Emphysema

Background

Emphysema, along with chronic bronchitis, is part of chronic obstructive pulmonary disease (COPD). It is a serious lung disease and is progressive, usually occurring in elderly patients. It is defined as over-inflation of structures in the lungs known as alveoli or air sacs. The walls of the alveoli break down resulting in a decrease in the respiratory ability of the lungs. Patients with this disease may first experience shortness of breath and cough.

OUTLINE

Epidemiology

Disease Associations

Pathogenesis

Laboratory/Radiologic/Other Diagnostic Testing

Gross Appearance and Clinical Variants

Histopathological Features and Variants

Special Stains/Immunohistochemistry/Electron Microscopy

Differential Diagnosis

Prognosis Destructive index

Treatment

Commonly Used Terms

Internet Links

EPIDEMIOLOGY CHARACTERIZATION

SYNONYMS

INCIDENCE/PREVALENCE

AGE

SEX

GEOGRAPHY

EPIDEMIOLOGIC ASSOCIATIONS

DISEASE ASSOCIATIONS CHARACTERIZATION

PATHOGENESIS CHARACTERIZATION

LABORATORY/RADIOLOGIC/
OTHER TESTS
CHARACTERIZATION

RADIOLOGIC

The diagnosis of mild emphysema. Correlation of computed tomography and pathology scores.

Kuwano K, Matsuba K, Ikeda T, Murakami J, Araki A, Nishitani H, Ishida T, Yasumoto K, Shigematsu N.

Department of Radiology, Faculty of Medicine, Kyushu University, Fukuoka, Japan.

Am Rev Respir Dis 1990 Jan;141(1):169-78 Abstract quote
Early and accurate diagnosis of emphysema is said to be invaluable for identification of clinically silent and mild emphysema. Recently, computed tomography (CT) has been much advocated for its efficacy in detailed diagnosis of emphysema, and the results have been compared with the pathology grade of emphysema in resected lung specimens.

To assess the ability of high resolution CT scan in detecting and grading mild emphysema, we correlated the high resolution CT scan with the pathology grade of emphysema and the destructive index (DI) of lung specimens from 42 patients undergoing thoracotomy for a solitary pulmonary nodule. The high resolution CT scan and the cut surface of the lung, corresponding exactly to the same plane of the CT scan image, were assessed using the picture-grading system of Thurlbeck and coworkers on a scale of zero to 100. The CT scores for all patients ranged from 12 to 57, with a mean +/- SD of 22.1 +/- 9.6 using 1-mm collimation (n = 35), and from 7 to 46 with a mean +/- SD of 16.5 +/- 8.3 using 5-mm collimation (n = 33). The pathology scores ranged from 10 to 57, with a mean +/- SD of 23.2 +/- 9.8 (n = 42). The DI ranged from 15.4 to 67.1, with a mean +/- SD of 31.4 +/- 10.8 (n = 42). The CT scores using 1-mm and 5-mm collimation correlated significantly with the pathology scores (r = 0.68 and 0.76, respectively, p less than 0.001), and with the DI (r = 0.62 and 0.74, respectively, p less than 0.001). The pathology scores correlated significantly with the DI (r = 0.72, p less than 0.001).

We therefore concluded that high resolution CT can help to identify the presence and grading of mild emphysema.

LABORATORY MARKERS

GROSS APPEARANCE/
CLINICAL VARIANTS CHARACTERIZATION

GENERAL

VARIANTS

HISTOLOGICAL TYPES CHARACTERIZATION

GENERAL

Morphological quantification of emphysema in small human lung specimens: comparison of methods and relation with clinical data.

Robbesom AA, Versteeg EM, Veerkamp JH, Van Krieken JH, Bulten HJ, Smits HT, Willems LN, Van Herwaarden CL, Dekhuijzen PN, Van Kuppevelt TH.

Departments of Biochemistry (AAR, EMMV, JHV, THvK), Pathology (JHJMvK, HJB), Cell Biology and Histology (HTJS), and Lung Diseases (CLAvH, PNRD), NCMLS, University Medical Centre, Nijmegen, The Netherlands.

Mod Pathol 2003 Jan;16(1):1-7 Abstract quote
Small human lung specimens are frequently used for cell biological studies of the pathogenesis of emphysema. In general, lung function and other clinical parameters are used to establish the presence and severity of emphysema/chronic obstructive pulmonary disease without morphological analysis of the specimens under investigation. In this study we compared three morphological methods to analyze emphysema, and evaluated whether clinical data correlate with the morphological data of individual lung samples.

A total of 306 lung specimens from resected lung(lobes) from 221 patients were inflated and characterized using three morphological parameters: the Destructive Index, the Mean Linear Intercept, and Section Assessment. Morphological data were related to each other, to lung function data, and to smoking behavior. Significant correlations (P <.001) were observed between Section Assessment and Destructive Index (r = 0.92), Mean Linear Intercept with Destructive Index (r = 0.69) and Mean Linear Intercept with Section Assessment (r = 0.65). Section Assessment, being much less time consuming than Mean Linear Intercept and Destructive Index, is the parameter of choice for initial analysis. Destructive Index is the most sensitive parameter.

There was a significant (P <.001), but weak correlation for all three parameters with the diffusion capacity for CO (K(CO)) (Destructive Index:r = -0.28; Mean Linear Intercept:r = -0.34; Section Assessment:r = -0.32), and with FEV(1)/IVC (Destructive Index:r = -0.29; Mean Linear Intercept:r = -0.33; Section Assessment:r = -0.28), but not with other lung function parameters. A significant difference (P <.05) between (ex-) smokers and never-smokers was observed for Destructive Index and Section Assessment.

It is concluded that the application of the three morphological parameters represents a useful method to characterize emphysematous lesions in a (semi-)quantitative manner in small human lung specimens, and that Section Assessment is a suitable and fast method for initial screening. The extent of emphysema ofindividual lung specimens should be established by means of morphometry, rather than lung function data.

SPECIAL STAINS/IMMUNOPEROXIDASE/
OTHER CHARACTERIZATION

SPECIAL STAINS

IMMUNOPEROXIDASE

ELECTRON MICROSCOPY

DIFFERENTIAL DIAGNOSIS KEY DIFFERENTIATING FEATURES

PROGNOSIS CHARACTERIZATION

DESTRUCTIVE INDEX

The destructive index and early lung destruction in smokers.

Eidelman DH, Ghezzo H, Kim WD, Cosio MG.

Royal Victoria Hospital, Quebec, Canada.

Am Rev Respir Dis 1991 Jul;144(1):156-9 Abstract quote
The destructive index (DI), a measure of alveolar septal damage and emphysema, has been proposed as a sensitive index of lung destruction that closely reflects functional abnormalities, especially loss of elastic recoil.

To better understand the progression of lung destruction in smokers, we studied the contribution of its principal components: breaks in the alveolar septa (DIb) and the presence of emphysematous spaces (DIe), and compared them to the mean linear intercept (Lm) and DI as originally described. To do this we employed lungs obtained at autopsy from non-smokers and smokers. Lungs were selected by emphysema score (ES) so that all cases were emphysema free (nonsmokers and seven smokers) or had minimal emphysema (nine smokers; ES = 5). Of these indices, only DIb was significantly increased in the lungs of smokers: 17.8 +/- 1.2 versus 12.4 +/- 1.6, p less than 0.05. We also investigated the regional distribution of destruction by comparing results in upper and lower lobes. DIe, but not DIb, was significantly increased in upper lobes of smokers.

These data support the notion that increases in DI in the lungs of smokers that occur before increases in Lm or ES reflect the presence of alveolar septal breaks and highlight the importance of alveolar septal destruction as a precursor to the development of airspace enlargement in the lungs of cigarette smokers.

The "destructive index" in nonemphysematous and emphysematous lungs. Morphologic observations and correlation with function.

Saito K, Cagle P, Berend N, Thurlbeck WM.

Department of Pathology, University of British Columbia, Vancouver, Canada.
Am Rev Respir Dis 1989 Feb;139(2):308-12 Abstract quote
We examined the relationship of the newly described "Destructive Index" (DI) to emphysema using nine nonemphysematous and 13 emphysematous lungs obtained at autopsy.

The amount of emphysema was assessed by the panel method (emphysema grade, EG) and measurement of the mean linear intercept (Lm). The DI depends on three components--alveolar wall/duct disruption, DId; alveolar fibrosis, DIf; and classic emphysema, DIe. DIf was a minor component in our series. The mean DI was 5.8 +/- 2.5, 10.9 +/- 3.9, and 55.7 +/- 7.0% (+/- 1 SEM) in the nonemphysematous (panel grade EG = 0), mild (0 less than EG less than or equal to 25), and moderate to severe (30 less than or equal to EG less than or equal to 60) emphysematous lungs, respectively. The increase in the DI in mild emphysema did not reach significant levels (p less than 0.2). The mean DId was 5.6 +/- 2.5, 10.0 +/- 4.0, and 12.8 +/- 3.9% in the above categories, and the DId in mild emphysema did not differ significantly from that of the nonemphysematous lungs.

Lm showed a similar trend and alveolar disruption did not precede airspace enlargement, rather both changes appeared to advance in parallel. The DI correlated closely with EG (r = 0.83, p less than 0.01), but this was due to the component of DIe. The DIe increased steeply in the lungs with EG greater than or equal to 30.

TREATMENT CHARACTERIZATION

GENERAL

Henry JB. Clinical Diagnosis and Management by Laboratory Methods. Twentieth Edition. WB Saunders. 2001.
Rosai J. Ackerman's Surgical Pathology. Eight Edition. Mosby 1996.
Sternberg S. Diagnostic Surgical Pathology. Third Edition. Lipincott Williams and Wilkins 1999.
Robbins Pathologic Basis of Disease. Sixth Edition. WB Saunders 1999.
DeMay RM. The Art and Science of Cytopathology. Volume 1 and 2. ASCP Press. 1996.
Weedon D. Weedon's Skin Pathology Second Edition. Churchill Livingstone. 2002
Fitzpatrick's Dermatology in General Medicine. 5th Edition. McGraw-Hill. 1999.
Weiss SW and Goldblum JR. Enzinger and Weiss's Soft Tissue Tumors. Fourth Edition. Mosby 2001.

Commonly Used Terms

Basic Principles of Disease
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Commonly Used Terms
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Diagnostic Process
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Surgical Pathology Report
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Special Stains
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How Accurate is My Report?
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Internet Links

Last Updated 2/7/2003

PROGNOSIS	CHARACTERIZATION
DESTRUCTIVE INDEX
The destructive index and early lung destruction in smokers. Eidelman DH, Ghezzo H, Kim WD, Cosio MG. Royal Victoria Hospital, Quebec, Canada.	Am Rev Respir Dis 1991 Jul;144(1):156-9 Abstract quote The destructive index (DI), a measure of alveolar septal damage and emphysema, has been proposed as a sensitive index of lung destruction that closely reflects functional abnormalities, especially loss of elastic recoil. To better understand the progression of lung destruction in smokers, we studied the contribution of its principal components: breaks in the alveolar septa (DIb) and the presence of emphysematous spaces (DIe), and compared them to the mean linear intercept (Lm) and DI as originally described. To do this we employed lungs obtained at autopsy from non-smokers and smokers. Lungs were selected by emphysema score (ES) so that all cases were emphysema free (nonsmokers and seven smokers) or had minimal emphysema (nine smokers; ES = 5). Of these indices, only DIb was significantly increased in the lungs of smokers: 17.8 +/- 1.2 versus 12.4 +/- 1.6, p less than 0.05. We also investigated the regional distribution of destruction by comparing results in upper and lower lobes. DIe, but not DIb, was significantly increased in upper lobes of smokers. These data support the notion that increases in DI in the lungs of smokers that occur before increases in Lm or ES reflect the presence of alveolar septal breaks and highlight the importance of alveolar septal destruction as a precursor to the development of airspace enlargement in the lungs of cigarette smokers.
The "destructive index" in nonemphysematous and emphysematous lungs. Morphologic observations and correlation with function. Saito K, Cagle P, Berend N, Thurlbeck WM. Department of Pathology, University of British Columbia, Vancouver, Canada.	Am Rev Respir Dis 1989 Feb;139(2):308-12 Abstract quote We examined the relationship of the newly described "Destructive Index" (DI) to emphysema using nine nonemphysematous and 13 emphysematous lungs obtained at autopsy. The amount of emphysema was assessed by the panel method (emphysema grade, EG) and measurement of the mean linear intercept (Lm). The DI depends on three components--alveolar wall/duct disruption, DId; alveolar fibrosis, DIf; and classic emphysema, DIe. DIf was a minor component in our series. The mean DI was 5.8 +/- 2.5, 10.9 +/- 3.9, and 55.7 +/- 7.0% (+/- 1 SEM) in the nonemphysematous (panel grade EG = 0), mild (0 less than EG less than or equal to 25), and moderate to severe (30 less than or equal to EG less than or equal to 60) emphysematous lungs, respectively. The increase in the DI in mild emphysema did not reach significant levels (p less than 0.2). The mean DId was 5.6 +/- 2.5, 10.0 +/- 4.0, and 12.8 +/- 3.9% in the above categories, and the DId in mild emphysema did not differ significantly from that of the nonemphysematous lungs. Lm showed a similar trend and alveolar disruption did not precede airspace enlargement, rather both changes appeared to advance in parallel. The DI correlated closely with EG (r = 0.83, p less than 0.01), but this was due to the component of DIe. The DIe increased steeply in the lungs with EG greater than or equal to 30.

Epidemiology
Disease Associations
Pathogenesis
Laboratory/Radiologic/Other Diagnostic Testing
Gross Appearance and Clinical Variants
Histopathological Features and Variants
Special Stains/Immunohistochemistry/Electron Microscopy
Differential Diagnosis
Prognosis	Destructive index
Treatment
Commonly Used Terms
Internet Links

EPIDEMIOLOGY	CHARACTERIZATION
SYNONYMS
INCIDENCE/PREVALENCE
AGE
SEX
GEOGRAPHY
EPIDEMIOLOGIC ASSOCIATIONS

LABORATORY/RADIOLOGIC/ OTHER TESTS	CHARACTERIZATION
RADIOLOGIC
The diagnosis of mild emphysema. Correlation of computed tomography and pathology scores. Kuwano K, Matsuba K, Ikeda T, Murakami J, Araki A, Nishitani H, Ishida T, Yasumoto K, Shigematsu N. Department of Radiology, Faculty of Medicine, Kyushu University, Fukuoka, Japan.	Am Rev Respir Dis 1990 Jan;141(1):169-78 Abstract quote Early and accurate diagnosis of emphysema is said to be invaluable for identification of clinically silent and mild emphysema. Recently, computed tomography (CT) has been much advocated for its efficacy in detailed diagnosis of emphysema, and the results have been compared with the pathology grade of emphysema in resected lung specimens. To assess the ability of high resolution CT scan in detecting and grading mild emphysema, we correlated the high resolution CT scan with the pathology grade of emphysema and the destructive index (DI) of lung specimens from 42 patients undergoing thoracotomy for a solitary pulmonary nodule. The high resolution CT scan and the cut surface of the lung, corresponding exactly to the same plane of the CT scan image, were assessed using the picture-grading system of Thurlbeck and coworkers on a scale of zero to 100. The CT scores for all patients ranged from 12 to 57, with a mean +/- SD of 22.1 +/- 9.6 using 1-mm collimation (n = 35), and from 7 to 46 with a mean +/- SD of 16.5 +/- 8.3 using 5-mm collimation (n = 33). The pathology scores ranged from 10 to 57, with a mean +/- SD of 23.2 +/- 9.8 (n = 42). The DI ranged from 15.4 to 67.1, with a mean +/- SD of 31.4 +/- 10.8 (n = 42). The CT scores using 1-mm and 5-mm collimation correlated significantly with the pathology scores (r = 0.68 and 0.76, respectively, p less than 0.001), and with the DI (r = 0.62 and 0.74, respectively, p less than 0.001). The pathology scores correlated significantly with the DI (r = 0.72, p less than 0.001). We therefore concluded that high resolution CT can help to identify the presence and grading of mild emphysema.
LABORATORY MARKERS

GROSS APPEARANCE/ CLINICAL VARIANTS	CHARACTERIZATION
GENERAL
VARIANTS

SPECIAL STAINS/IMMUNOPEROXIDASE/ OTHER	CHARACTERIZATION
SPECIAL STAINS
IMMUNOPEROXIDASE
ELECTRON MICROSCOPY