RESPIRATORY SYSTEM-

AUTOPSY
INTRODUCTION
 Lungs are a pair of respiratory organs situated in
the thoracic cavity
 Covered by the parietal pleura and visceral
pleura
 spongy texture

 Brown / grey to mottled black

 Rt lung weighs 360 to 570g. 50 – 100g heavier

than Lt.
GROSS FEATURES
 Conical shape
 Apex

 Base

 Three borders – anterior, posterior & inferior

 Two surfaces – costal and medial

 Lobes – 3 in right and 2 in Left lung

 Fissures – 2 in right and 1 in left lung

LOBES AND FISSURES
OBLIQUE FISSURE
 Runs downwards and forwards cutting posterior
border 6cm below apex and inferior border 5cm
from the median plane
HORIZONTAL FISSURE
 Runs from anterior border horizontally and
meets the oblique fissure
ROOT OF THE LUNG

RIGHT LUNG
 2 bronchi – eparterial and hyparterial
 One pulmonary artery between the bronchi

 2 pulmonary veins – upper anteriorly and lower

below the bronchus
LEFT LUNG
 Single bronchus posteriorly
 One pulmonary artery above bronchus

 2 pulmonary veins – upper anterior to and lower

below the bronchus
ROOT OF LUNG
BRONCHIAL TREE
 Trachea divides into two principal bronchi – Rt
and Lt
 Principal bronchi divides into secondary lobar
bronchi one for each lobe
 Lobar bronchi divide into tertiary or segmental
bronchi one for each bronchopulmonary segment
10 on each side
 Segmental bronchi divide repeatedly to form
terminal bronchioles and then respiratory
bronchioles which aerates the pulmonary unit
BRONCHIAL TREE
 AUTOPSY
 Wooden block placed under the spinal column.
 Y shaped incision made from anterior axilla to form an angle
at xiphoid process. From here incision extends to symphysis
pubis passing left of umbilicus.
 After, skin & muscles dissected away from thorax.
OPENING OF THORACIC CAVITY
 Done by cutting
through cartilaginous
portion of ribs with rib
knife.
 First ICS incised.
Next ribs are cut
starting with 2nd rib
extending parallel to
costochondral jn.
 Sternum with attached
cartilaginous ends of ribs is
lifted & outer portion of
pericardium dissected from
posterior wall of sternum.
 1st rib cut with cartilage
knife from below &
sternoclavicular jt opened
from its posterior aspect
 Now pleural cavity is
inspected for presence of
fluid, dullness, fibrin,
adhesions, plaques and
masses.
LUNGS IN THORACIC CAVITY-NORMAL

Dr.D.Gomathinayagam, M.D.,
NORMAL LUNG: PLEURAL SURFACE

Dr.
D.G
oma
thin
aya
gam
,
M.D.
ABNORMALITIES OF PLEURAL
CAVITY
PNEUMOTHOR
AX
 Complication of pulmonary
diseases ( emphysema, TB,
asthma)
 Spontaneous idiopathic
 Trauma
DIAGNOSIS
 Fill the space between ribs
and thoracic skin flap with
water and look for escape
of air bubbles while
incising the 1 st IC space.
EFFUSIONS WITHOUT PLEURITIS
 Clear straw coloured
HEMOTHORAX
serous ( hydrothorax )
clear straw coloured serous
(hydothorax)– CCF
 Frank blood ( hemothorax
) – ruptured aortic
aneurysm, cardiac rupture,
thoracic trauma
 Milky white chyle (
chylothorax ) –
obstruction by
malignancies
HEMOTHORAX

Dr.
D.G
oma
thin
aya
gam
,
M.D.
CHYLOTHORAX

Dr.
D.G
oma
thin
aya
gam
,
M.D.
EFFUSIONS WITH PLEURITIS

 Serofibrinous – inflammation of adjacent lung (

TB, pneumonia, infarct, abscess, bronchiectasis
).systemic diseases ( RA, SLE )
 Purulent yellow green pus ( empyema ) –
suppurative infection of adjacent lung.
 Bloody exudates – neoplasms, rickettsial
disease, coagulation disorders
 Fibrous adhesions – after healing , particularly
empyema
 Plaques – primary or secondary neoplasms
EMPYEMA

Dr.
D.G
oma
thin
aya
gam
,
M.D.
 SEROFIBRINOUS
EMPYEMA PLEURITIS
MASSES
 Solid with whorled
appearance ,
occasional cyst – SFT
 Soft gelatinous
greyish pink tumour
tissue – malignant
mesothelioma
 Variable nodularity –
metastasis.
MESOTHELIOMA

Dr.
D.G
oma
thin
aya
gam
,
M.D.
LARNYX, TRACHEA & BRONCHI
 After removal of chest organs, larynx, trachea
and both bronchi are opened along their posterior
walls and inspect mucosa.
CONGENITAL ANOMALIES
 AGENESIS
 HYPOPLASIA
 HETEROTOPIC
TISSUE
 VASCULAR
ANOMALIE
 TRACHEAL AND
BRONCHIAL
ANOMALIES
 CONGENITAL CYSTS
 BRONCHOPULMON
ARY
SEQUESTRATION
ABNORMALITIES OF LARYNX
 Edema of glottis – mucosa swollen
 Pseudomembranous inflammation – fibrinous
exudate removed without leaving ulcer
 Diphtheritic or necrotising inflammation –
necrosis with fibrinous membrane, removal yields
bloody ulcer
 Laryngotracheobronchitis – mucosa hyperemic
and edematous, young children
 TB – small nodules, shallow ulcer with undermined
margins
 Syphilis – gummatous ulcers, large stellate scars
 Tumours – benign polyps, papilloma, fibroma.
Malignant primary or secondary
 PAPILLOMA
SCC LARYNX
LARYNX
ABNORMALITIES OF TRACHEA
 Congenital anamolies – tracheoesophageal
fistula , branchial fistula
 Tracheitis – red and edematous

 Tumors – chondromas, osteomas

 Obstructed lumen – FB, primary tumors or

tumor fragments from oral cavity or larynx
ABNORMALITIES OF BRONCHI
 Acute catarrhal bronchitis – mucosa red and glossy

 Chronic bronchitis – excess mucous or

mucopurulent secretion, increased Reid index

 TB – tubercles through out mucosa, chronic

peribronchial TB affecting small bronchi

 Bronchial asthma – thick mucous plugs, thickening

of wall. Alternating areas of over distention and
atelectasis.

 Occasionally FB occurs
ASTHMA:INFLATED EXTRA

Dr.
D.G
oma
thin
aya
gam
,
M.D.
Bronchiectasis –
dilated airways ( 4 times
) that reach pleural
surface, filled with pus
Types
 Diffuse – CF, ciliary
dyskinesia,
immunodeficiency states
 Localised – post
infection ( TB,
suppurative
pneumonias, measles)
BRONCHIECTASIS

Dr.
D.G
oma
thin
aya
gam
,
M.D.
EXAMINATION OF LUNGS
 Lungs removed by cutting bronchi close to carina
and root structures as far away from hilus as
possible
 Left lung removed first

 Weigh the lungs

 Inspect lungs for anamolies including lobation,

the visceral pleural surface
 Palpate the lung for consistency, crepitation

 Examine bronchi, vessels, parenchyma and

lymphnodes
DISSECTION OF FRESH LUNGS
 Lungs placed with their
anterior surface in the
immediate view of the
dissector
 Left lung dissected first
 With long knife, incise
anterior surface from apex
to base of upper lobe
 Rotate through 90 degree
so that lateral margin
faces the dissector
 Second incision goes along
lateral margin starting at
upper portion of UL and
extending through base of
LL.
 Right lung cut in
similar fashion but
first section also cut
through middle lobe
 While examining c/s ,
cross sections of
bronchi, their
ramifications and
blood vessels also
investigated
particularly for emboli
OTHER METHODS
 Dissection from the hilus:
Pulmonary artery & bronchi are
opened from hilus toward periphery of
mediastinal surface.
Subsequently lungs are cut into
several sagittal slices parallel with the
mediastinal surface.
Continuity of the organ is lost, so

difficult to identify original site of

individual slices.
 Dissection in transverse plane
 Hilar region faces up &lateral pleural surface on
the cutting board.
 Incision made from apex to base of

pulmonary lobes along their longest lateral

axis parallel to cutting board.
 In the hilar region cut using scissors

 Finally all vascular and bronchial branches

opened.
WET FIXATION OF LUNGS
 Generally one lung dissected fresh other formalin
fixed

SIMPLE GRAVITY METHOD

 Lungs inflated through main bronchus with
about 2L of 10% formalin solution with a large
syringe from a bottle 30 – 50cm above specimen.
 The bronchus is clamped and lung floated in a
formalin bath.
 Fixation time – 3 days.
WET FIXATION OF LUNGS
FORMALIN PERFUSION
TECHNIQUE (
PRESSURE FIXATION )
 Pressure set in range of 15
– 95cm of water.
 Fixative cascades through
staked plastic containers
and flows through nozzles
tied into main bronchus.
 An electric pump causes
the fixative to circulate
 After 3 or more days of
continuous cascade
perfusion can be sliced.
ABNORMALITIES OF LUNGS
Postmortem changes – LL dark bluish purple
due to hypostasis.

Atelectasis (collapse) – airless areas appear

small dark blue and fleshy.
 Diagnosis – make incision through lung under
water. Ascertain if putrefaction has set in or not.
Emphysema
 Lungs large, pale and overdistended
 Aircushion consistency
 Dilated and fused alveoli seen as small gas
bubbles
Types
 Centriacinar – UL worse, normal and
emphysematous areas within same lobule/ acini
 Panacinar – LL worse, acini uniformly enlarged
 Distal acinar ( paraseptal ) – subpleural, along
lobular septa
 Irregular – associated with fibrosis
EMPHYSEMA

Dr.
D.G
oma
thin
aya
gam
,
M.D.
EMPHYSEMATOUS BULLAE
Edema of lungs – enlarged, heavy firm, . c/s –
large amount of red foamy liquid.

Chronic passive congesion – airless, firm with

rust brown colour.
Pulmonary
embolus
 Source – DVT of lower
extremities
 Embolus – may be
large coiled, snakelike
and smooth. Lodges in
the main pulmonaryA
, its major or small
branches or at the
bifurcation ( saddle
thrombus )
PULMONARY SADDLE EMBOLUS

Dr.
D.G
oma
thin
aya
gam
,
M.D.
PULMONARY EMBOLISM

Dr.
D.G
oma
thin
aya
gam
,
M.D.
Fat emboli
 Follows fracture of long bones, operations in fatty
tissues
 Pulmonary A opened under water and watched for
escape of fat droplets

Air emboli
 Follows injections of air into body, operations(
laproscopic ) , cutting of large veins, decompression
sickness/ caisson disease
 Again pulmonary A may be opened under water

Amniotic fluid embolism

 Presence of lanugo hair, fat from vernix caseosa or
mucin within pulmonary vasculature
INFARCTS
Haemorrhagic infarcts
 Firm airless
 Wedge shaped with apex
containing blocked artery
and pointing towards hilus
 Mc in LL, multiple
 c/s – early – granular
raised red blue
 Late – pale, red brown
 If fibrous replacement –
GW peripheral zone

Septic infarct – yellow with

soft granular centre
containing pus
PNEUMONIA

Bronchopneu
monia
 Slightly elevated,
granular, firm
 Gray red to yellow

 Poorly demarcated,
patchy distribution
 Multilobar, often
basilar
Lobar pneumonia
 Consolidation of large
areas of lobe or entire lobe
Stages
 Congestion – lungs heavy
boggy
 Red hepatization – airless,
red, firm ( liver like
consistency )
 Gray hepatization – gray
brown, firm, dry
 Resolution – return to
normal app of parenchyma
 Organization – firm, gray
tan
PNEUMONIA
  LUNG ABSCESS
Atypical viral / interstitial
pneumonia
 Heavy red with prominent white
streaks indicating outlines of
lobules
 U/L or B/L, patchy or confluent
consolidation

Lung abscess
 Yellow or red yellow areas filled
with pus In the midst of a
pneumonic area
 Follows infarct, pneumonia

Gangrene of lung
 Irregularly bound cavity with
green brown foul smelling liquid
CHRONIC DIFFUSE INTERSTITIAL
LUNG DISEASE( RESTRICTIVE)
Coal workers
COAL WORKERS
ANTHRACOSIS LUNG
PNEUMOCONIASIS
pneumoconiasis(CWP)
 Anthracosis – large
firm black coloured
 progressive massive
fibrosis or
complicated CWP –
black scars 2 – 10cm
diameter. Usually
multiple.
 Simple CWP-coal
macules and coal
nodules.
PNEUMOCONIOSIS:FIBROUS PLEURAL PLAQUE

Dr.
D.G
oma
thin
aya
gam
,
M.D.
Silicosis – hard
scars with central
softening and
cavitation. Fibrotic
lesions in hilar
lymphnodes and
pleura
ASBESTOS RELATED DISEASES
 Localised or diffuse pleural fibrosis.
 Pleural effusions.

 Parenchymal interstitial fibrosis.

 Lung carcinoma.

 Mesothelioma.
Honey comb lung
- end stage
interstitial
fibrosis – cysts of
varying size surrounded
by gray tan parenchyma
INTERSTITIAL LUNG DISEASE
TUBERCULOSIS

Primary pulmonary
TB
 Subpleural GW to
yellow caseous lesion
 upper part of lower
lobe or lower part of
upper lobe.
 Associated hilar LN
GHON COMPLEX

Dr.
D.G
oma
thin
aya
gam
,
M.D.
TUBERCULOSIS
Early secondary TB
(reactivation )
 Small foci of caseous
lesion in apex of one or
both upper lobes
 Assosciated regional LN
Progressive secondary
TB (fibrocavitary )
 irregular ragged cavity
with casseous material
Healed secondary TB
 Fibrocalcific scars ,
cavities in apex
TB LUNG: CAVITATION

Dr.
D.G
oma
thin
aya
gam
,
M.D.
MILIARY TB

Dr.
D.G
oma
thin
aya
gam
,
M.D.
MILIARY TB

Dr.
D.G
oma
thin
aya
gam
,
M.D.
Miliary TB
 Minute pinpoint size
nodules throughout
the lungs
 Easy to palpate
FUNGAL INFECTIONS
Histoplasmosis
 Minute nodules
resembling TB
 Later scars with concentric
calcification

Blastomycosis
 Discrete nodules with
caseous lesions
 Cavities not large

Coccidioidomycosis
 Bronchopneumonia with
minute nodules
Aspergillosis
 Immunocompromised
host
 Necrotizing
pneumonia with
hemorrhagic borders
LUNG TUMOURS
PRIMARY
CARCINOMAS

Squamous cell ca
 Gray yellow, white
masses with or
without cavitation
 predominantly
central
 90% occupying
segmental or large
bronchi
CA LUNG EXTENDING FROM HILUM TO
PLEURA

Dr.
D.G
oma
thin
aya
gam
,
M.D.
Adenocarcinoma
 Gray or white
peripheral mass
 Cavitation rare

 Necrosis may be
present
Bronchioloalveolar
carcinoma
 Single nodule or
multiple diffuse or
coalescing GW nodule
 Covered by sticky
mucoid material
 Resembles pneumonia
Large cell carcinoma
 Soft, gray or tan

 Often necrotic mass

 50% central, 50%

peripheral
Small cell
neuroendocrine
carcinoma
 Gray to white

 Somewhat fleshy
mass
 Generally arising
centrally
Carcinoid tumors:
 Polypoid mass projecting
into bronchial lumen.
 Central /peripherally.
SECONDARY
TUMORS

 Multiple discrete firm

gray yellow nodule
 Throughout the lungs

 MC – from breast,
thyroid, suprarenal,
kidney
REFERENCES
 Pathologic basis of disease-Robbins and
Cotran.8th edidion.
 Autopsy diagnosis and technic-Otto saphir.
4th edition.
 Handbook of autopsy practice-jurgen
ludwig.3rd edition.
 Autopsy pathology-A manual and
atlas.Walter E.Finkbeiner.2nd edition.
THANK YOU