KURSK STATE MEDICAL

UNIVERSITY
Department of
propaedeutics of inner
diseases
Neoplasm of the lung.
Pleural effusion. Dry
pleurisy.
Pneumothorax.

Lung carcinoma

Is the most common malignant

neoplasm in men throughout the world,
2nd in women (breast cancer first).
It constitutes 16% of all malignant
tumors and accounts for 28% of all
cancer deaths (35% in men and 19% in
women).
The peak incidence 55-65 years old.

Primary lung carcinoma is a major

health problem with a generally grim
prognosis

20% of all lung cancer patients have

local disease (5 years survival 30%
for males, 50% - for females)
25% - disease spread to regional
lymph nodes
55% - distant metastasis

Etiology

of lung cancer is multifactorial

Risk factors

Tobacco smoking.
Atmospheric pollution (benzpyrene,
arsenious oxide, nickel).
Occupational factors (radioactive materials,
asbestos, nickel, chromium-containing iron).
Existing lung damage COPD, lung fibrosis.
Genetic factors (loss of DNA sequences of
the short arm of chromosome 3 or 11).

Classification according to the

histology

Squamous cell carcinoma

(epidermoid)-30-35%.
Adenocarcinoma 30-35%.
Large cell carcinoma - 15-20%.
Small cell (oat cell) carcinoma 2025%.

Classification according to the

location

Centrally located (endobronchial growth):

squamous cell carcinoma,
small cell carcinoma (70%)
Peripherally located (with pleural
involvement):
adenocarcinoma,
large cell carcinoma (30%).

Staging classification

Stages (0, I, II, III a, III b, IV).

Stage grouping according to the TNM
classification:
T- primary tumor (X, 0, IS,1-4).
N- nodal involvement (0-3).
M- distant metastasis (0-1).

STAGE GROUPING

Stage 0

T is

N0

MO

Stage I

T1
T2

NO
N0

MO
MO

Stage II

T1
T2

N1
N1

MO
MO

Stage IIIa

T3
T3
T1 T3

NO
N1
N2

MO
MO
MO

Stage IIIb

Any T
T4
Any T

N3
Any N
Any N

MO
MO
M1

Stage IV

Main syndromes

Obstructive atelectasis
Lung tissue focal consolidation
Lung destruction
Intoxication
Paraneoplastic
Distant metastasis

Symptoms

Cough with sputum.

Hemoptysis.
Dyspnea.
Pain in the chest (when pleura is
involved).

Endobronchial growth
of the tumor

Occlusion of the
bronchus.
Symptoms of
obstructive
atelectasis.
Displacement of
mediastinum toward
the affected side.
Displacement of the
trachea.

Exobronchial growth of the tumor

intrathorasic spreading of the tumor

Compression of the esophagus dysphagia.

Compression of the trachea stridor.
Recurrent laryngeal nerve affection hoarseness.
Damage of the frenicus nerve elevated
diaphragm with paradoxical movements
(elevation in inspiration).
Pericardial and cardiac extension
tamponade, arrhythmia, cardiac failure.
Lymphatic obstruction pleural effusion.
Metastasis to the ribs - spontaneous fractures.
Metastasis to the lymph nodes
(supraclavicular, infraclavicular, cervical).

intrathorasic spreading of the

tumor

Compression of the
vena cava superiorStocks collar
(edema of the
neck), cyanotic
face, dilated chest
wall veins.
Pembertons sign

intrathorasic spreading of the

tumor

Pancoasts syndrome superior

sulcus tumor (lung apex carcinoma,
involvement of the C8-Th1, 2 nerves)
- Shoulder and ulnar surface radiation
pain (affection of the brachial
plexus), destruction of the 1-2nd ribs.
Pancoasts syndrome often coexists
with Horners syndrome.

intrathorasic spreading of the

tumor

Horners syndrome
(damage of the
Sympathetic
column - Th1)
ptosis,
enophthalmus,
miosis, anhydrosis
(affected side)

Extrathoracic metastasis

Brain neurologic
deficits.
Bones pain,
pathological fractures.
Bone marrow
cytopenia.
Liver biochemical
dysfunction, biliary
obstruction, pain.
Lymph nodes
metastases.

Skeletal connective tissue

syndromes
Clubbing
(30% - non small cell).

Hypertrophic pulmonary
osteoarthropathy Mary
Bumbergers syndrome
(1-10% - adenocarcinoma).

Neurologic myopathic
syndromes

Eaton Lamberts syndrome

Retinal blindness
Peripheral neuropathy
Subacute cerebellar degeneration
Cortical degeneration
Polymyositis

Coagulation and thrombotic

and hematologic syndrome (18%)

Trousseaus syndrome migratory venous

thrombophlebitis.
Nonbacterial thrombotic endocarditis with
arterial emboli.
Disseminated intravascular coagulation
with hemorrhage.
Anemia.
Granulocytosis.
Leucoerythroblastosis.

Cutaneous manifestation
(1% or less)

Dermatomyositis.

Acanthosis
nigricans.

Renal manifestation (1% or

less)

Nephrotic syndrome.
Glomerulonephritis.

Paraneoplastic syndromes
Systemic
symptoms
[30%] anorexia,
weight loss
(cachexia),
fever,
suppressed
immunity.

Paraneoplastic syndromes

Endocrine &
metabolic
syndromes [12%]hypercalemia,
hypophsphatemia,
hyponatremia,
Cushing's syndrome,
ectopic
gonadotropin,
hypoglycemia

Investigations
X-ray

Investigations
scintigraphy
Scintigraphy
with Tc99.
Defect of Tc99
accumulation in
cancer region

Investigations
computer tomography

Investigations
Bronchoscopy

Biopsy (bronchoscopy,
needle aspiration, pleural,
lymph node biopsy)
Lag cell
cancer

Small
sell
cancer

squamo
us

adenocarcino
ma

Treatment

Surgery resection.
Radiation therapy.
Chemotherapy.
Immunotherapy.
Laser therapy.

Pleurisy with effusion.

Etiology and pathogenesis
Pleural fluid accumulates when pleural fluid
formation exceeds pleural fluid absorption.
Reasons:
Excess pleural fluid formation:
1. from the parietal pleura.
2. from the interstitial spaces of the lungs.
3. from the peritoneal cavity.

Decreased fluid removal by the lymphatics.

The first step

whether the
transudative or an

is to determine
patient has a
exudative effusion.

A transudate the fluid that passes through a

membrane (capillary walls).
A transudative pleural effusion occurs when
systemic factors that influence the formation and
absorption of pleural fluid are altered.
An exudate accumulation of fluid in a cavity or
matter that penetrates through vessel walls into
adjoining tissue or the production of pus or
serum.
An exudative pleural effusion occurs when local
factors that influence the formation and
absorption of pleural fluid are altered.

The leading causes of exudative effusion:

Bacterial pneumonia (-300.000 per year).

Malignancy (-200.000 per year).

Viral infection (-100.000 per year).

Pulmonary embolism (-75.000 per year).

The leading causes of transudative
effusion:

Left cardiac failure (-500.000 per year).

Cirrhosis (-50.000 per year).

Pulmonary embolism (-75.000 per year).

Etiology

Transudative Pleural Effusion

a. Congestive heart failure
b. Pericardial diseases
c. Cirrhosis
d. Nephrotic Syndrome
e. Superior vena cava obstruction
f. Myxedema
g. Urinothorax
h. Pulmonary emboli
I. Peritoneal dialysis
J. Meigs syndrome

Etiology

Exudative Pleural Effusion

Neoplastic diseases
Metastatic disease
Mesothelioma (primary tumor from the
mesothelial cells that line the pleural cavities)
Infectious diseases ( Bacterial, Fungal,
Tuberculosis, Viral, Parasitic)
Pulmonary embolism
Gastrointestinal diseases (Esophageal
perforation, Pancreatic disease, Intra-abdominal
abscess, Diaphragmatic hernia, After abdominal
surgery)
Collagen - vascular diseases (rheumatoid
pleuritis, Systemic lupus erythematosus,
Wegeners granulomatosis)

Etiology

Exudative Pleural Effusion

Post-cardiac injury syndrome

Asbestos Exposure
Sarcoidosis
Uremia
Hemothorax, Chylothorax
Drug-indused pleural disease
Radiation therapy

Main Syndromes

Accumulation of
fluid in the
pleural cavity

Compressive
atelectasis

Clinical Manifestations
Complaints:

Fever, chills (empyema of pleura)

Pain in the chest (increases in cough and deep
respiration)
Dyspnea (respiratory insufficiency due to
compression of the lung)
Cough - dry (reflexogenous)
In mediastinal pleurisy
dysphagia (compression of the esophagus)
compression of the superior vena cava (edema
of the face, neck and the hands)
compression of the recurrent nerve
(hoarseness)
General Intoxication (general weakness,
oversweating, anorexia)

Objective Examination
Inspection
Asymmetry of the
chest
Tracheal
displacement away
from the fluid
Lagging of the
affected side
Protrusion of the
intercostal spaces

Objective Examination
Palpation

Vocal fremitus
Increased over the
compressed lung

Diminished or
not transmitted at
the area of the
fluid accumulation

Objective Examination
Percussion

Dullness over the area of fluid.

Damoiseaus curve.
Garlands triangle on the affected side characterized
by a dulled tympanic sound. It corresponds the lung
pressed by the effusion compression atelectasis.
Rauchfuss-Grocco triangle is found on the healthy
side and is a kind of extension of dullness determined
on the affected side. The sides of the triangle are
formed by the diaphragm and the spine, while the
continued Damoiseaus curve is the hypotenuse.
Absence of the Traubes space in the left sided
pleuritis

Objective Examination
Percussion
Garlands
triangle

Damoiseaus
Curve
Effusion

RauchfussGrocco triangle
(due to
displacement of
the
mediastinum)

Objective Examination
Auscultation

In the region of accumulated

fluid -diminished vesicular
breathing or not auscultated

Above the effusion - bronchial

breathing - echo like
(compressive atelectasis)

Bronchophony over the

effusion is not determined

Objective Examination
Cardiovascular System

Displacement of the heart by the

effusion onto the healthy side.
Tachycardia.
Deafened heart sounds.

Investigations
X-ray and ultrasound

Homogenous
density

Diaphragmatic
pleurisy is
characterized by a
limited mobility of
the diaphragm.

Investigations
Blood Test

Leukocytosis marked leukocytosis

is characteristic of purulent pleurisy
Sometime eosinophilia
ESR increased
Tuberculosis pleurisy is
characterized by lymphocytosis

Diagnostics (pleural fluid)

Feature

Transudative

Exudative

Appearance

Clear, thin,
non-clotting

Cloudy,
viscous

LDH

Normal

Increased

Protein

<30g/l

>30 g/l

Relative density

1.006-1.012

1.018-1.022

Rivaltas reaction

Negative

Positive

WBC

Absent or few in
number

Large number, RBC

may present

Fluid/serum LDH
ratio

<0,6

>0,6

Fluid/serum protein
ratio

<0,5

>0,5

Dry Pleurisy
Complaints:

Pain in the chest ( increased during

breathing and coughing)
Dry cough
Subfebrile temperature. General
weakness.

Objective Examination
Inspection

forced posture
(on the affected
side or sitting)
superficial
respiration
unilateral
thoracic lagging

Objective Examination
palpation and percussion

Painful palpation of trapezoid and large

thoracic muscles (Sternbergs and
Pottengers signs).
decreased mobility of the lung border on
the affected side

Objective Examination
Auscultation

pleural friction
rub

Investigations
X-ray
- Limited mobility of the diaphragm
Blood test
- Moderate leukocytosis

Pneumothorax
Presence of gas in the pleural
space

Pneumothorax
1. Spontaneous pneumothorax occurs without
antecedent trauma to the thorax
A. Primary spontaneous occurs in an
individual without underlying lung disease.
B. Secondary with underlying lung disease
2. Traumatic pneumothorax caused by
penetrating or non-penetrating chest injuries
3. Tension pneumothorax in which the pressure
in the pleural space is positive throughout
the respiratory cycle

Complaints

Pain in the chest

Dyspnea
Dry cough
Palpitation

Clinical manifestations
Inspection.

asymmetrical
chest.
Displacement of
the trachea to
the opposite side
lagging of the
affected side
intercostal
spaces are
increased and
smoothed

Clinical manifestations.
Palpation.

Subcutaneous
emphysema (in
traumatic
pneumothorax )
vocal fremitus is
decreased or absent

Clinical manifestations.
Percussion.

tympanic percussion sound

shift of the mediastinum to the opposite
side

Clinical manifestations.
auscultation.

diminished vesicular
breathing or absent

Connection of the
pleural cavity with
bronchus amphoric
breathing

In open pneumothorax
metallic breathing

Investigations
X-ray