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The chest cavity is opened at autopsy to reveal numerous large bullae apparent on the surface of the lungs in a patient dying with emphysema. Bullae are large dilated airspaces that bulge out from beneath the pleura. Emphysema is characterized by a loss of lung parenchyma by destruction of alveoli so that there is permanent dilation of airspaces. Lung cancer.

On cut section of the lung, the dilated airspaces with emphysema are seen. Although there tends to be some scarring with time because of superimposed infections, the emphysematous process is one of loss of lung parenchyma, not fibrosis. There are two major types of emphysema: centrilobular (centriacinar) and panlobular (panacinar). The former involves primarily the upper lobes while the latter involves all lung fields, particularly the bases. Centrilobular emphysema occurs with loss of the respiratory bronchioles in the proximal portion of the acinus, with sparing of distal alveoli. This pattern is most typical for smokers. Panacinar emphysema occurs with loss of all portions of the acinus from the respiratory bronchiole to the alveoli. This is a more subtle appearance for centrilobular emphysema in which there are dirty holes that appear focally where the central portions of lung acini have lost lung parenchyma while collecting anthracotic pigment at the same time. This pattern is typical for smokers. Smokers have a greater number of neutrophils and macrophages in their alveoli. Smoking irritates alveolar macrophages, which in turn release neutrophil chemotactic factors, such as interleukin 8, thus recruiting neutrophils. In addition, nicotine is chemotactic for neutrophils, and smoke can activate the alternative complement pathway (an inflammatory cascade). Proteases, particularly elastase, are secreted by these neutrophils and macrophages. Proteases are enzymes that are capable of digesting lung tissue and these chemicals are responsible for the damage seen in emphysema. Oxidants and free radicals in smoke also inhibit the alpha-1-antitrypsin circulating in the lung that protects alveoli from proteases. Chronic irritation by smoke also can lead to chronic bronchitis with excess production of mucus. Smoke interferes with the ciliary action of the respiratory epithelium and the mucus cannot be cleared. This predisposes the smoker to secondary and repeated infections.

Emphysema, representating a late 20th century version of The Masque of the Red Death in Edgar Allen Poe's short story, is shown here. Note the loss of lung parenchyma with irregular holes. It should be remembered that deaths from emphysema, as well as lung cancer, have increased greatly over the past few decades because of smoking. The pelvis of the kidney is shown here with a urothelial carcinoma. These carcinomas are more likely to occur in a smoker. These carcinomas also have a tendency to recur and to be multiple.

This is a squamous cell carcinoma of the lung. It is a bulky mass that extends into surrounding lung parenchyma. Arising centrally in this lung and spreading extensively is a small cell anaplastic (oat cell) carcinoma. The cut surface of this tumor has a soft, lobulated, white to tan appearance. The tumor seen here has caused obstruction of the main bronchus to left lung so that the distal lung is collapsed. Oat cell carcinomas are very aggressive and often metastasize widely before the primary tumor mass in the lung reaches a large size.

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