SMOKING RELATED LUNG DISEASES

Question 1

TYPES OF COPD (2)

Answer 1

Empysema (Morpjologic)

AND

Chronic Bronchitis (clinical) - will NOT see in a POT a diagnosis because of cough for years

Often will co-exist

Question 2

EMPHYSEMA

Answer 2

“Abnormal permanent enlargement of the a_irspaces distal to the terminal bronchioles_ with destruction of alveolar walls without fibrosis

(does not trigger healing and repair)

Two Types

Panacinar emphysema - near the end of alveolus

Centriacinar emphysma - lower down in resporatory bronchiole

Question 3

What causes EMPHYSEMA?

Answer 3

= PROTEASE-ANTIPROTEASE THEORY

Neutrophils and macrophages accumulate in the alveoli of smokers

neutrophils release PROTEASES and macrophages release ELASTASE

Free radicals in smoke DECREASE LUNG ANTIOXIDANT (a-1-antitrypsin) and decreases protection of cells

SUMMARY

INCREASE in ELASTASE –> Elastic Damage –> Empysema

DECREASE in ANTIELASTASE –> Elastic Damage –> Empysema

Question 4

What does it look like?

Answer 4

Often carbon (black) in the lungs “atherocastis”

Broken down alveoli

NOT PINK

JOINED ALVEOLI - DESTRUCTION WITH HOLES

SEE IMAGES SLIDE 7

Question 5

What are the CLINICAL FEATURES of EMPHYSEMA?

Answer 5

Gradual cough or wheeze

Weight Loss

Barrel Chest

Prolonged expiration

“pink puffers” - long time to breathe

Question 6

CHRONIC BRONCHITIS

Definition

What Casues

Answer 6

“persistent cough with sputum production for at least 3 months in at least 2 consecutive years”

Hypersecretion of mucous in the large airways

Hypertrophy of submucosal glands

Increase in goblet cells of smaller airways

ALL EQUAL - MUCUS SECRETION

Question 7

Later features of Chronic Bronchitis?

Answer 7

Mucis plugging of small airways

Inflammation

Fibrosis (Causing reduced lumen size)

Infection plays a secondary role –> pooling of mucus = BACTERIA!!!

Question 8

Clinical Features of CHRONIC BRONCHITIS?

Answer 8

Persistent cough with copius sputum

Dysponea on exhertion (can’t breate out)

Cor Pulmonare

“Blue Bloaters” - blue lips and skin

Question 9

LUNG CANCER

What type are we looking at?

Risk Factors

Answer 9

Most common cause of death from neoplasia

Looking at BRONCHOGENUC CARCINOMAS

RISK FACTORS? SMOKING (also air pollution and industrial hazards)

Question 10

WHAT ARE THE FOUR TYPES OF LUNG CANCER??

Answer 10

Squamous Cell Carcinoma

Adenocarcinoma

Small Cell Carcinoma

Large Cell Carcinoma

Question 11

Clinical Features of LUNG CANCER

Answer 11

cough, weight loss, chest pain, shortness of breath, metastic disease

BUT remember the lungs have no pain receptors. If you are getting back pain = secondary or jaundice = secondary

Question 12

LOCAL EFFECTS of LUNG CANCER

Answer 12

bronchial obstruction –> pneumonia/abscess/collapse

pleural invasion –> pleural effusion

chest wall invasion –> rib destruction

pericardial involvement –> pericarditis; temponade

Question 13

Bronchogenic Carsimomas

Who is affected (commonly)

Specific Risk Factors

Answer 13

most common in MEN but increasing in WOMEN

Peak age of incidence = 40 -70 YEARS OF AGE

Risk Factors?

• Tobacco Smoking (risk increases with number of cigarettes)
• Industrial hazards (radiation, asbestos)
• Air pollution (by radon)

Question 14

Bronchocarcimonas - what are they (SC, AD, SMALL or LARGE CELL) %

Answer 14

Squamous Cell - 25% - 40% MOST COMMON

Adenocarcinoma 25% - 40%

Small Cell Carcinoma 20% - 25%

Large Cell Carcinoma 10-15%

Question 15

MORPHOLOGY of BC CARCINOMAS

Answer 15

May arise in and about the HILUS of the lung (near main bronchi) More centrally located e.g. squamous cell carcinomas

Some arise in the PERIPHERY (alveolar septal cells or terminal bronchioles) e.g. adenocarcinomas

Cancers are WHITE due to the FIBROTIC nature. They are HARD and OBSTRUCTIVE

Look for LYMPH nodes full of tumour material.

What type of cancer is it? LOOK AT PISTURES

SCC = top of the lungs but need to take a biopsy

Adenocarcinoma looks a bit like TB - SO LOOK AT HISTORY

Question 16

Symptoms of Lung Cancer?

Answer 16

No early symptoms

many have…

• general cough(infection distal to blocked airway)
• haemoptysis (ulceration of tumour in bronchus)
• dyspnoea (local extention of tumour)
• chest pain (involvement of pleura and chest wall)
• wheeze (airway narrowing)

Question 17

TYPE 1:

Squamous Cell Carcinomas

Location

and

Morphology

Answer 17

Location:

Usually CENTRAL and close to the CARINA

Often found in an area that has previously undergone metaplasia

FIRM, GREY-WHITE AND MAY BE ULCERATED

Morphology:

Highly variable microscopic appearance

slow growing - 60% resectable at diagnosis

Median survival time = less than 1 year

KERTAIN WHIRLS OR PERALS, purple cells (mitosis) and Pink with white around edges) see image Slide 16

Question 18

Type 2:

Adenocarcinoma

Epidemiology

Answer 18

• not as closely related to SMOKING and equal sex incidence. Most common in women

LOOK AT IMAGES

The GLANDS are not normal. Lots of purple plus glands (not as big as the keratin whirls) Pg 17

Question 19

Type 3:

Small Cell Carcinomas

Epidemiology

and

Ectopic Hormone Production

Answer 19

Epidemiology

Highly malignant lung cancer

Strong relationship to smoking

Male to female 2:1

MOST COMMONLY ASSOCIATED WITH ECTOPIC HORMONE PRODUCTION

Dervived from neuroendocrine cerlls of the lining bronchial epithelium

Results of Ectopic Hormone Production

• antidiuretic hormone
• adrenocorticotrophic hormone (ACTH) = cushing syndrome

LOOKS LIKE - Lymphocytes “oat cell” no structure

Question 20

Type 4

Large Cell Carcinomas

Microscopic Features

Answer 20

Probably represent a poorly differentiated unrecognisable combination of a squamous cell carcinoma and an adencarcinoma

May be found centrally or perphherallyn–> everywhere in lungs

Really poor diagnosis!

LOOK LIKE HUGE CELLS

Question 21

PATHWAY OF TUMOUR GROWTH

Answer 21

May follow a variety of paths.

• Fungate into bronchial lumen
• penetrate wall of bronchus
• extend to pleural surface
• spread to tracneal, bronchial and mediastinal nodes
• metastisise to adrenals, liver, brain, bone