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Lung Cancer Esther SleighLearningObjectives-Anatomy 1) Describe the subdivisions ofthe thorax 2) Describe the basic structure ofthe airway 3) Summarise the anatomy ofthe bronchialtree and bronchopulmonary segments and explaintheir functional significance 4) Identify the features ofeachlung and the difference betweenleft and right lungs 5) Identify the root ofthe lung and the structures that form it as they enter and leave the lung and its hilum 6) Identify the lobes and fissures ofthe lungs and describe their major anatomicalrelationships tothe ribs, heart, aorta and other major vessels ofthe thorax 7) Describe the lymphatic drainage ofthe lungs and its medicalsignificance 8) Describe the nerve supply ofthe lungs 9) Describe the arterialsupply ofthe thoracic wall 10)Describe the neurovascular bundle inthe intercostalspace 11)Recognise normalstructures onradiographs and recognise commonabnormalitiesLearningObjectives-Clinical 1) Describe how lung cancers are classified 2) Describe the main risk factors 3) Describe the clinical features of lung cancer and what other differentials should be considered 4) Describe the red flag features to look out for 5) Explain where lung cancers are likely to metastasise to 6) Explain the clinical features that result from local invasion of lung cancer (eg Pancoast tumour) 7) Describe the relevant investigations for suspected lung cancer (bloods, chest X-ray, bronchoscopy & biopsy, CT, PET scan) - including the criteria for urgent CXR 8) Discuss management options (chemotherapy, radiotherapy, surgical management) o including the contraindications to surgery 9) Describe video-assisted thoracoscopic surgery (VATS) lobectomy and compare to open surgery 10)Describe complications such as superior vena cava syndrome (and how to manage) 11)the various thoracic surgical scars, how to describe them in an OSCE scenario, and how them can point you to a diagnosis (e.g. lobectomy secondary to TB or traumatic lung injury)Anatomy • Subdivisions of the thorax [1] Superior Anterior Middle Posterior Superior Thoracic inlet Sternal angle Sternal angle Sternal angle Inferior Sternal angle Diaphragm Diaphragm Diaphragm Anterior Manubrium of Body of sternum Anterior Pericardium sternum and transversus margin of thoracis muscles pericardium Posterio Vertebral Pericardium Posterior T5-T12 r bodies of T1- border of vertebrae T4 pericardium Lateral Pleuraeof the Mediastinal pleura Mediastinal Mediastinal lungs pleura of pleura lungsAnatomy Superior mediastinum – contents [1] • Great vessels: • arch of aorta + 3 branches • Superior vena cava + 4 drainage • Nerves: • Vagus nerve, left recurrent laryngeal, phrenic nerve, cardiac nerves, sympathetic trunk • Others: • Thymus, trachea, oesophagus, thoracic duct, musclesAnatomy Anterior mediastinum – contents [2] • Sternopericardial ligaments (loose connective tissue) • Branches of internal thoracic vessels • ThymusAnatomy Middle mediastinum – contents [3] • Heart + pericardium, tracheal bifurcation, L+R main bronchi • Vessels: origin of great vessels (ascending aorta, pulmonary trunk, SVC/IVC) • Nerves: cardiac plexus, phrenic nerves (L+R) • Lymphatics: tracheobronchial lymph nodes** characteristically enlarged incertainlung pathologies. Have a think about what might cause this?Anatomy Posterior mediastinum – contents [4] • Thoracic aorta + branches • Oesophagus • Thoracic duct • Azygous venous system • Sympathetic trunksAnatomy Airway Trachea: C shaped cartilaginous rings arising • Upper airway [5] at lower border of cricoid • Nasal cavity cartilage, bifurcates at • Nasopharynx sternal angle (T4) [6] • Oropharynx • Larynx • Lower airway • Trachea** • Bronchi Right mainbronchus • Bronchioles shorter, wider and • Alveoli more straight à • Diaphragm inhaled foreignbody Anatomy Clinical relevance: each bronchopulmonary Bronchial Tree segment has own pulmonary artery branch • Bronchus à lobar bronchi à segmental and bronchus à anatomically discrete bronchi à terminal bronchiolesà alveoli Surgical resection of segments without [8] affecting gross lung function • Lung segments • Right: three lobes and 10 segments • Left: two lobes and 10 segments • Right:A PALM Seed Makes Another Little Palm [9] • Apical, posterior, anterior, lateral, medial, superior, medial, anterior, lateral, posterior • Left:ASIA ALPS [9] • Apicoposterior (2), anterior, superior lingular, anteromedial (2), lateral, posterioral), Anatomy Lung hilum [10] • Medial aspect of lung, connection between parietal and visceral pleura at Why are the hilar of the the mediastinum lungs important in • Triangular depression posterior to clinical practice? cardiac impression at T5-7 level What abnormalities • Contents: bronchus x1, pulmonary might they artery x1, pulmonary vein x2, bronchial demonstrate? artery and veins, pulmonary nerve plexuses, lymphatics and bronchial lymph nodes Anatomy Lung hilum: clinical relevance • Bilateral enlargement • TB, sarcoidosis, lymphoma, pulmonary artery HTN, metastatic malignancy • Unilateral enlargement • Lung cancer, metastatic malignancy • Abnormal hilar position • Pneumonia (consolidation pulls hilar to affected side) • Pneumothorax (push hilar away from affected side) Anatomy Lung lobes and fissures [12] • Right: upper, middle, lower • Left: upper, lower Fissures • Horizontal fissure • Oblique fissures • Accessory fissures Anatomy Lung lobes and fissures - CXR • What does each colour represent? How would you describe where an abnormality is on a CXR? Anatomy CXR anatomy [12] • Diaphragm Clinical relevance: why • Cardiophrenic angles is it important to check • Costophrenic angles the costophrenic angles bilaterally? • Cardio-thoracic ratio • Cardiac contours • Mediastinal contours – aortic knuckle • Right para-tracheal stripe or accessory fissure Anatomy Nerves[8] Lymphatics [8] • Two plexuses • Pulmonary plexues • Parasympathetic (vagus nerve) • Superficial (subpleural) • Stimulate secretion from bronchial glands, • Drains lung parenchyma contraction of bronchial smooth muscle, • Deep vasodilation of pulmonary vessels • Drains structures of lung root • Sympathetic (sympathetic trunks) • Both drain into trachea- • Stimulate relaxation of bronchial smooth bronchial nodes at lung hilum muscle, vasoconstriction of pulmonary vessels then to broncho-mediastinal • Visceral afferent trunks • Conduct pain impulses to sensory ganglion of vagus nerve Anatomy Arterial supply of the thoracic wall [15] Mummy • Three sources: thoracic aorta, subclavian artery, axillary artery Swallowed Ancient Papyrus • Internal thoracic or internal mammary arteries Scrolls à • Stem: subclavian artery musculophrenic, • Supply: intercostal muscles, skin, parietal pleura 1-6 ics, superior indirectly to breast epigastric, • 5 branches given off: anterior • upper 6 anterior intercostal arteries (ICA) intercostal, • Musculophrenic arteries (7-9 ICA) perforating, • Superior epigastric arteries • Sternal branches (posterior sternum and tranversus thoracis muscles)rnal • Perforating branches alongside anterior cutaneous intercostal nerve Anatomy Neurovascular bundle in intercostal space [16] • Location: costal groove between internal and Clinical relevance innermost muscles 1. Thoracic surgery à • VAN access points for • Veins à anterior intercostal vein and posterior intercostal thoracentesis and veins VATS • Arteries à intercostal arteries (1-6 from internal thoracic,2. Cardiac surgery à 7-12 from musculophrenic artery) CABG use collateral • Nerves à anterior rami of spinal nerves T1-T11 (motor + artery supply for sensory) CABG (LIMA to LAD)Clinical–LungCancer [17] Lung cancer classification • Histologically Small-celllung cancer Non-small-celllung Mesothelioma (SCLC) (20%) cancer (NSCLC) (80%) Adenocarcinoma (40%) Squamous cellcarcinoma (20%) Large-cellcarcinoma (10%) Other types (10%)Clinical–LungCancer [17] Lung cancer risk factors [18] • Smoking • Age • Family history • Passive smoking • Radon gas • Air pollution • Occupation:asbestos,silica,arsenic,radiation,diesel fumes •cancerous cancer treatment: radiotherapy lymphoma or testicular • Lowered immunity:HIV,immunosuppressant drugsClinical–LungCancer [17] Lung cancer clinical features • SOB • Cough • Haemoptysis • Finger clubbing • Recurrent pneumonia • Weight loss • Lymphadenopathy • FatigueClinical–LungCancer [17] Lung cancer extrapulmonary manifestations and paraneoplastic syndrome • Recurrent laryngeal nerve palsy (hoarse voice) • Phrenic nerve palsy • Superior vena cava obstruction* • Horner’s syndrome Small cell Squamouscell Adenocarcinoma • SIADH ADH PTH-related proteinsecreGynaecomastia • Cushing’s syndrome ACTH Clubbing HPOA Lambert-Eaton HPOA • Hypercalcaemia syndrome Hyperthyroidism (ectopic TSH) • Limbic encephalitis • Lambert-Eaton myasthenic syndromeClinical–LungCancer [17] Lung cancer red flag – what could these be? • Haemoptysis NICE 2 week wait CXR: >40y/o + • Supraclavicular lymphadenopathy Clubbing, lymphadenopathy, recurrent or persistent chest • Weight loss infections, thrombocytosis, chest • Superior vena cava obstruction signs • Finger clubbing CXR for unexplained symptoms: >40 and never smoked + 2, or >40 and smoker or asbestos + 1: LOW THRESHOLD Cough, SOB, chest pain, fatigue, weight loss, loss of appetiteClinical–LungCancer Superior Vena Cava Obstruction [19] Oncological • Features: SOB, swelling, headache (worse in Emergency morning), visual disturbance, pulseless JVP distension • oedemang: face, neck, arms, conjunctival & periorbiCauses: • Malignancy (SCLC, • Pemberton’s sign: raising hands over head causes lymphoma) facial congestion and cyanosis [17] • Aortic aneurysm • Management: • Mediastinal fibrosis • Endovascular stenting, radical chemo or chemo- • Goitre radiotherapy • Glucocorticoids (despite weak evidence) • SVC thrombosisClinical–LungCancer Lung metastases [20] • Where does lung cancer usually metastasize to? (5) • Brain • Bones • Liver • Adrenal glands • Other: stomach, intestines, pancreas, eye, skin, kidneys, breastClinical–LungCancer [17] If you had a patient presenting with suspected lung cancer which investigations would you want to do? • Bedside: baseline obs, examination (resp, lymph nodes) • Bloods: FBC (raised platelets), U&Es, LFTs, bone profile, tumour markers • Bombesin – SCLC [19] • Imaging: CXR (first line), CT • CXR: hilar enlargement, peripheral opacity, pleural effusion (unilateral), collapseClinical–LungCancer [17] Lung cancer investigations • CXR • Staging CT à CT CAP , lymph nodes, metasases, contrast-enhanced • PET-CT à radioactive tracer (glucose), metabolically active tissue • Bronchoscopy + endobronchial US (EBUS) • Endoscope + US for detailed tumour assessment +/- US guided biopsy • Histological diagnosis • Bronchoscopy or percutaneous biopsy • Mesothelioma**Clinical–LungCancer [17] Lung cancer management NSCLC SCLC 20% suitable for Early stage (T1-2a, N0, M0) • MDT surgery consider for surgery • Surgery Curative or palliative Limited disease: chemo • Radiotherapy radiotherapy and radio Poor chemotherapy Extensive: palliative chemo • Chemotherapy response • Endobronchial treatment Usually metastatic at diagnosis [19]Clinical–LungCancer [17] Lung cancer surgery Contraindications [19] • Segmentectomy or wedge • General health resection** • Stage IIIb or IV (mets • Lobectomy present) • Pneumonectomy • FEV1<1.5L lobectomy, <2.0 pneumonectomy • Malignant pleural effusion • Thoracotomy • Tumour near hilum • VATS or robotic • Vocal cord paralysis • SVC obstructionClinical–LungCancer Lung cancer surgery – VATS vs open lobectomy [21] • Video-assisted thoracoscopic surgery • Thoracoscope and surgical instruments through chest wall • Indication: diagnose and treat thoracic disease • E.g. tissue removal to diagnose chest cancers, procedures to remove excess fluid/air from the area around lung, surgery to relieve excess sweating (hyperhidrosis), thymectomy • Risks: pneumonia, bleeding, short-term or permanent nerve damage, damage to surrounding organs, anaesthetic side effectsClinical–LungCancer Lung cancer surgery – VATS vs open lobectomy VATS Open surgery Less post operative pain Higher risk of pneumonia post- Same overall year survival operatively (2) Faster recovery and shorter hospital stays [24] [25]Clinical–LungCancer Lung cancer surgery – VATS A 3.5cm Single Incision VATS Lobectomy for Lung CancerClinical–LungCancer [17] OSCE scenarios • Thoracotomy scar = lobectomy, pneumonectomy, lung volume reduction surgery for COPD • Right sided mini-thoractomy (CARDIOLOGY) = minimally invasive mitral valve surgery • Absent breath sounds on entire side = pneumonectomy • Focal absent breath sounds = lobectomy • **pneumonectomy and lobectomy used to be used to treat tuberculosis – remember in older patients • Chest drains à left after thoracic surgery – air and fluid drains and lungs to expand, external end of drain placed underwater = seal prevent air flowing back through into chest. Normal respiration, water in drain will rise and fall due to changes in pressure in chest = swingingReferences 1. Sanders, K. The Superior Mediastinum. 2022 30/12/24]; Available from: https://teachmeanatomy.info/thorax/areas/superior-mediastinum/. 2. Theakston, V. The Anterior Mediastinum. 2019 30/12/24]; Available from: https://teachmeanatomy.info/thorax/areas/anterior-mediastinum/. 3. Baguley, M. The Middle Mediastinum. 2019 30/12/24]; Available from: https://teachmeanatomy.info/thorax/areas/middle-mediastinum/. 4. Theakston, V. The Posterior Mediastinum. 2020 31/12/24]; Available from: https://teachmeanatomy.info/thorax/areas/posterior-mediastinum/. 5. Beutler, C. An Overview of Airway Anatomy. 2019 30/12/24]; Available from: https://emttrainingbase.com/airway-anatomy/. 6. Ditki. Respiratory System Anatomy (Overview). 30/12/24]; Available from: https://ditki.com/course/gross-anatomy/glossary/term/respiratory-system. 7. 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Symptoms and More. 2024 30/12/24]; Available from: https://www.mylungcancerteam.com/resources/understanding-metastatic-lung-cancer. 21. Mayo clinic. Video-assisted thoracoscopic surgery (VATS). 2022 30/12/24]; Available from: https://www.mayoclinic.org/tests-procedures/video-assisted-thoracic- surgery/about/pac-20384922. 22. Harrison, Oliver & Bakir, Adnan & Chamberlain, Martin & Nader-Sepahi, Ali & Amer, Khalid. (2021). Combined minimally invasive resection of thoracic neurogenic dumbbell tumors: A European case series. Thoracic Cancer. 12. 10.1111/1759-7714.14122. 23. Bhimji, S. Lung Segmentectomy and Limited Pulmonary Resection Technique. 2023 30/12/24]; Available from: https://emedicine.medscape.com/article/1894257- technique?form=fpf. 24. Beddow, E. VATS lobectomy or traditional lung cancer surgery? 2024 30/12/24]; Available from: https://guysandstthomasspecialistcare.co.uk/news/vats-lobectomy-or- traditional-lung-cancer-surgery/. 25. Francis, J., Domingues, D.M., Chan, J. et al. Open thoracotomy versus VATS versus RATS for segmentectomy: a systematic review & Bayesian network meta-analysis. J Cardiothorac Surg 19, 551 (2024). https://doi.org/10.1186/s13019-024-03015-zThank you for listening – any questions?