DISEASES OF RESPIRATORY SYSTEM (3)

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

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

ContentsContents

• Chronic diffuse interstitial lung diseases

• Nasopharyngeal carcinoma

Carcinoma of the lung

Chronic Interstitial Lung DiseasesChronic Interstitial Lung Diseases

• Clinical history lasting months or years• Slowly increasing respiratory insufficiency,

dyspnea, cough and finger-clubbing• Interstitial fibrosis, infiltration with lymphocytes

and macrophages.• Fibrosing diseases• Granulomatous diseases

PneumoconiosesPneumoconioses 尘肺尘肺• 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• Reason ： silicon dioxide (silica) 二氧

化硅 dust particles.

• Size: 1-5um in diameter

• Basic pathological features ： Progressive fibrosis 进行性纤维化 Numerous silicotic nodules 硅结节

A. PathogenesisA. Pathogenesis -- hypothesis -- hypothesis

• > 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 PneumoconiosisPathogenesis of Pneumoconiosis

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

Asbestosis 肺石棉沉着症

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 （恶性胸膜瘤）

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

Fibrosing diseasesIdiopathic pulmonary fibrosis (IPF)

• Unknown etiology

• Diffuse interstitial fibrosis

• Usual interstitial pneumonia

• The pleural surfaces have the appearance of cobblestones

Idiopathic pulmonary fibrosis

• Fibrosis

• Lower lobes

Usual interstitial pneumonia

Usual interstitial pneumonia

Sarcoidosis

• The etiology remains unknown

• < 40 years old

• Danish and Swedish

• Several immunologic abnormalities

• Nonsmokers

Morphology

• Noncaseating epithelioid granuloma

Asteroid body

Schaumann body

Extrapulmonary sarcoidosis

• Lymph nodes

• Skin lesions: erythema nodosum

• Eye and lacrimal glands

• Spleen

• Liver

• Bone marrow

Skin lesions: erythema nodosum

Respiratory System Respiratory System Malignant TumorsMalignant Tumors

• Nasopharyngeal carcinoamaNasopharyngeal carcinoama

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

Localized in nasopharynx

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 （非角化性） (1) undifferentiated*:common

(2) differentiated

2. Keratinizing squamous cell carcinoma （角化性）Well, moderately, poorly differentiated

3. Basaloid squamous cell carcinoma

Vesicular nuclei cell carcinomaVesicular nuclei cell carcinoma泡状核细胞癌泡状核细胞癌

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 p206

Primary 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*

组织起源： 支气管粘膜上皮 * 支气管腺体 细支气管粘膜上皮 clara 细胞 嗜银细胞 II 型肺泡上皮

Grossly Type

• Hilar ：最常见，位于肺门

• Peripheral ：发生于段以下支气管

• Diffuse ：少见

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 痰液涂片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 声嘶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 cancer G. Methods for lung cancer diagnosisdiagnosis

•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

Thanks