Transcript
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CHAPTER8:RESPIRATORY
A-agradient
A-agradient:definedasthegradientbetweenthealveolarO2andarterialO2 Normally,alveolarO2is100andthearterialpO2is95.AnormalA-agradientis
about5mmHg.Theupperlimitofnormalis30mmHg(sethightoachieveahigh
specificity/PPV)
Whyarethetwodifferent?BecauseofphysiologicV/Qmismatcho Whenstandinguptheventilationisbetterthanperfusionintheapex,
whereasperfusionisbetterthanventilationatlowerlobes.
o Thisexplainswhyalmostallpulmonaryinfarctionsareinthelowerlobesperfusionisgreaterthere.
o Also,thisexplainswhyreactivationTBisintheapexTBisastrictaerobeandneedsasmoreO2,andthereismoreventilationintheupperlobes
(higherO2content).
AhighA-agradientmeanshypoxemiaisduetoV/Qdefectinthelungs,andanormalA-agradientmeanshypoxemiaisduetosomethingoutsidethelungs Hypoxemia+highA-agradient(indicativeofprimarylungdisease)
o Ventilationdefects:produceshypoxemia,andthereforeprolongsthegradientdroppingthePO2andsubtracting,andthereforeagreater
differencebetweenthetwo
o Perfusiondefect:e.g.,PEo Diffusiondefect
Hypoxemia+normalA-agradient(indicativeofaproblemoutsidethelungs):o Depressionofthemedullaryrespiratorycenter(aswithbarbiturates)o Nerveproblems:GuillainBarresyndrome,ALSo Obstructionoftheupperairwayfromepiglottitis,
laryngeotracheobronchitis
o Paralysisofdiaphragm Calculation:(0.21x713)pCO2/0.8=100(0.21istheatmosphericO2;760
minusthewatervapor=713;pCO2isnormally40,giveninABG;0.8istheRQ).
MeasuredarterialpO2100=A-adifference
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UpperRespiratoryDisease
NasalPolyps:
Mostcommonisallergicpolyp(developsinadultswithlong-standingallergicrhinitis)
Polypsinnoseofchildren=CF Triadasthma(ASA-intolerantasthma):triadofasthma,aspirininduced
bronchospasm,andnasalpolyps.Classicis35yowomanwithchronicpain
(headachesorfibromyalgia,etc.)withoccasionalasthma(theywonttellyoushe
istakinganNSAID,orthatshehasapolyp!).Mechanism:COXblock=
lipoxygenasepathwaydominanceLTC4,D4,andE4bronchoconstriction.
ThisisNOTatypeIhypersensitivityreaction;ratheritischemicalmediated
Laryngealcarcinoma
Asquamouscellcarcinoma Majorriskfactorsforsquamouscancers
inmouth,esophagusandlarynx:
smoking,alcohol,smokingandalcohol
hassynergisticeffect
Presentswithhoarsenessofthethroat Laryngectomyspecimen
Epiglottitis
InfectioncausedbyH.influenzae Presentswithinsiratorystridor X-rayoflateralneck:thumbprintsignofacute
epiglottitisduetoHemophilusinfluenzae Anothercauseofairwayobstructioniscroup
(PIV)inyoungchildrencausestracheal
inflammation
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RespiratoryDistressSyndromes
NeonatalRespiratoryDistressSyndrome/HyalinemembraneDisease
Collapsingpressureintheairways=surfacetension/radiusofairway.o Onexpiration,normallytheairwaywillbesmallerb/cthereisapostive
intrathoracicpressure.o Surfactantistheretodecrease
surfacetensionandkeep
airwaysopenonexpiration.
o Ifthereisnosurfactant,atelectasiswilloccur
PinkhyalinemembranesareduetodegenerationoftypeIIpneumocytes
andleakageoffibrinogenwhich
congealstoformthemembrane Pathophysiologyofhypoxemia:massiveintrapulmonaryshunt BabieswithRDScommonlyhavePDAbecauseofhypoxemia(normalbreathingis
requiredtoclosePDA)murmur
Tx:PEEPtherapypositiveendexpiratorypressuretopreventairway
collapse,administrationofsurfactant
TypeIIpneumocyte(progenitorcellofthelung)haslamellarbodies(looklike
onion)containingsurfactant;donot
confusewithamacrophage,whichhas
junkinthecytosol
ThreecausesofiRDS
Prematurity:surfactantbeginssynearly,butitpeaksat32-35week,soifyouarebornprematurely,youwillnothaveenoughsurfactant,andbabywill
developincreasedriskofdevelopingRDS.
o Administrationofantenatalglucocorticoidsstimulatessurfactantsynthesis.
o Thyroxineandprolactincantheoreticallyalsodothesameo Complicationsofprematurity:superoxidefreeradicaldamageseenin
retinopathyofprematurityandblindnessandbronchopulmonary
dysplasia GestationalDiabetes:gestationaldiabetesglucosecrossestheplacenta
stimulatesinsulinsynthesisinthebabyinsulinhasanegativeeffecton
surfactantsynthesis
o Marosomia-insulinwillincreasestorageoftriglycerideinadipose,andincreasetheuptakeofaminoacidsintomuscle(likegrowthhormone)
o Thesebabiesarefrequentlyhypoglycemicwhentheyarebornbecausetheglucosesupplyiscutoffbutthebabystillhashyperinsulinemia
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Csection:thestressofvaginaldeliveryleadstoreleaseofACTHandcortisolarenotreleased,andsurfactantisnotmade.
AdultRespiratoryDistressSyndrome(ARDS)
SimilartoiRDS,buttheinjuryisduetoneutrophilicinflammatoryinfiltrate Mostcommoncauseissepticshock(andthemostcommoncauseofseptic
shockisE.colifromanindwellingcatheter)
ForICUpatientso Thefirstdaytheyhavesepticshock,theseconddaytheygetARDS,the
thirddaytheygetDIC.
Pathogenesis:Neutrophilsdestroypneumocytesofthelung,decreasingsurfactantproductionmassiveatelectasis(collapse).
o Hyalinemembranesarisefromholesthatneutrophilspunchinthepulmonarycapillariesastheyextravasate,allowingproteinand
fibrinogentoenterandcausehyalinemembraneformation;leaky
capillarysyndrome
Pathophysiology:intrapulmonaryshunting ReallybadprognosiscomparedtoiRDS
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Pneumothorax
Spontaneouspneumothorax
Majorcauseisarupturedsubpleuralbleb(i.e.anairpocketunderthepleurathatpops,causingaholeinthepleura)
Lungstaysinflatedbecauseofthenegativeintrathoracicpressure,butbreakingthepleuradisruptsthepressuregradientcollapse
o Diaphragmaticelevationonthatsidetofillupthespaceo Deviationofthetracheatothesideofthecollapse
Usuallyseenintallmaleorinascubadiverswhentheycomeuptooquickly
Tensionpneumothorax
Majorcauseduetopunctureinjuriestothelung Cause:atearinthepleurameansthatwitheveryinspiration,airispulledinto
thepleuralcavity,andwithexpirationtheflapclosesastheairbuildsup,it
pushesthelungandmediastinumtotheoppositesideofthethorax,leadingto
compressionatelectasis
Thereisnodeflation,butratherapositiveintrathoracicpressureinthepleuralcavitybearingdownontherestofthethorax
ThiscompressioncanaffecttheSVC,rightventricle,rightatriummedicalemergency.
Withthepositiveintrathroacicpressure,thediaphragmwillgodown
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PulmonaryInfection
Pneumonia
TypicalPNAacuteonsetfever,chillsproductivecougho Productivecoughexudate(pus)o LobarPNAconsolidationinthelung,leading
toincreasedtactile/vocalfremitus,decreased
resonanceofpercussion,egophony,whispered
pectoriloquy
o Ifthereisapleuraleffusionoverlyingthelungtheonlyfindingyouwouldhaveisdecreased
percussion
AtypicalPNAsubacuteonsetofnonproductivecoughwithouthighfever
o Thisisinterstitialinflammationwithoutexudateandsignsof
consolidation
CommunityacquiredPNAo Typicalform:S.pneumoniae
(gram+diplococcus)
Oldtx:PCNG Newtx:azithromycin
o Atypicalform:Mycoplasmapneumoniae,followedby
Chlamydiapneumoniae
NosocomialPNAcouldbeE.coli,P.aeruginosaorS.aureus
Bronchopneumonia
MostcommonlyduetoS.pneumoniae(communityacquired):
LobarPneumonia
MostcommonlyduetoS.pneumoniae Notetheconsolidationintherightupperlobe
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ViralPNA
Rhinoviruso Themostcommoncauseofthecommoncoldo Acidlabiledestroyedbygastricacid(notatummybug!)o Neverwillhaveavaccinebecausethereare>100serotypes
RSVo Themostcommoncauseofbronchiolitiso Presentswithwheezing(smallairwayinflammation)andPNAinasmall
child
Influenzao Hemagglutininshelpattachthevirustothemucosao Neuraminidaseboresaholethroughthemucosao Antigenicdrift=minormutationinHAorNA;noneedforanewvaccineo Antigenicshift=majorchangeinHAorNAneedanewvaccine.o TheflushotisagainstAantigen
BacterialPNA
Chlamydiapsittacosisfrombirds(ieparrots,turkeys). Chlamydiatrachomatiswheezingat1weekofage,PNA,increasedAP
diameter,tympanicpercussionsounds,nofever,bilateralconjunctivitis,staccato
cough.
o Mocstcommoncauseofconjunctivitisinthe2ndweekoflifeisChlamydiatrachomatis(althoughoverallmostcommoncauseofconjunctivitisis
inflammationduetoerythromycindrops
Hospital-acquiredgram-negativePNA
Pseudomonaso Waterlovingbacteriao Ventilatorinfectionso Greenproductivecough
Klebsiellao Famousinthealcoholic-highspikingfevers,productivecoughwith
mucoidsputum(Klebsiellahasacapsule)
o AlcoholicscanalsogetS.pneumonia.o Klebsiellalivesintheupperlobesandcancavitate,thereforecancbe
onfusedwithTB.
Legionella
o Atypical,nonproductivecougho Deadlyo Spreadsfromwatercoolersorinmistsingroceriesoratrestaurants.o Legionellacanalsocauseliverdisease,interstialnephritis(juxtaglomerlur
celldiseaselowreninhyponatremia)
o Tx=erythromycin
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FungalInfections
Candidao Indwellingcatheters,usuallythoseinthesubclaviano Candidasepsisisthesystemicform
Histoplasmosiso Midwest(Ohio/Tennesseevalley)o Histoplasmacapsulatumiscarriedby
dungofstarlingsandbats
o Presentsasanon-productivecoughinspelunkers/caveexplorers
o Histoplasmaistheonlysystemicfungusthathasyeastforms
phagocytosedbyalveolar
macrophages
o NotetheyeastformsofHistoplasmainthismacrophageinthebone
marrow
o Infectioncanbesystemic Cryptococcus
o Pigeonsi.e.,NYCexecutivewithpigeonsroostinginhisA/Cunit
developsnon-productivecough
o Lookslikemickeymouseyeastformsarenarrowbasedbuds.
o Tx:AmphotericinBo FieldstainshowsCryptococcus
speciesinlungtissue Blastomycosis
o SoutheastUSAo Skinandlunginfectionso Broadbasedbuddingo Verrucousskinlesion(raised,wart-
like)ontheface:Blastomyces
dermatitidis
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Coccidioidomycosiso SouthwestUSA(NewMexico,
Arizona,SoCal
o SpherulewithendosporesisCoccidioidesimmitis
o LAearthquakefollowedbynonproductivecough:the
arthrospore(theinfectiousform)
isinthedust.
o Or,spelunkerdeveopsnonproductivecoughinthesonarandesert-Coccidiomycosis(notHistob/cthisisnotinthemidwest)
Aspergillosiso Aspergillomaaspergilluslovestoinhabit
abandonedTBfunguscavities
Presentswithmassivehemoptysis Fungusballsinbilateralupperlobe
cavitarylesions
o Invasiveaspergillus:invasionofthevesselsinlung,leadingtothrombosisandinfarction
o Allergiesthemold,leadingtoextrinsicasthmaandtypeIhypersensitivity
o Corona(lookslikeacrown)byPASstain-septatehyphae(unlikemucor)
withnarrow-anglebranching(unlike
mucor)
PneumocystitiscariniiPNAo Fungus(usedtobeaprotozoa)o ThisisthemostcommonAIDS-
defininglesion(CD4
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o Otherorganismsonlyseenwithsilverstain:Bartonellahenselae(bacillaryangiomatosis),Legionella
Tuberculosis
PrimaryTBoccursinthelowerpartoftheupperlobeortheupperpartofthelowerlobeandclosetothepleura
o PrimaryTBhasaGhonfocusandaGhoncomplex.
o Mostpatientsrecover ReactivationTBoccursinICH,andgoe
totheapex,producingacavitarylesion.
o Cavitarylesionlinedbycaseousmaterial
o NoGhonfocusorcomplex AcidfaststaininTB-mycolicacidinthecellwallisresponsibleforacid-fastness
CXRwithmiliaryTB:
Otherthingsthatcavitateinupperlobes:
o WhichsystemicfungusistheTBofthelungs?Histoplasmosiso Whichcancercancavitateinthelung?Squamouscelllungcarcinomao Whichbacteriacanproducecavitationsintheupperlobe?K.pneumoniae
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ForeignBodies
Ifyouarestandingorsittingup,foreignbodywillgotoposterobasalsegmentoftherightlowerlobe(i.e.,themostposteriorsegmentoftherightlowerlobe)
Ifyouarelyingdown(mostcommonwaytoaspiratethings),foreignbodywillgotosuperiorsegmentoftherightlowerlobe.
Ifyouarelyingontherightside,foreignbodywillgotoeithero Middlelobeofrightlungo Posteriorsegmentofrightupperlobe(thisistheonlyonethatisinthe
upperlobe.
Ifyouarelyingdownontheleftside,foreignbodywillgotothelingula.
Abscess
Mostcommoncauseofabscessisaspirationoforopharyngealmaterialo Riskfactors:poordentition,alcoholismo Aspirateconsistsofaerobesandanaerobes,fusobacterium,bacteroides
(putridsmell)
AsecondarycauseoflungabscessisPNA:S.aureus,Klebsiella
CXRwillshowfluid-filledcavitiesinthelung
Lungabscessinsuperiorsegmentoftherightlowerlobe(patientmust
havebeenlyingdown)
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PulmonaryVascularDisease
PulmonaryEmbolus
Smallemboliproducewedgeshapedhemorrhagicinfarcts,onlyifyouhave
underlyinglungidseaseo 85%ofthetimeemboluswillnot
produceinfarct
Largeemboli(saddleembolus)lodginginthepulmonaryartery
o Ifthisembolusblocksatleast3outofthe5orifices,youaredeadinamillisecondacuterightheart
strainsuddendeath
Mostcommonsiteforthrombosisisthedeepveinsofthelowerleg.
Themostcommonsiteforembolizationtothelungisthefemoralvein
Screeningtestofchoice:ventilationperfusionscanshowingventilation,butno
perfusion
o ObservePEtotherightlowerlobe(RLL)
Confirmatorytestispulmonaryangiogram.
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o Smoking+asbestos=greatlyincreasedriskofprimarylungcancero Noincreasedincidenceofmesotheliomawithsmoking(notsynergistic)
Notethato Mesotheliomatakes25-30yearstodevelop
mostpeoplediebeforetheygetto
mesothelioma!o Lungcancerstakeabout10yearstodevelopo Lungcancersaremorecommon,andyoudie
earlier
Maincausesofasbestosexposure:roofers,peopleworkinginanavalshipyard(allthepipesintheship
areinsulatedwithasbestos),alsoinbrakeliningof
carsandheadgear
Mesothelioma-entirelungisencasedbythickenedpleura,ahighlymalignanttumor
Sacroidosis
Agranulomatousdiseaseofunknownetiology The2ndmostcommonrestrictivelungdisease Morecommoninblackpeople ClassicCXR:enlargedhilarLNs(potatonodes),
hazinessofinterstitialfibrosis(alongbothlung
basesthereisaveryfinereticulonodular
pattern)
Non-caseatinggranulomainahilarlymphnodeinapatientwithsarcoidosis-notethe
multinucleatedgiantcellsandthepinkstainingepithelioidcellsrepresentingactivatedmacrophages:
Presentswithdyspnea,uveitis(blurryvision)duetoinflammationintheuveal
tract),involvementofsalivaryglandsorlacrimalglands,nodularskinlesionswith
noncaseatinggranulomas
o Also,hypercalcemia:macrophages(epitheloidcells)make1-alpha-hydroxylasehypervitaminosisDabsorptionofCa++fromgut,
reabsorptionofCa++inkidneys
Diagnosisofexclusionruleoutothercausesofgranuloma(TB,histo)
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DiagnoseviahighACE(goodmarkerofdiseaseactivityandresponsetotx)o ACEiselevatedbecauseofgranulomasinthekidney
Tx:steroids Sarcoidisthemostcommonnoninfectiouscauseofgranulomatoushepatitis(TB
isthethemostcommoncauseofinfectioushepatitis)
HypersensitivityPneumonitides
Farmerslungo Thermophilicactinomyces(amold)isblownupintheairo Hypersensitivityanddyspnea
SilofillersDiseaseo Fermentationinthesilonitrogendioxidewheezinganddyspnea.o Silosexplodebecauseofgasproductionfromfermentation
Byssinosiso Workersintextileindustry(linen,cotton,hemp)o Dyspneaduringtheweek,andMondaymorningblueswhentheyhaveto
gobacktoworkonMonday
Goodpasturesyndrome
Beginsinthelungswitharestrictivelungdiseasehemoptysis Proceedstorenaldisease
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ObstructiveLungDisease
OverviewofObstructiveDisease
Obstructiondifficultyexpiringo Compliance(filling/inspirationterm)highcomplianceinobstructive
disease,becauseelastictissuesupportisdestroyed(floppylungmakesiteasytogetairin)
o Elasticity(recoil/expirationterm)decreaseelasticityinobstructivediseasebecausethelungcollapsesonexpiration
Hyperinflationo IncreasedresidualvolumeandTLCo DiaphragmaticdepressionandAPdiameterincreaseo Asairtrappinggetsworseandworse,othervolumesarecompressed
down:tidalvolume,vitalcapacity,andothervolumesdecrease
o So,TLCandRVincreases,everythingelsedecreases FEV1/FVCwaydecreased,clearlydistinguishingrestrictivefromobstructive
lungdisease
o FEV1isverylow;cantakeagestoexpirealltheairo FVCisalsodecreased
ChronicBronchitis
Definedclinicallyasproductivecoughfor3monthsoutoftheyearfor2consecutiveyears.
Adiseaseoftheterminalbronchioleso Anatomy:mainstembronchus,segmentalbronchi,terminalbronchioles,
respbronchioles,alveolarducts,alveoli.Airflowchangesformturbulent
tolaminarattheterminalbronchioleso Smallairwaydisease;presentswithwheezing
Adiseaseofthemucusglandso Mucusglandhyperplasiainproximalairwayo Gobletcellmetaplasiao Mucousplugs
Result:V/Qmismatcho Bluebloaterscyanosisbecauseofinabilitytoventilatecloggedairways
Pinkpuffer(left)vsbluebloater(right)
oPinkpufferspredominantlyhave
emphysema,which
involvesthe
respiratoryunit,while
bluebloatershave
chronicbronchitis
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Emphysema
Adiseaseoftherespiratoryunit(i.e.,non-respiratorybronchiole)distaltowherechronicbronchitishits
o Evendestructionofrespiratoryunitandvasculaturesurroundingito EvenlossofVandQnoCO2retentionpinkpufferphenotype
respiratoryalkalosis Presentswithexpiratorywheeze COPDCXR:hardtoseetheheart,depresseddiaphragmsincreasedAPdiameter OtherCXRslikethisoccurinotherobstructivediseaseswithair-trapping:3
montholdwithRSV,newbornwithC.trachomatisPNA
Typesofemphysema:centrilobularandpanacinar CentrilobularEmphysema
o Associatedwithsmokingo Involvesupperlobeso Primarilydestructionofrespiratory
bronchiolebyneutrophils(PMNs
chemotaxinresponsetocigarette
smoke)
o Smokershavedenaturedalpha-1antitrypsin
o Triggerhappyneutrophilsdestroytheelastictissuesupportofthe
respiratorybronchiolesnoelasticrecoilcysticspaceswithair-
trapping
PanacinarEmphysemao Destructionoftheentire
respiratoryunit(panacinar)o Geneticabsenceofalpha-1
antitrypsin
o Presentsatayoungagewithdestructionofthelowerlobes
o SmokerswithacquireA1ATdeficiencycanalsohavean
elementofpanacinaremphysema
Bronchiectasis
Abnormaldilationsofbronchifurtherthanthehilum,abuttingthepleura
Mechanism:infection,destructionofelastictissuesupport,dilatationoftheairways.
Segmentalbronchifillwithpus
Presentation:cupfullsofsputum Causes
o MostcommonlyintheUS:cysticfibrosis
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o Mostcommonlyin3rdworld:TBo Kartagenerssyndrome
Immotilecilia Ciliahavea9+2configurationarrangementwithciliaand
microtubules
Absentdyneinarmabsenceofarmskeepingthe9microtubulesontheoutsidetogether
Presentswithsinusitis,bronchiectasis,infertility(spermandfallopiantubecilia)anddextrocardiawithouttranspositionof
greatvessels,orsitusinversus
Main-stembronchuscancerassociatedwithbronchiectasis.Atthetopoftheslidethereisawhitecoloredmassthathascompletelyobstructedthemain-
stembronchus:
Asthma
Canbeextrinsic(type1HPY)orintrinsic(chemicals)twoseparateentities!
Intrinsicasthma:o TriadasthmainpatientstakingNSAIDso Exercise-inducedasthmatxwithcromolyn
sodium
o Coldtemperaturecancauseasthma. Thewheezingisduetoinflammationoftheterminal
bronchiolesbecauseLTC4,D4,E4andPGscausing
inflammationandnarrowingoftheairways
IncreasedAPdiameterinchronialasthma SputumwithCharcot-Leydencrystalsinapatientwithbronchialasthma
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LungCancer
Location
CXRs:leftx-raywithaprimaryperipheraladenocarcinoma,rightx-raywithprimarycentrallylocatedcancer
Centrallylocated
o Havethehighestassociationwithsmoking.o Includesquamouscellcarcinoma(morecommon)andsmallcell
carcinoma(lesscommon)
o Generallylocatedaroundthemainstembronchuso Primarymain-stembronchuscancernotethattoothpicksarenecessary
tokeepthelumenopen.Notethewhitematerialencirclingandinvading
intothelumenofthemain-stembronchi.Thiscouldbeeithera
squamousorsmallcellcancer
o Welldifferentiatedsquamouscellcarcinomaoflungs-notethe
concentricareasofeosinophilicstainingcellsonthelowermarginofthe
side.Thesearemalignantsquamouscellswithkeratinformation(called
squamouspearls)
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Peripherallylocatedo Adenocarcinomas:themostcommonprimarylungcancer,more
commonthansquamous-moreperipheralthancentral.
o Shiftedtotheperipheryb/cofthefiltersonthecigarettes-thefilterspreventedthelargecarcinogensfrompassingin,butthesmall
carcinogensstillpassedthrough,andtheyarenottrappedinthemainstem,buttrappedintheperiphery.Thus,filtersincigarettesare
responsiblefortheincreaseinperipherallylocatedadenocarcinoma
o Thereareatleast3or4typesofadenocarcinoma. Oneobviouslydoeshaveasmokingrelationship Theonesthatdonothaveasmokingrelationshipinclude
bronchiolaralveolarcarcinoma,andlargecelladenocarcinomaof
thelung,scarcancers
Cytology:
Papsmearstainskeratinbrightred Squamouscellcarcinomainsputumspecimen:
Papsmearwithamalignantsquamouspearl-notetheconcentricappearanceof
thismalignantcellcontainingkeratin
Smallcellcarcinoma-smallcellsthatlook
likelymphocytes;thisisthemostmalignant
cancerofthelung.TxviaCtx/RT(forSCLC
surgeryisineffective).Thesetumorshave
neurosecretorygranules(canmakeADHand
ACTH)andareS-100Agpositive
Biopsyandpapsmearshowntotheright
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AslightlylessmalignanttumorwithAPUDoriginisbronchiocarcinoid.o Lowgrademalignancyofthesametypesofcellsthatproducesmallcell
carcinoma.
o Theycaninvade,metastasize,andevenproducecarcinoidsyndrome(make5-HT)
o Veryuncommon
MetastaticDisease
Themostcommoncancerofthelungbreastisthemostcommon Notethemultifocalnatureofmetastasis(left);canspreadtothevisceralpleura
(whitenodularmasses,middle),andlymphatics(whitetumorencirclingsmall
airwaysthroughoutthelungs,right)
Hornerssyndrome
Pancoasttumor/superiorsulcustumortumorsthatareintheupperlobeposteriorly(inpostmediastinum)
o Mostofthetimeiscausedbysquamouscarcinomainthatarea Tumorinvadeslocallyintothelower
trunkofthebrachialplexus,socan
getlowertrunkbrachialplexusfindings
Tumorinvadeslocallyintothesuperiorcervicalganglionknock
outsympatheticactivity
o Ptosis(eyeliddroop)o Anhydrosis(lackofsweating)o Miosis(pinpointpupil)
PleuralEffusion
Exudatevs.transudate
o Exudate:protein>3grams,andhascellsinit(PNA,pulmonaryinfarction)o Transudate:
top related