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Pathology of lung, pleura and upper airways PowerPoint Presentation

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Slide 1-

Pathology of lung, pleura and upper airways Assoc. Professor Jan Laco, MD, PhD
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Summary 1. Atelectasis 2. Obstructive lung diseases 3. Restrictive lung diseases 4. Vascular lung diseases 5. Pulmonary infections 6. Lung tumors 7. Pleural lesions 8. Lesions of upper RT
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Atelectasis = inadequate expansion of airspaces (collapse) ventilation - perfusion imbalance – hypoxia 1. resorption atelectasis obstruction of airway – air resoption mucous / mucopurulent plug - bronchial asthma foreign body aspiration bronchogenic carcinoma, enlarged LN (TBC,…) 2. compression atelectasis pleural effusions, pneumothorax, ascites
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Summary 1. Atelectasis 2. Obstructive lung diseases 3. Restrictive lung diseases 4. Vascular lung diseases 5. Pulmonary infections 6. Lung tumors 7. Pleural lesions 8. Lesions of upper RT
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Obstructive lung diseases  resistance due to parcial / complete obstruction at any level TLC + FVC normal x  expiratory flow rate (FEV1) 1. bronchial asthma 2. chronic obstructive pulmonary disease 2a. emphysema 2b. chronic bronchitis / bronchiolitis 3. bronchiectasis 4. cystic fibrosis
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Bronchial asthma = episodic reversible bronchospasm basis: tracheobronchial hyperreactivity  chronic inflammation of bronchi incidence: 7-10% children + 5% adults early onset dyspnea, cough, wheezing ~ hours expiratory difficulty  lung hyperinflation status asthmaticus ~ days  fatal
Slide 7-

Bronchial asthma 1. extrinsic asthma type I hypersensitivity reaction to extrinsic antigens most common, familial predisposition diet proteins, herbal pollen, animal hair, mites 2. intrinsic asthma drugs, viral infection
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Bronchial asthma grossly: bronchial occlusion by thick mucus plug microscopically: mucus Curshmann spirals, eosinophils, Charcot-Leyden crystals bronchial wall edema + hyperemia inflammation – eosinophils, basophils, macrophages, lymphocytes (Th2 subset) hypertrophy of submucosal mucous glands thickened basement membrane hypertrophy / hyperplasia of SMCs
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Emphysema = permanent enlargement of airspaces distal to terminal bronchioles due to destruction of their walls smoking pathogenesis oxidant-antioxidant imbalance protease-antiprotease imbalance α1-antitrypsin deficiency dyspnea + prolonged expiration barrel-chested patients
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Emphysema 1. centriacinar emphysema only respiratory bronchioles affected upper lobes smoking 2. panacinar emphysema respiratory bronchioles + alveoli affected lower lobes α1-antitrypsin deficiency G: pale voluminous areas Mi: thining / destruction of alveolar walls  large airspaces
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Emphysema complications respiratory failure pulmonary hypertension  right-sided heart failure related conditions compensatory emphysema senile emphysema / hyperinflation obstructive emphysema mediastinal emphysema
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Chronic bronchitis = persistent productive cough for 3 consecutive months in 2 consecutive years smoking, air pollutants several forms: simple CB mucopurulent CB asthmatic CB obstructive CB
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Chronic bronchitis basis: hypersecretion / hypertrophy of bronchial mucous glands + inflammation grossly mucosal hyperemia + edema mucous / mucopurulent secretion in lumen microscopy enlargement of mucus-secreting glands (Reid index) squamous metaplasia mononuclear inflammation bronchioles goblet cells metaplasia + wall fibrosis
Slide 14-

Chronic bronchitis complications pulmonary hypertension respiratory failure recurrent infections ? bronchogenic carcinoma
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Bronchiectasis = permanent bronchial / bronchiolar dilation due to wall components destruction persistent cough + mucopurulent / fetid sputum 1. bronchial obstruction tumors, foreign bodies, mucous plugs 2. congenital conditions cystic fibrosis, Kartagener syndrome 3. supurative / necrotizing pneumonias Staphylococcus aureus Klebsiella spp.
Slide 16-

Bronchiectasis obstruction + chronic infection  wall damage  wall weakening  wall dilation grossly - dilated distal bronchi / bronchioles + pus microscopically surface ulcerations + mixed inflammation peribronchial fibrosis complications: lung abscess obstructive ventilatory defects metastatic brain abscess AA amyloidosis
Slide 17-

Summary 1. Atelectasis 2. Obstructive lung diseases 3. Restrictive lung diseases 4. Vascular lung diseases 5. Pulmonary infections 6. Lung tumors 7. Pleural lesions 8. Lesions of upper RT
Slide 18-

Restrictive lung diseases reduced expansion of lung parenchyma   FVC x FEV1 normal 1. extra-pulmonary disorders severe obesity, kyphoscoliosis, neuromuscular diseases 2. interstitial lung disorders acute acute respiratory distress sydrome (ARDS) chronic pneumoconioses sarcoidosis idiopathic pulmonary fibrosis hypersensitivity pneumonitis
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Acute respiratory distress syndrome (ARDS) = acute dyspnea onset + hypoxemia + RTG bilateral infiltrates + NO left-sided HF = diffuse alveolar damage (DAD) direct lung injury pneumonia - viral aspiration pulmonary contusion, inhalation injury indirect lung injury sepsis, shock – „shock lung“ uremia drug overdose (cytostatics)
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Acute respiratory distress syndrome (ARDS) epithelium + endothelium injury  alveolar capillary membrane damage   vascular permeability  alveolar flooding + surfactant abnormalities grossly dark red + firm + airless + heavy lung ~ liver microscopically - acute phase capillary congestion + alveolar cells necrosis interstitial + alveolar edema + hemorrhage hyaline membranes (edema fluid + cell debries)
Slide 21-

Acute respiratory distress syndrome (ARDS) microscopically - proliferative phase pneumocytes II proliferation + hyaline membranes phagocytosis (macrophages) P II differentiate into pneumocytes I interstitial fibroblasts proliferation  interstitial fibrosis = honeycomb lung
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Acute respiratory distress syndrome (ARDS) clinical course !!! mortality 30-40% !!! normal respiratory function within 6-12 months diffuse interstitial fibrosis
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Sudden Infant Death Syndrome „sudden death of infant < 1 year + complete autopsy does not reveal other cause of death“ 1 to 700-1,000 liveborn age: 2 - 4 months, boys (2 : 1) crib death x night ~ day winter (infection – trigger ???) mother´s smoking autopsy: big thymus + serosal petechiae ??? brain stem ganglia abnomalities ??? heart conductive system abnormalities
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Sarcoidosis = multisystemic disease with noncaseating granulomas in many tissues and organs etiology – unknown (??? Th lymphocytes) younger adults, non-smokers familial clustering, Scandinavia hypercalcemia + hypercalciuria microscopy (dg. of exclusion) noncaseating granulomas + specific granulation tissue epithelioid + multinucleated cells Schaumann bodies + asteroid bodies
Slide 25-

Sarcoidosis - distribution hilar LN (75-90%) lungs (90%) around bronchioles + venules + subpleural skin (25%) erythema nodosum (legs) lupus pernio (nose, cheeks, lips) eye + lacrimal glands (20-50%) iridocyclitis, retinitis, optic nerve involvement salivary glands (10%) xerostomia spleen + liver + bone marrow
Slide 26-

Sarcoidosis – clinical course asymptomatic respiratory symptoms dyspnea, cough, … constitutional signs fever, fatique, weight loss… uveoparotid involvement = Heerfordt syndrome prognosis – unpredictable 70% - complete recovery 20% - lung dysfunction + visual impairment 10% progressive pulmonary fibrosis + cor pulmonale
Slide 27-

Summary 1. Atelectasis 2. Obstructive lung diseases 3. Restrictive lung diseases 4. Vascular lung diseases 5. Pulmonary infections 6. Lung tumors 7. Pleural lesions 8. Lesions of upper RT
Slide 28-

Pulmonary hypertension primary hypertension plexiform pulmonary arteriopathy pulmonary venoocclusive disease secondary hypertension cardiac disease – L-to-R shunts, mitral stenosis lung diseases chronic obstructive and restrictive diseases recurrent thrombembolism
Slide 29-

Pulmonary hypertension - morphology 1. main elastic arteries atheromas ~ ATH 2. medium-sized muscular aa. myointimal cells proliferation  lumen narrowing 3. arterioles medial hypertrophy / thickening plexiform lesions, fibrinoid necroses
Slide 30-

Summary 1. Atelectasis 2. Obstructive lung diseases 3. Restrictive lung diseases 4. Vascular lung diseases 5. Pulmonary infections 6. Lung tumors 7. Pleural lesions 8. Lesions of upper RT
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Pneumonias = infectious inflammation of lung 1. comm.- acq. acute pneumonia (bacteria) 2. atypical pneumonia (viruses, Mycoplasma, Chlamydia) 3. nosocomial pneumonia (gram-negative rods) 4. aspiration pneumonia (anaerobic oral flora) 5. chronic pneumonia (TBC) 6. necrotizing pneumonia / lung abscess anaerobic bacteria, S. aureus, K. pneumoniae 7. pneumonia in immunocompromised host CMV, P. carinii, atypical Mycobacteria, fungi
Slide 32-

Bronchopneumonia Streptococci, Staphylococci, H. influenzae from lower airways  alveoli grossly patchy inflammatory consolidation bilateral basal localization 3-4 cm, red to yellow patches microscopically suppurative inflammation in bronchi + bronchioles + alveoli
Slide 33-

Lobar pneumonia Streptococcus pneumoniae 1, 2, 3 rapid spread within alveoli 1. congestion - heavy, red, boggy alveolar edema + neutrophils 2. red hepatization - liver-like consistency alveoli fulfilled by neutrophils, RBCs, fibrin fibrinous / fibrinopurulent pleuritis 3. gray hepatization - dry, firm RBCs lysis + fibrin persistance 4. resolution
Slide 34-

Pneumonia - complications 1. lung abscess acute x chronic bronchogenic – S. aureus, K. pneumoniae x hematogenic (peripheral pyemia) bronchopleural fistulas – pneumothorax + empyema brain abscess + AA amyloidosis 2. empyema 3. lung fibrosis + pleural adhesions 4. bacteremia meningitis, arthritis, infective endocarditis
Slide 35-

Atypical pneumonia viruses (influenza, adenovirus, RSV, CMV) Chlamydiae, Rickettsiae grossly patchy x segmental x lobular, red-blue, congested areas microscopically alveolar septa – edema + mononuclear infiltrate prognosis complete recovery bacterial superinfection ARDS
Slide 36-

Tuberculosis Mycobacterium tuberculosis Ziehl-Neelsen – acid-fast red rod inhalation  lungs T cells mediated immunity organism resistance tissue hypersensitivity – caseous necrosis caseating granulomas central caseous necrosis epithelioid cells + multinucleated giant cells (Langhans) T-lymphocytic rim
Slide 37-

Primary TBC previously unexposed (unsensitized) person Ghon focus lung middle line + subpleural location 1-1.5 cm, gray-white lesion Ghon complex: + TBC hilar LNitis + lympho / hematogenous dissemination under immune control
Slide 38-

Primary TBC - further course 1. healed lesions – fibrocalcific scar 2. latent lesions (dormant TBC organisms) 3. cervical LNitis („scrophula“) 3. progressive primary TBC miliary („millet“) TBC - 2 mm, yellow-white pulmonary lymphatics – thoracic duct – venous circulation – right heart – pulmonary a. – lungs pleural effusion, TBC empyema systemic pulmonary veins – left heart – systemic circulation liver, BM, spleen, adrenals, menings, kidneys, fall.t., epid.
Slide 39-

Secondary TBC in previously sensitized person 1. exogenous reinfection 2. reactivation pulmonary TBC (from adenobronchial fistula) upper lobes apex cavitation – airways dissemination – progressive pulmonary TBC bronchus erosion - endo-bronchial,-tracheal, laryngeal TBC blood vessel erosion – hemoptysis pulmonary + systemic miliary TBC isolated-organ metastasis (from primary TBC metast.) TBC meningitis, epinephritis, osteomyelitis, salpingitis
Slide 40-

Summary 1. Atelectasis 2. Obstructive lung diseases 3. Restrictive lung diseases 4. Vascular lung diseases 5. Pulmonary infections 6. Lung tumors 7. Pleural lesions 8. Lesions of upper RT
Slide 41-

Lung carcinoma primary x secondary (metastases) 95 % bronchogenic carcinoma bronchial epithelium 5% miscellaneous carcinoid, bronchial glands, mesenchyma benign - hamartomas
Slide 42-

Bronchogenic carcinoma very common, !!! smoking !!! peak incidence 55 – 65 years M : F … 2 : 1 1. non-small cell lung carcinoma (70-75%) surgery squamous cell carcinoma (25-30%) adenocarcinoma (30-35%) large cell carcinoma (10-15%) 2. small cell lung carcinoma (20-25%) chemotherapy +/- actinotherapy 3. combined carcinoma (5-10%)
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Bronchogenic carcinoma advanced stage + metastases – symptoms chronic cough, hoarseness, chest pain Pancoast tumors – upper lobe apex branchial plexus invasion sympathetic plexus invasion – Horner syndrome paraneoplastic syndromes hypercalcemia – PTH-related peptide Cushing syndrome - ACTH SIADH - ADH neuromuscular syndromes – myasthenic syndrome hematologic – NBTE, DIC
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Squamous cell carcinoma central location in major bronchi local spread x later distant metastases bronchial epithelium squamous metaplasia – dysplasia – carcinoma in situ – invasive carcinoma grey-white tumor mass + necroses lumen obstruction – atelectasis + infection Mi: squamous cell carcinoma + keratin pearls
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Adenocarcinoma peripheral location, in lung scars slow growth x early metastases atypical adenomatous hyperplasia Mi: solid x acinar x papillary bronchioloalveolar carcinoma growth along preexisting structures NO destruction
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Small cell carcinoma = poorly differentiated neuroendocrine Ca central location + early metastases Mi: 2x than lymphocytes, scant cytoplasm +  mitotic rate highly aggressive tumor
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Bronchogenic carcinoma local spread lungs, mediastinum pericardium, pleura lymphatic nodes hilar, mediastinal, paratracheal distant metastases liver, brain, adrenals, bone !!! poor prognosis: 5-year survival 14% !!! biologic therapy – TKIs of EGFR and of ALK
Slide 48-

Summary 1. Atelectasis 2. Obstructive lung diseases 3. Restrictive lung diseases 4. Vascular lung diseases 5. Pulmonary infections 6. Lung tumors 7. Pleural lesions 8. Lesions of upper RT
Slide 49-

Pleural effusion 1. hydrothorax – transudate congestive heart failure 2. pleuritis + exudate pulmonary infections + TBC neoplasms (lung, mesothelioma) pulmonary infarction viral pleuritis complications suppurative, fibrinous pleuritis  organization  adhesions + calcification
Slide 50-

Other pleural conditions 3. pneumothorax – air in pleural sac lung disease (emphysema, abscess, carcinoma) thoracic wall injury (rib fracture) complications mediastinum shift + lung compression 4. hemothorax – blood in pleural sac thoracic aorta aneurysm rupture 5. chylothorax – lymph in pleural sac obstruction of lymphatic ducts (mediastinal neoplasms)
Slide 51-

Mesothelioma rare malignant tumor of mesothelial cells asbestos exposure + long latent period grossly lung ensheathed by yellow-white firm / gelatinous mass + pleural obliteration invasion into lung + thoracic wall microscopically epithelial + sarcomatoid + biphasic poor prognosis
Slide 52-

Summary 1. Atelectasis 2. Obstructive lung diseases 3. Restrictive lung diseases 4. Vascular lung diseases 5. Pulmonary infections 6. Lung tumors 7. Pleural lesions 8. Lesions of upper RT
Slide 53-

Acute infections 1. „common cold“ rhinoviruses, coronaviruses, influenza virus self-limiting diseases 2. acute tonsilitis beta-hemolytic Streptococci, adenoviruses peritonsillar abscess post-streptococcal glomerulonephritis acute rheumatic fever 3. herpangina Coxsackievirus A 4. infectious mononucleosis (EBV)
Slide 54-

Acute infections 5. acute epiglottitis !!! young children H. influenzae airway obstruction – tracheotomy x lethal 6. acute laryngitis air irritants, allergic diphtheria – pseudomembranous l. (aspiration) TBC
Slide 55-

Sinonasal tumors 1. squamous cell papilloma benign, HPV 6, 11, recurrence (inverted type) 2. squamous cell carcinoma – HR-HPV (20 %) 3. adenocarcinoma 4. olfactory neuroblastoma 5. malignant lymphomas extranodal NK/T-cell lymphoma, nasal type
Slide 56-

Nasopharyngeal tumors 1. angiofibroma young boys benign x locally destructive + bleeding 2. keratinizing squamous cell carcinoma 3. nonkeratinizing carcinoma (lymphoepithelial carcinoma) EBV, China 4. malignant lymphomas
Slide 57-

Non-neoplastic laryngeal lesions vocal cord nodules heavy smokers, singers, teachers true vocal cords, 0.5 cm
Slide 58-

Benign laryngeal tumors squamous papilloma benign true vocal cords soft excrescence, 1cm children – multiple juvenile laryngeal papillomatosis HPV 6, 11 spontaneous regress
Slide 59-

Malignant laryngeal tumors laryngeal carcinoma (2% of all carcinomas) > 40 years M : F … 7 : 1 smoking + alcohol 95% squamous cell carcinomas dysplasia  carcinoma in situ  invasive Ca grey plaque  ulceration glottic (60-75%) -  prognosis supraglottic (25-40%) -  prognosis subglotic (5%) -  prognosis