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Clinical Pathology > Lecture 27 - Pleural Pathology > Flashcards

Lecture 27 - Pleural Pathology Flashcards

1
Q

What are the most common pleural pathology?

A

Inflammation - pleurisy or pleuritis
Fibrosis
Neoplasia

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2
Q

What are the causes of pleural inflammation?

A 
Primary inflammation diseases
Infections
Pulmonary infarction
Emphysema
Neoplasms
Therapeutic 
Iatrogenic
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3
Q

How can primary inflammatory diseases cause pleural inflammation?

A

Collagen vascular diseases such as SLE and rheumatoid arthritis

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4
Q

What infections can cause pleural inflammation?

A

Usually secondary to pneumonias or pulmonary tuberculosis.

Viral - primary Coxsackie B infection (Bornholm disease)

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5
Q

How can a pulmonary infarction be a cause of pleural inflammation?

A

usually secondary to pulmonary arterial thromboembolus

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6
Q

How can emphysema cause pleural inflammation?

A

secondary to ruptured bullae

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7
Q

How can neoplasms cause pleural inflammation?

A

Primary or secondary pleural neoplasms

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8
Q

what are neoplasms?

A

a new and abnormal growth of tissue in a part of the body, especially as a characteristic of cancer.

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9
Q

What therapy can be a cause of pleural inflammation?

A

pleurodesis usually with talc to treat recurrent pleural effusions or recurrent pneumothoraxes.

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10
Q

What are the iatrogenic causes of pleural inflammation?

A

Radiotherapy to the thorax immune reactions to a drug

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11
Q

What signs and symptoms would you diagnose pleural inflammation with if there is no associated pleural effusion?

A

Sign - Auscultation of a pleural rub during breathing

symptom - pleuritic chest pain, a sharp localised pain exacerbated by breathing

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12
Q

What is pleural fibrosis?

A

Usually secondary to pleural inflammation.

  • Unilateral of bilateral
  • Localised or diffuse

Asbestos associated pleural fibrosis

  • Parietal pleural fibrous plaques
  • Diffuse pleural fibrous
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13
Q

The effects of pleural fibrosis?

A

Widespread thick fibrosis can prevent normal expansion and compression of the lung during respiration causing breathlessness.

Fibrous adhesions can wholly or partly obliterate the pleural cavity

Removal of the fibrous tissue (pleural decortication) can improve the expansion and compression of the lung during respiration.

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14
Q

What is removal of fibrous tissue called?

A

pleural decortication

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15
Q

What does pleural decortication do?

A

can improve the expansion and compression of the lung during respiration

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16
Q

What are parietal pleural fibrous plaques?

A

Associated with low level asbestos dust exposure
Asymptomatic
May be visible on chest radiographs
Dense poorly cellular collagen

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17
Q

Why are parietal pleural fibrous plaques not eligible for Industrial Injuries Disablement Benefit?

A

Not a UK Government Prescribed Occupational Disease for specified high exposure occupations.

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18
Q

Pathological fluids in the pleural cavities

Serous fluid

A

pleural effusion

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19
Q

Pus in the pleural cavity

A

empyema or pyothorax

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20
Q

when does empyema or pyothorax occur usually?

A

usually secondary to pneumonia

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21
Q

Blood in pleural cavity

A

haemothorax

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22
Q

What causes a haemothrorax

A

usually traumatic or a ruptures thoracic aortic aneurysm

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23
Q

Bile in pleural cavity

A

chylothorax

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24
Q

what can cause a chylothorax

A

usually trauma

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25
Q

Gas in the pleural cavity

A

pneumothorax

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26
Q

What are the 2 types of pleural effusions?

A

Transudates or exudates

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27
Q

What are transudates?

A
  • Low capillary oncotic (colloid osmotic) pressure and/or high capillary hydrostatic pressure
  • Intact capillaries retain semipermeability
  • Low protein (<2.5 g/dL) & low lactate dehydrogenase
28
Q

What are exudates?

A
  • Pathological capillaries loose semipermeability
  • Normal capillary oncotic pressure and normal vascular hydrostatic pressure
  • High protein (>2.9 g/dL) & high lactate dehydrogenase
29
Q

What are exudates?

A
  • Pathological capillaries loose semipermeability
  • Normal capillary oncotic pressure and normal vascular hydrostatic pressure
  • High protein (>2.9 g/dL) & high lactate dehydrogenase
30
Q

Causes of transudates?

A

High vascular hydrostatic pressure

  • Left ventricular failure, renal failure
  • Low capillary oncotic (colloid osmotic) pressure
  • Hypoalbumenaemia - hepatic cirrhosis, nephrotic syndrome
31
Q

Causes of exudates?

A

Inflammation with/without infection

Neoplasms either primary or secondary

32
Q

What are the signs and symptoms of pleural effusions?

A

Symptoms

  • Breathlessness - effusion compresses the lung
  • Little/no pleuritic pain - the visceral and parietal pleura are not in contact

Signs

  • Percussion - dull
  • Auscultation - reduced breath sounds
33
Q

What are the investigations to support the diagnosis?

A

Imaging - ultrasound, chest, radiograph, CT

34
Q

Treatment for pleural effusions

A

Treat the breathlessness by removing the fluid

  • aspiration with a needle and syringe, ultrsound guided
  • reaspirate if the fluid reaccumulates
  • For recurrent effusions consider a temporary or permanent pleural drain
  • For recurrent effusions when the lung expands after drainage and the underlying cause remains consider pleurodesis to obliterate the pleural cavity
35
Q

What is pleurodesis?

A

Pleurodesis is a medical procedure in which the pleural space is artificially obliterated.[1] It involves the adhesion of the two pleurae.

It is not a curative treatment, but rather an approach that is recommended when symptoms like chest pain and shortness of breath are causing discomfort.

36
Q

What are the local and systemic causes for pleural effusions and how would they be treated accordingly?

A

Local

  • Pleural fluid for cytology, microbiology, & biochemistry
  • Pleural biopsy

Systemic
- Investigate the systemic causes of pleural effusions

37
Q

What is a pneumothorax?

A

Air in the pleural cavity

38
Q

What is an open pneumothorax

A
  • A chest wall perforation usually traumatic - a “sucking chest wound’ - connects the body surface to the pleural cavity
  • External air is drawn into the pleural cavity during inspiration, reducing potential lung expansion
39
Q

What is a closed pneumothorax

A
  • A lung perforation, usually not traumatic, connects the lung air spaces to the pleural cavity
  • Lung air is drawn into the pleural cavity during inspiration, reducing potential lung expansion
40
Q

What are the causes of a closed pneumothorax?

A
  • Ruptured emphysematous bullae - as in picture left
  • Common inflammatory lung diseases
    • Asthma, pneumonia, tuberculosis, cystic fibrosis

-Traumatic - lung tears from fractured ribs
- Iatrogenic
- Mechanical ventilation at high pressures
- Lung and pleural biopsy procedures
- Some rare cystic lung diseases - Langerhan’s cell
histiocytosis, lymphangioleiomyomatosis
- Catamenial due to pleural endometriosis

41
Q

what is a tension pneumothorax?

A

Perforation into a pleural cavity in an open or a closed pneumothorax can be valvular, letting air into the cavity on inspiration but not letting air out.

Pressure can rise above atm pressure - blowing up a balloon.
Can compress mediastinal structures including the vena cavae and heart and move the mediastinum compressing the contralateral lung.

A tension pneumothorax is potentially fatal and requires urgent treatment

42
Q

How would you diagnose a pneumothorax?

A

Symptoms - small may be asymptomatic

  • breathlessness
  • Pleuritic chest pain

Signs

  • Cyanosis
  • Tachychardia
  • Contralateral tracheal deviation in tension pneumothorax
  • Percussion -hyper resonant
  • Auscultation - reduced breath sounds

Investigations to support the diagnosis

  • imaging - ultrasound, chest radiograph, CT
  • symptomatic pneumothoraces are often initially treated without further investigation
43
Q

What’s the treatment for a pneumothorax?

A
  • May resolve spontaneously
  • A tension pneumothorax can be decompressed as an emergency procedure using a needle inserted via an intercostal space
  • With an open pneumothorax the penetrating chest wound causing it can be covered with an occlusive adhesive dressing that may incorporate a valve to allow air our but not in
  • For any pneumothorax a chest drain tube can be inserted incorporating a valve to allow air out but not in while the pneumothorax resolves.
  • For recurrent pneumothoraces pleurodesis is usually considered.
44
Q

What are the 2 types of pleural neoplasms?

A

Primary

  • Benign/low grade malignant - uncommon/rare
    • Includes low grade mesothelial tumours
  • Malignant
    • Malignant mesothelioma - common
    • Others - uncommon/rare
  • Secondary malignant
    • Carcinomas - breast, lung, others - common
  • Others - lymphoma, melanoma, others
45
Q

What are malignant mesotheliomas

A

A neoplasm of the mesothelial cells that line serous cavities - pleura, peritoneum, pericardium, tunica vaginalis

  • 92% are pleural, 8% are peritoneal
    • Both are commoner in men
      Peritoneal - effect higher proportionof women, having a higher proportion of low grade type and are less strongly associated with asbestos dust exposure

-Tend not to metastasise widely

46
Q

What do early malignant mesotheliomas do?

A

A small tumour can produce a large pleural effusion.

The tumour can be difficult to identify on imaging and therefore it is difficult to target biopsies at it.

Malignant cells may be shed into the effusion therefore effusion cytology may allow an early tissue diagnosis to be made.

47
Q

Malignant mesothelioma histology

A
  • Mixed tubulopapillary epithelioid and spindle cell sarcomatoid morphology
  • Can be either type alone
  • Can be poorly cellular - ‘desmoplatic’
  • The main morphological differential diagnosis is malignant mesothelioma or non-small carcinoma
48
Q

Histology of malignant mesothelioma

A

Tubules of solid aggregates of malignant mesothelial cells

The morphological differential diagnosis is adenocarcinoma or epithelioid malignant mesothelioma

49
Q

Immunostaining of malignant mesothelioma

A

Uses antibodies linked to a dye to identify antigens in cells
Mesothelial cells and epithelial cells tend to express different antigens so can be differentiated

-cross reaction so a panel of 4 or more antibodies is used

50
Q

what stains on the left?

A

Mesothelium-associated antigen

51
Q

What stains on the top?

A

Cytokeratin 5

52
Q

What stains on the middle?

A

Wilms tumour antigen

53
Q

What stains on the bottom?

A

Calretinin

54
Q

what is the major cause of malignant mesothliomas?

A
  • Asbestos - 80 to 90% of cases
    strong association above general population exposure level but exposure can be low level

link identified first in south african asbestos mining towns in 1960
develops over 15-60 years after exposure
risk increases with cumulative exposure level and time from exposure

estimated 1-2 spontaneous cases per million persons per year

  • Thoracic irradiation
  • BAP1 (BRCA1 - associated protein 1) mutations
  • Germline mutations in a familial cancer syndrome with uveal melanoams and mesotheliomas
55
Q

What is asbestos?

A

Fibrous metal silicates

5-100mm x diameter 0.25-0.5 mm

56
Q

What are the different types of asbestos?

A

Blue - amphibole ( crocidolite)
Brown - amosite
White - serpentine (chrysotile)

57
Q

What happens when fibrous metal silicates are inhaled?

A

They become coated with mucopolysaccharides containing iron to form asbestos bodies

58
Q

How can asbestos bodies be identified?

A

Can be seen in tissue sections by light microscopy, brown when unstained or blue if the iron is stained, and quantified - a cheap simple process

59
Q

How can asbestos fibres be quantified in lung extracts?

A

By electron microscopy - expensive process

60
Q

Which type of asbestos is most oncogenic?

A

Blue asbestos/crocidolite which are amphiboles

61
Q

what type of asbestos is less oncogenic?

A

white asbestos/ chrysotile and is more readily cleared from the lung

62
Q

Why and what is the cause of a very high incidence of mesotheliomas in young people of Cappadocia?

A

Erionite is a fibrous zeolite mineral that has a fibre structure similar to asbestos. It is used as a building material in Turkey.

63
Q

How is asbestos used?

A

A fire proof material widely used in commercial and domestic buildings and in ship building from the 1940’s and to the 1990’s

Between 1940 and 1998 there were 5.5 million tons of asbestos imported into the UK

Crocidolite and amosite imports were banned in 1985 and all asbestos imports were banned in 1999

64
Q

What is asbestosis?

A

Interstitial pneumonia-like progressive pulmonary interstitial fibrosis caused by high level exposure to asbestos dust

65
Q

What occurs during asbestosis?

A

Fibrosis of the alveolar walls impairs both gas exchange and lung expansion and contraction during breathing.

66
Q

Is asbestosis related to the pleura or the lung?

A

lung

67
Q

What is virchows triad

A

Virchow’s triad or the triad of Virchow describes the three broad categories of factors that are thought to contribute to thrombosis.

Hypercoagulability
Haemodynamic changes (stasis, turbulence)
Endothelial injury/dysfunction

Clinical Pathology (16 decks)

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