Diseases of the Pleura
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DISEASES OF THE PLEURA
Dr.CSBR.Prasad, M.D.
CSBRP-Dec-2012
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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
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Pleural Effusion
CSBRP-Dec-2012
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Pleural effusion - Mechanisms
• Hydrostatic pressure - CHF
• Vascular permeability - Pneumonia
• Oncotic pressure - Nephrotic syndrome
• Negative intrapleural pressure - Atelectasis
• Lymphatic drainage - Carcinomatosis
CSBRP-Dec-2012
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Nephrotic syndrome
CSBRP-Dec-2012
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CHF – Cardiomegaly & Pleural effusion
CSBRP-Dec-2012
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Pneumonia
CSBRP-Dec-2012
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Pneumonia with effusion
CSBRP-Dec-2012
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Pneumonia with effusion
CSBRP-Dec-2012
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Carcinomatosis
CSBRP-Dec-2012
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Lymphangitis carcinomatosa
CSBRP-Dec-2012
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Lymphangitis carcinomatosanomatosa
CSBRP-Dec-2012
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A nest of malignant cells is seen in a dilated lymphatic
channel causing complete occlusion
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Inflammatory Pleural Effusions:
• Serofibrinous pleuritis
• Suppurative pleuritis
• Hemorrhagic pleuritis
CSBRP-Dec-2012
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Serofibrinous pleuritis
• Pulmonary inflammation:
– TB
– Pneumonia
– Infarcts
– Abscess
• Systemic disease: – Rheumatoid arthritis
– Uremia
CSBRP-Dec-2012
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Suppurative pleuritis
• Empyema
• Pleural space infection
CSBRP-Dec-2012
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Hemorrhagic pleuritis
• Bleeding disorders
• Mets
• Rickettssial diseases
• TB
CSBRP-Dec-2012
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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
CSBRP-Dec-2012
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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
CSBRP-Dec-2012
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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
CSBRP-Dec-2012
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Chylothorax
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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
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Meig’s syndrome
• Ovarian fibroma
• Right sided pleural effusion
• Ascitis
CSBRP-Dec-2012
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Pneumothorax
CSBRP-Dec-2012
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Pneumothorax
• Air or gas in pleural cavities
• Spontaneous, traumatic, therapeutic
• Associated with emphysema, asthma, tuberculosis
CSBRP-Dec-2012
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Spontaneous idiopathic Pneumothorax
• Young
• Rupture of small, peripheral, usually apical subpleural blebs
• Subsides spontaneously with air absorption
• Recurrent, disabling
CSBRP-Dec-2012
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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
CSBRP-Dec-2012
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Tumors of the Pleura
CSBRP-Dec-2012
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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)
CSBRP-Dec-2012
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Carcinoma of breast metastasizing to pleura
CSBRP-Dec-2012
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Tumor embolus in a lymphatic CSBRP-Dec-2012
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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
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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
CSBRP-Dec-2012
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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
CSBRP-Dec-2012
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Markers of asbestos exposure:
• Asbestos bodies in the lung tissue
• Pleural plaques
CSBRP-Dec-2012
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Pleural plaques
CSBRP-Dec-2012
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Fibrous pleural plaque
CSBRP-Dec-2012
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Diffuse visceral
Pleural fibrosis
CSBRP-Dec-2012
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CSBRP-Dec-2012
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CSBRP-Dec-2012
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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)
CSBRP-Dec-2012
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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
CSBRP-Dec-2012
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Mesothelioma
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Encased lung in Mesothelioma CSBRP-Dec-2012
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Encased lungs in Mesothelioma
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Encased lung in Mesothelioma
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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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CSBRP-Dec-2012
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CSBRP-Dec-2012
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CSBRP-Dec-2012
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Clinical features:
• Chest pain
• Dyspnea
• Rapidly filling pleural effusion
• Mets in Hilar LNs, Liver, chest wall
CSBRP-Dec-2012
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CSBRP-Dec-2012
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Superior
venacaval
syndrome
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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)
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Clinical features:
Prognosis:
50% die with in 12 months
of diagnosis.
CSBRP-Dec-2012
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Other sites:
Mesothelioma can also arise in:
… Peritoneum
… Pericardium
… Tunica vaginalis
CSBRP-Dec-2012
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Mesothelioma of the pericardium
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E N D
CSBRP-Dec-2012