DISEASES OF DISEASES OF RESPIRATORY RESPIRATORY SYSTEM (3)SYSTEM (3)

The Department of Pathology The Department of Pathology Zili Lv Zili Lv 吕自力吕自力1590781763415907817634

E-mail:lvzili@yahoo.com.cnE-mail:lvzili@yahoo.com.cn

ContentsContents

•Chronic diffuse interstitial lung diseases 慢性肺间质性病

•Nasopharyngeal carcinoma 鼻咽癌•Carcinoma of the lung 肺癌

Chronic Interstitial Lung Chronic Interstitial Lung DiseasesDiseases

• Clinical history lasting months or years• Slowly increasing respiratory

insufficiency, dyspnea, cough and finger-clubbing

• Interstitial fibrosis, infiltration with lymphocytes and macrophages.

• Pneumoconioses 肺尘埃沉着病• Sarcoidosis 肺结节病

PneumoconiosesPneumoconioses• Lung diseases caused by inhaled

dusts• Dusts may be inorganic or organic• Reaction may be inert, fibrous,

allergic or neoplastic• Co-existing disease may aggravate

the reaction• Silicosis 硅肺• Asbestosis 石棉肺

SilicosisSilicosis 硅沉着病硅沉着病 p200p200•Reason ： caused by inhalation of

crystalline silicon dioxide (silica) 二氧化硅 dust particles.

•Size: 1-5um in diameter•Basic pathological features ： Progressive fibrosis + Numerous

silicotic nodules 硅结节

A. PathogenesisA. Pathogenesis -- -- hypothesishypothesis

• > 5um, bronchial mucus layer, wafted upward by ciliary action to be expelled.

• < 1um, airborne and are exhaled

• 1-5 um, toxic to macrophages

Pathogenesis of Pathogenesis of PneumoconiosisPneumoconiosis

Proteolytic enzymes

Fibroblast-stimulating factor

Fibrosis

Inflammatory mediator

Inflammatory cells infiltrate

Fibrosis

•1. Silicotic nodule （硅结节）•2. Diffuse pulmonary fibrosis （肺弥漫纤维化）

B. Pathology*

• 2 – 5 mm• Gray-black• Hard • Brittle• Hilum and

upper lobes• Fibrosis• Irregular

emphysema

Grossly

Microscopically 1 、 Silicotic nodules 硅结节① Macrophages

② Fibroblast

③ Collagen

2 、 Diffuse fibrosis

Microscopically

Restrictive ventilatory defect

C. Clinical FeaturesC. Clinical Features

•Asymptomatic

•Slowly progressive dyspnea, pulmonary hypertension, cor pulmonale.

D. ComplicationsD. Complications •Lung Tuberculosis 肺结核病•Chronic cor pulmonale • Infection of lungs•Lung emphysema•Lung carcinoma

AsbestosisAsbestosis 肺石棉沉着症肺石棉沉着症p201p201

• Fire-resistant

• Be used for insulation and the manufacture of brake linings

A. PathologyA. Pathology

1. Fibrosis*1. Fibrosis*

• Thickening of the parietal pleura • A plaque-like deposition of

hyalinized collagen• Lateral and diaphragmatic

Pleural FibrosisPleural Fibrosis

Pathology Pathology 2. Asbestos bodies*2. Asbestos bodies*

石棉小体石棉小体

•Coated in acid mucopolysaccharide 粘多糖 and encrusted with haemosiderin

•Brown and beaded

Asbestos bodies 石棉小体

• Iron-containing glycoprotein

• Diagnostic changes

Asbestosis

B. Clinical FeaturesB. Clinical Features

• Chronic dry cough• Progressive dyspnoea• Finger-clubbing• Asbestos bodies in the sputum• Rarely in respiratory failure• At a risk from malignant tumor:

bronchogenic carcinoma, malignant mesothelioma

Silicosis AsbestosisSilicosis AsbestosisSilica Asbestos fiber

Coal-mining Shipyard worker

Silicotic nodules Asbestos bodies

Interstitial diffuse fibrosis

Upper, hilum Lower lobes

Hilar lymph nodule Pleural fibrosis

Tuberculosis Malignant tumor

Respiratory System Respiratory System Malignant TumorsMalignant Tumors

• Nasopharyngeal Nasopharyngeal carcinoamacarcinoama

鼻咽癌鼻咽癌• Bronchogenic carcinomaBronchogenic carcinoma

支气管肺癌支气管肺癌

NASOPHARYNGEANASOPHARYNGEACARCINOMA, NPCCARCINOMA, NPC

鼻咽癌鼻咽癌p205p205

Nasopharyngeal carcinomaNasopharyngeal carcinoma

•Localized in nasopharynx•Arising from nasopharynx

epithelium• It shows a distinct racial and

geographical distribution.• It is more common in

Southeast Asia, North Africans than others

Incidences of NPCIncidences of NPC

•Hong Kong, Guangdong, Guangxi

•40- 60 years old•Male:female = 2-3 : 1

A. EtiologyA. Etiology• Infection with Epstein-Barr virus

(EBV)• Genetic susceptibility• Environmental factors• Smoking • Carcinogen contents are rich in

food

LocationLocation 1. Nasopharyngeal

roof *

( 鼻咽顶部 )

2. Lateral wall

( 外侧壁 )

3. Pharyngeal recess

（咽隐窝）

B. Pathology*

Grossly: nodular, ulcerative, infiltrative,

clauliflower

HistopathologyHistopathology

1. Nonkeratinizing carcinoma (1) undifferentiated*:common (2) differentiated

2. Keratinizing squamous cell carcinomaWell, moderately, poorly differentiated

3. Basaloid squamous cell carcinoma

Vesicular nuclei cell Vesicular nuclei cell carcinomacarcinoma

Direct extensionDirect extension

1. upwards: skull

2. forwards: nasal, orbit

3. downwards: oraopharynx, tonsil

4. backwards: vertebra

5. lateral: middle

ear

C. Spread

Metastasis* Metastasis* • Lymphatic*: Upper cervix lymph node 颈上深淋巴结

enlargement painless.

• Haematogenous: bone, lung, liver, brain, etc.

Lymphatic metastasisLymphatic metastasis

D. Clinical FeaturesD. Clinical Features•Early stage: asymptomatic 无症状•Nasal symptoms: blood stained

post-nasal drip 抽吸性血痰•Extensive spread: headache,

otitis, dizzy, tinnitus 耳鸣•Lymphatic ： painless enlargement •Haematogenous ： bone fracture

Lung Carcinoma p206Lung Carcinoma p206Primary malignant tumor

1.1 million deaths annually worldwide

Most frequent and one of the most deadly cancer

A. EtiologyA. Etiology • 1. Smoking*: 40/day, 20-fold

A. EtiologyA. Etiology • 2. Air pollution: urban > country • 3. Occupational hazards:

asbestos, heavy metals( uranium, nickel, chromate, gold)

• 4. Radiation• 5. Molecular genetics: p53, c-

myc, K-ras

B. Pathology*B. Pathology*

Grossly• Central or hilar tumors• Peripheral tumors• Diffuse type

Central typeCentral type

60-70% Hila typeHila type

Peripheral tumors•30%, mainly

adenocarcinomas, arise in peripheral airways or alveoli

Peripheral typePeripheral type

30-40%30-40%

Diffuse type, rarelyDiffuse type, rarely

HistologyHistology • 1. Small cell carcinoma (20%)• 2. Non-small cell carcinoma (80%)• (1) Squamous cell carcinoma• (2) Adenocarcinoma• (3) Large cell carcinoma

Small cell lung carcinoma

Round to polygonal cells with scant cytoplasm. Note mitotic figure in center

Squamous cell carcinoma*Squamous cell carcinoma*

• The commonest type• The most closely associated with the

cigarette smoking.• Most of them are central type.

A. goblet-cell hyperplasia

B. basal cell (or reserve

cell) hyperplasia C. squamous metaplasia

Bronchogenioc carcinoma

The precursor lesions (the earliest "mild“ changes) of squamous cell carcinomas

Bronchogenioc carcinoma

D. squamous dysplasia

E. Carcinoma-in-situ

F. invasive squamous carcinoma

Adenocarcinoma

• Usually peripherally located• Derived from glandular cells• Having the weakest association

with a previous history of smoking

• Tend to metastasize widely at an early stage by blood spread

Bronchioloalveolar carcinoma

Large cell carcinomaLarge cell carcinoma

•< 2cm in diameter•Confined to bronchial wall or infiltrate to the wall and surrounding tissues

•No lymph node metastasis•Carcinoma in situ in bronchial mucosa

C. Early lung cancer*C. Early lung cancer*

• Intraluminal type （管内型）• Peribronchial type （管周型）• Infiltrative type （管壁浸润型）

D. Occult lung cancerD. Occult lung cancer隐性肺癌隐性肺癌 **

• Both clinical and X-ray are negative

• Cytology of sputum smears shows cancer cells

• Biopsy and surgical materials are diagnosed as cancer in situ or early infiltrating carcinoma

• Without lymph node metastasis

E. Spread of lung carcinoam1. Local: central tumors invade the surrounding lung.

Direct extension into pleura, pericardium, superior vena cava

2. Lymphatic spread: carcinomas spread to the peri-bronchial and hilar lymph nodes ----> supraclavicular node (Virchow node).

3. Seeding of cancers: tumor cells may seed within the pleural cavity, causing a malignant pleural effusion.

4. Haematogenous spread: to the brain, bone, liver, and adrenal glands.

F. Clinical features•Silent, no early symptoms;

•The presenting symptoms of lung cancer are

Bronchial obstruction: cough, haemoptysis, chest pain

Clinical features

Local invasion symptoms: hoarseness

Pancoast’s syndrome: Horner syndrome

Metastatic : brain (mental changes), liver (hepatomegaly), or bones (pain).

Paraneoplastic syndrome

Paraneoplastic syndrome, 副肿瘤综合征

Cushing syndrome

G. Methods for lung G. Methods for lung cancer diagnosiscancer diagnosis

•Sputum cytology, pleural effusion cytology•Fiberbronchoscope examination and biopsy•X-ray examination and CT•Fine-needle aspiration biopsy

• Pneumonia

• Chronic Obstructive Passive Diseases

• Silicosis

• NPC and Lung cancer

Summary Summary

Air space

pneumonia

Lobar pneumonia

Lobular pneumonia

Interstitial

pneumonia

Viral pneumonia

Mycoplasma pneumonia

COPD & SilicosisCOPD & SilicosisCOPD: Chronic bronchitis Asthma Emphysema Bronchiectasis

Silicosis

Asbestosis

Pulmonary hypertension

Chronic cor pulmonale

NPC & Lung carcinomaNPC & Lung carcinoma NPC• EBV infection• Nasopharygeal

roof• Non-keratinizing

squamous carcinoma

• Lymphatic route metastasis

Lung carcinoma• Smoking • Hilar, periphera,

diffuse type• Squamous

carcinoma and small cell carcinoma

• Haematogenous spread

Case abstract 1Case abstract 1•Male, 70, he had suffered from

cough and sputum for 15 years, rapid and short breath after physical labor for 5 years, lower limbs edema repeatedly for 1 year. These symptoms aggravated 4 days ago with fever and purulent sputum.

•Blood WBC: 10.2 X 109/L•X-ray: The lungs are enlarged,

Several scattered patchy shadows evidently in bilateral lower lobes.

•Biopsy: Thinning and destruction of alveolar walls, large airspaces formation. Terminal bronchiole and alveoli are filled with neutrophil.

Chronic bronchitisChronic bronchitis

Emphysema Emphysema

Chronic Cor pulmonaleChronic Cor pulmonale

Lobular pneumoniaLobular pneumonia

COMPLICATED WITH

• 65, woman, cough with purulent sputum after catching cold 15 years ago.

• She developed cough and expectoration of white spumy sputum every winter and spring.

• Since 3 years ago, she felt breath shortness and palpitation after physical labor.

•Pitting edema occurred repeatedly on her lower limbs for 2 years.

•Two months ago after catching cold, she developed fever, cough with purulent sputum, palpitation, breath shortness, and abdominal distension, and could not lie down.

Physical examination: • T: 37.6℃, HR:102 times/min, R: 30

times/min. • Chronic sickness appearance, up-

straight sit breathing, sleepiness, dark purple lip and skin, cervix venous engorgement

Chest: Barrel-shape chest, hyper-resonance to percussion, scattered dry and moist rales.

Abdomen: Abdominal bulge, a large amount of ascites, the liver is hard with the rim under the rib 7.8 cm, lower limbs show pitting edema.

QuestionsQuestions

•1. what is the pathological diagnosis of the patient?

•2. how to explain the process of the development of the diseases about the patient.

Pathological diagnosisPathological diagnosis• Chronic bronchitis• Emphysema • Chronic cor pulmonale complicated with: (1) right heart failure---- liver

congestion, lower limbs edema, ascites

(2) pulmonary encephalopathy

The relationshipThe relationship

•Chronic bronchitis---- emphysema----

chronic cor pulmonale---- right heart failure and pulmonary encephalopathy.