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- 1. DISEASES OF THE PLEURA Dr.CSBR.Prasad, M.D. CSBRP-Dec-2012
- 2. PLEURA Normal data: --- 15 ml, serous, clear fluid --- Helps in lubrication --- Visceral & Parietal pleura --- Has mesothelial covering --- Mets more common than primary tumors CSBRP-Dec-2012
- 4. Pleural effusion - Mechanisms • Hydrostatic pressure - CHF • Vascular permeability - Pneumonia • Oncotic pressure - Nephrotic syndrome • Negative intrapleural pressure - Atelectasis • Lymphatic drainage - Carcinomatosis CSBRP-Dec-2012
- 6. CHF – Cardiomegaly & Pleural effusion CSBRP-Dec-2012
- 13. A nest of malignant cells is seen in a dilated lymphatic channel causing complete occlusion
- 14. Inflammatory Pleural Effusions: • Serofibrinous pleuritis • Suppurative pleuritis • Hemorrhagic pleuritis CSBRP-Dec-2012
- 15. Serofibrinous pleuritis • Pulmonary inflammation: – TB – Pneumonia – Infarcts – Abscess • Systemic disease: – Rheumatoid arthritis – Uremia CSBRP-Dec-2012
- 16. Suppurative pleuritis • Empyema • Pleural space infection CSBRP-Dec-2012
- 17. Hemorrhagic pleuritis • Bleeding disorders • Mets • Rickettssial diseases • TB CSBRP-Dec-2012
- 18. Purulent pleural effusions: [Empyema] Causes: Bacterial or mycotic seedling of pleura * Commonly contiguous spread * Lymphatic or blood dissemination * Sympathetic effusion: Primary liver abscess CSBRP-Dec-2012
- 19. Non-inflammatory Pleural Effusions: Hydrothorax: • Straw-colored • Common cause - Cardiac failure Hemothorax: • Ruptured aortic aneurysms • Vascular trauma Chylothorax: • Lymphatic obstruction / rupture CSBRP-Dec-2012
- 20. Chylothorax • Milky fluid • Finely emulsified fat • Often unilateral • Thoracic duct trauma / obstruction • Malignant conditions of thoracic cavity • Thoracic duct involvement by mets High Triglycerides CSBRP-Dec-2012
- 21. Chylothorax
- 22. 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 CSBRP-Dec-2012
- 23. Meig’s syndrome • Ovarian fibroma • Right sided pleural effusion • Ascitis CSBRP-Dec-2012
- 25. Pneumothorax • Air or gas in pleural cavities • Spontaneous, traumatic, therapeutic • Associated with emphysema, asthma, tuberculosis CSBRP-Dec-2012
- 26. Spontaneous idiopathic Pneumothorax • Young • Rupture of small, peripheral, usually apical subpleural blebs • Subsides spontaneously with air absorption • Recurrent, disabling CSBRP-Dec-2012
- 27. Complications - Pneumothorax • Compression • Collapse • Atelectasis • When defect acts as flap valve- one way entry of air-progressively increases pressure - TENSION PNEUMOTHORAX CSBRP-Dec-2012
- 28. Tumors of the Pleura CSBRP-Dec-2012
- 29. 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) CSBRP-Dec-2012
- 30. Carcinoma of breast metastasizing to pleura CSBRP-Dec-2012
- 31. Tumor embolus in a lymphatic CSBRP-Dec-2012
- 32. 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: CSBRP-Dec-2012
- 33. 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 CSBRP-Dec-2012
- 34. 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 CSBRP-Dec-2012
- 35. Markers of asbestos exposure: • Asbestos bodies in the lung tissue • Pleural plaques CSBRP-Dec-2012
- 39. CSBRP-Dec-2012
- 40. CSBRP-Dec-2012
- 41. Cytogenetics: • Seen in 60-80% of tumors • Deletion in 1p, 3p, 6q, 22q • p53 mutations • SV40 viral DNA (inactivate p53, RB genes) CSBRP-Dec-2012
- 42. 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 CSBRP-Dec-2012
- 43. Mesothelioma
- 44. Encased lung in Mesothelioma CSBRP-Dec-2012
- 45. Encased lungs in Mesothelioma
- 46. Encased lung in Mesothelioma
- 47. 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
- 48. CSBRP-Dec-2012
- 49. CSBRP-Dec-2012
- 50. CSBRP-Dec-2012
- 51. Clinical features: • Chest pain • Dyspnea • Rapidly filling pleural effusion • Mets in Hilar LNs, Liver, chest wall CSBRP-Dec-2012
- 52. CSBRP-Dec-2012
- 54. 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)
- 55. Clinical features: Prognosis: 50% die with in 12 months of diagnosis. CSBRP-Dec-2012
- 56. Other sites: Mesothelioma can also arise in: … Peritoneum … Pericardium … Tunica vaginalis CSBRP-Dec-2012
- 57. Mesothelioma of the pericardium