Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Today's lecture will cover 4 concepts :1- Pleural lesion 2- Paraneoplastic syndromes 3- Nasopharyngeal carcinoma 4- Laryngeal tumors Pleural lesions Primary intra-pleural bacterial infections Pleural effusion Pleuritis Pneumothorax Primary neoplasm of the pleura Malignant mesothelioma Pleural effusion Is the presence of fluid in the pleural space Types of pleural effusion Pleural effusion classify to different types according to the pleural fluid there are various methods to classify the pleural fluid Classification of pleural fluid By pathophysiology By the origin of the fluid: Transudative pleural effusion Exudative pleural effusion Serous fluid (hydrothorax) Blood (haemothorax) Chyle (chylothorax) Pus (pyothorax or empyem a) What is the difference between exudate and transudate ? Exudate fluid ------ protein content greater than 2.9 gm/dl While Transudate fluid ----- less protein content ( less than 2.9 gm/dl transudative pleural effusions ** also called hydrothorax ** The most common cause is CHF , also may occur due to cirrhosis( Liver failure ) ,Renal failure like nephrotic syndrome ( excessive loss of protein with urine) ** Releasing of cytokines or inflammatory mediators --increasing permeability of lung capillaries --- The excessive interstitial lung fluid pass through the visceral pleura and accumulates in the pleural space. Exudative pleural effusion Pneumonias ** there is inflammatory cells --- pleuritis --- more dangerous --- sometimes with fibrinous , hemorhagic and suppurative --- fibrous organization – fibrous pleural thickening --- minimal to massive calcifications ** no inflammatory cells --- no pleuritis *****// Hemorrhagic- Cancer ,TB, Infarcts ** four common • causes :- ) Viral pleuritis • 2) Pulmonary infarction 1 • 3) Cancer ( lung carcinoma , mesothelioma , metastatic • neoplasms to the lung or pleural surface ) 4) Microbial invasion through either direct extension of • a pulmonary infection or blood – borne seeding ( suppurative pleuritis or empyema ) • Exudative pleural effusion ** less common causes :1* Autoimmune diseases like SLE , rheumatoid arthritis and uremia ,2* as well as previous thoracic surgery Whatever the cause , Transudates and serous exudates usually are resorbed without residual effects if the cause is controlled or remits Classification of pleural fluid By pathophysiology By the origin of the fluid: Transudative pleural effusion Exudative pleural effusion Serous fluid (hydrothorax) Blood (haemothorax) Chyle (chylothorax) Pus (pyothorax or empyem a) Hemothorax ** the collection of blood in the pleural cavity ** almost always fatal ** is a complication of a ruptured intrathoracic aortic aneurysm / trauma Chylothorax ** is the collection of chyle in the pleural cavity ** chyle – formed in the digestive system , accumulate in the lymphatic ducts , consist of microglobules of lipids which will mix with milky lymphatic fluid in the lymphatic ducts ** occur due to disruption or obstruction of the thoracic duct. Obstruction occur due to intrathoracic cancer ( primry OR SECONDARY mediastinal neoplasm such as lymphoma ) Chylothorax ** always significant Pneumothorax ** presence of air in the pleural sac ** occur in young , healthy , usually men without any known pulmonary disease ( simple /spontaneous / primary ) or as a result of thoracic /lung disorder ( secondary ) , emphysema , lung abscess , TB , carcinoma , asthma ** Traumatic – Penetrating injury – ** tension Pneumothorax – Complications of pneumothorax 1) Hydropneumothorax the presence of both air and fluid within the pleural space surrounding the lung 2) Pyopneumothorax The accumulation of air (or other gas) and pus in the pleural cavity. With prolonged collapse Common symptoms of pleural effusion: • Chest pain • Ipsilateral shoulder pain – diaphragm ((At the same side )) Non-productive cough – Pleural lesions Primary intra-pleural bacterial infections Pleural effusion Pleuritis Pneumothorax Primary neoplasm of the pleura Malignant mesothelioma Malignant mesothelioma ** rare cancer of mesothelial cells :-- usually arising in the parietal or visceral pleura -- less commonly occur in the peritoneum and pericardium ** related to occupational exposure to asbestos in the air ( 50% of patients ) Living in proximity to an asbestos factory / asbestos worker ** latent period for developing malignant mesothelioma is long ( 25 to 40 years ) cuz multiple somatic genetic events are required for neoplastic conversion of a mesothelial cells ** asbestos ie not removed or metabolized from the lung , the fibers remain in the body for life Asbestos exposure 1- P16/CDKN2A ( 9p21 locus) 2- NF1 (22q12 locus ) Gathering near the mesothelial cell layer Generate reactive o2 species 1) Inactivation of Tumor suppressor genes like :- DNA damage ONCOgenic somatic mutations lead to :- 2) Inactivation of p53 and RB mesothelioma Start as pleural fibrosis with plaque formation Then the affected lung is ensheathed by firm yellow-white sometimes gelatinous layer of tumor Mesothelioma microscoply /histologically conform to one of three patterns :1) Epithelial mesothelioma :** most common pattern ** may confused with a pulmonary adenocarcinoma ** epithelial cells turn cancerous , Once epithelial cells become cancerous they are called epithelioid cells , they lose uniformity or otherwise become atypical in appearance ** Epithelioid cells occur more commonly in cases of malignant pleural mesothelioma rather than peritoneal mesothelioma. ** epithelial cells lack mobility , less likely to spread to distant locations , may spread to nearby lymph nodes and from there migrate locally via the lymphatic system . ** there is A certain type of epithelial mesothelioma occurs more commonly in women, and it’s known as well-differentiated papillary mesothelioma ( projecting of small papillary buds ) . 2) Sarcomatous :** sarcomatoid cells are loosely organized, and they can migrate easily, leading to quicker metastasis. ** cells appear elongated, spindle-shaped and often form a fibrous pattern( fibroblastappearing cells ) ** Some epithelioid cells may be present within sarcomatoid tumors, but by definition they must make up less than 10 percent of the tumor’s mass . Epitheial - Most common pattern - Most effective treatment options - slow metastasis , spread by lymphatic System - less aggressive Sarcomatous - Least common pattern - the most resistance to cancer therapies - quicker metastasis , spread easily - More aggressive 3) Biphasic ** have both sacromatous and epithelial areas diagnosis 1- patient's medical history. A history of exposure to asbestos may increase clinical suspicion for mesothelioma. 2- physical examination . 3- chest X-rays may reveal pleural thickening 4- LFT 5- CT scan 6- biopsy treatment ** poor prognosis ** Mesothelioma is generally resistant to radiation and chemotherapy treatment -Long-term survival and cures are exceedingly rare ** immunotherapy and surgery could be used