1、病理學管毅剛高雄榮民總醫院胸腔外科主任病理學 為醫學領域的一門分支學科 專門探討疾病在個體發生的 起因 發展及變化 以及整個過程對患者產生的各種影響。呼吸系統呼吸系統 上呼吸道疾病 鼻腔、咽和喉；常見但致命疾病少見 急性、慢性發炎 息肉 腫瘤 肺臟和氣道疾病 含氣管及支氣管 胸膜及胸膜腔疾病急性、慢性發炎(1) 感染性鼻炎(infectious rhinitis) 俗稱感冒(common cold) 病毒感染 常見病源：腺病毒、鼻病毒、伊科(echo)病毒 卡他性(catarrhal)鼻腔炎症 過敏性鼻炎(allergic rhinitis) IgE增加組織胺分泌增加 鼻黏膜嗜酸性白血球浸潤
2、季節性過敏性鼻炎花粉熱(hay fever) 過敏原：花粉、黴菌孢子 常年性過敏性鼻炎(perennial allergic rhinitis) 以屋內塵蟎、真菌等微生物引發本病為主 鼻息肉(Nasal polyp) 反覆鼻炎引起之鼻腔突起物 非真正腫瘤 可引起鼻腔阻塞 手術治療，但容易復發Paranasal sinus急性、慢性發炎(2) 鼻竇炎(sinusitis) Paranasal sinus發炎 卡他性炎症 鼻炎鼻竇炎 急性慢性 鼻竇炎 顱腔骨髓炎和顱內感染急性、慢性發炎(3) 咽炎(pharyngitis)和扁桃腺炎(tonsilitis) 常同時發生 多為病毒感染，但續發性細菌感
3、染亦常見 鏈球菌感染風濕熱、腎小球腎炎 嚴重扁桃腺炎需手術治療急性、慢性發炎(4) 急性會厭炎(acute epiglottitis) 好發於嬰幼兒 多為流行性感冒嗜血桿菌引起 可引起嚴重上呼吸道阻塞而死亡 喉炎(laryngitis) 感染、過敏、吸煙或其他化學性刺激引起 白喉(diphtheria)：喉部偽膜聲帶息肉(vocal cord polyp)聲帶結節(vocal cord nodule) 吸煙或過度使用聲帶 如教師、牧師、歌手、小販 (singers nodule, teachers nodule, screamers nodule) 聲音沙啞 手術治療上呼吸道腫瘤(1) 鼻腔及
4、副鼻竇腫瘤 乳突狀瘤(papilloma)：三型，少數演變為惡性 鱗狀細胞癌(squamous cell carcinoma) 鼻咽癌(nasopharyngeal carcinoma) 廣東腫瘤(Canton tumor) EB (Epstein-Barr virus) 成年男性 癌症死亡第13位(2002年) 鼻涕帶血、留鼻血、鼻塞、頸部淋巴結腫大 顱底侵襲 未分化癌(undifferentiated carcinoma)或鱗狀細胞癌 未分化癌中常有癌細胞浸潤於淋巴組織間又稱淋巴上皮瘤(lymphoepithelioma) 放射線治療Nasopharyngeal carcinoma上呼吸道
5、腫瘤(2) 喉癌(laryngeal carcinoma) 中老年男性 吸煙 漸進性聲音沙啞、吞嚥困難、頸部淋巴結腫大 多為鱗狀細胞癌laryngeal carcinoma肺臟和氣道疾病 2002年非癌症之主要死亡原因 肺炎：第7位 支氣管炎、肺氣腫及氣喘：第11位 結核病：第12位 國人十大癌症死亡原因 肺癌： 男性第2位 女性第1位炎症 支氣管炎 肺炎 大葉性肺炎 支氣管肺炎 間質性肺炎 吸入性肺炎 肺膿瘍支氣管炎(Bronchitis) 急性支氣管炎(acute bronchitis) 感染或其他刺激物 大多數自癒，少數併發肺炎 可氣道阻塞 慢性支氣管炎(chronic bronchit
6、is) 二年、每年三個月、持續帶痰咳嗽 吸煙 氣管及支氣管黏液腺肥大，呼吸道上皮鱗狀化生 細支氣管(bronchiole)亦常有發炎及管腔變窄 可併發肺氣腫，氣道阻塞肺炎(pneumonia, pneumonitis) 感染性肺炎 細菌性肺炎 大葉性肺炎、支氣管肺炎 發燒、不適、咳嗽、有痰、胸痛及呼吸困難 非典型肺炎(atypical pneumonia) 間質性肺炎 非感染性炎症 吸入化學物質Pneumonia (RLL)支氣管肺炎(bronchopneumonia, lobular pneumonia) 氣管炎或支氣管炎的延伸 可形成多發性病灶 兒童、老人 葡萄球菌、鏈球菌、嗜血桿菌 慢性
7、心衰竭及癌末病人常見大葉性肺炎(lobar pneumonia) 炎症波及肺葉絕大部分或一整個或多個肺葉 肺炎鏈球菌(Streptococcus pneumoniae) 四階段 水腫充血期 紅色肝變期(red hepatization)：大量滲出液內含紅血球、嗜中性白血球、纖維蛋白 灰色肝變期(gray hepatization)：紅血球遭破壞、纖維蛋白化膿性滲出液持續存在 消解期(resolution)：滲出液堅實化後被酵素分解，再被巨噬細胞吞噬移除 併發症：胸膜炎、胸膜腔滲液、胸膜腔積膿、肺膿腫、敗血症、腦膜炎、心內膜炎、關節炎等Lobar pneumonia間質性肺炎(interstit
8、ial pneumonitis) 肺泡中隔和間質組織炎症 Atypical pneumonia 肺炎黴漿菌(mycoplasma pneumoniae)、病毒或其他細菌 Idiopathic interstitial pneumonia 肺臟纖維化疾病SARS (1)(Severe Acute Respiratory Syndrome) 2003年，Hanoi，Dr. Urbani Atypical pneumonia China, Hongkong, Taiwan, Toranto of Canada, Singapore Coronavirus (冠狀病毒)SARS (2)(Severe
9、Acute Respiratory Syndrome) 飛沫、接觸體液傳染 潛伏期3-7天、可能超過十天 症狀(Fig 11-6)，出現症狀後始具傳染力 X-ray and CT：肺部浸潤 Pathology: patchy organizing pneumonia, diffuse alveolar damage, respiratory distress syndrome (呼吸窘迫), respiratory failure (呼吸衰竭) 電子顯微鏡：SARS virus in type II pneumocytes No vaccine Mortality rate: 15%吸入性肺炎
10、(aspiration pneumonia) 氣體、液體、固體微粒 引起細菌感染、機械性阻塞及化學性傷害 溺水、酒醉、昏迷、虛弱、食道或神經病變的病患 污水、胃液和食物 多為支氣管肺炎Aspiration pnemoniaSup. Segment, RLL肺膿腫(pulmonary abscess) 局部化膿性病變 病因：口咽部手術、上呼吸道感染、頭頸部膿腫、支氣管擴張 併發症：胸膜炎、腦膜炎、腦膿腫、全身性感染氣喘(asthma) 支氣管通道收縮引起的陣發性呼吸困難及wheezing，又稱支氣管氣喘(bronchial asthma) 心因性氣喘氣喘(asthma)分類 外因性 過敏性原因，
11、又稱allergic asthma 過敏原：花粉、塵螨、毛或微生物 兒童期開始反覆發病 IgE 非過敏性原因 Infectious asthma: 常為病毒感染 Occupational asthma: 有機或無機物質引起 內因性 可經由drugs, pressure, sport, chemical substance or infection引起 Mechanism: not clear氣喘(asthma) 病理 小支氣管及細支氣管為黏液阻塞 黏液中可發現Eosinophil, Curschmann spiral, Charcot-Leyden crystal 管壁水腫及炎症細胞浸潤 管壁
12、平滑肌spasm及肥大 黏膜下層黏液腺增大 Status asthmaticus支氣管擴張症(bronchiectasis) 破壞管壁結構或增加外在牽引力 支氣管和細支氣管不正常且永久性的擴大 Etiology: TB, pneumonia, tumor, foreign body, asthma, chronic bronchitis, cystic fibrosis, congenital abnormality 局部性或瀰漫性 症狀：chronic productive cough, respiratory difficulty, clubbing finger, fever, pulm
13、onary abscess, cyanosis, cor pulmonale, brain abscess, etc.肺膨脹不全(atelectasis) 先天性 Premature baby Associated with hyaline membrane disease (neonatal respiratory distress syndrome, lack of surfactant) 後天性 因支氣管、肺臟或胸膜疾病引起的肺臟塌陷及無氣狀態 易引起感染 胸痛、呼吸困難、cyanosis；無咳嗽或咳血肺氣腫(emphysema) 肺臟腺泡不正常且永久性的擴大 無纖維化現象 Larger
14、 pulmonary compliance than normal individuals Barrel chest Broader definition includes Senile emphysema, compensatory emphysema, obstructive overinflation, interstitial emphysema肺氣腫(emphysema)Chronic Obstructive Pulmonary Disease (COPD) Respiratory difficulty and airway obstruction Emphysema, chroni
15、c bronchiolitis, brochiectasia, bronchial asthma Pink puffer Emphysema, older age, rapid and short respiration, adequate oxygenation, no cyanosis Blue bloater Chronic bronchiolitis, younger age, much sputum, cor pulmonale, cyanosis, swellingPulmonary edema and pulmonary congestion Left heart failure
16、 Macrophage in alveoli (heart failure cell) Brown induration: 血鐵質堆積+纖維化Pulmonary embolism Emboli from vein of lower extremities Chest pain, respiratory difficulty, pulmonary infarction, sudden deathAdult Respiratory Distress Syndrome (ARDS) Diffuse alveolar damage Acute respiratory failure Overall m
17、ortality: 50% Etiology: shock, infection, sepsis, fat embolism, drowning, aspiration of toxic substance, irradiation, drugs Pathology: Exudative phase (acute phase): intra-alveolar edema, exudate, aggregation of inflammatory cells, type II pulmonary cells hyperplasia, hyaline membrane in alveoli Org
18、anizing phase: fibroblast hyperplasia in alveolar wall, hyaline membrane removed by macrophage, fibrosis of alveolar septum, cystic change of lung parenchymaARDSPneumoconiosisTumor of Lung 肺癌最常見，多為bronchogenic carcinoma No. 1 cancer death in western country No. 2 cancer death in Taiwan (2002) 中老年男性常
19、見 女性增加中：吸煙女性增加 Etiology: smoking, air pollution, chemical substance, radiation, genetic factor, scar cancer Smoking Odds ratio:10 Amount, duration 80% of lung cancer patients are smokers肺癌種類 Non-small cell carcinoma Squamous cell carcinoma Hilum, larger airway, 1/3 of all lung Ca, smoking Adenocarci
20、noma 1/3, female and non-smoker, scar cancer Bronchioloalveolar carcinoma 沿肺泡壁生長，易誤為間質性肺炎 Large cell carcinoma Less common Small cell carcinoma 1/5, paraneoplastic syndrome, hilum, smoking, oat cell carcinoma, poor prognosis, chemotherapyClinical symptoms and Complication Cough, weight loss, chest p
21、ain, dyspnea, hemoptysis, pneumonia, pleural effusion, hoarseness, dysphagia, rib destruction, lung abscess, fever Superior vena caval syndrome Horner syndrome Apical tumor, Pancoast tumor Cervical sympathetic ganglion invasion Ipsilateral ptosis, miosis, and not sweating in the forehead Paraneoplas
22、tic syndrome Endocrine abnormalities, hypercalcemia, clubbing fingerTreatment and Prognosis of Lung Cancer Worst: small cell cancer, chemotherapy or radiation NSCLC: surgery Metastatic lung cancer: Multiple, from breast, stomach, colon, ovary, uterus, prostate, bone, liver etc. Hamartoma, carcinoidO
23、ther lung diseases Sarcoidosis Granuloma, hilar lymph nodes or skin, eyes, liver, spleen and bone marrow Asteroid body and Schaumann body in multinucleated giant cell Scandinavian and black people Good prognosis, spontaneous resolution 50%, steroid胸膜及胸膜腔疾病 Visceral pleura, parietal pleura, pleural c
24、avity, pleural fluid Pleural effusion Increased hydrostatic pressure: CHF Decreased oncotic pressure: Nephrotic syndrome, liver cirrosis Increased vascular permeability: pleuritis, pneumonia, TB, lung abscess, pulmonary infarction, bronchiectasis, metastatic cancer, systemic infection or inflammatio
25、n Impaired lymphatic drainage: mediastinal malignancy increased negative pressure in pleural cavity: atelectasisPleural effusionFluid in Pleural Cavity Exudate Inflammatory pleural effusion, parapneumonic pleural effusion Increased vascular permeability due to inflammatory pleural diseases Pyothorax
26、, empyema bacteria or fungus Adhesion, fibrosis, obliteration of pleural cavity, limitation of lung expansion Transudate Imbalance of hydrostatic and oncotic pressure Hydrothorax Hemothorax trauma, ruptured aortic aneurysm, coagulopathy, inflammation, tumor Chylothorax Thoracic duct injury, impaired
27、 lymphatic drainage by tumorPneumothorax Spontaneous pneumothorax Young male, subpleural bleb rupture, apex Simple pneumothorax: young healthy individuals Complicated pneumothorax: associated with emphysema, asthma or TB Traumatic pneumothorax Penetrating trauma, barotrauma Tension pneumothoraxPneum
28、othoraxMesothelioma Benign or malignant Asbestosis21.所謂歌手的結節是指：(A)鼻息肉 (B)手指結節 (C)喉癌 (D)聲帶息肉22.鼻咽癌的發生跟下列何者關係密切： (A)乳突狀瘤 (B)病毒感染 (C)吸煙 (D) 外傷23.大葉性肺炎的初期病理變化為： (A)充血 (B)灰色肝變 (C)紅色肝變 (D)纖維化24.氣喘病患體內何種抗體會明顯增加：(A)IgA (B) IgG (C) IgD (D) IgM25.支氣管擴張症好發於：(A) 肺臟上葉 (B) 肺臟下葉 (C) 肺尖 (D) 肺門 26.新生兒呼吸窘迫症候群的發生與何者密切相關：(A)先天性畸形(B)休克(C)表面張力素不足(D)細菌性肺炎27.肺氣腫的病因不包括：(A)吸煙(B)礦物微塵(C)纖維化(D)肺水腫28.最易引起副贅瘤症候群的肺癌是(A)小細胞癌(B)大細胞癌(C)鱗狀細胞癌(D)腺癌29.與石綿塵最有關的腫瘤是(A)喉癌(B)良性間皮瘤(C)乳頭狀瘤(D)惡性間皮瘤30.心衰竭細胞出現在(A)心臟(B)肺臟(C)肝臟(D)腎臟
