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					                 Chapter 8 Diseases of Respiratory System



OBSERVATION METHODS OF SPECIMEN


     The visceral pleura overly the lungs, through which many polygonal lobules are
visible. Normal lungs are light red, soft, and sponginess. Weight of adult lungs is
equivalent to 1/50 of body weight. The left lung is divided into two lobes (upper and
lower); the right lung has three lobes (upper, middle, lower). The main bronchi branch
dichotomously give rise to gradually smaller and smaller bronchi.
     While observing the sample we should discern which side of lung it is, if the
pleura has exudation, adhesion and is thickened .While observing the lung sections,
we should notice the distribution, thickness and color of the bronchi, the mucous
membrane is smooth or not, bronchus lumens are dilated or narrow. See if there are
exudation, secretions, blood clotting, foreign material, neoplasm , etc ,in the bronchus
lumens; whether the thickness of the bronchial wall is normal; whether the alveoli are
dilated(focal or diffused) or not; whether there are consolidation and neoplasm in the
lung parenchyma. Observe the position, size, shape, distribution, structure, texture and
color of the lesions, their relations with bronchi, changes around the lesions and
lymph node at the hilum of lung, etc.
     Observing the tissue sections of lung should note the lung structure Grossly: with
low power microscopy, observe if there are changes on the pleura, the structure of the
alveolus, the status of the bronchi and blood vessels, the structure and distribution of
the lesions and their relations with the bronchi and surrounding tissues. On the basis
of observation in low power microscopic appearance, we can choose one or several
lesions to observe especially with the high power microscope, focusing on the tissue
structure and morphologic characteristics of the lesion ,etc.



AIMS


                                                                                       1
1. To grasp the pathological characteristics and relationship between clinic and
     pathology of lobar pneumonia, lobular pneumonia and viral pneumonia.
2. To grasp the pathological characteristics and clinical pathological correlation of
     chronic bronchitis, pulmonary emphysema, bronchiectasis, silicosis and chronic
     cor pulmonale.
3. To grasp the pathological characteristics and clinic pathological correlation of
     lung cancer.
4. To comprehend the pathological characteristics and relationship between clinic
     and pathology of asthma, sarcoidosis, idiopathic pulmonary fibrosis, ARDS, and
     nasopharyngeal carcinoma.



CONTENTS


                                Gross specimen            Tissue section

Chronic obstructive             Emphysema                 Chronic bronchitis
pulmonary diseases
                                Bronchiectasis            Emphysema

                                                          Asthma

                                                          Bronchiectasis

Chronic cor pulmonale           Changes of the heart      Changes of the lung

Pneumonia                       Lobar pneumonia           Lobar pneumonia

                                Lobular pneumonia         Lobular pneumonia

                                                          Viral pneumonia

Diffuse interstitial diseases   Silicosis                 Silicosis

                                Asbestosis                Asbestosis

                                                          Sarcoidosis

                                                          Idiopathic pulmonary fibrosis
Respiratory distress                                      ARDS
 syndrome


                                                                                          2
Lung cancer                    Centralized type              Small cell carcinoma

                               Peripheral type               Bronchioloalveolar carcinoma

                               Diffuse type                  Large cell carcinoma

                                                             Carcinoid of lung




KEY POINTS OF SPECIMEN OBSERVATION
1. Chronic obstructive pulmonary diseases
(ⅰ) Chronic bronchitis
Basic pathologic changes
Histopathology
   ◆   Pathological changes occur originally in the larger airways, then involve
        gradually the smaller bronchi and bronchioles.
   ◆   Injury and repair of mucosa epithelium. There is degeneration, necrosis and
        desquamation accompanied by an increased number of goblet cells and
        squamous metaplastic changes in the lining epithelial cells.
   ◆   Hyperplasia and hypertrophy of the glands and serous metaplasia of mucous
        glands in the submucosa is the diagnostic feature of chronic bronchitis in the
        major airways. Mucus plug may appear in the bronchial lumens.
   ◆   Hyperemia, mononuclear cells and neutrophils infiltration, rupture of smooth
        muscles and atrophy and calcification of cartilage can be seen in the bronchial
        walls.
Specimen observation
Case abstract: Male, 74 years old, a cigarette smoke. He has coughed and
expectorated white spumous sputum for 20 years, which occurred in every winter and
spring and last up to 3 months every year. Physical examination: the chest signs are
weak breath sound to auscultation and few moist rales in the lower left lung.
Laboratory examination: WBC: 10.2×109/L. Chest X-ray: lung texture increases.
Tissue section (Fig.8-01 a,b,c,d):
       To observe the changes of epithelium of the mucosa, glands, cartilage and


                                                                                        3
smooth muscle of bronchi, whether there is obstruction in the lumens of the bronchi,
and the changes of lung tissue around the bronchi.
(a) The lining epithelial cells are necrosis and desquamation accompanied by
   lymphocytes and plasma cells infiltration, and the smooth muscles are rupture.
(b) Squamous metaplastic changes in the lining epithelial cells.
(c) Atrophy and calcification of cartilage in the bronchial walls.
(d) The mucous glands are hyperplastic and hypertrophic; the serous glands show
   metaplasia of mucous glands in the submucosa.
Question: What are the pathologic changes that lead to cough and the production of
sputum in patients with chronic bronchitis?


(ⅱ) Emphysema
Alveolar emphysema
Basic pathologic changes
(1) Gross morphology
   ◆   The lungs appear voluminous with round margin.
   ◆   The color of lungs looks pale, and the cut surface of the lungs is alveolate.
   ◆   The lung tissue is pillowy with decreased elasticity.
(2) Histopathology
   ◆   Abnormal enlargement of the airspaces; thinning and destruction of alveolar
       septa; the adjacent airspaces can combine into large bullae.
   ◆   Obvious loss of the pulmonary capillaries surface area; fibrous thickness of
       intima of the pulmonary small arteries.
   ◆   Bronchiolitis involving the terminal and respiratory bronchioles.


Specimen observation
Case abstract: Male, 65 years old. He has suffered chronic bronchitis for 13 years.
Dyspnea accompanied by wheezing after physical labor occurred 5 years ago.
Physical examination: Inspection: Barrel-chest; Percussion: hyper-resonance;
Auscultation: weak breath sound and scattered dry rales. Chest X-ray: The
                                                                                       4
transparency of bilateral lungs increases.
Gross specimen (Fig.8-02): ① To observe the volume and texture of lung and the
changes of lung sections. ② What type of emphysema is this sample classified as?
What diseases may cause it?
Tissue section (Fig.8-03a,b):
       To observe the alveolus changes, especially its size, the width and destruction of
alveolar walls. See if the capillaries of the alveolar walls, bronchi and bronchioles
have changes.
Question: Why patients with pulmonary emphysema often develop hypoxia?


Interstitial emphysema
Gross specimen (Fig.8-04): Toruliform small gas vacuoles distributed reticular in
lobular septa and subpleura, and the gas spread to the hilum and mediastinum, causing
the hilum and mediastinum emphysema.


(ⅲ) Asthma
Histopathology
   ◆   An increase in number of goblet cells and in size of the submucosal glands.
       There are hypertrophy of the bronchial wall muscle, and thickening of the
       basement membrane of the bronchial epithelium.
   ◆   An inflammatory infiltrate in the bronchial walls, with a prominence of
       eosinophils, monocytes, lymphocytes and plasma cells.
   ◆   There are occlusion of bronchi and bronchioles by thick, tenacious mucous plugs.
       Histologically the mucous plugs contain Curschmann spirals and Charcot-leyden
       crystals.
Specimen Observation
Case abstract: Male,26 years old. Ten years ago, she suffered from dyspnea,
wheezing and chest distress triggered by pollens. Anti-allergic medicine and
antiasthmatic medicine could relieve the symptoms.
Tissue section (Fig08-05a,b): (a) An inflammatory infiltrate in the bronchial walls.
                                                                                        5
The airways are filled with mucous plugs, and pink, needle-like Charcot-leyden
crystals are present. (b) The bronchial wall muscle are hyperplasic with infiltration of
eosinophils, and the lumen contains Curshman spiral.


(ⅳ) Bronchiectasis
Basic pathologic changes
(1) Gross morphology
   ◆   The most severe involvements are found in the smaller bronchi and bronchioles
       which are dilated. The dilated segments may be long and tube-like (cylindroid),
       or they may be fusiform or saccular in shape.
   ◆   The lumens of the affected bronchi are characteristically filled with suppurative
       yellow-green, sometimes hemorrhagic exudates.
   ◆   In the more chronic cases, fibrosis of peribronchial lung tissue often develops.
(2) Histopathology
   ◆   There is chronic inflammatory exudate within the walls of the affected airways
       that is associated with desquamation of the lining epithelium and extensive areas
       of necrotizing ulceration.
   ◆   Fibrosis of the bronchial and bronchiolar walls and peribronchiolar fibrosis
       develop.
Specimen observation
Case abstract: Female, 27 years old. She has coughed and expectorated yellow
purulent sputum for 18 years. Hemoptysis occurred 3 years ago. Physical examination:
the chest signs are moist rales to auscultation in the lower left lung. Chest X-ray: The
texture of the lower left lung increase, and there are several irregular annular bright
shadows. CT: The thickness of the bronchial walls increases, and the dilated bronchi
of the lower left lung appear cylindroid or saccular in shape.
Gross specimen (Fig.8-06):
       To focus on the pathological changes of the bronchi and their surrounding tissue.
       ① To notice the sizes and shapes of the lumens of the bronchi. ② Whether
there is obstruction in the lumens of the bronchi, and if so, result from what reason?
                                                                                          6
③ What changes occurred in the bronchial walls and the peribronchial lung tissue?
④ How to diagnose bronchiectasis by gross observation?
Tissue section (Fig.8-07a,b):
       Compared with the tissue section of chronic bronchitis, observe the size, shape
and content of bronchial lumens, the changes of bronchial mucous membrane, the
wall of bronchi and their surrounding tissues, etc.
Question: Why patients with bronchiectasis often cough with large amounts of
purulent sputum when their body postures change?         Can bronchiectasis result in the
cor pulmonale and lung cancer? Why?


2. Chromic cor pulmonale
Basic pathologic changes
(1) Gross morphology
   ◆   Changes of the lung: we can see the original lesions, such as chronic bronchitis,
       and emphysema, etc. in the lung tissue.
   ◆   Changes of the heart: the right ventricular wall develops hypertrophy, and its
       thickness exceeding 0.5cm right under the pulmonary artery valve 2cm is the
       diagnosis criterion of chronic cor pulmonale in pathology. The right ventricle
       may be dilated and the pulmonary arterial cone is significantly inflated.
(2) Histopathology
   ◆   In the lung tissue pathological changes of original pulmonary diseases can see
       the loss of the capillaries.
   ◆   The small arteries are affected with increase in muscular thickness of the media,
       and there are muscularization of arterioles, arteriolitis accompanying with
       organizing or recanalized thrombi and with the loss of the capillaries.
   ◆   Myocytes of the right ventricle develop hypertrophy with enlarged and
       deep-staining nucleus.
Specimen observation:
Case abstract: Male, 64 years old. He has coughed and expectorated for 20 years,
panting after physical labor for 10 year. These symptoms aggravated one week ago,

                                                                                        7
coughing with purulent sputum. Physical examination: The body temperature is
normal. Heart rate 130 times / min. Systole phase noises can be heard in the district of
bicuspid valve. The chest shows the signs of pulmonary emphysema. Liver shows
enlargement. The lower limbs are edematous. The chest X-ray: The transparency of
the lung increase. The texture of the lower lobes appears the shape of residual root.
The diameter of the heart increases with the round and blunt cardiac apex. The
pulmonary artery segment is protruded and the diameter of the right lower pulmonary
artery increases.
Gross specimen (Fig.8-08): ① To observe the thickness of right ventricular wall,
the changes of the trabeculae carneae, papillary m, cardiac chamber and pulmonary
artery cone. ② To notice the changes of cardiac valve, epicardium and left heart.
Tissue section (Fig.8-09a,b,c): (a) The media of the small muscular artery thicken. (b)
Muscularization of arterioles. (c) Arteriolitis accompanying with thrombosis and
organization of thrombus.
Question: What’s the mechanism of the hypertrophy and dilatation of the right heart
in the chronic cor pulmonale? Why patients at the late stage of chronic cor pulmonale
can show congestion of systemic circulation?


3. Pneumonia
(ⅰ) Lobar pneumonia
Basic pathologic changes
       Four anatomic stages of lobar pneumonia have classically been described of
congestion, red hepatization, gray hepatization, and resolution.
(1) Gross morphology
   ◆   The lesion usually involves a segment or even whole lobe of the lung.
   ◆   The affected lobe is swollen.
   ◆   The color is dark red or gray.
   ◆   With the development of the lesion, the consistency changes from soft to firm
       (liver-like) and then to soft.
(2) Histopathology
                                                                                       8
   ◆   Vascular engorges, while in gray hepatization the capillaries in the alveolar wall
       are compressed.
   ◆   Intra-alveolar contents are different in different stages, the basic component is
       large amounts of fibrinous exudates, and massive exudation with red cells (red
       hepatization) or large amounts of neutroplils (gray hepatization).
   ◆   The underlying alveolar wall architecture is preserved.
   ◆   If the fibrinous exudates are not completely dissolved, they will be organized by
       granulation, called pulmonary carnification.
Specimen observation
Case abstract: Male, 29 years old. After suffering from cold, he got high fever, chill,
rapid breathing and chest pain. After two days, he coughed with “rusty” sputum. In
hospital he was considered to be pneumonia and given drugs like sulphanilamide.
Physical examination: body temperature 40 ℃, breath rate 32 times /min. The chest
signs are dullness to percussion and vocal fremitus enhancement to palpation in the
middle right lung and upper left lung. Chest X-ray: the anterior segment of right upper
lobe and the apex-posterior segment of left upper lobe become consolidated and show
large-area uniform dense well-delimited shadow (Fig.8-10). Laboratory examination:
WBC: 20.0×109/L
Gross specimen (Fig.8-11a,b): ① To notice whether the volume of lung increases,
and what changes does the pleura have? ② What changes and color do the lung
sections have? ③ Which stage is this type of pathological change defined? What
symptoms and signs can the patients at this stage have?
Tissue section (Fig.8-12a,b,c,d,e): ① To notice how the pathological changes
distribute in lung tissue. ②To observe the pathological characteristics of the lung
parenchyma, whether the alveolar septa are destroyed, whether the capillaries are
dilated and what contents are in the alveoli. ③ Which stage is the histopathological
change defined? Why?
Question: Which type of inflammation dose the lobar pneumonia belong to? Why do
patients cough with the “rusty” sputum? Can the involved lung tissue be recovered
completely?
                                                                                        9
(ⅱ) Lobular pneumonia
Basic pathologic changes
(1) Gross morphology
   ◆   Gray-yellowed foci of inflammatory consolidation distribute patchily throughout
       one or several lobes on the surface and the cut surface.
   ◆   The lesions vary in size up to 1cm in diameter, and irregular, and poorly
       delimited at their margins.
   ◆   The cross section of bronchiole is usually seen in the center of the foci.
   ◆   Confluence of foci occurs in the more florid instances, producing the appearance
       of total lobular consolidation.
(2) Histopathology
   ◆   The bronchiole wall is hyperemic and edematous, and neutrophils infiltrate. The
       mucosal epithelial are necrosis, and a suppurative exudates fills the bronchi and
       bronchioles.
   ◆   Adjacent alveolar spaces are filled with suppurative exudates, RBC and necrotic
       alveolar epithelium.
   ◆   In severe instances, the foci may confluent to present patchy distribution.
   ◆   The adjacent alveolar spaces show compensating emphysema.
Specimen observation
Case abstract: Male, 70 years old. He had suffered hypertensive heart disease and
left heart failure for half a year, and cough and expectoration for 1 year. These
symptoms aggravated 4 days ago with fever and purulent sputum. Physical
examination: body temperature 38 ℃, pulses 112 times / min, breath rate 35
times/min, blood pressure 22.6/13.5 kPa. Lips appear cyanosis. The chest signs are
resonance to percussion and the scattered moise rales to auscultation in the bilateral
lungs. Laboratory examination: WBC: 10.2×109/L The chest X-ray: there are several
scattered patchy shadows evidently in bilateral lower lobes.
Gross specimen (Fig8-13a,b): ① To notice the volume change of lung and the
exudate on the pleura. ② To observe the characteristics of the lesions on the lung

                                                                                      10
surface and section, such as shape, color and distribution.
Tissue section (Fig8-14a,b,c): ① Are the pathological changes focal or diffused? ②
To pay attention to the characteristics, involvement of pathological changes and the
relation between bronchioles and foci. ③ What changes occur to the lung tissue
surrounding the foci? Can you call it pulmonary emphysema, why?
Question:what differences are between lobar pneumonia and lobular pneumonia?


(ⅲ) Viral pneumonia
Basic pathologic changes
(1) Gross morphology
   ◆   The lesions are usually unobvious. The affected lung tissue are congested and
       edematous, and the volume of the lungs is only mildly increased.
(2) Histopathology
   ◆   The alveolar septa are widened and edematous and have a mononuclear
       inflammatory infiltrate of lymphocytes, histocytes. Predominant is the interstitial
       nature of the inflammatory reaction.
   ◆   The alveolar spaces are free of exudates but may contain a proteinaceous fluid.
   ◆   In severe cases, there are intra-alveolar exudates, and the alveolar epithelial cells
       are degeneration and necrosis.
   ◆   Sometimes there are pink hyaline membranes lining the alveolar walls, and
       multinuclear giant cells.
   ◆   Viral inclusion body (the round or oval shape, erythrocyte-like in size, acidophil
       and having peripheral vacant space) can be seen in cytoplasm and nucleus of the
       hyperplastic epithelium and multinuclear giant cell.


Specimen observation
Case abstract: Male, 5 years old. After catching cold the boy showed pharyngagia,
weakening, high fever and coughed with no sputum. Physical examination: body
temperature 39.5 ℃, pulses 140 times / min, breath 45 times / min. The chest signs
are dullness to percussion in the lower left lobe and weaken breath sound and a small
                                                                                          11
amount of moist rales in the bilateral lobes. Laboratory examination: WBC: 9.5×109/L;
the proportion of lymphocyte is 0.60. Chest X-ray: The texture of bilateral lung
increases. The lower left lung show large patchy shadow.
Tissue section (Fig.8-15a,b,c):To observe the changes of alveolar septa, the types of
the inflammatory cells infiltrated in the lesion, and the exudate in the alveoli.
Question: ① What are the differences of pathological changes among lobar
pneumonia, lobular pneumonia and viral pneumonia? ② Which part of the lung does
the viral pneumonia involve? And what pathogen can result in this kind of pneumonia
besides to virus? ③ What’s the main evidence to diagnose the viral pneumonia in
histology?


4. Diffuse interstitial diseases
(ⅰ)Silicosis
Basic pathologic changes
(1) Gross morphology
   ◆   Gray-white, 2-5mm in diameter, hard silicotic nodules can be palpated in the
       lung substance.
   ◆   In the late stages, the silicotic nodules coalesce with fibrotic lung tissue to form
       conglomerate masses, some of which may undergo central cavitation due to
       necrosis and liquefaction.
   ◆   The pleura are dense fibrosing thickened.
(2) Histopathology
   ◆   Silicotic nodules: in early stage, the nodules are the local aggregation of
       macrophages phagocytosed the silica, and progressively undergo fibrosis and
       hyaline degeneration.
   ◆   Diffuse pulmonary interstitial fibrosis.
   ◆   According to the number , size and scope and extent of fibrosis of the silictic
       nodules, silicosis is divided into 3 stages: stageⅠ: silicotic nodules are small
       and few, only located in the hilum; stageⅡ: silicotic nodules are large and more,


                                                                                         12
       but the scope <1/3 of the whole lung; stageⅢ: silicotic nodules coalesce into
       tumor like masses, the scope >1/3 of the whole lung.
Specimen observation
Case abstract: Male, 45 years old, working on porcelain casting for 20 years. He has
coughed and expectorated repeatedly for 9years and panted for 5 years. Physical
examination: body temperature 37.6℃. The breath sound of bilateral lungs is weak
and no rale can be heard. Chest X-ray: Bilateral lungs show shadows of several big
nodules with the size of 3cm×2.5cm. The shadow of the hilum of lung, the lung
texture and the transparency of lung increase.
Gross specimen (Fig.8-16): ①There is a large number of carbon powder deposited
in the lung which makes the lung tissue black. ② To look for small ashen nodules on
the black background of the lung. ③What changes do the involved lung tissue and its
surrounding tissue occur? ④What changes does the lymph node at the hilum of lung
occur?
Tissue section (Fig.8-17a,b): ① To observe and describe characteristics of the
pathological changes, which kind of pathological change is what you see? ② What
changes does the surrounding tissue have?
Question: ① If the patients with early stage of silicosis leave the environment of
silicon, whether their pathological changes can be fully recovered or stop developing?
② Why the patients at late stage of silicosis often present the clinic symptoms of
severe dyspnea and hear failure? ③ Why are the patients easy to develop the
complication of pulmonary tuberculosis?


(ⅱ) Asbestosis
(1)Gross morphology
   ◆   Diffuse interstitial fibrosis results in the shrinkage and the hardness of the lungs.
   ◆   If accompanied with apparent emphysema and bronchiectasis, the affected
       regions become honeycombed.
   ◆   The pleura undergoes thickening, and well-circumscribed pleural plaques form.
       The plaques exhibit the appearance of ivory and the consistency of leather and

                                                                                          13
       with irregular bosselations on the surface.
(2)Histopathology
   ◆   There are large amounts of alveolar epithelial cells and macrophages in the
       alveolar spaces.
   ◆   Diffuse interstitial fibrosis accompanying with lymphocytes and monocytes
       infiltration.
   ◆   Asbestos bodies are found in the walls of the bronchioles or within alveolar
       spaces.
Specimen observation
Gross specimen (Fig.8-18): The lungs are shrinkage and the pleura is diffuse
thickening to form yellow-white, well-circumscribed, bosselated pleural plaques.
Tissue section (Fig.8-19a,b): Fibrosis of pulmonary interstitium. Asbestos bodies
appear as golden brown, beaded rods in the fibrosis tissues or within alveolar spaces.


(ⅲ) Sarcoidosis
Basic pathologic changes
   ◆   Non-specific alveolitis, noncaseating granulomas and pulmonary interstitial
       fibrosis are presented.
   ◆   The granulomas are composed of an aggregate of tightly clustered epithelioid
       cells, with Langhans giant cells. Central necrosis is unusual Stellate inclusions
       known as asteroid bodies and Shaumann bodies are enclosed with giant cells.
Specimen observation
Tissue section (Fig.8-20): Noncaseating granulomas are present, consisting of tight
clusters of epithelioid macrophages and multinucleated giant cells.


(ⅳ) Idiopathic pulmonary fibrosis
Basic pathologic changes
(1) Gross morphology
   ◆   The lungs become shrinkage and solid, gray-white, and small cysts are seen to
       give the appearance of the honeycomb lung on the cut surface.
                                                                                      14
(2) Histopathology
   ◆   In the early stages, there is patchy interstitial chronic inflammation, later there is
       diffuse interstitial fibrosis.
Specimen observation
Tissue section (Fig.8-21): There is diffuse pulmonary interstitial fibrosis as well as
thickening of the interstitial septa, and the pneumocytes are hyperplasia.


5. ARDS
Basic pathologic changes
   ◆   The lungs are congestion, edema and the alveolar walls are lined with waxy
       hyaline membranes. There are also local lung collapse.
Specimen observation
Tissue section (Fig.8-22): The alveoli are lined by eosinophilic hyaline membranes,
consisting of precipitated plasma proteins and fibrin and nuclear debris from sloughed
epithelial cells.


6. Carcinoma of the lung
Basic pathologic changes
(1) Gross morphology
   ◆   Lung carcinoma can be divided into three types, which are the centralized lung
       carcinoma, diffuse lung carcinoma and peripheral lung carcinoma.
(2) Histopathology
   ◆   The four major histologic types of bronchogenic carcinoma are squamous cell
       carcinoma, adenocarcinoma, small cell carcinoma and large cell carcinoma.
Specimen observation
Case abstract: Male, 68 years old, a cigarette smoker. He has coughed and
expectorated for 15 year. The sputum contained blood for 20 days. The chest X-ray: A
round shadow with coarse edge can be seen at the hilum of the left lung. Chest CT:
the bronchus of upper left lobe is narrow, and a soft tissue lump is found around the
left bronchus.

                                                                                           15
Gross specimen (Fig.8-23a,b,c): ① To observe the location of the lesion and its
relation with the hilum of lung and larger bronchus. ② To observe the size, shape ,
distribution , color , texture and boundary of the lesion. ③ What changes do the
bronchial lymph node and the pulmonary hilar lymph node occur? ④ Which type
does the carcinoma belong to according to gross morphology?
Tissue section (Fig.8-24a,b,c,d) :① What’s the histologic type of the carcinoma? ②
What’s the significance of histologic classification of the lung carcinoma?



CASE DISCUSSION
Case 1
Case abstract. 25 years old, male. He suffered chill, fever, cough with brown sputum
and chest pain for 1 week.
Present medical history. About one week ago, he feel malaise, then suffered chill,
fever with body temperature 40℃. The symptoms alleviated slightly after treated by
antibiotics. He still suffered chill and high fever on the second day. He developed
chest pain, dry cough accompanying with brown reddish sputum then developed
dyspnea in the afternoon.
Past history. Healthy.
Physical examination. Good nutrition, consciousness, high fever features, mandible
lymph nodes swell, tenderness (+). There are herps around mouth, congestion at
pharynx. Tubular breath sound can be heard at right scapular region, no dry rales and
wet rales; Heart rate: 100/min. Body temperature: 39.7℃,X-ray: there are large piece
of clouding shadow at upper lobe of right lung.
Blood routine. WBC: 15000, st: 19, S: 76, L: 5.
Process of treatment. After treated by antibiotics and anti-symptom therapy, fever
relieved rapidly; symptoms disappeared. He discharged after 3-week treatment.
Discussion
     1. What is the diagnosis of the case?
     2. What lesions does this case show?


                                                                                   16
     3. What are the reasons of these symptoms, signs and abnormal results of lab
examination?



Case 2
Case abstract. 65 years old. She showed cough with purulent sputum after catching
cold 15 years ago. Since then, she developed cough and expectoration of white
spumous sputum every winter and spring. Since 3 years ago, she felt breath shortness
and palpitation after physical labor. Pitting edema occurred repeatedly on her lower
limbs for 2 years. Two months ago after catching cold, she developed fever, cough
with purulent sputum, palpitation, breath shortness, and abdominal distension, and
couldn’t lie down. The patient failed to rescue and died after being in hospital.
Physical examination. Body temperature 37.6 ℃, pulses 102times / min, breath rate
30 times / min, blood pressure 13.5/10.5kPa. Chronic sickness appearance, up-straight
sit breathing , sleepiness, dark purple lip and skin, cervical venous engorgement,
barrel-shape chest, hyper-resonance to percussion, scattered dry and moist rales. Heart
rate 102 times / min, cardiac rhythm is normal. Abdominal bulge, a large amount of
ascites, the liver is hard with the rim under the rib 7.8cm, Lower limbs show pitting
edema.
Laboratory examination: Hemoglobin 98g/L, leukocyte 6.7X109/L.
Autopsy findings. There are 250ml accumulating fluid respectively in the Left and
right thoracic cavity, and 500ml light-yellow transparent accumulating liquid with the
specific gravity of 1.012 in the abdominal cavity. The lungs appear voluminous and
inflated weighing 760 grams each. In the section of the lung scattered ashen
consolidation areas can be seen, more severely affecting lower lobes.
Histological features. airspaces are dilated, alveolar septa become thin and partly
destructed. Edema fluid, Neutrophils, deciduous necrotic epithelia fills the
bronchioles and adjacent alveolar spaces. An increased number of goblet cells and
squamous metaplastic changes can be seen in the lining bronchial epithelial cells.
Hyperplasia and hypertrophy occur to mucous glands. Focal calcification and fibrosis


                                                                                     17
of cartilage develop. Fibrous tissue proliferates. Mononuclear cells and neutrophils
infiltrate are present.
     The weight of the heart is 350g. The thickness of the right ventricular wall is
0.55cm. The right ventricle is obviously dilated with thickening of trabeculae carneae
and papillary muscle. The pulmonary arterial cone is inflated. The live shows
cardiogenic liver cirrhosis. Extensive congestion and degeneration of parenchyma
cells occur to other organs.
Discussion
     1. To make a diagnosis according to the clinical manifestation and autopsy
        examination and state the diagnostic basis.
     2. To explain the process of the development of the disease of this patient.
     3. To explain the patient’s symptoms and signs with the pathological changes.



PRACTICE REPORT
     1. To paint the histological morphology of lobar pneumonia.
     2. To describe the pathologic characteristic of lobular pneumonia.
     3. To write out the discussion outline of case2.



QUESTIONS FOR REVIEW
     1. If it could be called lobar pneumonia when confluent lobular pneumonia
        involves the entire lobe?
     2. Which diseases learned could cause chronic cor pulmonale.
     3. If the silicotic nodules are granuloma? What is the difference to foreign body
        granuloma?
     4. Which type of lung cancer has the worst prognosis?


                                          ( Haerbin Medical University Zhao Ruibo )




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