Download 2-3-8 Lung cancer

‫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).

In female age group (61-70) is the more effective age.

It found that the Sensitivity and specificity of CT scan for chest was 100% and
100% compared with sensitivity and specificity of chest x- ray was 90.7% and
76.9% respectively.

The right side is more affecte compared to left side.

The more zone is the upper zone in both lung.

It found the central lesion is more than peripheral lesion.

The pleural effusion is more than other chest disease.
52
5-3 Recommendation.

recommend that chest x-ray is available and cheap, it should be done every three
months to detect chest disease.

other study will be done to identify the relationship between number of cigarette
per day and the effect with lung cancer.

Other study will be done with increase of number of patients.
53
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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