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Yeah. Right. I believe we're live. So, hi, everyone. Welcome. Hope you can hear me. Ok. Uh My name is Glenn. I'm one of the fourth years of Queens and also one of the education officers with I MS this year. Um Tonight's talk is brought to you by Donovan Campbell, who's 1/4 year medical student also at Queens. Donovan's got quite a longstanding interest in cardiothoracic surgery and there was quite a, quite a bit about lung cancer. So he's going to be taking us through quite a detailed talk on lung cancer this evening. Uh A bit of anatomy, refresh your knowledge. Um And then some of the main forms of lung cancer you need to be aware of for your finals. Um If you have any questions, feel free to add them to the chat, there's going to be M CQ throughout as well. So keep an eye on the polls. Um And I hope you enjoy the talk. So I'm just going to pass it over to Donovan. Thank you Glen I induction. So I, as Grant said, I'm Donovan uh one of the four years and feel free at any time. Just fire into the chat. Any questions I can see it here so be fit to stop as you're going through, but try to keep it to the r so we'll make a start here. But we're covering on oncology and the baby wasn't stopped her. And what we'll try to get covered in the next hour or so is the epidemiology sort of set the scene of lung cancer and the extent of the problem as well as uh too brief anatomy recap along with going through risk factors investigations, the different types of lung cancer as well as having a look at the management. And yeah, this will be based on cases of VMC QS here and there. Right. So, epidemiology, don't worry, it's only this page. So lung cancer is currently the third most common cancer in the UK behind breast and prostate. And it's the second most common in each sex. So second in males behind prostate and females behind breast and as well as how common it is the actual extent of it really isn't really, really bad. And that's most of the problem with the condition. 2 million people die every year of lung cancer. And that's about 22% of the total cancer mortality. And this is worldwide and five year survival is really low. It sets it currently only 16% now work has been done by Cancer Research UK. And they have this graph which shows a different demographic. So the amount of cases in a two year period, deaths in a two year period and 10 year survival in England. But quite startling to me was the preventable cases on the right hand side. So they attributed about 80% of lung cancers are thought to be preventable. And we'll get onto the risk factors of why. That is. So first off to understand uh lung cancer and especially when it comes to the management of lung cancer, the anatomy is crucial and absolutely important. So we'll start, we have a very simple question. We get us going. This is more of a test to pull that. It works as well. But at what vertebral level does the bifurcation of the turkey occur? Also the Corina uh hopefully get a pool started here. Yeah. Very good. Yeah, very good. Most people getting this, so I'll stop the pull here as well, hopefully as they closed. So there's T four. So we'll start with the trach bronchial tree anatomy. And really what this consists of is the JIA right down to that bifurcation. And obviously being the horseshoe shaped cartilages at the anterior and both lateral aspects with the callus muscle at the posterior. And this runs down to T four T five, mostly T four and bifurcates at the carina into the right and left, main bronchi and they correspond to the right and left lung. The right, obviously for a very common exam question, as you can see in the photo it's shorter and thicker. So foreign objects go down there more commonly as well as aspiration and form aspiration pneumonia. And the longer left main bronchus is to get around the heart structure it sits in from. So the main bronchi then divide into lobar bronchi or in this case, in the vote of the secondary bronchi and they correlate to the lobes of the lump. So the right lung has three, the upper middle and lower and the left has two. It's actually the upper and the lower da sac or lower bronchi then split further into the segmental bronchi. And each according to a segment of the lung with a photo that in a second and from them, the segmental bronchi branch further into the bronchioles and finally, the alveoli. And if you're a person that loves mnemonics, too many lollies spoil bad appetites a way to learn it. And then this quickly shows the upper, middle and lower lobe of the right and the upper and lower of the left along with the fissures, which are very, very important when it comes to surgery because uh often these are divided as part of the anatomical resection. So on the left, nice and easy, there's only one, the oblique fissure separates the upper and lower lobe, but it's on the right, you've got the two. So you again have the oblique which separates the lower and middle as well as on the posterior where you can see from here, the lower and upper and then you have the horizontal fissure which separates the middle from the upper lobe. So much the same again, shows you how the different aspects of Jacob bronchial tree interact with each lobe. And importantly, again, especially for surgery, each lung has a slightly different percentage when it comes to lung function. So your right lung is slightly bigger, which is the nature of the heart being on the left hand side. And so it's total lung function is slightly higher than that of the left lung. So, 55 and 45 and that's very important when it comes to resecting uh a lobe or more in the patient. And then surrounding the long tissue is the pleura and the fist in a balloon diagram illustrates it quite well. So you've got your outer and kind of visceral pleur, sorry parietal pleur, outer and inner visceral PPL, but they are extensions of each other. So, on the right hand side and nicely color coded. So the purple visceral runs into the blue mediastinal part of the Prattle player. And between each is the pleural cavity, which is very important to know in common conditions like pneumothorax. But it's also quite important to know for a particular type of lung cancer. No spoilers, we'll get onto that shortly. Now, we'll not spend too much time on this, but this is the different segments of the right and left lung. Usually you have 10 on the right and there is a natural variation on the left. So you can have eight, you can have nine, some people with 10. Well, I'll be amazed if they ask the question on my progress test or finals about this and the same for this. So for lung cancer, it's incredibly important to know the different nodes, especially if it becomes to the stage in the lung cancer. So where hr is very important when it comes to deciding what type of diagnostic modality are you gonna choose to get a tissue biopsy? So if you have uh cancer in one or both lungs, you want to sample the surrounding lymph tissue because lung cancer very commonly metastasized through the lymphatic system. No, we go on their first case and I'm not sure how if, if you want me to read it or not, but I'll give you a couple of seconds before I upload the pool start all night. So this question is intentionally vague to ask him really just one question. OK, good. We're spread across two in particular, but the crack answers, pulling head. It was good. I just close this again. So correct answer is the most common type of lung cancer. Uh No carcinoma. This. So I know this question's really asking, what is the most common. So what does this man most likely have the most common cancer? The second is squamous cell carcinoma, which is the second most popular answer. Cha and large cell, very rare carcinoid, even rare. And sarcoma isn't exactly a lung cancer. It's one more of the thoracic wall. So, adenocarcinoma, we've done these slides. It kind of just the take home messages. So I haven't run too much into the science behind them. But how would you distinguish these and the potential M TQ? So, adenocarcinomas are peripherally located and that's very, very important when it comes to management. They are the most common type of lung cancer. And the exam question that they love asking is what is the most common type of lung cancer in nonsmokers, a adenocarcinoma even though 80% is attributed to smoking. But it's the most common in nonsmokers. And the histology on the right shows that there's a glandular. So adeno, I think it's Latin is gland and glandular uh cancer and there was a few very distinct signs. One of which being the pitch in the bottom, right? It's got this hypertrophic osteoarthritis with percent of the triad of finger clubbing, uh bone swelling and arthritic pain and the nature of adenocarcinoma is it produces a lot of mucin. So a lot of sputum uh in the question, this gentleman was bringing up a lot of clear sputum and he can get of course in the hemoptysis throughout. But adenocarcinoma, you get a lot of mucin as well. You can get in men, bilateral gynecomastia and supracollicular lymphadenopathy, but you can also get them and other counselors. So that's adenocarcinoma. These are just general signs and symptoms that you'd be asking in your respiratory history or your respiratory exam. And these aren't specific to any type of uh lung cancer. You can get them at all. So you present with cough and then your red flag. So your hemoptysis, so I can get the shortness of breath, uh pain and this can be many different types of pain. It can be pleuritic, but it can just be a dull ache, more likely to have recurrent infections as well as more constitutional sign of recurrent or sorry, fatigue. And then another red flag is the weight loss. Um You then get put the photo in the top, right. So once you've done your general exam at the bottom of the bed, you can then sorry, the hands and you can look for that. There's nicotine staining on the fingers. Uh Then you got the finger clubbing, you get a monophonic wheeze so opposed to something like asthma where you can get polyphonic where there's multiple airways uh restricted here or obstructive. Sorry, monophonic is usually you have an extrinsic sort of tumor that's pressing on one of the airways and compressing it where you get the and then more late stages would be the pleural effusions as well as hylax or lung collapse. So on the case, two Margaret, 68 year old uh start to pull up. Brilliant. It's fine. Everybody got that one right for everybody. So squamous cell carcinoma. Absolutely. So, squamous cell carcinoma is the second most common type of lung cancer. And the giveaway is smoking. Absolutely. It's down to smoking. Now, compared to adenocarcinoma. Squamous cell carcinomas are found well in the squamous cells which are found in the Jacob Bronco tree. And so they are central tumors and they're a brilliant one to learn because they're just buzzword after buzzword, after buzzword. First one being hypercalcemia. So patients can present with the signs and symptoms there in the bottom right corner, the stones grown. So they had confusion. So psychiatric moans as well as that left iliac fossa pain alluding to constipation, common is common and on histology, you get them probably the nicest thing I've seen in histology, although it's terrible outcome with it, but it is very, very distinctive. And when it comes to investigating and doing a chest X ray, they do have a cavitating lesion which you can see on the top. Right. Also, they have very distinct finger clubbing and like adenocarcinoma, they do have the hypertrophic pulmonary osteoarthropathy, but they're central, they're attributed to smoking. So if you got a question with smoking, it's more than likely gonna be squamous cell and remember hypercalcemia as well. So briefly talk about risk factors and that was the main one covered there. So the most common risk factor is smoking and it's important to remember that smoking can be first or second hand if you have a genetic predisposition to, it's family history tends to run in families a little bit as well. Like a lot of cancers do. And interestingly, there is a occupational association. So minors, people that breathe in dust a lot as well as the standard shipyard workers. There's a link with types of cancers. Oh, and the lights, light in the room. Um There are dietary factors as well, like all cancers as well and rad on gas is a particular interesting one. And we have a map maybe to scare everybody in a moment. Aging again, like all cancers is a big risk factor as well as having other respiratory conditions. So, COPD, tuberculosis, air pollution, an increase in one and the iatrogenic ones with the exposure to radiation. So, and that would fall in with people that have other illnesses such as safety where they'd be exposed to more radiation. So one could feed into another, unfortunately. But that's again on the first, on the first slides where cancer research UK thought that 80% of lung cancers were preventable. A lot of it is down to tobacco smoking and to answer the question, if a patient asks, oh, I've been smoking for 40 years. Is it worth me stopping? Absolutely. Graph B shows up. So former smokers have less of a chance of getting lung cancer and of course, how much you smoke is a huge factor as well. So people have very heavy smoking are more likely to get lung cancer and then graph a showing the genetic risk. No. Was that with the rad on one in the middle? This is a risk factor in the UK currently and I'll not point out in the map where most of us I are based in Belfast. The left and right are showing the same uh risk factor. So if you grew up, which I don't imagine many people did here in farms and trone like I did, the one on the lefthand side is very frequent, seen. It's on most cattle sheds and most farming buildings in nature build using this stuff. And on the right hand side, especially old tires because of its properties were also made with it. And that is asbestos and it was quite a durable and fire resistant material, which is why it was so commonly used but causes methio. So we'll move on to question three where we're back with Margaret again, I'll give you another couple of minutes and now open up the pool. In the meantime, I'll find the lights and turn it on on you. I thought it was a great hard question. Everybody got right as well for my close as four. So everybody got S VC O. So severe ve and cal obstruction is in this case, an oncological emergency caused by the compression of the S VC is shown in this foot in the top, right where the tumor is crushing S VCA in the right atrium and it comes with a particular set of symptoms. So you are profoundly dyn as the blood is then not able to drain into the rad atrium, it backs up. So you get the swelling in the face, neck and arms as well as the distended Juggler V. And you see the sta quite easily and it does then back up further into the head and you get that uh raised intracranial pressure, headaches. So you get the, when you sneeze, bend over, lift something heavy cough and as well as a visual disturbance. And this is quite an interesting sign on the bottom, right called Pemberton sign. So you get the patient to lift both their arms above their head. And I wish I had a video to show with this, but it happens nearly instantaneously. I very red in the face. And that's because the sec is compressed even further. Although in this gentleman's case, he does have what looks like a goiter in the neck, which is probably causing it. But if it happens due to lung cancer, it's an oncological emergency. So management, it's usually quite a bad saying if you get this. So it's a bit of troubleshooting. So there is endovascular statin you can do to try Riess open the S VC but that doesn't get rid of the tumor. So you can give radical chemotherapy or radical chemo radiotherapy and attempt to salvage and debulk the humor um dexamethasone. So it doesn't, I was reading stuff on it. It doesn't work too well, but it still as a non emergency given and marginal effect we'll say. And I will move on to the next case which is based made up John. Ok. I'm saying, hey, doctor in the chat, I will be honest. I, I'm not 100% sure on these now side up stuff. Hello, these pools. Yeah. Oh, very good. Which paper you got this right? Should have made these questions hard uh gooses. Ok. So what to John about first CT cap? So there's a lot to unpack and there's several questions gonna stem from this but first case adverse effect of lung cancer. If there is an option of doing a chest X ray, do a chest X ray because it can rule out other non lung cancer diagnosis. But to properly assess the location of the lung cancer, you need a CT. So investigations, this is my homemade adopted from nice guidelines or the flow chart of what investigations you do just take off a pinch of salt but it's there thereabouts. So you start with and most patients that come through, especially in emergency settings with suspected lung cancer have a chest x-ray already done. But you start with a chest X ray and you follow that up with Act and CTC because you want to assess quite early on. Uh first where is it the primary, where is it located? But also is there any metastases especially you wanna be looking for any enlarged lymph nodes. Now, you have two options. So the CT confirmed, yes, there's a lesion that looks very suspicious for lung cancer. Is it in the peripheries? So, is it in the lung parenchyma? Is the actual lung tissue or is it central, is it in the trach tree? So if it's peripheral, what can be done is CT FN act guided fine needle aspiration. Uh essentially using a CT like guide a needle biopsy into the peripheral gimmer, take a sample. If that doesn't work, you can do this relatively new diagnostic procedure called navigational bronchoscopy on the photo on the next page. But it is, it's like playing a game to be honest, it's using a bronchoscope. So a tube that goes into the airways and you can pass very, very fine tissue biopsy through it and it can go to these peripheral lesions using scanners on the outside and probes that are placed on the patient's chest. Um It knows the scanner, it knows where the tumor is and it directs you. So you literally follow a line on the monitor very cool. Or if it's a central tumor, you can do standard flexible bronchoscopy or uh Ebo, which is on further down, you can do that as well, which is endobronchial ultrasound. So they're both very similar, just a flexible tube down. You can pass there's a canal in it and you can pass biopsy, forceps through and take a sample, for example, consumers if uh both are found to be. Yes. So a tissue diagnosis positive, it is lung cancer and you've already done a CT and it hasn't showed any metastases. You wanna double check that using a better modality, which is the pet CT. So if you think that this lung cancer will be a curative procedure, so you can undergo surgery or uh radiotherapy and the and result will be ac outcome, you need to do a pet CT first. And also, so if you do opacity and you see some lymph nodes lit up, you can do abos again, find these uh lymph nodes and take a sample or for central uh lymph nodes that couldn't be accessed or they weren't successfully accessed by you. But you can do uh me stenos which is a surgical procedure done under G A where a transverse incision is made uh just below the tracheal and the paratracheal lymph nodes can be got from here. So got photo just to roughly demonstrate each of the different modalities and what they can look like act with act scanner. And that's done by a radiologist and pet CT on the nuclear medicine. The tumor is lights up very distinctly yellow or gold and that's usually the high uh energy consumption. And for pets, they give a glucose based iodine or uh isotope and it lights up in areas of high metabolic activity. So tumors, the brain, you can see the kidneys lit up there as well. Uh flexibile, I can't speak flexible bronchoscopy. Very simple procedure, patient again sedated or can be on G A. Uh That's the image might be very small. What you can see allegation of bronchoscopy. The same idea is flexible only, you can go much further out into the peripheries as you're guided by the monitors. EBUS bronchoscopy with an ultrasound probe and median stenos copy where the incision is made and you go and get the central lymph node. Now why you need the lymph nodes and why I need the CT is for staging. So that's very complicated. You do not need to know all of that, but essentially it's at and M system. This is the eighth edition. There is 1/9 1 currently being made and within it, there's T which stands for tumor. And this essentially outlines the size of the tumor and for nodes where are the nodes? Are they on the same side of the mediastinum in the middle or the other side? And, and metastases is there or is there not? So typically as a rough rule of thumb, if you're going for curative surgery, if you have any metastases, no, do not get surgery. Are if there is an N two or an N three find, no, because if you're gonna resect the tumor on the right side and there's positive nodes on the left side alone, that surgery alone isn't gonna cure them of lung cancer. So they need systemic therapy. So we're back with John. We give another minute. So this is from my home flu shot. PVI. Yep. Brilliant. Everybody's got up. So curative treatment you have seen on CT what they've got and you've sampled some of the regional lymph nodes. Very good. Close the ball. So well done. Pat CT and back to back questions. Unfortunately. So in the next stage with John, uh I'll start to pull here as well. OK. So more of a split, but it's quite a hard question and it's mostly between the two that I thought it would be. So I'll close this pool and I, right. So John has T three N two M one. So he has distant metastases as well as uh mediastinal lymph nodes. So that immediately rules them out for curative surgery. So that is just a type of surgery. So it's not really a management option. Lobectomy and Segmentectomy are types of lumbar section. So no, they're not for them. And it was between Radiotherapy and chemo radiotherapy. But with this in mind, so that uh staging as well as the probable diagnosis that he has, there's a type of treatment that you go for and that is a chemoimmunotherapy that's called John small cell lung cancer. So I'll go back to the actual sta of the question. This was a couple of pages ago. Um Right. So the first thing about John is he has hyponatremia with small cell lung cancer. That is, they have a huge association. So, hyponatremia and small cell go together. So, if I forget about that was just the red herring, I guess. And a dull smoke, alcohol. Not really, I think, but it's just uh persistent hyponatremia and the fact that he smokes, so we'll go back to the small cell. So it is a huge association with smoking and these are quite sinister cancers and they're often found late and they already have metastasized. So, the prognosis is quite terrible for them, but they arise from neuroendocrine cells and I don't want to know about them. They too like squamous are central and what I was getting to with the hyponatremia is a ectopic A DH secretion. So, uh typically patients can develop si A DH syndrome of inappropriate A DH release as well as that. They can have symptoms of uh Cushing's today with ectopic S CDH secretion. Uh Unfortunately, the histopathology is not as nice as, as with the first two, you get the salt and pepper chromatin. It's the best that you get with it and the management is so it's already metastatic in many cases. So, a lot of treatment is based on palliative care, although nice have changed their guidelines recently where if it's caught in the rare instance of being at one or T two, it can be considered for surgery, the same as with nonsmall cell cancers and with small cell lung cancer. The first line is chemo and radiotherapy together to give a better chance. And unfortunately, a lot of patients are quite advanced and so they'll be offered the palliative chemotherapy. But central ectopic Eddie H and you can get the Cushing's feature and associated with smoking. So on. Now we go to different types of lung cancer. So you have either nonsmall cell or small cell carcinomas and small cell accounts for 15% non small cell by far the most common of 85. And our of them, we've already touched on this. But adenocarcinoma is by far the most common than squamous cell carcinoma. Although historically, squamous cell did used to be the most common due to the old cigarettes, which didn't have the filters in them. So all the carcinogens landed in the bronchi and developed a cancer there whilst now cigarettes have the filter inside them. So only finer particles can go through and then finer particles go into the peripheries where you get adenocarcinomas. Large cell carcinoma will come on to, but it's kind of a diagnosis of exclusion. So it looks like, I don't know, it looks like squamous, but it isn't either. And carcinoid quite a rare on its kind of in a gray area. Is it non small cell? Is it even a proper malignancy that's still up for debate. It's the one if you're going to have a lung cancer, you'd want carcinoid, which is a terrible thing to say but one of the surgeons sold me out. So he's going to be sick of John. But we're back with John for one more. Ok. So keep in mind the diagnosis is John House for this one. I'll start the pull here. Yeah, most people doing very well. So regular lung cancers. Right. And most people got to stop the fall. So this is a perineoplastic syndrome. You get associated with small cell labra myasthenic syndrome. So it's not type two diabetes. It's it doesn't usually cause struggling from sta certain positions. Myasthenia gravis can and we'll come back to it. Dermatomyositis is also part of aplastic associated with cancer in general, but this is specific to small cell carcinoma in this question. Um Lambert is associated with small cells and it differs slightly from myasthenic gravis. So, mycena gravis causes the fati fatiguability. However, in this question, it says one standing, John's very strong and stable on his feet. Myasthenia would be the opposite. So as you exert yourself more, you get weaker and weaker, whereas there's a phenomenon with Labra myasthenic syndrome where the opposite happened, you're initially quite weak but you get stronger. Now on that and this is the first point of signs and symptoms that's only in about half of the patient list they have where increased use of their muscles causes an increased strength. The other half, it's more of Myasthenia gravis type picture where they fatigue with more and more exertion. So that tricky question. But yeah. So it is paraneoplastic syndrome, small cell where there's an antibody created as directed against the P pre and optic voltage gated calcium myo channels in the peripheral nervous system. And in your examination, you would find limb girdle weakness. So, proximal weakness affects the lower limbs. Usually first uh check and reflex is has hyporeflexia and you do have the quite noticeable autonomic symptoms. So you have that dry mouth impotence as well as difficulty uh going to the toilet like John has now another interesting feature which is a kind of a gray area. Uh any signs with the eyes, they can and cannot be present. It depends on the patient, but they're quite uncommon compared to myasthenia gravis, which most patients are gonna have a ptosis and you can elicit that ptosis. Um not so much with the Stale syndrome management is quite difficult because if you have it with obviously a small cell, it's quite a progressive small cell. So ideally, if you can treat the underlying small cell, you can treat it. But it's usually quite a bad saying if you have this kind of immunosuppression start with steroids. Um there is this relatively new treatment with the diagrams also shown this 34 diaminopyridine gain maybe. But that but it's a potassium blocker and the idea is to increase the action potential. And so it leaves the calcium ions open in time for longer, two more acho stimulated and you can do IV IG and plasma exchange as well, but it's not a good thing to get this. Well, it's an interesting one they can ask you. It's quite a good question to get, got in past before. So I'm not a management options. Is there. So if the patient has got early enough, uh it's quite a localized disease. The goal standard this surgery and what surgery? The first question you always should ask is resectability. So, can I get to the tumor? The second question? And probably the more important one, definitely, the more important one is operability is the patient fit for an operation or not. So you could have the best peripheral tiny lesion but patient severe heart failure, COPD, peripheral vascular disease, an anesthetic nightmare, you're not fit for surgery, a different surgery. So most commonly done now is vats. So video assisted thsc or minimally invasive surgery, which is shown the top right. Previously, the most common wassom. So open procedures where you have there's anterior or posterior soy wounds, but really massive quite gruesome wounds and but it allows for better access of the lungs. And this is still used for large tumors as well as perhaps if somebody's had radiotherapy before and they've now got fibrotic tissue around their lungs and everything's quite stuck and congealed. Same if somebody's had a pleural effusion, if it's gonna be a very awkward case to do minimally invasive, still revert to open and on the increase is robotic-assisted thoracic surgery, which is shown in the middle where the surgeon sits in the corner of the room and takes out somebody's lung cancer president. Now there's different types of procedures you can do. So that's you are different approaches. Now, different types of operations you can do is a wedge resection for really, really small uh lung cancers. You can just take a walk out segmentectomy. Again, this is becoming more and more common where you just take one of them segments instead of a whole lobe. But the current gold standard is Lobectomy. I do think with more research and more practice done on segmentectomy that will become the go to option for small lung cancers confined to a segment you can have in the right uh lung or bilobectomy. You can have two either the upper lobe and middle or lower middle and then pneumonectomy, the total removal of the lung don't quite rarely, no. And options there are there as well. So systemic therapy, chemotherapy quite good for some lung cancers. Again, it was caught early enough, but it's not the best option. Radiotherapy is becoming a fantastic option, especially safer. So say we and that's an image of it there on the bottom, right? It can pinpoint exactly where the lesion is and in time if the person still breathing, it can uh blast away essentially at the tumor. And so the patient doesn't need to go under a operation. And yeah, it's for peripheral lesions. It's showing great purpose and it's very close now to surgery in terms of outcomes. And our newest one is immunotherapy. So I don't know a lot on it. It's ongoing, but I think it'll become now the mainstream of treatment in the years to come. So another po another question, that's the time of a, a gentleman called Steve. Fire up the pool here. Powerful. Right. Right. Very good. Close the BS, keep us going. But yeah, most people are getting this one right as well. Mesothelioma. So very prevalent in this part of the world actually is a cancer of the endothelial layer of the pleural cavity. And it is strongly associated with asbestos exposure. So that gentleman who was working with farm buildings in that photo from earlier on with the roving of farm buildings having a lot of asbestos historically. So it presents a little bit differently to tumors of the lung parenchyma. With you have the normal dysnea and weight loss, but you get this distinct chest wall pain. Do you have finger coin? And 30% are presenting with this painless terror effusion and that will contribute to their dyspnea. That's a bad thing and interesting thing with mesothelioma and asbestos exposure, the latent periods massive. So it's in the system for about 30 or 40 years before the patient will present with Methio and the Harlem Wolf as a standard pass made question about a shipyard worker investigation. So again, if they have another chest x-ray, they're gonna do a chest X ray. And it's a very good sign. So you can see the pleural thickening and the lung looking, you can hardly see the lung cause the there is so thick on this chest x-ray. And then again, we've done an X ray. What do you do after act, do a ct of the clear and if they do have a pleural effusion, you can sample, you can do an aspirate of the pleural effusion and a pleural biopsy as well. So, management again, is a very poor condition to get the prognosis isn't good. So, a lot of it is based on symptomatic management. So, draining effusions to allow the relief of that dysnea can get chemotherapy and surgery rarely. And so we can do perect, you can remove the pleura and there's now a trial ongoing on extended perect toy, including pericardium and diaphragm. But results are up in the air. But it, and interestingly, a lot of it is attributed to occupational uh hazards. So there is industrial compensation. So now on to Sally, she's a distinct type of lung cancer. Open the book uh spot on these are great. The Pine Coast tumor. Again, there's ocular involvement is in my gravis, but she does have the a cough and the weight loss and she has quite a distinctive sign. So that's severe scapular pain, very distinctive, the pancreas tumor. So, ankle tumors are essentially any type of tumor. So they can be adeno or squamous cell, but they're most commonly adeno. Their tumors are found in the apices of the lungs. So when you're doing a chest X ray, it's always important for everything else for that. You know, your doctor O ABCD E when you go to E if you've, you've already looked at your lung tissue during b also your E have a look at your apacies and the some of the signs that she was having is due to the compression of the vagal plexus. And you can get that severe pain sometimes in shoulder and scapula and you can get pain and weakness in that epi silat arm and hand. And if it compresses a simple like ganglion, you can get Horner syndrome or you get myo and hidrosis a lovely triad. So our question involved in Mary, it's a lot different. Yeah. Very, very good. So this is perhaps less sinister type of lung cancer. It's a carcinoid tumor. Now, they are relatively rare. Although I've seen a couple of them, they too like small cell originate from neuroendocrine cells, but they secrete hormones. You also commonly get them in a small bile and one of the hormones that it secretes is serotonin. So that's where you get the systemic symptoms of Carcinoid syndrome. So you get the lights off that facial flushing and diarrhea. That was in question. You also get high BP, you can get weight gain. And along with that you do, it's a lung cancer. So you can get the common presenting symptoms, coughing, wheezing hemoptysis, and you can get atyla. So it can be a mixed location tumor. So you can get it in the peripheries or centrally. And if it's more sad, it can cause the collapse investigations. So it secretes serotonin. So you can get urinary five hydroxy into that. Yeah, that acid. Um, that's uh one of the breakdown components of serotonin and m more rarely done as a 24 hour urine for free cortisol levels, but very good prognosis. Most go to surgery. Uh most endo uh successful resection. No, I didn't get a question. I'll just move on with large cells. So it is a type of nonsmall cell lung cancer and is found and next location as well. So it can be in the center or peripheries of the lung and it's the diagnosis of exclusion. So it's, they know it's a non small cell lung cancer. It doesn't have glandular features of adeno a squamous cells. So it's put down to large cell. Although on histology, it does have a distinct feature of having as in the name of suggest a very large cell with very, very prominent nucleoli and it is quite aggressive and it metastasizes early, which is a concern. So it can go to the C NS nervous system as well as the gi tract and you can get then the presentation of bony pain, headaches and seizures. And that can be people's presenting complaints and it may also secrete the beta H EG. And yeah, overall, it's a quite a poor prognosis due to the early metastases of it. So, one more question, I know our host will love this question. I'm gonna open the port and this involves no one per plastic things that we haven't discussed yet. Small cell lung cancer. Yeah. Cracking all done. Most people are getting this you on couple seconds. Yeah. So unfortunately, this man has developed limbic encephalitis, which is very late and that's a terrible, terrible prognosis and I get to this stage. But so they're all uh s small cell lung cancer per aplastic syndromes here. So, Cushing's syndrome, but it doesn't describe Cushing's the si DH hypercalcemia. Of course, with the squamous cell carcinoma and frantic nerve palsy, which is just uh the struggling to breathe cause the diaphragm isn't working now. That's to do with any cancer essentially compressed in the Ron light keeps going on me. Sorry. So, limbic encephalitis is another corneoplasty syndrome associated with small cell lung cancer. And it has to do with onal antibodies, what you produced by in response to the small cell lung cancer that affect the limbic regions of the brain particularly. And it presents quite acutely subacutely with personality and behavioral changes. You do get the memory deficit seizures and the hallucinations like the gentleman was having in the question, it has a strong association with anti antibodies and you can do uh MRI which can show inflammation of the hippocampus and the Magdala, both sides of the brain. And CSF shows oligoclonal bands. So not just multiple sclerosis has that. And CSF also shows elevated protein. You can do an eeg. But again, I'm not sure what you'll get out of that, especially if you know one diagnosis of lung cancer on a brain of the or an image of the extremely straightforward limbic system. So quick fire spot diagnosis time, what's up? So I would that. So I guess it's known what is that show and what causes that? Jo OK. So we're split between two. That's very good cal close support. So it shows cannonball Mets and got this from really Pia resp I don't remember where it comes from, but the most common place that Campbell Mets come from is renal cell carcinoma. Um If you see, if you do get a chest X ray, basically, it's showing multiple metastases all over the lungs, both sides and they're that distinct. Well, demarcated circular lesions if you see this next step is ct abdomen because renal cell carcinoma is by and large, the most common. But it can also be from colorectal carcinomas or choriocarcinomas, especially in uh younger percent. Man can also be from endometrial carcinomas, synovial sarcomas. Again, gentleman prostate carcinomas. So grasp, again, this is quite uh we've alluded to this earlier in one of the pictures. Yeah. I don't open the po, ok. Interesting and spread. I like it. Yeah. The crackdowns just pulling the head close. This so occupation. He's a retired mechanic and he's presenting with dyspnea, um, in the stem. Maybe it was leading it a little bit but potential lung or pleural malignancy. There's only really one pleural malignancy that we know. And that's mesothelioma. And at the picture to start with the radon gas And on the other side, we had the farming shed, on the other side, we had the tires. So, tire mechanic, uh, especially the ones, uh, possibly worked with tires a lot more. And from that, he's picked up the asbestos with the 30 to 40 year latent period. It's been in the system a long time and now he's presenting with signs of mesothelioma pet I put in, I put, yeah, part, I think it's a hypersensitivity pneumonitis. But it's still that in because why not red herring and smoking? So he's a never smoker. So there's no, uh, risk factor for lung cancer. There, there is an association with age, but there's a more obvious one that this question's alluding to and alcohol. Again, it's quite a uncommon risk factor and tires. Again, it should be spot diagnosis two seconds or is it? I think this is my last question. Ok. And this one quite divided. Not. Ok. But the two main differentials are leaving it to close it. This is not mesothelioma this is per plaques. So third Plax, I think it was maybe the next page on it. Yeah. So it is associated with asbestos. Although when you look on the X ray. So on the left is the methio x-ray. On the right is the third Plax. Three of these discrete and they are plaques, but they are weird opacities on each lung and actually benign, there's no follow up required. So if somebody is diagnosed with this, essentially they're discharged, that's there's no intervention or follow up needed and it doesn't have that same characteristic thickening of the pleura and occluding of what you can see of the lung tissue that you have in the sit over here and the left hand side just being awkward question, wasn't it? So I think everybody's Glenn will be able to confirm this with me, but I think everybody will get slides sent out or access to the slides. So that's just question summaries if you're going through it again and why each case? And M CQ was the answer. It was night I got this. If you're a visual learner again, I can't attribute it to anybody. I got off on Twitter, but they weren't actual authors. They weren't this guy Stuart, but it shows different lung cancers where they are and some risk factors for them. And a similar being of thought is this one from wiped again, really, really good uh Chrom image of the lungs and where you can get the different types of lung cancers. Now, if there's one page that's essentially a take home message, is this so you can take photos off it. You'll get the slides anyway. But something like over a couple of days before the exam, there are different types of common lung cancers and buzzwords essentially or as the signs and symptoms you get with them. What do you do with the treatment? And is there any hernioplastic syndromes associated with each or histological signs that you can see? And yeah, so mostly it takes me surgery and possible. Very, very good for put this together cancer research. UK. Quite informative and, and for the anatomy stuff was teach me anatomy and really pia for the scans. Oh, yeah, crowded the SLS go. I didn't come this powerpoint and uh thank you all very much. Fantastic participation. Sound good. That's great. Thanks very much Donovan. So guys, um that's the end of the talk. Um The feedback form is in the chat. I think we'll also send it out by email as well. If you have to run on. Um, if you fill a feedback form, you'll get a copy of Donovan's slides and I believe the recording will also be made available um at some point. So thanks for joining in and we'll catch you next time all the best. Thank you, everybody.