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بسم هللا الرحمن الرحيم The National Ribat University Faculty of Graduate Studies and Scientific Research THE ROLE OF CONVENTIONAL X-RAY IN DETECTION OF LUNG CANCER COMPARED WITH CT SCAN IN SMOKER SUDANESE PATIENT دور االشعة العادية في اكتشاف سرطان الرئة ومقارنتها مع األشعة المقطعية لدي المرضي السودانيين المدخنين A Research Submitted For The Requirements of The Award of M.Sc. Degree In Diagnostic Radiologic Technology. Prepared By: MARWA BABIKER OMER Supervisor: Prof. Dr / BUSHRA H.A.ABDELMALIK MBBS, M.SC., MD.Radiology. PhD 2012-2015 اآلية قال اهلل تعالى: } إق أر ِ رب َك الَّذي خلَق{ باسم ِّ صدق هللا العظيم سورة العلق :اآلية ()1 I Dedication To my parents To my husband To my lovely children To my family To my teacher II Acknowledgements Thank God Almighty who blessed and guided me to work on this research during all of it`s stages and complete it up to this form. I would like to express my deep gratitude`s and appreciation to my supervisor. ― Prof. Dr. Bushra Hussein Ahmed A.Elmalik ― the dean of the college of Diagnostic Radiology and Nuclear Medicine, The National University of ―EL Ribat ― for his Patience, Keen, giving his valuable times, and tireless efforts in guiding, revising, discussing and correcting this study throughout all it`s stages. I also deeply thank all those, whom taught me & transfer their knowledge to me & made me eligible to get this great honor. III Abstract Lung cancer is the number one cause of cancer deaths in both men and women. Cigarette smoking is the principal risk factor for development of lung cancer. The study was done in Sudanese smoker patients to show the role of x-ray in detection of lung cancer compared with CT scan. 140 patients was done chest x. ray and CT scan for chest in Tiba center for tumors. Calculation of sensitivity and specificity was 100%, 100% for CT scan for chest and 90.7 %and 76.9% respectively for chest x-ray. The study found the male was more affected than female, the right lung more affected than left lung and the upper lobe more affected than middle and lower lobe. Chest x-ray was available and cheap for every one and has role in detection lung cancer and other chest disease. IV ملخص البحث سرطان الرئة من اول انواع السرطانات المسببة لمموت ويمثل التدخين من اهم العوامل التي لها دور رئيسي في اإلصابة بسرطان الرئة. اجريت الدراسة في المرضي السودانيين المدخنين المصابين بي سرطان الرئه وزلك لتوضيح دور األشعة العادية في اكتشاف سرطان الرئة ومقارنتها مع األشعة المقطعية 041 .مريض اجريت لهم األشعة المقطعية لمصدر واألشعة العادية لمصدر في مركز طيبه لألورام ومستشفي الذرة. وجدت الحساسيه والخاصيه لالشعه المقطعيه بنسبه %011و %011واألشعة العادية لمصدر كانت الحساسيه 90. 7%.والخاصية76.9%. وجدت الد ارسه نسبه االصابه في الرجال اكتر من النساء وفي الرئه اليمني اكتر من اليسري وفي االعمي اكتر من الوسط واالسفل. األشعة العادية لمصدر متوفرة ورخيصة وليها دور كبير في اكتشاف سرطان الرئة وامراض الصدر األخرى ومتاحه لكل المرضي. V List of Contents اآلية...................................................................................................................................... I Dedication .........................................................................................................................II Acknowledgements ......................................................................................................... III Abstract ........................................................................................................................... IV ملخص البحث........................................................................................................................ V List of Contents ............................................................................................................... VI List of Figures .............................................................................................................. VIII List of Tables .................................................................................................................. IX List of abbreviations ........................................................................................................ X CHAPTER ONE: INTRODUCTION ........................................................................... 1 1.1 Introduction ......................................................................................................... 1 1.2 The problem of the study .................................................................................... 2 1.3 Objectives of the study ....................................................................................... 2 1.3.1 General objective ................................................................................................ 2 1.3.2 Specific objectives .............................................................................................. 2 CHAPTER TWO: LITERATURE REVIEW .............................................................. 3 2-1 Anatomy of the lung ........................................................................................... 3 2-1-1 The apex of the lung ............................................................................................ 4 2-1-2 The base of the lung ............................................................................................ 4 2-1-3 Surfaces and borders ........................................................................................... 4 2-1-4 Lobes and fissure................................................................................................. 6 2-1-5 The Root of the lung or hilum of the lung .......................................................... 6 2-1-6 Divisions of the Bronchi ..................................................................................... 8 2-1-7 Structure of The lungs .......................................................................................... 9 2-1-8 Blood supply ..................................................................................................... 10 2-1-9 Nerve supply ..................................................................................................... 11 2-1-10 Lymphatic supply .............................................................................................. 11 2-2 Physiology of the lung ....................................................................................... 12 2-2-1 Breathing and Lung Mechanics ........................................................................ 12 2-2-2 Inspiration ......................................................................................................... 12 2-2-3 Expiration .......................................................................................................... 13 2-2-4 Exchanging oxygen and carbon dioxide ........................................................... 13 2-2-5 Pulmonary circulation ....................................................................................... 15 2-2-6 Role of Surfactant ............................................................................................. 16 2-2-7 lung protection .................................................................................................. 16 2-3 Pathology of the chest ....................................................................................... 18 2-3-1 Tuberculosis (TB) ............................................................................................. 18 2-3-2 Asbestosis ......................................................................................................... 19 2-3-3 Lymphoma: ....................................................................................................... 19 2-3-4 Chronic obstructive pulmonary disease (COPD): ............................................. 19 2-3-5 Asthma: ............................................................................................................. 20 2-3-6 Cystic fibrosis.................................................................................................... 20 2-3-7 Bronchiectasis ................................................................................................... 21 2-3-8 Lung cancer: ...................................................................................................... 21 2-3-8-1 The causes of lung cancer .................................................................................. 22 2-3-8-2 Types of lung cancer .......................................................................................... 22 VI 2-3-8-3 General symptoms of lung cancer .................................................................... 23 2-3-8-4 The risk factor for lung cancer .......................................................................... 24 2-3-8-5 The stage lung cancer ....................................................................................... 24 2-3-8-6 Diagnosis of lung cancer................................................................................... 25 2-3-8-7 Sensitivity and specificity ................................................................................. 27 2-4 Imaging modalities ........................................................................................... 29 2-4-1 Conventional x. ray (chest x-ray) ..................................................................... 29 2-4-1-1 (Patient) preparation and methods .................................................................... 29 2-4-2 Computed tomography (CT scan for chest) ..................................................... 31 2-4-2-1 Types of Chest CT Scans ( A CT scanner) ....................................................... 32 2-4-2-2 High-Resolution Chest CT Scan ....................................................................... 32 2-4-2-3 Spiral Chest CT Scan ........................................................................................ 32 2-4-2-4 Patient preparation and procedure .................................................................... 32 2-4-3 Bronchoscopy.................................................................................................... 33 2-5 Previous studies ................................................................................................. 35 CHAPTER THREE: MATERIAL AND METHODS............................................... 37 3-1 Material.............................................................................................................. 37 3-1-1 Area of study ...................................................................................................... 37 3-1-2 Place department ................................................................................................ 37 3-1-3 Duration of study................................................................................................ 37 3-1-4 Machines used: ................................................................................................... 37 3-2 Methods: ............................................................................................................. 37 3-2-1 Technique (PA Chest x-ray ).............................................................................. 37 3-2-2 Lateral chest x-ray .............................................................................................. 38 3-2-3 Reading criteria .................................................................................................. 38 3-3 Statistical Analysis ............................................................................................. 38 CHAPTER FOUR: RESULTS .................................................................................... 39 4Results ................................................................................................................ 39 CHAPTER FIVE: DISCUSSION, CONCLUSION AND RECOMMENDATION 49 5-1 Discussion........................................................................................................... 49 5-2 Conclusion. ......................................................................................................... 52 5-3 Recommendation. ............................................................................................... 53 References ....................................................................................................................... 54 Appendix (A) .................................................................................................................. 60 Appendix (B) .................................................................................................................. 61 VII List of Figures Fig (2-1) Fig (2-2) Fig (2-3) Fig (2-4) Fig (2-5) Fig (2-6) Fig (2-7) Fig (2-8) Fig (2-9) Fig (2-10) Fig (2-11) Fig (2-12) Fig (2-13) Fig (2-14) Fig (2-15) Fig (2-16) Fig (2-17) Fig (2-18) Fig (2-19) Fig (2-20) Fig (2-21) Fig (4-1) Fig (4-2) Fig (4-3) Fig(4-4) Fig (4-5) Fig (4-6) Fig(4-7) Fig (4-8) Fig (4-9) lungs and bronchi ........................................................................................... 3 surfaces of lung .............................................................................................. 5 lobe and fissure .............................................................................................. 5 Mediastinal surface of right lung show the roots of right lung ...................... 7 Mediastinal surface of left lung show the roots of left lung .......................... 7 division of bronchi ......................................................................................... 8 Internal structure and organization of lungs ................................................ 10 Bronchial arteries and veins. ........................................................................ 11 Inspiration and Expiration............................................................................ 13 Alveolus-gas exchange ................................................................................ 14 pulmonary circulation .................................................................................. 15 Cilia -Tiny hairs, called cilia, line the bronchi. Cilia move back and forth in an ongoing motion– like a wave. Mucus is carried on top of cilia. ............. 17 Chest radiograph shows a consolidation in the upper lobe of the left lung . 26 CT scan for the same patient (fig2-13) shows tumor in the upper lobe of the left lung (arrow). .......................................................................................... 26 Non–small cell lung cancer right lower lobe squamous cell carcinoma. ..... 27 Adenocarcinoma in the right lung - chest x-ray........................................... 28 Bronchial cancer In the right lung-chest ..................................................... 28 Lung cancer, lateral chest x-ray ................................................................... 28 Chest x-ray. Frontal view of a male patient ................................................. 30 Chest x- ray. Lateral view of the chest showing lung and heart shadow .... 31 Bronchogram of the right lung the branching pattern of the trachea and bronchi, in a slightly oblique anteroposterior view. .................................... 34 Gender distribution ...................................................................................... 39 Age group distribution ................................................................................. 40 Female age group distribution. .................................................................... 41 Smoking year versus age group distribution ................................................ 42 Chest side distribution and lesion ................................................................ 44 Lung zone distribution ................................................................................. 45 Size and lesion distribution .......................................................................... 46 Other chest disease distribution in plain radiograph .................................... 47 CT chest finding distribution ....................................................................... 48 VIII List of Tables Table (4-1) Gender distribution .................................................................................. 39 Table (4-2) Age group distribution ............................................................................. 40 Table (4-3) Female age group distribution.................................................................. 41 Table (4-4) Smoking years versus Age group distribution ......................................... 42 Table (4-5) Calculation the sensitivity and specificity of conventional x. ray ........... 43 Table (4-6) Chest Side distribution and lesion............................................................ 44 Table (4 -7) Lung Zone distribution............................................................................. 45 Table (4-8) Size and Lesion distribution ...................................................................... 46 Table (4-9) Other Chest disease distribution in plain radioghraph .............................. 47 Table (4-10) CT chest finding distribution .................................................................... 48 IX List of abbreviations C.X.R CT S.C.L.C Chest x-ray Computed tomography Small cell lung cancer N.S.C.L.C N.L.S.T A.L.A COPD None small cell lung cancer National lung screening trial American lung association Chronic obstructive pulmonary disease TB tuberculosis LDCT Low dose computed tomography I-ELCAP International Early Lung Cancer Action Project X Chapter One Introduction Chapter one Introduction 1.1 Introduction: Lung cancer is the uncontrolled growth of abnormal cells in one or both of the lungs or in the bronchi or in the alveoli. Cigarette smoking is by far the most important cause of lung cancer, and the risk from smoking increases with the number of cigarettes smoked and the length of time spent smoking. Smoking is responsible for close to 90 percent of lung cancer cases (1). The lung cancer symptoms include a persistent cough, shortness of breath, wheezing, haemoptysis, chest pain and recurring pneumonia or bronchitis (2). Lung cancer is the most commonly diagnosed cancer worldwide as well as the leading cause of death in males. Among females, it is the fourth most commonly diagnosed cancer and the second leading cause of death. Lung cancer accounts for 12.3% (1.6 million) of the total cases and 18% (2.2 million) of the deaths. Global incidence of lung cancer is increasing at 0.5% yearly (3). Although lung cancer incidence and mortalities are still low in the Arab world as compared to Europe or USA, they are gradually increasing in the region. Furthermore, there is great variation between different parts of the Arab world. For instance, the agestandardized rates (ASRs) for lung cancer incidence are about 15 fold higher in Tunisia than in Sudan for men, and about 10 fold higher in Bahrain than in Yemen for females. Percentage data for both sexes of lung cancer in the Arab world show that (68.1%) of the Arab countries have lung cancer as one of the most frequent five types of cancer. The estimated numbers of new lung cancer cases in 2008 were 9,537 in ages below 65 for both sexes, and 7,059 cases for ages above 65(4). Reducing rates of lung cancer and improving diagnosis and treatment of people with lung cancer are priorities although there is a current concern that many people with lung cancer are not getting a diagnosis early enough to get curative or effective treatment (5). Chest x-ray is usually the first diagnostic test performed to evaluate any concerns based on a careful history. This may show a mass in the lungs or enlarged lymph nodes. Lung cancer is often suspected after an abnormal spot is found on a chest x-ray done to evaluate a cough or chest pain. For those without symptoms, lung cancer screening has 1 now been approved for early detection in people who are between the ages of 55 and 80, have smoked for at least 30 pack-years, and smoke or quit smoking within the past 15 years (6). In several randomized controlled trials of lung cancer screening, chest X-ray and/or sputum cytology were used simultaneously. For example, Melamed et al. examined the annually dual screening with X-ray and cytology for the Memorial SloanKettering study, concluding that the cytology is not necessary as an annual screening. Chien et al. studied mean sojourn time for lung cancer by chest X-ray screening (7). 1.2 The problem of the study Computed tomography is expensive. But conventional x. ray is cheap and available and can detect lung cancer and chest disease. 1.3 Objectives of the study 1.3.1 General objective: To evaluate the role of conventional X. ray in detection of lung cancer compared to CT scan in smoker Sudanese patients. 1.3.2 Specific objectives: To set a criteria for the detection of lung cancer on chest X-ray. To distinguish the radiographic signs and complications of lung cancer in the chest like pleural effusion, lung fibrosis, lungs masses and enlarged lymph nodes. To determine the sensitivity & specificity of conventional X-ray in detecting of lung cancer. Over view of the study chapter one introduction, chapter two literature review, chapter three material and method, chapter four results, conclusion and recommendation. 2 chapter five discussion, Chapter Two Literature Review Chapter two Literature review 2-1 Anatomy of the lung The lungs are the essential organs of respiration; they are two in number, placed one on either side within the thorax, and separated from each other by the heart and other contents of the mediastinum. The substance of the lung is of a light, porous, spongy texture; it floats in water, and crepitates when handled, owing to the presence of air in the alveoli; it is also highly elastic; hence the retracted state of these organs when they are removed from the closed cavity of the thorax. The surface is smooth, shining, and marked out into numerous polyhedral areas, indicating the lobules of the organ: each of these areas is crossed by numerous lighter lines. at birth the lungs are pinkish white in color; in adult life the color is a dark slaty gray, mottled in patches; and as age advances, this mottling assumes a black color. The coloring matter consists of granules of a carbonaceous substance deposited in the areolar tissue near the surface of the organ. It increases in quantity as age advances, and is more abundant in males than in females. As a rule, the posterior border of the lung is darker than the anterior. The right lung usually weighs about 625 gm., the left 567 gm., but much variation is met with according to the amount of blood or serous fluid they may contain. Each lung is conical in shape, and presents for examination an apex, a base, three borders, and two surfaces.(9) Fig (2-1) lungs and bronchi (18) 3 2-1-1 The apex of the lung: Is the rounded upper part of the human lung. It extends into the root of the neck, reaching between 2.5 centimetres (0.98 in) and 4 centimetres (1.6 in) above the level of the sternal end of the first rib. A sulcus, produced by the subclavian artery as it curves in front of the pleura, runs upward and lateralward immediately below the apex. It is positioned above the lobes and is partly responsible for filtering the air 2-1-2 The base of the lung: Is broad, concave, and rests upon the convex surface of the diaphragm, which separates the right lung from the right lobe of the liver, and the left lung from the left lobe of the liver, the stomach, and the spleen. Since the human diaphragm extends higher on the right than on the left side, the concavity on the base of the right lung is deeper than that on the left. Laterally and behind, the base is bounded by a thin, sharp margin which projects for some distance into the costodiaphragmatic recess of the pleura, between the lower ribs and the costal attachment of the diaphragm. The base of the lung descends during inspiration and ascends during expiration.(10) 2-1-3 Surfaces and borders The costal surface, which is related to the sternum, costal cartilages, and ribs, joins the medial surface at the anterior and posterior borders and the diaphragmatic surface at the inferior border. The medial surface is related posteriorly to the sides of the bodies of the vertebrae. Anteriorly, the medial surface is related to the superior, middle, and posterior parts of the mediastinum and includes the hilus. The diaphragmatic surface, or base, rests on the dome of the diaphragm, which separates the lung from the liver (on the right side) or the stomach, spleen, and sometimes liver and left colic flexure (on the left side). The anterior border of the lung corresponds to that of the pleura, although it is uncertain whether the costomediastinal recess of the pleura is completely filled by the lung during quiet breathing, as it is in deep inspiration. The anterior border of the left lung probably deviates more to the left (cardiac notch) than does that of the pleura. The portion of the upper lobe of the left lung that lies between the cardiac notch and the oblique fissure is known as the lingula, and it corresponds to the middle lobe of the right lung. The inferior border of the lung occupies the costodiaphragmatic recess of the pleura, although it is too thin to be demonstrated by 4 percussion during quiet breathing. The liver, stomach, spleen, colon, kidney, and peritoneal cavity extend to a higher level than the periphery of the diaphragm and the inferior border of the lung. The inferior limit of the lung that can be outlined by percussion extends laterally from the xiphisternal joint and about two intercostal spaces higher than the pleura. It crosses rib 6 in the midclavicular line and rib 8 in the midaxillary line and then proceeds toward the 10th thorac vertebra. (11) Fig (2-2) surfaces of lung (18) Fig (2-3) lobe and fissure (12) 5 2-1-4 Lobes and fissure: The left lung is divided into two lobes, upper and lower. These lobes have their own pleural covering and these lie together to form the oblique (major) fissure. In the right lung there is an oblique fissure and a horizontal fissure, separating the lung into three lobes - upper, middle, and lower. Each lobe again has its own visceral pleural covering (12). The fissure cuts the vertebral border of both the lungs at the level of 4th or 5th thoracic spine Traced downwards on the medial surface it ends above the hilum; traced downwards on the costal surface, it will be found to continue across the diaphragmatic surface and turn upward on to the medial surface to end just below the lower end of the hilum Horizontal fissure, seen only in the right lung begins laterally at the oblique fissure and runs almost transversely across the costal surface to the anterior margin and around this margin back to the hilum. The fissures facilitate the movement of the lobes in relation to one another, which accommodates the greater distention and movement of the lower lobes during respiration. Thus, they help in a more uniform expansion of the whole lung. As the fissures form the boundaries for the lobes of the lungs. (13) 2-1-5 The Root of the lung or hilum of the lung: Is a triangular depression in the human body that is located just above the middle of the mediastinal surface and behind the cardiac impression of each lung, and nearer to the posterior border (back) than the anterior border (front). The root of the lung is connected by the structures that form it to the heart and the trachea. The rib cage is separated from the lung by a two-layered membranous coating, the pleura. The hilum is where the connection between the parietal pleura (covering the rib cage) and the visceral pleura (covering the lung) is made, and this marks the meeting point between the mediastinum and the pleural cavities. The root is formed by the bronchus, the pulmonary artery, the pulmonary veins, the bronchial arteries and veins, the pulmonary plexuses of nerves, lymphatic vessels, bronchial lymph glands, and areolar tissue, all of which are enclosed by a reflection of the pleura. The root of the right lung lies behind the superior vena cava and part of the right atrium, and below the azygos vein. That of the left lung passes beneath the aortic arch and in front of the descending aorta; the phrenic nerve, pericardiacophrenic artery and 6 vein, and the anterior pulmonary plexus, lie in front of each, and the vagus nerve and posterior pulmonary plexus lie behind. The chief structures composing the root of each lung are arranged in a similar manner from the front to the back on each side. This means that the upper of the two pulmonary veins are in front, the pulmonary artery is in the middle, and the bronchus and bronchial vessels are behind (10) Fig (2-4) Mediastinal surface of right lung show the roots of right lung(10) Fig (2-5) Mediastinal surface of left lung show the roots of left lung (10) 7 2-1-6 Divisions of the Bronchi: The human trachea (windpipe) divides into two main bronchi (also mainstem bronchi), the left and the right, at the level of the sternal angle and of the fifth thoracic vertebra or up to two vertebrae higher or lower, depending on breathing, at the anatomical point known as the carina. The right main bronchus is more vertical, wider, shorter, and subdivides into three lobar bronchi and than the left main bronchus, which divides into two. The lobar bronchi divide into tertiary bronchi, also known as segmentalinic bronchi, each of which supplies a bronchopulmonary segment. The segmental bronchi divide into many primary bronchioles which divide into terminal bronchioles, each of which then gives rise to several respiratory bronchioles, which go on to divide into and terminate in tiny air sacs called alveoli. The alveolus is the basic anatomical unit of gas exchange in the lung. The mucous membrane of the primary bronchi is initially lined by ciliated pseudostratified columnar epithelium, but ultimately the lining transitions to simple cuboidal epithelium and then to simple squamous epithelium. The mucous membrane of the primary bronchi is initially lined by ciliated pseudostratified columnar epithelium, but ultimately the lining transitions to simple cuboidal epithelium and then to simple squamous epithelium. The alveolar ducts and alveoli consist primarily of simple squamous epithelium, which permits rapid diffusion of oxygen and carbon dioxide. (14) Fig (2-6) division of bronchi (15) 8 2-1-7: Structure of The lungs: The lungs are composed of an external serous coat, a subserous areolar tissue and the pulmonary substance or parenchyma. The serous coat is the pulmonary pleura it is thin, transparent, and invests the entire organ as far as the root. The subserous areolar tissue contains a large proportion of elastic fibers; it invests the entire surface of the lung, and extends inward between the lobules. The parenchyma is composed of secondary lobules which, although closely connected together by an interlobular areolar tissue, are quite distinct from one another, and may be teased asunder without much difficulty in the fetus. The secondary lobules vary in size; those on the surface are large, of pyramidal form, the base turned toward the surface; those in the interior smaller, and of various forms. Each secondary lobule is composed of several primary lobules, the anatomical units of the lung. The primary lobule consists of an alveolar duct, the air spaces connected with it and their bloodvessels, lymphatics and nerves. The intrapulmonary bronchi divide and subdivide throughout the entire organ, the smallest subdivisions constituting the lobular bronchioles. The larger divisions consist of an outer coat of fibrous tissue in which are found at intervals irregular plates of hyaline cartilage, most developed at the points of division, internal to the fibrous coat, a layer of circularly disposed smooth muscle fibers, the bronchial muscle; and most internally, the mucous membrane, lined by columnar ciliated epithelium resting on a basement membrane. The corium of the mucous membrane contains numerous elastic fibers running longitudinally, and a certain amount of lymphoid tissue; it also contains the ducts of mucous glands, the acini of which lie in the fibrous coat. The lobular bronchioles differ from the larger tubes in containing no cartilage and in the fact that the ciliated epithelial cells are cubical in shape. The lobular bronchioles are about 0.2 mm. in diameter. Each bronchiole divides into two or more respiratory bronchioles, with scattered alveoli, and each of these again divides into several alveolar ducts, with a greater number of alveoli connected with them. Each alveolar duct is connected with a variable number of irregularly spherical spaces, which also possess alveoli, the atria. With each atrium a variable number (2–5) of alveolar sacs are connected which bear on all parts of their circumference alveoli or air sacs. (Miller.) The alveoli are lined by a delicate layer of simple squamous epithelium, the cells of which are united at their edges by cement substance. Between the squames are here and there smaller, polygonal, nucleated cells. Outside the epithelial lining is a little delicate 9 connective tissue containing numerous elastic fibers and a close net-work of blood capillaries, and forming a common wall to adjacent alveol The fetal lung resembles a gland in that the alveoli have a small lumen and are lined by cubical epithelium. After the first respiration the alveoli become distended, and the epithelium takes on the characters described above. (9) Fig (2-7) Internal structure and organization of lungs Within the lungs, the bronchi and pulmonary arteries are paired and branch in unison. Tertiary segmental (tertiary) branches supply the bronchopulmonary segments. Each intrasegmental pulmonary artery, carrying poorly oxygenated blood, ends in a capillary plexus in the walls of the alveolar sacs and alveoli, where oxygen and carbon dioxide are exchanged. The intersegmental pulmonary veins arise from the pulmonary capillaries, carrying well-oxygenated blood to the heart. Bronchial arteries are distributed along and supply the bronchial tree. Their distalmost branches supply capillary beds drained by the pulmonary veins, such as those of the visceral pleura. A very small amount of low-oxygen blood thus drains into the otherwise oxygen-rich blood conveyed by the pulmonary veins. (7) 2-1-8 Blood supply The lungs have dual arterial supply and venous drainage: pulmonary arteries and veins as well as bronchial arteries and veins: arterial supply pulmonary arteries: supply de-oxygenated blood from the right ventricle. bronchial arteries branches of the thoracic aorta that supply oxygenated blood venous drainage pulmonary veins: drains to the left 10 atrium. bronchial veins: drains to the pulmonary veins, superior vena cava and azygos venous system. 2-1-9 Nerve supply: The lungs are supplied by sympathetic, parasympathetic and visceral afferent fibres from the pulmonary plexus, which itself is composed of fibres from the vagus nerve (parasympathetic and visceral afferent fibres) and fibres from the upper four sympathetic ganglia. 2-1-10 Lymphatic supply: The lymphatics drain via superficial and deep lymphatic plexuses to bronchopulmonary nodes at the hilum. The superficial lymphatic plexus is subpleural while the deep lymphatic plexus accompanies the bronchovascular structures with associated intrapulmonary lymph nodes(16) (A) bronchial arteries (B) bronchial veins Fig (2-8): Bronchial arteries and veins.(8) 11 A. The bronchial arteries supply the supporting tissues of the lungs and visceral pleura. B. The bronchial veins drain the moreproximatlyapillary beds supplied by the bronchial arteries; the rest is drained by the pulmonary veins.(7) 2-2-Physiology of the lung 2-2-1 Breathing and Lung Mechanics Ventilation is the exchange of air between the external environment and the alveoli. Air moves by bulk flow from an area of high pressure to low pressure. All pressures in the respiratory system are relative to atmospheric pressure Air will move in or out of the lungs depending on the pressure in the alveoli. The body changes the pressure in the alveoli by changing the volume of the lungs. As volume increases pressure decreases and as volume decreases pressure increases. There are two phases of ventilation; inspiration and expiration. During each phase the body changes the lung dimensions to produce a flow of air either in or out of the lungs.(17) 2-2-2 Inspiration: Inspiration is the active part of the breathing process, which s initiated by the Respiratory control center in medulla oblongata (Brain stem). ctivation of medulla causes a contraction of the diaphragm and intercostal muscles leading to an expansion of thoracic cavity and a decrease in the pleural space pressure. The diaphragm is a dome-shaped structure that separates the thoracic and abdominal cavities and is the most important muscle of inspiration. When it contracts, it moves downward and because it is attached to the lower ribs it also rotates the ribs toward the horizontal plane, and thereby further expands the chest cavity. In normal quite breathing the diaphragm moves downward about 1 cm but on forced inspiration/expiration total movement could be up to 10 cm. When it is paralysed it moves to the opposite direction (upwards) with inspiration, paradoxical movement. The external intercostal muscles connect adjacent ribs. When they contract the ribs are pulled upward and forward causing further increase in the volume of the thoracic cavity. As a result fresh air flows along the branching airways into the alveoli until the alveolar pressure equals to the pressure at the airway opening. (19) 12 2-2-3 Expiration: During quiet breathing, expiration is normally a passive process and does not require muscles to work (rather it is the result of the muscles relaxing). When the lungs are stretched and expanded, stretch receptors within the alveoli send inhibitory nerve impulses to the medulla oblongata, causing it to stop sending signals to the rib cage and diaphragm to contract. The muscles of respiration and the lungs themselves are elastic, so when the diaphragm and intercostal muscles relax there is an elastic recoil, which creates a positive pressure (pressure in the lungs becomes greater than atmospheric pressure), and air moves out of the lungs by flowing down its pressure gradient. When under physical or emotional stress, more frequent and deep breathing is needed, and both inspiration and expiration will work as active processes. Additional muscles in the rib cage forcefully contract and push air quickly out of the lungs. (20) Fig (2-9) Inspiration and Expiration (21) 2-2-4 Exchanging oxygen and carbon dioxide: The primary function of the respiratory system is to exchange oxygen and carbon dioxide. Inhaled oxygen enters the lungs and reaches the alveoli. The layers of cells lining the alveoli and the surrounding capillaries are each only one cell thick and are in very close contact with each other. Oxygen passes quickly through this air-blood barrier into the blood in the capillaries. Similarly, carbon dioxide passes from the blood into the 13 alveoli and is then exhaled. Oxygenated blood travels from the lungs through the pulmonary veins and into the left side of the heart, which pumps the blood to the rest of the body. Oxygen-deficient, carbon dioxide-rich blood returns to the right side of the heart through two large veins, the superior vena cava and the inferior vena cava. Then the blood is pumped through the pulmonary artery to the lungs, where it picks up oxygen and releases carbon dioxide. To support the exchange of oxygen and carbon dioxide, about 5 to 8 liters (about 1.3 to 2.1 gallons) of air per minute are brought in and out of the lungs, and about three tenths of a liter of oxygen is transferred from the alveoli to the blood each minute, even when the person is at rest. At the same time, a similar volume of carbon dioxide moves from the blood to the alveoli and is exhaled. During exercise, it is possible to breathe in and out more than 100 liters (about 26 gallons) of air per minute and extract 3 liters (a little less than 1 gallon) of oxygen from this air per minute. The rate at which oxygen is used by the body is one measure of the rate of energy expended by the body. Breathing in and out is accomplished by respiratory muscles. (22) Fig (2-10) Alveolus-gas exchange (14) 14 2-2-5 Pulmonary circulation: Is the movement of blood from the heart to the lungs for oxygenation, then back to the heart a gain Oxygen-depleted blood from the body leaves the systemic circulation when it enters the right atrium through the superior and inferior vena cava. The blood is then pumped through the tricuspid valve into the right ventricle. From the right ventricle, blood is pumped through the pulmonary valve and into the pulmonary artery. The pulmonary artery splits into the right and left pulmonary arteries and travel to each lung. At the lungs, the blood travels through capillary beds on the alveoli where respiration occurs, removing carbon dioxide and adding oxygen to the blood. The alveoli are air sacs in the lungs that provide the surface for gas exchange during respiration. The oxygenated blood then leaves the lungs through pulmonary veins, which returns it to the left atrium, completing the pulmonary circuit. Once entering the left heart, the blood flows through the bicuspid valve into the left ventricle. From the left ventricle, the blood is pumped through the aortic valve into the aorta to travel through systemic circulation, delivering oxygenated blood to the body before returning again to the pulmonary circulation (14) Fig (2-11) pulmonary circulation (10) 15 2-2-6 Role of Surfactant: The surface of the alveolar membrane is covered with a substance called surfactant which reduces the surface tension in the fluid on the surface of the alveoli, allowing them to expand at the first breath, and remain open. If the sacs either fail to expand, or expand then collapse on expiration, the result is labored breathing. Gas Transport Oxygen – most is bound to hemoglobin of red blood cells; small amount dissolved in blood plasma Carbon dioxide is transported in three forms Carbonic acid – 90% of carbon dioxide reacts with water to form carbonic acid Carboamino compounds – 5% binds to plasma proteins and hemoglobin Dissolved gas – 5% carried in the blood as dissolved gas Systemic Gas Exchange Carbon dioxide loading -The Haldane effect – the lower the partial pressure of oxygen and saturation of it in hemoglobin, the more carbon dioxide can be carried in the blood Oxygen unloading from hemoglobin molecules Factors that adjust the rate of oxygen unloading to metabolic rates of different tissues. Dead Space-Anatomical dead space –areas of the conducting zone that contains air that never contributes to the gas exchange in the alveoli. Alveolar dead space – alveoli that or collapsed or obstructed and are not able to participate in gas exchange. (24) 2-2-7 lung protection: The lungs have several ways of protecting themselves from irritants. First, the nose acts as a filter when breathing in, preventing large particles of pollutants from entering the lungs. If an irritant does enter the lung, it will get stuck in a thin layer of mucus (also called sputum or phlegm) that lines the inside of the breathing tubes. An average of 3 ounces of mucus are secreted onto the lining of these breathing tubes every day. This mucus is "swept up" toward the mouth by little hairs called cilia that line the breathing tubes. Cilia move mucus from the lungs upward toward the throat to the epiglottis. The epiglottis is the gate, which opens allowing the mucus to be swallowed. This occurs without us even thinking about it. Spitting up sputum is not "normal" and does not occur unless the individual has chronic bronchitis or there is an infection, such as a chest cold, pneumonia or an exacerbation of chronic obstructive pulmonary disease (COPD). Another protective mechanism for the lungs is the cough. A cough, while a common event, is also not a normal event and is the result of irritation to the bronchial tubes. A cough can expel mucus from the lungs faster than cilia. The last of the common 16 methods used by the lungs to protect themselves can also create problems. The airways in the lungs are surrounded by bands of muscle. When the lungs are irritated, these muscle bands can tighten, making the breathing tube narrower as the lungs try to keep the irritant out. The rapid tightening of these muscles is called bronchospasm. Some lungs are very sensitive to irritants. Bronchospams may cause serious problems for people with COPD and they are often a major problem for those with asthma, because it is more difficult to breathe through narrowed airways (25) Fig (2-12) Cilia -Tiny hairs, called cilia, line the bronchi. Cilia move back and forth in an ongoing motion– like a wave. Mucus is carried on top of cilia.(21) The cilia rhythmically beat and move the mucous-trapped material up to the throat where it can be swallowed or spit out, and thus eliminated from the body. This process is called the mucociliary escalator. Alveolar macrophages are specialized cells that mobilize to destroy bacteria and viruses. In healthy lungs, the production of macrophages and mucous increase as needed to remove foreign matter and then return to normal levels. Coughing usually removes irritating particles instantly and the mucociliary escalator may take only a few hours to expel foreign materials. However, the innermost areas of the lungs can take considerably longer to clear out foreign matter.(26) 17 2-3 Pathology of the chest 2-3-1 Tuberculosis (TB): Is an infectious disease caused by the bacillus Mycobacterium tuberculosis. It typically affects the lungs (pulmonary TB) but can affect other sites as well (extrapulmonary TB). The disease is spread in the air when people who are sick with pulmonary TB expel bacteria, for example by coughing. In general, a relatively small proportion of people infected with M. tuberculosis will develop TB disease; however, the probability of developing TB is much higher among people infected with HIV. TB is also more common among men than women, and affects mostly adults in the economically productive age groups. The most common method for diagnosing TB worldwide is sputum smear microscopy (developed more than 100 years ago), in which bacteria are observed in sputum samples examined under a microscope. (27) Patients with active pulmonary TB may be asymptomatic, have mild or progressive dry cough, or present with multiple symptoms, including fever, fatigue, weight loss, night sweats, and a cough that produces bloody sputum. If TB is detected early and fully treated, people with the disease quickly become noninfectious and eventually cured. M. tuberculosis is an aerobic, nonmotile, non-spore-forming rod that is highly resistant to drying, acid, and alcohol. It is transmitted from person to person via droplet nuclei containing the organism and is spread mainly by coughing. A person with active but untreated TB infects approximately 10–15 other people per year. The probability of transmission from one person to another depends on the number of infectious droplets expelled by a carrier, the duration of exposure, and the virulence of the M. tuberculosis. The risk of developing active TB is greatest in patients with altered host cellular immunity, including extremes of age, malnutrition, cancer, immunosuppressive therapy, HIV infection, end-stage renal disease, and diabetes. TB infection begins when the mycobacteria reach the pulmonary alveoli, where they invade and replicate within alveolar macrophages. Inhaled mycobacteria are phagocytized by alveolar macrophages, which interact with T lymphocytes, resulting in differentiation of macrophages into epithelioid histiocytes (28) 18 2-3-2 Asbestosis : Is defined as diffuse pulmonary fibrosis caused by the inhalation of excessive amounts of asbestos fibers. Pathologically, both pulmonary fibrosis of a particular pattern and evidence of excess asbestos in the lungs must be present. Clinically, the disease usually progresses slowly, with a typical latent period of more than 20 years from first exposure to onset of symptoms. Differential Diagnosis: Idiopathic Pulmonary Fibrosis.—The pulmonary fibrosis of asbestosis is interstitial and has a basal subpleural distribution, similar to that seen in idiopathic pulmonary fibrosis, which is the principal differential diagnosis. However, there are differences between the two diseases apart from the presence or absence of asbestos. First, the interstitial fibrosis of asbestosis is accompanied by very little inflammation, which, although not marked, is better developed in idiopathic pulmonary fibrosis. Second, in keeping with the slow tempo of the disease, the fibroblastic foci that characterize idiopathic pulmonary fibrosis are infrequent in asbestosis. Third, asbestosis is almost always accompanied by mild fibrosis of the visceral pleura, a feature that is rare in idiopathic pulmonary fibrosis.(29). 2-3-3 Lymphoma: Non-Hodgkin lymphoma (also known as non-Hodgkin’s lymphoma, NHL, or sometimes just lymphoma) is a cancer that starts in cells called lymphocytes, which are part of the body’s immune system. Lymphocytes are in the lymph nodes and other lymphoid tissues (such as the spleen and bone marrow). These. Some other types of cancer – lung or colon cancers, for example – can spread to lymph tissue such as the lymph nodes. But cancers that start in these places and then spread to the lymph tissue are not lymphomas. The main types of lymphomas are Hodgkin lymphoma (also known as Hodgkin’s lymphoma, Hodgkin disease, or Hodgkin’s disease), which is named after Dr. Thomas Hodgkin, who first described it. Non- Hodgkin lymphoma These different types of lymphomas behave, spread, and respond to treatment differently.(30) 2-3-4 Chronic obstructive pulmonary disease (COPD): Is a type of obstructive lung disease in which chronic incompletely reversible poor airflow (airflow limitation) and inability to breathe out fully (air trapping) exist. The poor airflow is the result of breakdown of lung tissue (known as emphysema) and small airways disease known as obstructive bronchiolitis. The relative contributions of these two factors vary between people. Severe destruction of small airways can lead to the 19 formation of large air pockets-known as bullae-that replace lung tissue. This form of disease is called bullous emphysema. COPD develops as a significant and chronic inflammatory response to inhaled irritants. Chronic bacterial infections may also add to this inflammatory state. The inflammatory cells involved include neutrophil granulocytes and macrophages, two types of white blood cell. Those who smoke additionally have Tc1 lymphocyte involvement and some people with COPD have eosinophil involvement similar to that in asthma. The diagnosis of COPD should be considered in anyone over the age of 35 to 40 who has shortness of breath, a chronic cough, sputum production, or frequent winter colds and a history of exposure to risk factors for the disease. Spirometry is then used to confirm the diagnosis. Spirometry measures the amount of airflow obstruction present and is generally carried out after the use of a bronchodilator, a medication to open up the airways.(31) 2-3-5 Asthma: Is a chronic lung disease characterized by reversible airway obstruction resulting from inflammation of the lung’s airways and a tightening of the muscles around them. Some degree of airway obstruction is often constantly present in those with asthma, but more severe reactions can occur due to exposure to a variety of triggers. Asthma triggers vary depending upon person and environment, but some known triggers include cigarette and other smoke, mold, pollen, dust, animal dander, exercise, cold air, household and industrial products, air pollutants, and infections. Asthma symptoms include coughing, wheezing and shortness of breath. During an asthma attack, these symptoms worsen and a person feels like they cannot breathe. An asthma attack is often the result of exposure to one or more asthma triggers(32) 2-3-6 Cystic fibrosis: (usually called CF) is an inherited disease. It causes certain glands in the body to not work properly. These glands are called the exocrine (outward-secreting) glands. Exocrine glands normally make thin, slippery secretions including sweat, mucus, tears, saliva and digestive juices. These secretions move through ducts (small tubes) to the surface of the body or into hollow organs, such as intestines or airways. Exocrine glands and their secretions help the body function normally. In CF, exocrine glands (except sweat glands) make mucus that is too thick and sticky. This mucus plugs ducts and other 20 passageways. Mucous plugs are most often in the lungs and intestines and can cause problems with breathing and digestion. (33) 2-3-7 Bronchiectasis: Is an abnormal, chronic enlargement of the bronchi, the passageways from the trachea to the alveoli that are the air-exchanging parts of the lungs. Bronchiectasis generally occurs as a result of infection, although noninfectious factors may contribute to the development of this condition. Accompanying the enlargement of the bronchi is their decreased ability to clear secretions. Failure to clear secretions allows microbes and particles to collect in them, which leads to more secretions and inflammation that further damage the airways, causing more dilation in a vicious cycle. Bronchiectasis may occur in a single portion of the lung (localized) or throughout the lungs (diffuse) and is the major lung abnormality of cystic fibrosis. It may have several different contributing factors, such as abnormal cilia, and its course may vary greatly from causing no symptoms to causing death. The prevalence of bronchiectasis is unknown largely because the symptoms are variable and the diagnosis is often not made. In the pre-antibiotic era, it was estimated to be as common as or more common than tuberculosis and to be wide range of causes of bronchiectasis has been reported in adults, but for more than half of the cases, there is no known cause or association. It is estimated that between 30 and 35 percent of cases follow a lung infection that damages the bronchi for the first time. In addition to bacterial pneumonia, other infections, such as whooping cough (pertussis) or tuberculosis, may cause the bronchial damage. Although the inciting infections are usually severe, bronchiectasis can also occur with minimal or silent infections. This is often the case when the inciting infection is caused by non tuberculous mycobacteria. Individuals with an inadequate immune system are at increased risk for chronic bronchial infections, which can damage airways and set up conditions for bronchiectasis. Persons who fail to produce antibodies, a condition that can be congenital or acquired, commonly develop bronchiectasis. Other immune deficiency states are also associated with bronchiectasis.(34) 2-3-8 Lung cancer: Is the uncontrolled growth of abnormal cells in one or both of the lungs. While normal cells reproduce and develop into healthy lung tissue, these abnormal cells reproduce faster and never grow into normal lung tissue. Lumps of cancer cells (tumors) 21 then form and grow. Besides interfering with how the lung functions, cancer cells can spread from the tumor into the bloodstream or lymphatic system where they can spread to other organs. 2-3-8-1 The causes of lung cancer: Cigarette smoking is by far the most important cause of lung cancer, and the risk from smoking increases with the number of cigarettes smoked and the length of time spent smoking. Other recognized causes include radon, secondhand smoke, and some occupational chemicals and air pollutants like benzene, formaldehyde, and diesel air pollution. Asbestos, a product used in insulation and manufacturing for years, is also an important cause of lung cancer. It has been estimated that active smoking is responsible for close to 90 percent of lung cancer cases; radon causes 10 percent, occupational exposures to carcinogens account for approximately to 15 percent and outdoor air pollution 1 to 2 percent. Because of the interactions between exposures, the combined attributable risk for lung cancer exceeds 100 percent. (35) 2-3-8-2 Types of lung cancer: There are two main types of lung cancer: Small cell lung cancer (SCLC), Nonsmall cell lung cancer (NSCLC). Small cell lung cancer about 10% to 15% of all lung cancers are small cell lung cancer (SCLC), named for the size of the cancer cells when seen under a microscope. Other names for SCLC are oat cell cancer, oat cell carcinoma, and small cell undifferentiated carcinoma. It is very rare for someone who has never smoked to have small cell lung cancer. SCLC often starts in the bronchi near the center of the chest, and it tends to spread widely through the body. Non-small cell lung cancer about 85% to 90% of lung cancers are non-small cell lung cancer (NSCLC). There are 3main subtypes of NSCLC. The cells in these subtypes differ in size, shape, and chemical make-up. But they are grouped together because the approach to treatment and prognosis (outlook) are often very similar. Squamous cell (epidermoid) carcinoma: About 25% to 30% of all lung cancers are squamous cell carcinomas. These cancers start in early versions of squamous cells, which are flat cells that line the inside of the airways in the lungs. They are often linked to ahistory of smoking and tend to be found in the middle of the lungs, near a bronchus. Adenocarcinoma: About 40% of lung cancers are adenocarcinomas. These cancers start in early versions of the cells that would normally secrete substances such as mucus. This type of lung cancer occurs 22 mainly in current or former smokers, but it is also the most common type of lung cancer in non-smokers. It is more common in women than in men, and it is more likely to occur in younger people than other types of lung cancer. Adenocarcinoma is usually found in the outer parts of the lung. It tends to grow slower than other types of lung cancer, and is more likely to be found before it has spread outside of the lung. People with a type of adenocarcinoma called adenocarcinoma in situ (previously called bronchioloalveolar carcinoma) tend to have a better outlook (prognosis) than those with other types of lung cancer.Large cell (undifferentiated) carcinoma: This type of cancer accounts for about 10% to 15% of lung cancers. It can appear in any part of the lung. It tends to grow and spread quickly, which can make it harder to treat. A subtype of large cell carcinoma, known as large cell neuroendocrine carcinoma, is a fast-growing cancer that is very similar to small cell lung cancer.(30) 2-3-8-3 General symptoms of lung cancer: Having a cough most of the time, a change in a cough for a long time Being short of breath Coughing up phlegm (sputum) with signs of blood in it An ache or pain in the chest or shoulder, loss of appetite, tiredness (fatigue),Losing weight. Other less common symptoms of lung cancer are usually associated with more advanced lung cancer. They include :a hoarse voice, difficulty swallowing, changes in the shape of the fingers and nails called finger clubbing, swelling of the face caused by a blockage of a main blood vessel (superior vena cava obstruction),swelling in the neck caused by enlarged lymph nodes, pain or discomfort under the ribs on the right side (from cancer cells in the liver),shortness of breath caused by fluid around the lungs (called a pleural effusion) Some types of lung cancer cells produce hormones that get into the bloodstream. These hormones can cause symptoms that do not seem related to the lung cancer called paraneoplastic symptoms or paraneoplastic syndrome. These hormone related symptoms vary from person to person but may include:pins and needles or numbness in the fingers or toes, muscle weakness, drowsiness, weakness, dizziness or confusion, breast swelling in men and Blood clots (thrombosis). Lung cancer growing right at the top of the lung is called a pancoast tumour. These tumours can cause very specific symptoms. The most common is severe shoulder pain or pain that travels down the arm. Pancoast tumours can also cause a collection of symptoms called Horner's syndrome.These are drooping or weakness of one eyelid, a small pupil in that eye,loss of sweating on that same side of the face. These symptoms of Horner's syndrome are 23 caused by the tumour pressing on or damaging a nerve that runs up from the neck to that side of the face. (36). 2-3-8-4 The risk factor for lung cancer: Smoking : smoking tobacco, particularly cigarettes, is the main cause of lung cancer. Tobacco smoke contains many harmful chemicals that can cause cancer (are carcinogenic). Smoking affects a person’s health and causes genetic changes in the cells of the lung that lead to the development of lung cancer. Smoking is related to more than 85% of lung cancer cases in Canada. The risk of developing lung cancer is influenced by how long a person smoked, their age when they started smoking and the number of cigarettes smoked each day. When smoking is combined with other risk factors, the risk of lung cancer is increased. Other types of tobacco products such as low-tar and lownicotine cigarettes, pipes, cigars, herbal cigarettes, hookahs and chewing tobacco also cause cancer and are not considered safe. Second-hand smoke is what smokers exhale and what rises from a burning cigarette, pipe or cigar. It is also called environmental tobacco smoke (ETS), or involuntary or passive smoking. Second-hand smoke contains the same chemicals as smoke that is actively inhaled. People exposed to second-hand smoke have an increased risk of lung cancer. Second-hand smoke is a main risk factor for lung cancer among non-smokers. No amount of exposure to second-hand smoke is safe. Also, the following may increase the risk : Radon, Asbestos, Outdoor air pollution, Occupational exposure to chemical carcinogens, Arsenic, Previous lung diseas, Exposure to radiatione, Indoor burning of coal, Personal or family history of lung cancer and Weakened immune system. (37) 2-3-8-5 The stage lung cancer: The stage for of both small cell and non-small cell lung cancer is described by a number, zero (0) through four (Roman numerals I through IV). Stage zero(0) this is called in situ disease, meaning the cancer is ―in place‖ and has not grown into nearby tissues and spread outside the lung. A stage one (I) lung cancer is a small tumor that has not spread to any lymph nodes. Stage one is divided into two sub stage s: stage IA or stage IB, based on the size of the tumor. Smaller tumors, such as those less than 3 centimeters (cm) wide are stage IA, and slightly larger ones, such as those more than 3 cm but less than 5 cm wide, are stage IB. Stage two (II) lung cancer is divided into two sub stages: stage IIA or IIB. A stage IIA cancer describes a tumor larger than 5 cm but 24 less than 7 cm wide that has not spread to the nearby lymph nodes or a small tumor less than 5 cm wide that has spread to the nearby lymph nodes. Stage IIB lung cancer describes a tumor larger than 5 cm but less than 7 cm wide that has spread to the lymph nodes or a tumor more than 7 cm wide that may or may not have grown into nearby structures in the lung but has not spread to the lymph nodes. Stage three (III) lung cancers are classified as either stage IIIA or IIIB. For many stage IIIA cancers and nearly all stage IIIB cancers the lung cancer may have spread to the lymph nodes located in the center of the chest, which is outside the lung. Or, the tumor may have grown into nearby structures in the lung. Stage four (IV) means the lung cancer has spread to more than one area in the other lung, the fluid surrounding the lung or the heart, or distant parts of the body through the bloodstream. Once released in the blood, cancer can spread anywhere in the body, but it is more likely to spread to the brain, bones, liver, and adrenal glands. It is called stage IVA when the cancer has spread within the chest or IVB when it has spread outside of the chest. (38) 2-3-8-6 Diagnosis of lung cancer: The chest X-ray is the most common first diagnostic step when any new symptoms of lung cancer are present. The chest X-ray procedure often involves a view from the back to the front of the chest as well as a view from the side. Like any X-ray procedure, chest X-rays expose the patient briefly to a small amount of radiation. Chest X-rays may reveal suspicious areas in the lungs but are unable to determine if these areas are cancerous. In particular, calcified nodules in the lungs or benign tumors called hamartomas may be identified on a chest X-ray and mimic lung cancer. CT (computerized tomography, computerized axial tomography, or CAT) scans may be performed on the chest, abdomen, and/or brain to examine for both metastatic and lung tumors. A CT scan of the chest may be ordered when X-rays do not show an abnormality or do not yield sufficient information about the extent or location of a tumor. CT scans are X-ray procedures that combine multiple images with the aid of a computer to generate cross-sectional views of the body. The images are taken by a large donut-shaped X-ray machine at different angles around the body. One advantage of CT scans is that they are more sensitive than standard chest X-rays in the detection of lung nodules, that is, they will demonstrate more nodules. Sometimes intravenous contrast material is given prior to the scan to help delineate the organs and their positions. A CT scan exposes the patient to a minimal amount of radiation. The most common side effect 25 is an adverse reaction to intravenous contrast material that may have been given prior to the procedure. This may result in itching, a rash, or hives that generally disappear rather quickly. Severe anaphylactic reactions (life-threatening allergic reactions with breathing difficulties) to contrast material are rare. CT scans of the abdomen may identify metastatic cancer in the liver or adrenal glands, and CT scans of the head may be ordered to reveal the presence and extent of metastatic cancer in the brain. A technique called a low-dose helical CT scan (or spiral CT scan) is recommended for use annually in current and former smokers between ages 55 and 80 with at least a 30 pack-year history of cigarette smoking who have smoked cigarettes within the past 15 years per the USPSTF recommendations. The technique appears to increase the likelihood of detection of smaller, earlier, and more curable lung cancers. Three years of low-dose CT scanning in this group reduced the risk of lung cancer death by 20%. Use of models and rules for analyzing the results of these tests are decreasing the need for testing to evaluate detected nodules when the likelihood is high the nodule is not cancerous.(39) (Fig 2-13) Chest radiograph shows a consolidation in the upper lobe of the left lung (40) (Fig 2-14) CT scan for the same patient (fig2-13) shows tumor in the upper lobe of the left lung (arrow). (40) 26 2-3-8-7 Sensitivity and specificity: The National Lung Screening Trial found that CT scans were highly sensitive in detecting lung cancer in smokers, when compared with chest X-rays, but they weren't very specific in ruling out the malignancy. Note that more of the lung cancers were diagnosed at stage I with CT than x-ray screening. The National Lung Screening Trial found that CT scans were highly sensitive in detecting lung cancer in smokers, when compared with chest x-rays, but they weren't very specific in ruling out the malignancy. Sensitivity was 94% and specificity 73% for lung cancer detection with CT compared with 74% and 91% with chest x-rays in the first round of screening for high-risk smokers and former smokers included in the trial.(41) Fig(2-15) Non–small cell lung cancer right lower lobe squamous cell carcinoma (59). 27 Fig (2-16) Adenocarcinoma in Fig ( 2-17)Bronchial cancer (60) the right lung - chest x-ray In the right lung-chest-(60) (60) Fig (2-18)Lung cancer, lateral chest x-ray(60) 28 2-4 Imaging modalities 2-4-1 Conventional x. ray (chest x-ray): Plain film X-rays remain an important tool for the diagnosis of many disorders. In radiography, a beam of X-rays, produced by an X-ray generator, is transmitted through an object, e.g. the part of the body to be scanned. The X-rays are absorbed by the material they pass through in differing amounts depending on the density and composition of the material. X-rays that are not absorbed pass through the object and are recorded on X-ray sensitive film. While bone absorbs X-rays particularly well, soft tissue such as muscle fiber, which has a lower density than bone, absorbs fewer X-rays. This results in the familiar contrast seen in X-ray images, with bones shown as clearly defined white areas and darker areas of tissue. This makes conventional X-rays very suitable for scans of bones and tissue dense in calcium such as in dental images and detection of bone fractures. Other uses of radiography include the study of the organs in the abdomen, such as the liver and bladder. (42) The chest x-ray is the most commonly performed diagnostic x-ray examination. A chest x-ray produces images of the heart, lungs, airways, blood vessels and the bones of the spine and chest. An x-ray (radiograph) is a noninvasive medical test that helps physicians diagnose and treat medical conditions. Imaging with x-rays involves exposing a part of the body to a small dose of ionizing radiation to produce pictures of the inside of the body. X-rays are the oldest and most frequently used form of medical imaging. The chest x-ray is performed to evaluate the lungs, heart and chest wall. A chest x-ray is typically the first imaging test used to help diagnose symptoms such as: shortness of breath, a bad or persistent cough, chest pain or injury and fever. Physicians use the examination to help diagnose or monitor treatment for conditions such as : pneumonia, heart failure, other heart problems, emphysema, lung cancer, line and tube placement, fluid or air collection around the lungs and other medical conditions.(43) 2-4-1-1 (Patient) preparation and methods: To prepare for a chest X-ray, the patient is typically instructed to wear a gown and remove all metal containing objects around the upper body (necklaces, zippers, bras, buttons, jewelry, eyeglasses, etc.) as these will interfere with the visualization of the tissues. No other specific preparation, such as fasting, is necessary for a routine chest X29 ray. The patient is then asked by the technician to stand in front of a surface adjacent to the film that records the images. The front of the chest is closest to the surface. Another part of the machine that releases the radiation is then placed about six feet away, behind the patient. When the positioning is appropriate (normal standing position with arms on the sides), the technician may advise the patient to take a deep breath and hold it and then takes the image by activating the device. The image is then captured on the film within a few seconds. The film can be developed within a few minutes to be reviewed by the doctor. Usually one image is done from back to front (referred to as posterioranterior, or "PA" view) as described above a second image using a sideways view from side-to-side (lateral). In situations where someone is unable to stand (too weak, disabled, or hospitalized), the image can be taken while laying down with the recording surface placed behind the back. Because the image is taken from the front to back in this scenario, it is called an anterior-posterior (AP) view. A lateral film is generally not possible in these situations. This method can also be called a portable chest X-ray because the X-ray machine is wheeled in to the patient in order to take the X-ray. Other chest images from different positions are sometimes ordered by the doctor for special situations.(44) (Fig2-19) Chest x-ray. Frontal view of a male patient (43) 30 (Fig 2-20) Chest x- ray. Lateral view of the chest showing lung and heart shadow (43) 2-4-2 Computed tomography (CT scan for chest): (CT or CAT scan) is a noninvasive diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce horizontal, or axial, images (often called slices) of the body. A CT scan shows detailed images of any part of the body, including the bones, muscles, fat, and organs. CT scans are more detailed than standard X-ray. In computed tomography, the X-ray beam moves in a circle around the body. This allows many different views of the same organ or structure. The X-ray information is sent to a computer that interprets the X-ray data and displays it in a twodimensional (2D) form on a monitor. CT scans may be done with or without "contrast." Contrast refers to a substance taken by mouth or injected into an intravenous (IV) line that causes the particular organ or tissue under study to be seen more clearly. Contrast examinations may require the patient to fast for a certain period of time before the procedure. CT scans of the chest can provide more detailed information about organs and structures inside the chest than standard X-rays of the chest, thus providing more information related to injuries and/or diseases of the chest (thoracic) organs. CT scans of the chest may also be used to visualize placement of needles during biopsies of thoracic organs or tumors, or during aspiration of fluid from the chest. CT scans of the chest are useful in monitoring tumors and other conditions of the chest before and after treatment (45). 31 Chest CT is used to examine abnormalities found on conventional chest x-rays, help diagnose the causes of clinical signs or symptoms of disease of the chest, such as cough, shortness of breath, chest pain, or fever, detect and evaluate the extent of tumors that arise in the chest, or tumors that have spread there from other parts of the body, assess whether tumors are responding to treatment, help plan radiation therapy, evaluate injury to the chest, including the heart, blood vessels, lungs, ribs and spine, evaluate abnormalities of the chest found on fetal ultrasound examinations. Chest CT can demonstrate various lung disorders, such as lung cancer, pneumonia, tuberculosis, emphysema and obstructive lung disease (COPD), bronchiectasis, inflammation or other diseases of the pleura, the covering of the lungs, diffuse interstitial lung disease and congenital abnormalities.A CT angiogram (CTA) may be performed to evaluate the blood vessels (arteries and veins) in the chest. This involves the rapid injection of an iodine-containing fluid (contrast material) into a vein while obtaining CT images.(43) 2-4-2-1 Types of Chest CT Scans ( A CT scanner): Is a large, tunnel-like machine with a hole in the center. During a chest CT scan, the patient lie on a table as it moves small distances at a time through the hole. An x-ray beam rotates around patient body as the patient move through the hole. A computer takes data from the x rays and creates a series of pictures, called slices, of the inside of patient chest. Different types of chest CT scans have different diagnostic uses. 2-4-2-2 High-Resolution Chest CT Scan: High-resolution CT (HRCT) scans provide more than one slice in a single rotation of the x-ray tube. Each slice is very thin and provides a lot of details about the organs and other structures in the chest. 2-4-2-3 Spiral Chest CT Scan: For this scan, the table moves continuously through the tunnel-like hole as the xray tube rotates around patient. This allows the x-ray beam to follow a spiral path. The machine's computer can process the many slices into a very detailed, three-dimensional (3D) picture of the lungs and other structures in the chest. (46) 2-4-2-4 Patient preparation and procedure: In preparation for a CT scan, patients are often asked to avoid food, especially when contrast material is to be used. Contrast material may be injected intravenously, or 32 administered by mouth or by an enema in order to increase the distinction between various organs or areas of the body. Therefore, fluids and food may be restricted for several hours prior to the examination. If the patient has a history of allergy to contrast material (such as iodine), the requesting physician and radiology staff should be notified. All metallic materials and certain clothing around the body are removed because they can interfere with the clarity of the images. Patients are placed on a movable table, and the table is slipped into the center of a large donut-shaped machine which takes the X-ray images around the body. The actual procedure can take from half an hour to an hour and a half. If specific tests, biopsies, or interventions are performed by the radiologist during CT scanning, additional time and monitoring may be required. It is important during the CT scan procedure that the patient minimizes any body movement by remaining as still and quiet as is possible. This significantly increases the clarity of the X-ray images. The CT scan technologist tells the patient when to breathe or hold his/her breath during scans of the chest and abdomen. If any problems are experienced during the CT scan, the technologist should be informed immediately. The technologist directly watches the patient through an observation window during the procedure, and there is an intercom system in the room for added patient safety. CT scans known as "spiral" or "helical" CT scans can provide more rapid and accurate visualization of internal organs. High resolution CT scans (HRCT) are used to accurately assess the lungs for inflammation and scarring. CT angiography is a newer technique that allows noninvasive imaging of the coronary arteries. (39) 2-4-3 Bronchoscopy: Use bronchoscopy technology to diagnose and stage certain cancers, such as lung cancer and esophageal cancer. In this procedure, a thin, lighted tube connected to a camera (called a bronchoscope) is inserted through the patient’s mouth or nose and into the lungs. The bronchoscope helps us examine the bronchial path, including the trachea (windpipe), bronchi (tubes inside the lungs), and lungs. Specifically, our cancer doctors use bronchoscopy procedures to Locate and identify suspected tumors, Evaluate the extent of the cancer, Identify the cause of symptoms (e.g., difficulty breathing), Reveal and treat obstructions in the airway, Collect sample lung tissue or fluid for lab analysis and Perform certain treatment procedures (e.g., brachytherapy).Bronchoscopy procedures can find cancerous cells that other surgical and imaging tools may not detect. For lung cancer patients, bronchoscopies often minimize the risks of more 33 invasive lung biopsies. Types of bronchoscopies: We perform rigid and flexible bronchoscopies, as well as laser bronchoscopies. Some specific bronchoscopy procedures include Whitlight bronchoscopy, Autofluorescence bronchoscopy and Navigationalbronchoscopy.(47) Fig (2-21) Bronchogram of the right lung the branching pattern of the trachea and bronchi, in a slightly oblique anteroposterior view. In this procedure, a radiopaque contrast medium has been introduced into the respiratory tract to coat the walls of the respiratory passages. For identification of the major branches CT images demonstrating lobar and segmental bronchial branching. (B– E) correspond to the 1st, 2nd, 3rd and 4th intercostal spaces, respectively.)(7) 34 2-5 Previous studies: Dennis Thompson on WEDNESDAY, Sept. 4, 2013 in More Evidence Backs Routine CT Scans for Early Lung Cancer Detection study found that early screenings with CT scans are more effective than regular chest X-rays in finding early stage cancers.(48) Mark and Linda in Lung Cancer Prevention in their study that comparing chest xray to CT scan for lung cancer screening, found that only CT showed reduced risk of death. Current guide lines recommend against screening at-risk subjects by chest xray.(49) Randy Dontinga in may 2010 in the benefit and risk of CT scan for detecting lung cancer, the study found that low-dose CT scan pick up significantly more lung tumors than chest x-ray. (50) The American College of Chest Physicians in 2007 recommended against routine screening for lung cancer because of a lack of evidence that such screening was effective. The smokers who are age 55 to74 and who have smoked for 30 pack- year or more and either continue to smoke or have quit within the past 15 years, They found that annual screening with low-dose CT (LDCT) should be offered over both annual screening with Chest x-ray or no screening. (51) Duke Lung Cancer Screening Program, In Lung cancer annual screening with low-dose spiral computed tomography (CT) can find lung cancers in their earliest stage, when the cancer is most easily treated. A large national study involving more 50,000 participants showed that annual screenings using a low- dose chest CT can reduce the risk of lung cancer death by 25 percent in current and former heavy smoker, compared to those who were screened using a chest X-ray. (52) The International Early Lung Cancer Action Project (I-ELCAP) published the results of CT screening in late 2006, In this study, 85% detected lung cancers were stage 1 and thus highly treatable. It is generally recognized that the prognosis of lung cancer decreases dramatically when the disease is in late stage and that CT screening for lung cancer allows detection of lung cancer during its earliest, most curable stage. CT screening for lung cancer has already been extensively compared to chest x-ray screening in Japan. Among over 6,800 subjects screened in Japan 67% to 73% of CTdetected lung cancers were missed by chest x-ray.(53) 35 The National Cancer Institute in Reduced Lung- cancer Mortality with low-Dose Computed Tomographic Screening In June 29,2011. The study found a 20 percent reduction in deaths from lung cancer among current or former heavy smokers who were screened with low-dose helical computed tomography (CT) versus those screened by Chest X-ray. (40) Author study clear that Rationale Screening for lung cancer with modern imaging technology may decrease lung cancer mortality. They concluded that after a median follow-up of 33 months, lung cancer was detected in 60 (4.7%) patient receiving LDCT and 34 (2.8%) control subject. The mortality benefit from lung cancer screening by LDCT might be far smaller than anticipated. (54) The American Association of Thoracic Surgery, Lung cancer has become an epidemic, and initial clinical trials to use screening CXR or sputum cytology were unsuccessful in reducing lung cancer – spesific mortality. Now a useful screening method in LDCT has been proven to increase the survival of those with this disease.(55) American Lung Association in screening for lung cancer found in their studies that only low-dose spiral CT scan reduced the risk of dying from lung cancer in high – risk populations. Chest x-ray is screening that has been used to check for signs of lung cancer but do not decrease the risk of dying from lung cancer. (35). 36 Chapter Three Material and Method Chapter three Material and methods 3-1 Material: 3-1-1 Area of study: The study was conducted in Khartoum state hospitals. 3-1-2 Place department: 140 patient with lung cancer whom have been referred to radiology department (Modern medical center, El Feisal specialized hospital, Khartoum diagnostic center, Bahri advanced center, and Fidel medical center) for chest x-ray and CT chest imaging have been selected. 3-1-3 Duration of study: The period of study from ( May 2012 – May 2015) 3-1-4 Machines used: X-ray machine and CT scan machine used in the study were ( Shemazdu fourty Xray machine, Leu soft sixteen slice CT scan machine, Semine sixtheen slice, GECT/E/single slice – spiral-2005 and GE-CT/E-16 slice -2005 ) 3-2 Methods: 3-2-1 Technique (PA Chest x-ray ) To prepare for a chest X-ray, the patient is typically instructed to wear a gown and remove all metal containing objects around the upper body (necklaces, zippers, bras, buttons, jewelry, eyeglasses, etc.) as these will interfere with the visualization of the tissues. No other specific preparation, such as fasting, is necessary for a routine chest Xray (56) The PA chest x-ray is taken with the patient erect, on full inspiration, patient’s chin extended out of the lung fields, the scapula rotated out of the field, and if the patient has large breast move them upward and out away from the lungs. When these techniques are employed the chest x-ray will be without rotation and will meet maximum diagnostic evaluation criteria for patient positioning. (57) 37 3-2-2 Lateral chest x-ray Patient Preparation: Ask the patient to remove clothes from the waist up, put on a hospital gown, remove any jewelry (necklace, earrings), and, if necessary, tie hair up on top of the head. Patient position: Instruct the patient to sit erect or stand upright with their left side against the film cassette or image receptor (IR). A left lateral projection should be performed (The left lateral position is preferred because it permits better anatomical detail of the heart.), Make sure the patient is upright, with weight distributed evenly on both feet, Ask the patient to raise both arms above the head to prevent their superimposition on the chest field, Place a lead shield between the x-ray tube and the patient’s pelvis for gonadal protection. Chest position Adjust the patient so that the left shoulder is firmly against the film cassette, and the lower-left chest wall is no more than 1-2 inches away from the cassette. The goal is to have the midsagittal plane of the body vertical and parallel with the cassette, Make sure the patient is not leaning forward, backward, or sideways against the grid, Ask the patient to extend the neck, chin, and head upward and vertical, Ensure that there will be no rotation in the image by viewing the patient from the tube position. When be ready for exposure, ask the patient to take a deep breath. (58) 3-2-3 Reading criteria: It is important that the PA chest radiograph is well penetrated so that peripheral pulmonary vessels are demonstrated; vertebral bodies are seen through the mediastinum, and retrocardiac and retrodiaphragmatic pulmonary vessels are seen. The left lateral should be well penetrated so that the right lung is demonstrated superimposed on the left lung, thoracic vertebral bodies and intervertebral disc spaces are seen, heart and lung densities show good penetration, and bronchial and vascular markings are clearly displayed. The goals to be accomplished by positioning the patient for the PA chest xray is to accurately demonstrate lung pathology, show air-fluid levels when present, and correctly display the manediastinum with minimal magnification.(57) The radiologist read the images found the lung cancer and suggest to do bronchoscopy to take sample and sent to laboratory for test, and found lung cancer. 3-3 Statistical Analysis: SPSS version 16 was used to analysis the results 38 Chapter Four Results Chapter four Results 4- Results Table (4-1) Gender distribution Parameter N Percent% Male 113 % 80.7 Female 27 % 19.3 Total 140 % 100.0 Fig (4-1) Gender distribution 39 Table (4-2) Age group distribution Parameter N Percent% 40-50 year 14 % 10 51-60 year 23 % 16 61-70 year 41 %29 71-80 year 62 %45 Total 140 % 100.0 Fig (4-2) Age group distribution 40 Table (4-3) Female age group distribution Parameter Female Percent% 40-50 year 3 11% 51-60 year 3 11% 61-70 year 11 41% 71-80 year 10 37% Total 27 100% Fig (4-3) Female age group distribution. 41 Table (4-4) Smoking years versus Age group distribution Parameter N No of Smoking years Percent% 40-50 year 14 15 % 10 51-60 year 23 25 % 16 61-70 year 41 35 %29 71-80 year 62 45 %45 Total 140 % 100.0 Fig(4-4) Smoking year versus age group distribution 42 Table (4-5) Calculation the sensitivity and specificity of conventional x. ray Disease(Number) Non disease(Number) Total number Positive (number) A (True positive) B (False positive) Total positive Negative number C (False negative) D (True negative) Total negative T (Disease) T(Non disease) Total Sensitivity= A/ (A+C) X 100% =127/ (127+13) x 100% = 90.7% Specificity= D/ (D+B) X 100% =10/ (10+3) x100% =76.9% 43 Table (4-6) Chest Side distribution and lesion Parameter N Percent% Right 96 %68.6 Left 44 %31.4 Total 140 %100.0 Fig (4-5) Chest side distribution and lesion 44 Table ( 4 -7) Lung Zone distribution Parameter N Percent% Upper 65 46.4% Middle 23 16.4% Lower 52 37.1% Total 100 100% Fig (4-6) Lung zone distribution 45 Table (4-8) Size and Lesion distribution Lung Lesion N Percent% Peripheral 65 46% Medial 75 54% Total 140 100% Fig(4-7) Size and lesion distribution 46 Table (4-9) Other Chest disease distribution in plain radioghraph Parameter N Percent% pleural effusion 69 %49.3 Fibrosis 29 % 20.7 Enlarged lymph nodes 42 %30.0 Total 140 %100.0 Fig (4-8) Other chest disease distribution in plain radiograph 47 Table (4-10) CT chest finding distribution Parameter N Percent% Bone metastasis 19 %13.6 Abdominal metastasis 38 %27.1 Brain metastasis 20 %14.3 Chronic obstructive pulmonary disease 38 %27.1 Atelectasis 25 %17.9 Total 140 %100.0 Fig(4-9) CT chest finding distribution 48 Chapter Five Discussion, Conclusion and Recommendation Chapter Five Discussion, Conclusion and Recommendation 5-1 Discussion Table (4-1) and Fig (4-1) show the Gender distribution the study was found that the number of male were 113 and female were 27. the number in female was low because all of patients were smoker patients but in our community a few number of female do smoke. It is agree with Lubin JH, Blot WJ.in their study Assessment of lung cancer risk factors found that, When relative risks of lung cancer among female smokers first began to be reported, they tended to be lower than those for men, a finding not unexpected because of women's lower average levels of cigarette exposure from later age at starting, shorter duration of smoking and fewer cigarettes smoked per day. (59) Table (4-2) and Fig(4-2) show the male and female age groups distribution. The number of male and female were (14,23,41,and 62) in groups (40-50), (51- 60), (61-70) and (7180) respectively. the study found the highest number was( 62) in age group (71-80), because the highest incidence of lung cancer in older men and woman. It is agree with Cancer Research UK between 2009 and 2011 in their study Lung cancer incidence statistics found that Lung cancer incidence is strongly related to age, with the highest incidence rates being in older men and women.(36) Table (4-3) and Fig(4-3) show the female age group distribution. The number of female were (3,3,11 and 10) in groups (40-50),(51-60),(61-70) and (70-80) respectively. The study found highest number is (11) with percentage 41% in age group (61-70). The study agree with The International Early Lung Cancer Action Project (I-ELCAP) which found that the highest number of female with percentage 46 % in age group ( 60 70).(53) Table (4-4) and fig (4-4) show smoking years versus Age group distribution. The number of smoking year were (15,25,35 and 45) in groups (40-50),(51-60),(61-70) and (71-80) respectively. The study found increase of smoking year with increase of age, and the highest number of year was 45years in age group(71-80).it was disagree with lung cancer association which found that Smoking prevalence was lowest for those greater than 65 years of age (9.5%) and highest among People aged ( 25-44) years (24.0%). Those aged ( 25-44) have traditionally had much higher rates than those aged (18-24) (35) because the patient age in this study start from (40-50) year. 49 Table (4-5) Calculation of sensitivity and specificity of conventional x. ray The study found that the Sensitivity and specificity of CT scan for chest was 100% and 100% compare with sensitivity and specificity of chest x- ray was 96.4% and 83.3% respectively. It was disagree with Crystal Phend in their study CT Lung Screens Catch Most Cancers (2013) found that Sensitivity was 94% and specificity 73% for lung cancer detection with CT compared with 91% and 74% with chest x-rays in the first round of screening for high-risk smokers and former smokers included in the trial.(41) Because in these study there was a few cases than their study. Table (4-6) and fig (4-6) show chest side distribution. the study showed that the number of patients with right lung cancer were 96 patients with percentage 68.6% and patients with left lung cancer were 44 patients with percentage 31.4%. the study found the highest number of patients in the right lung. Because the right lung has three lobes and three bronchi and their form differ anatomically than the bronchi in the left lung which has two bronchi. The study agree with Omer S.Alamoudi in their study lung cancer prospective study found that the right lung was (64.9 %) was more commonly affected than the left lung (37.7%). (61) Table (4-7) and Fig (4-7 ) show the Lung Zone distribution, the study showed that the number of patients with upper lung cancer were 65 patients with percentage 46.4 %, patients with middle lung cancer were 23 patients with percentage 16.4% and patients with lower lung cancer were 52 patients with percentage 37.1%. The study found the highest number of patients in the upper zone. It was agree with C.P.Sharma in their study Radiographic Patterns in Lung Cancer found that upper zone was involved in maximum number of cases 158(42%), followed by mid zone 122(32.7%) and lower zone 60(16%). (62). Because the upper lobe is more reach of blood supply than the other lobe. Table (4-8) and fig (4-8) show size and lesion distribution, the study show that in peripheral lung lesion the number of patient were 65 patients with percentage 46% and in central lung lesion the number of patient were 75 patients with percentage 54%.The study found that the highest number of patients in central lung lesion. It was disagree with Henry S. Park, MD, in their study Central Versus Peripheral Tumor Location which found that 70 patients with central tumor location and 183 patient with peripheral tumor location (63). because in this study a few of patients with adenocarcinoma which found in peripheral lung lesion and most of patients with squamous carcinoma and small cell lung cancer found in central lung lesion. 50 Table (4-9) and Fig (4-9) show Other chest diseases distribution in plain radiograph showed that the number of patients with pleural effusion were 69 out of 140 patients with percentage 49.3% and the number of patients with fibrosis were 29 patients with percentage 20.7% and the number of patients with enlarged lymph nodes were 42 patients with percentage 30.0%. The study found that the highest number of patients with pleural effusion. It was disagree with S Raniga, P Sharma and in their study Interstitial Lung disease which found that enlarged lymph node (58%), evidence of lung fibrosis (29%), pleural effusion (18%). (64) it was found the highest percent with enlarged lymph node because in their study most of patient with tuberculosis. Table (4-10) and Fig (4-10 ) show other CT disease finding distribution. The study showed that the number of patients with Bone metastasis were 19 out of 140 patients with percentage 13.6%, the number of patients with abdominal metastasis were 38 patients with percentage 27.1%, the number of patients with Brain metastasis were 20 patients with percentage 14.3%, the number of patients with chronic obstructive pulmonary disease were 38 patients with percentage 27.1% and the number of patients with atelectasis were 25 patients with percentage 17.9 %. It was agree with N. Hollings, P. Shaw in their study Diagnostic imaging of lung cancer which found that the brain metastasis was 11%, bone metastasis was 8%, and abdominal metastasis was 12% (65). it found the highest percentage in abdominal metastasis. Because the abdominal has more contents (liver, adrenal, kidney and GIT tract). the study found that the CT scan was more effective in detection other chest disease and cancer metastasis. But chest radiography is still the most commonly used technique in clinical practice to rule out chest disease, to study the effects of treatment, and to monitor patients with chest abnormalities. Computed tomography (CT) has a much higher sensitivity for the detection of small intrapulmonary lesions than does chest radiography, but chest radiography has the advantage of low cost, low radiation dose, and easy accessibility. 51 5-2 Conclusion. It found the males are more affected than female. The more affected age in male and female was (71-80). 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Shaw, Diagnostic imaging of lung cancer URL/http://ersj.org.uk/content/19/4/722.full.pdf 59 Appendixes Appendix (A) Papers Data Collection Sheet Patient Information Date: \ \ Patient ID : Age: Gender M Place of residence: Habits Smoking F not smoking Past medical history and disease Shortness of breath Coughing up: phlegm mucus blood Chest pain Change in voice History of present of lung disease Other: Investigation Yes No a. Laboratory exam b. X.ray c. C T Findings of : Laboratory exam : …………………………………………………………………….. X.ray : …………………………………………………………………….. C T: …………………………………………………………………….. Others: …………………………………………………………………….. 60 Appendix (B) Images Image (1) Chest x-ray for male patient show right upper lung cancer Image (2) Chest x-ray for male patient show left upper lung cancer 61 Image (3) chest x-ray for male patient with right lung mass Image (4) CT scan for chest for male patient show right lung cancer 62 Image (5) CT scan for chest for male patient show right lung cancer Image (6) CT scan for chest for female patient show right lung cancer 63