DISEASES OF THE PLEURA

Dr.CSBR.Prasad, M.D.

CSBRP-Dec-2012

PLEURA

Normal data: --- 15 ml, serous, clear fluid --- Helps in lubrication --- Visceral & Parietal pleura --- Has mesothelial covering --- Mets more common than primary tumors

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Pleural Effusion

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Pleural effusion - Mechanisms

• Hydrostatic pressure - CHF

• Vascular permeability - Pneumonia

• Oncotic pressure - Nephrotic syndrome

• Negative intrapleural pressure - Atelectasis

• Lymphatic drainage - Carcinomatosis

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Nephrotic syndrome

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CHF – Cardiomegaly & Pleural effusion

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Pneumonia

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Pneumonia with effusion

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Pneumonia with effusion

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Carcinomatosis

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Lymphangitis carcinomatosa

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Lymphangitis carcinomatosanomatosa

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A nest of malignant cells is seen in a dilated lymphatic

channel causing complete occlusion

Inflammatory Pleural Effusions:

• Serofibrinous pleuritis

• Suppurative pleuritis

• Hemorrhagic pleuritis

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Serofibrinous pleuritis

• Pulmonary inflammation:

– TB

– Pneumonia

– Infarcts

– Abscess

• Systemic disease: – Rheumatoid arthritis

– Uremia

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Suppurative pleuritis

• Empyema

• Pleural space infection

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Hemorrhagic pleuritis

• Bleeding disorders

• Mets

• Rickettssial diseases

• TB

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Purulent pleural effusions: [Empyema]

Causes:

Bacterial or mycotic seedling of pleura

* Commonly contiguous spread

* Lymphatic or blood dissemination

* Sympathetic effusion: Primary liver abscess

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Non-inflammatory Pleural Effusions:

Hydrothorax:

• Straw-colored

• Common cause - Cardiac failure

Hemothorax:

• Ruptured aortic aneurysms

• Vascular trauma

Chylothorax:

• Lymphatic obstruction / rupture

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Chylothorax

• Milky fluid

• Finely emulsified fat

• Often unilateral

• Thoracic duct trauma / obstruction

• Malignant conditions of thoracic cavity

• Thoracic duct involvement by mets

High Triglycerides

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Chylothorax

Right sided pleural effusion

• Associated with ascites from any cause

• Pressure gradient b/n peritoneal and pleural cavities - favor movement of fluid - across lymphatics

Don’t forget Meig’s syndrome

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Meig’s syndrome

• Ovarian fibroma

• Right sided pleural effusion

• Ascitis

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Pneumothorax

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Pneumothorax

• Air or gas in pleural cavities

• Spontaneous, traumatic, therapeutic

• Associated with emphysema, asthma, tuberculosis

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Spontaneous idiopathic Pneumothorax

• Young

• Rupture of small, peripheral, usually apical subpleural blebs

• Subsides spontaneously with air absorption

• Recurrent, disabling

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Complications - Pneumothorax

• Compression

• Collapse

• Atelectasis

• When defect acts as flap valve- one way entry of air-progressively increases pressure -TENSION PNEUMOTHORAX

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Tumors of the Pleura

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Pleural Tumors

• Primary tumors - rare

• Secondary tumors - [Metastatic ] from

lung, breast, Ovary

Primary Pleural tumors: 1. Benign (SFT, Benign Mesothelioma)

2. Malignant (Pri. Effusion Lymphoma)

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Carcinoma of breast metastasizing to pleura

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Tumor embolus in a lymphatic CSBRP-Dec-2012

Solitary Fibrous Tumor

• Also called = Benign mesothelioma,

= Pleural fibroma

• Localized growth - 1 - 2 cms,

• Do not produce effusion,

• Gross: Dense fibrous tissues with cysts

• Micro: Whorls of collagen fibers.

Benign Pleural Tumors:

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Malignant Mesothelioma:

• Origin --- parietal or visceral pleura

• Uncommon [Frequency is 0.9 cases per 100,000 persons]

• 90% associated with asbestos exposure

• Latent period = 25 to 45 years

• No additional risk with smoking

• Life time risk = 7-10% (with asbestosis)

• Asbestos workers who smoke tend to die of Bronchogenic carcinoma than mesothelioma

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Exposure to asbestos linked to:

1. Fibrous plaque - localized or diffuse

2. Pleural effusions

3. Interstitial fibrosis [ asbestosis ]

4. Bronchogenic carcinoma,

5. Mesothelioma

6. Laryngeal and other neoplasm

including carcinoma colon

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Markers of asbestos exposure:

• Asbestos bodies in the lung tissue

• Pleural plaques

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Pleural plaques

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Fibrous pleural plaque

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Diffuse visceral

Pleural fibrosis

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Cytogenetics:

• Seen in 60-80% of tumors

• Deletion in 1p, 3p, 6q, 22q

• p53 mutations

• SV40 viral DNA (inactivate p53, RB genes)

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Morphology - gross:

• Diffuse lesion spreads widely along the pleural surface

• Pleural effusion

• Invasion of thoracic wall

• Encasement of lung by the pleural tumor

Rapidly accumulating

pleural effusion

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Mesothelioma

Encased lung in Mesothelioma CSBRP-Dec-2012

Encased lungs in Mesothelioma

Encased lung in Mesothelioma

Microscopy:

• Sarcomatoid type

• Epithelial type

Distinguished from adenocarcinomas

= Acid mucopolysaccharides - positive

= CEA - negative

= Keratin - positive (perinuclear)

= Calretinin - Positive

= EM - long microvilli

• Mixed type – Biphasic type CSBRP-Dec-2012

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Clinical features:

• Chest pain

• Dyspnea

• Rapidly filling pleural effusion

• Mets in Hilar LNs, Liver, chest wall

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Superior

venacaval

syndrome

Superior venacaval syndrome

Photographs of the patient showing the reduction in swelling of the

face, neck and upper extremities

(A) At initial presentation and (B) after treatment (hospital day 8)

Clinical features:

Prognosis:

50% die with in 12 months

of diagnosis.

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Other sites:

Mesothelioma can also arise in:

… Peritoneum

… Pericardium

… Tunica vaginalis

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Mesothelioma of the pericardium

E N D

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