Download Chest X-ray Interpretation Circulation

Lung Cancer Diagnosis and
Treatment
Odessa National Medical University
Grubnik V.V.
Lung anatomy
Lung anatomy
Anatomical differences in the left and right
lung
Various types of lung cancer
• Squamous cell lung cancer: commonest type in
males, central origin, manifests early
•Adenocarcinoma: commonest type in females,
peripheral origin, manifests late
•Large cell lung cancer: least common type,
peripheral origin
•Small cell lung cancer: most aggressive type,
central origin, spreads quickly
Who is at risk?
• Patients that are former (or current) smokers
with COPD/Emphysema
• Patients with prior lung, esophageal,
head/neck cancers
• Patients with pulmonary fibrosis
• Patients with pulmonary asbestosis
The Lung and Thorax Exam
Chest X-ray Interpretation
5 Steps to Chest X-ray
Interpretation:
• Assess lung
expansion
• Assess the pleura
• Look for infiltrates
• Look at the
mediastinum
• Assess the abdomen
Chest X-ray Interpretation
Details (D)
•Patient name, age / DOB, sex
•Type of film – PA or AP, erect or supine,
correct L/R marker,
inspiratory/expiratory series
•Date and time of study
Chest X-ray Interpretation
RIPE (Assessing The Image Quality) (R)
•Rotation – medial clavicle ends equidistant from
spinous process
•Inspiration – 5-6 anterior ribs in MCL or 8-10
posterior ribs above diaphragm, poor
inspiration?, hyperexpanded?
•Picture – straight vs oblique, entire lung fields,
scapulae outside lung fields, angulation (ie ’tilt’ in
vertical plane)
•Exposure (Penetration) – IV disc spaces, spinous
processes to ~T4, L) hemidiaphragm visible
through cardiac shadow.
Chest X-ray Interpretation
Soft Tissues And Bones (S)
•Ribs, sternum, spine, clavicles – symmetry,
fractures, dislocations, lytic lesions, density
•Soft tissues – looking for symmetry, swelling,
loss of tissue planes, subcutaneous air,
masses
•Breast shadows
•Calcification – great vessels, carotids
Chest X-ray Interpretation
Airway & Mediastinum (A)
•Trachea – central or slightly to right lung as
crosses aortic arch
•Paratracheal/mediastinal masses or
adenopathy
•Carina & RMB/LMB
•Mediastinal width <8cm on PA film
•Aortic knob
•Hilum – T6-7 IV disc level, left hilum is usually
higher (2cm) and squarer than the V-shaped
right hilum.
•Check vessels, calcification.
Chest X-ray Interpretation
Breathing (B)
•Lung fields
– Vascularity – to ~2cm of pleural surface (~3cm in
apices), vessels in bases > apices
– Pneumothorax – don’t forget apices
– Lung field outlines – abnormal opacity/lucency,
atelectasis, collapse, consolidation, bullae
– Horizontal fissure on Right Lung
– Pulmonary infiltrates – interstitial vs alveolar pattern
– Coin lesions
– Cavitary lesions
•Pleura
– Pleural reflections
– Pleural thickening
Chest X-ray Interpretation
Circulation (C)
•Heart position –⅔ to left, ⅓ to right
•Heart size – measure cardiothoracic ratio on
PA film (normal <0.5)
•Heart borders – R) border is R) atrium, L)
border is L) ventricle & atrium
•Heart shape
•Aortic stripe
Chest X-ray Interpretation
Diaphragm (D)
•Hemidiaphragm levels – Right Lung higher
than Left Lung (~2.5cm / 1 intercostal space)
•Diaphragm shape/contour
•Cardiophrenic and costophrenic angles –
clear and sharp
•Gastric bubble / colonic air
•Subdiaphragmatic air (pneumoperitoneum)
Chest X-ray Interpretation
Extras (E)
•ETT, CVP line, NG tube, PA catheters, ECG
electrodes, PICC line, chest tube
•PPM, AIDC, metalwork
CT scan - Lung cancer
New methods
AutoFluorscence bronchoscopy (lung
imaging fluorescence endoscopy LIFE)
Flexible video bronchoscopy (FVB)
and Lung imaging fluorescence endoscopy (LIFE)
a) and d) show normal appearance with flexible video bronchoscopy (FVB) and
abnormal lesion with lung imaging fluorescence endoscopy (LIFE), respectively, at
the same site. b) and e) show abnormal appearance at FVB and suspicious lesion
at LIFE, respectively, at the same site. c) and f) show suspicious lesions at both
FVB and LIFE, respectively, at the same site.
New methods
Transbronchial Needle Biopsy (WANG)
Specimen:
Transbronchial
fine needle aspiration
biopsy is
performed during the bro
nchoscopic procedure to
sample endobronchial or
peribronchial lesions
and peritracheal or
peribronchial lymph
nodes, usually for
evaluation of malignancy:
Transbronchial Needle Biopsy (WANG)
Wang needle biopsy should be done before other diagnostic procedures,
such as performing exfoliative cytologic studies or bronchial biopsy to
minimize contamination of the needle aspirate with blood and
mechanically exfoliated cells
Make direct smears from the WANG needle biopsy at
the procedure and fix in 95% alcohol (Pap fixative). At least
2 direct smears are required from each site sampled.
The needle itself must never be submitted to the laboratory.
Fresh specimen (or the syringe recapped with the needle removed) may
be refrigerated and submitted if transport time to the laboratory will be
less than 4 hours.
If transport to the laboratory will be less than 4 hours a physiologic
transport medium may be used. Refrigerate needle rinses in transport
medium until sent to the lab.
Transbronchial Needle Biopsy (WANG)
New methods
ELECTROMAGNETIC NAVIGATION BRONCHOSCOPY
Description: Electromagnetic Navigation Bronchoscopy®
(ENB)™ extends the reach the bronchoscope to regions deep
within the lung enabling physicians to locate small lung lesions
for diagnostic testing and potential treatment. The system uses
natural airway access, and implements proprietary software and
electromagnetic technology.
Benefits: ENB minimizes the need for more invasive, surgical
procedures to access lung lesions in the distant regions of the
lung. These procedures may require an inpatient hospital stay
or cause complications such as collapsed lung (pneumothorax).
ENB also provides the ability to detect lung disease and lung
cancer earlier, even before symptoms are evident, enhancing
treatment options for patients.
ELECTROMAGNETIC NAVIGATION BRONCHOSCOPY
Algorithm of management of lung cancer
Stage 0 – II
Central
Tumor doesn't invade lobar
bronchus
Tumor invades lobar of
principle bronchi
Lobectomy (pre- or
posoperative radiation
or chemotherapy is
possible)
Pulmonectomy (pre- or
posoperative radiation
or chemotherapy is
possible)
Algorithm of management of lung cancer
Stage 0 – II
Peripheral
Tumor is limited to
One lobe
Tumor spreads
into adjacent lobe
Lobectomy (pre- or
posoperative radiation
or chemotherapy is
possible)
Pulmonectomy (pre- or
posoperative radiation
or chemotherapy is
possible)
Algorithm of management of lung cancer
Stage III a
Non-small cell
carcinoma
Patient fit for common anesthesia
Small cell
Carcinoma
Patient doesn’t fit for common
anesthesia
Preoperative radiation with
further pulmonectomy (including
extended /lymphadenectomy/ or
combined/ resection of adjacent
structures/)
Radiation and
chemotherapy
Algorithm of management of lung cancer
Stage III b -IV
Uncomplicated
Radiation and
chemotherapy
Complicated by
obstruction of
major bronch
Laser reconalization
with further radiation and
chemotherapy
Treatment
Treatment
Surgical treatment
Thoracoscopic Right Upper Lobectomy
Surgical treatment
Thoracoscopic Right Lower Lobectomy
Surgical treatment
Pulmonary Left Upper Lobectomy for Lung Cancer
Treatment