is a lima of lung of the basic tissue of the lung itself, mesenchymal tissue of the lung itself. The omma growing slowly sharply defined could be taken for any of those things. This one is a fibrosarcoma of lung look how sharply defined it is. Also, it may have been way out in the periphery or it can look like it's per, per, depending on where it occurs. Of course, it's occurring in lung, not in bronchi, not in me or bronchi, it's in lung, but it's in lung that makes it look Paraty position, sharply defined, growing slowly yet it's a sarcoma. This is a Hamartoma. You see, it's discrete in size. They don't get too big 3 to 4 centimeters usually. And it has a little calcium in it, which would be more convincing if we had a tomogram. This border is quite sharp. Now, you might have to consider this against pseudotumor but you need to tomography and other views of it to come to grips with it. Here is a, a rather large mass for a fungus infection in a solitary one which makes it of course, very hard to deal with. If we had a scattered few of them, it would cut our possibilities way down against that list that we saw. But this one is a toma caused by cryptococcus fungus infection. This is a cyst. You're in the right part of the world. You must give it consideration. It can be large or small naturally. They look solid. Most of them. If they collapse and start to collapse, we then get some air dissecting between the cyst and the surrounding reactive lung. When that happens, we get the crescent sign, then we have no problem. But this is more notorious than it is frequent. Most heated cysts looks solid. But if you see that you have no problem, you don't even have a differential diagnostic problem anymore because the other masses are not going to do that. See what happens is the cyst itself, the heated cyst begins to shrink when it communicates with the bronchus and its contents start emptying out and it falls away from the surrounding lung and then the air gets in there. Eventually it may fall completely collapse and then you'll get the water Lily sign because or the sign because then the whole thing floats in liquid and looks like a lily floating in the water, of course, is not, is not a lily. But that's the expression that's used in South America for these is a bunch of grass and stuff that floats down these rivers. Now, there's one that again is solid and sharp, but it has a long ovoid shape. So you might say, hey, is that a pseudo tumor? Because it looks like a potato, doesn't, it isn't round. Of course, a lot of masses when they get large, tend to get less round but not so much off the track here. So for example, that would be a little difficult to call a primary bronchogenic carcinoma. Although possible, it might be difficult to think of Anoma. They're usually rounder than that. It would be difficult to think of hama or, or any of those things. It might be a measle Thoma, particularly if it's in the fissure, which it is lined up in the fissure pointing down here. And this is a mesothelioma of the interlobar fisher. Sometimes the chest wall may plague us. They push in against from the chest wall in the lung field. Unless you get lateral views and other views, sometimes it may be difficult. This is upside down, I'm sorry, but this is it from the posterior wall. So it's coming from the wall and it's, it's a primary chondrosarcoma, the chest wall simulating a lung lesion because it pushes in. Now, this one is a tiny little nodule, tiny. It's not really tiny, but it's small. It's a coin lesion size. And it's interesting because it's rather sharply defined. It's covered by vessels which may take away some of the sharpness, but it's rather sharpy to find and it has a tail on it. And we're very curious about that tale. We wonder what that was. So we got out the lung specimen which looked like this got the sharp coin leash. And then in here, the tail existed here's the plural surface and we asked our pathologist to study this on a slide to see what he can make of it. So we cut through this thing and here is the lesion itself, the coin lesion which turns out to be an adnoc carcinoma of lung well defined. You can see the gland like structures being organized here and having a sharp interface, a surrounding lung. This is all air containing lung here. And so it's a nice sharp interface. But interestingly enough, there's a bronchiole here which is plugged with tumor cells that little bronchial. Let's stick out a little closer. Here's the bronchial, here's the surrounding good lung air containing lung. And here is that little bronchial. You can see the respired TPI right there. And there are the tumor cells completely blocking this bronchial which caused the little tail that we saw. In other words, this tail that we see here is due to a blocked little bronchus and the tail is the lung distal to the bronchus that's collapsed. So this coin lesion with its tail indicates something that can involve lung. And this is the beginning of the shaggy margin we saw in some of the bigger ones. Usually the primary carcinomas in the lung fields are rather sharp. When they're small. 1 to 2 centimeters, they look like coin lesions. But once they get to three centimeters or more, they begin to involve the surrounding lung in various ways. And we get a speculated irregular border. So this border is the beginning. You see, we've caught it in the act. We have come along with our investigation at just the time when the slow growing little Anoma is beginning to invest this running lung. The first thing it did was block a bronchus. And when that collapses and when it fibros fibrosis down, it'll be like a sliver right now. It looks like it has a little volume to it because it's still full of uh, pneumonia. What kind of pneumonia? Endogenous lipid pneumonia, as we'll see, here's the urged bronchus and there is our endogenous lipid pneumonia. These tiny little chicken marks chicken wire marks are the walls. You can just barely see them. But this whole thing, this whole wedge here of lung is pneumonia and it's endogenous lipid pneumonia, endogenous cholesterol pneumonia, which is the kind of pneumonia we get in obstructions, particularly small airway obstruction. Here's the tumor sitting up here. So that's what we saw on the radio graph as the tail. Now, when they get larger, as I mentioned, when they get above 3 to 4 centimeters, then we begin to see the investment of surrounding lung in various ways. We get the shaggy border. This is another Adal carcinoma, but this one is bigger. It's been there longer. It's perhaps a little more aggressive, the more undifferentiated they are, the more they apt to cause the shaggy border. And so what happens is some of the cells grow out even though it's a hill growth to begin with. Even though it's a solid heli growth to begin with. If it's fully differentiated, the cells begin to march, especially if they're fully differentiated. If they're very well differentiated, may stay nice and sharp until it gets up to six centimeters and you saw one of those. But if it's fully differentiated, it starts marching out, it gets into a septum or it may get into lymphatics or it may stop up a bronchus and cause collapse. Like we saw all these things can contribute to this funny shaggy border. It may also pull, pull in on the plea when it sys these tumors cause a lot of fibrosis because of course, there's inflammatory action around them which goes on to fibrosis. And some tumors are even inherently fibrogenic or desmoplastic as we call them. So they may pull in on the plea and let us take a look at this one. Look how it sucks in on that plea. The plea is dipping down toward the tumor like a like it's caught up in a vortex. And we can see the little speculations right there at the edge of the tumor as it gets sucked in and the plural puckers inwards contributing to that peculiar speculation that stel a burst around the tumor that has been called a Corona rata corona. This is the tumor. We see the normal epithelium right here. Respirator epithelium. This is the lumen up here giving way to large big folds of tumor growth looking like glands but not, not too well differentiated because it goes down into the, into the basement membrane gets down in here and invades the stroma. Now, here is a case that shows us what lepi growth is lepi growth. The Greek word for fish scale Leis, Leis and this little area right here is the beginning of the growth of a bronchial Elvira cell carcinoma never recognized at all. At the time this picture was taken, they didn't see this. This was seen in retrospect, this is 1947. Let's see what he looked like when they finally did see this peculiarity right here. Now, you notice it's not like a coin lesion, you'll notice it's kind of soft, like an infiltration, it's kind of heterogeneous kind of a mixture of density and lucency. Later on, they saw it when did they see it? In 1953 years later, they saw this become more dense. It's still irregular. It never has been a coin lesion never will be. It's not right from the start. It's lipi, it's bronchial el cell carcinoma, which is an adenocarcinoma. But the propensity of this particular tumor, it's peculiarity is to grow along the, using the lung as a scaffold the way it grows. That's its nature. And so it's been doing that and it's been filling out lung units, lung spaces and covering and it's been encrusting the septa and walls the lung by its growth of cells, he wouldn't do anything about it. So finally, in 1951 they pointed out that this was enlarging, they told him to consider surgery and he wouldn't do it. Notice that he has a big line in here and another line here in a shaggy border. Those lines can be seen because they are thickened septa surrounded by air. You still get air in, inside, in, in and out of this particular kind of mask. Because the air ways are open, they're crusted with cells, but they're open so you can get air inside this mass. And that's why you can see a thicken septum because it's got air around it. By the same token, look at the speculation that occurs at the borders the same way because this is very rapidly invading the surrounding lung. It invaded the wall and the patient had so much pain he finally gave up, came in and he was operated on and they had to take three or four ribs by this time. And this is 1954 7 years from the first indication, seven years. It's a slowly growing neoplasm. Now, here's another bronchial Elvira cell Carno and not only do we see the thick concept, but we also see beautiful air bronchogram effects right inside the mass. They are the brock gram effects and they are the and the speculation this is bronchial Elvi cell Anoma again. And this can hardly be confused with a hill growth like the others that we saw, this can hardly be confused with pseudotumor or bronchial noma or hamartoma, any of those growths because it's moving along the scaffold along and it looks more like an infiltration. And the reason we can see a bronchogram effects is that don't forget that Alvero cell carcinoma is an adenocarcinoma and can produce mucus. And when it produces mucus, it floods the spaces with mucus. And then we see the open airways against the mucus pneumonia. That's why we're seeing those agra effects. So when you see a rounded mass in the lung field like this, it's very easy to come to grips with. It is hardly going to be one of the candidates of that gamut. That's hill, it's lipi. So we see both the septa because there's air around them in this area of the tumor. And here there's lots of mucus. So we see the air bro gram effects. And if we were cut through this mass, we can see the huge septa all thickened the, but we also see the Elvira walls intact. But of course, they're thick because they're covered with tumor cells which we need to see at higher power. So, here's a lobule of lung, there's another lobule, there's another lobule. So that's the mass that we saw radiographically. But yet we can see that it's not really mass. It's a hunk of lung covered by a lot of cells along its walls and including mucus or, and, or air in the air spaces. No, when we come up closer, we can see that the septa are thickened and also fibrous. Because of course, when we continually coat here, the cell here, the tumor cells coating the Alvear walls. When we coat the walls with tumor cells, we tend to cause hypoxia and other changes which lead to fibrosis and inflammatory reactions. And we can see if we get into an area, we can see how this goes. Now, these are uninvolved el Vira walls yet. But over here, the tumor cells have grown along the elevator walls. They keep marching and if we go a little closer, we can see them coating the vera walls and they look like fish scales. If you don't think those look like, don't look like fish scales, then you've never been fishing or you've never cleaned a fish put it that way. But those look like fish scale. And that's why we use the word Lepi Greek word for fish scale. And here they are again and they run along and coat these walls and they fill the spaces of the mucus. If they're differentiated enough, if it's well differentiated bronchial Sonoma, it coats the walls with mucus and then we see air block gram effects and we don't see anything but a solid continuous water density. But if on the other hand, we have an undifferentiated or poorly differentiated velar cell adnoc carcinoma, it may not produce mucus, which is already a sign of differentiation. That is, it's a sign of differentiation. If it does produce mucus and if it doesn't produce the mucus, then we are going to get more of the peculiar lines, effect, streaks of linear density because we're looking at the concept within, surrounded by air. Sometimes we'll see both as we saw in our last example, look how the cells up high, look how they grow along the walls. It's almost as if these cells are using the capillary bed itself for their nourishment. It's a little trick they get quick nourishment from the wall. Now, if they dump mucus in the spaces, we get this effect, we may even get bleeding from the wall from the capillary wall into the space and then the patient clinically has frothy bloody sputum, pinkish frothy sputum. And we have shown you now throughout this whole discussion, the solid mass and the mass that's caused by the pit growth. We have to get this concept in our minds because an organizing infarct, for example, may simulate this lipid growth even though it's not a growth because it fills the lung. And then later on some of the products, some of the in the blood are resorbed from the spaces, leaving thickened walls in an organizing infarct. So an organizing infarct may have this aspect too. And organizing pneumonia may have this aspect because in organizing pneumonia, we may clear the spaces of the pneumonia products and yet have still have the lingering thickening of the SEPT on the walls. And the SEPT are large enough, they'll come to our notice radiographically and we may get some of the same appearances in organizing infarctions and organizing pneumonias that we get in lipid tumor growth. So that's why el carcinoma is often said to look like pneumonia. It is pneumonia. It's a mucous pneumonia quite often. On the other hand, if tumors grow solidly, then they look like dense, homogeneously dense even balls, sometimes they're so solid round. And this can get confused with a whole gamut of lesions that grow that way, like the broncho, the carcinoid or like the slowly growing things like the well differentiated carcinomas that grow so slowly, they don't invest the surrounding lung or perhaps like Hamartoma or maybe even metastasis, which grows solidly. There are a few metastases that can get loose in the lung fields, but they don't usually cover the ovular walls. They usually go in the lymphatics and then we have lymphangitis, Carma tosa, but that's quite different. So, I think it behooves us to think about solid masses, the lungs in two ways. Are they he or are they therefore, what are they? And secondly, are they really neoplasms or are they a number of other things that can occur in benign lung? A medical media production from WR A MC TV.