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Let's just crack on. So according to your UK MLA syllabus, this is all that you need to know. Again, it's very worthy and it, it just sounds kind of a bit waff. So I've condensed that down into what essentially is important for you to know, which is how do we diagnose lung cancer and how do we treat lung cancer? Now, lung cancer and all kinds of cancer diagnoses are a team effort. And as you would know, we always involve a multidisciplinary team. So you wouldn't be doing any of this on your own. And as af one or F two or even registrar, um you're not expected to do a lot of the decision making. But um if you are vaguely aware of the process that will be really, really helpful just for the patient's journey. So you can sort of semi tell them what goes on. Now, I believe as a respiratory person that lung cancer is the most important cancer out of all of them. Why? Because if you look at the graph on the left hand side, this is prevalence of all kinds of cancer in the UK. And this is from 2018. Now, if you see lung cancer is actually the third most common cancer um diagnosed in the UK and that's behind prostate and breast. So actually it is the top cancer for both sexes. If you look on the graph on the right, this is comparison between incidence and survival. As you can see also here, lung cancer has got a very high incidence and the survival is relatively poor for such a common cancer. And the reason for this is because lung cancer ti tends to be diagnosed very, very late in stages three and four. And that is something that we're working on at the moment with uh lung cancer screening. So we can diagnose people earlier and treat them earlier. Now to talk about lung cancer first, you need to know about a, a bit about the anatomy as per your syllabus. So your lungs are made up of two sides and each side has technically three lobes. Although you would think that the left side only has two, the upper and lower lobe and the right side has three, the upper, middle and lower lobe. It's because the left upper lobe has this little thing here that is called the lingula that sometimes we consider as a separate thing. Um But it is kind of technically part of the upper lobe. And you will see from latest slide that the anatomy of the airways is what distinguishes the upper and the lingula. And if you look here, you can see actually, it's not divided into three sort of equal sections. If you're looking at the l phase on the it right lower lobe is actually just the very, very bottom anteriorly. And most of the right lower lobe actually exists posteriorly. So that is something to bear in mind when you're looking at imaging, similar story on the left, the left upper lobe occupies most of the anterior surface of the lung while the lower lobe occupies most of the posterior surface of the lung. And that's why when you are looking at anatomy, just having a two D image from a chest X ray is not going to be sufficient. Now, this is probably a bit too much for um what you need to know. But this is something that we care deeply, deeply about. Uh because when your um TriC descends into the carina, it bifurcates. And as you all know, it bifurcates into the right main bronchus and left main bronchus. However, subsequent to that, it divides into the segmental airways and subsegmental airways. So these are the segmental airways and these are the subsegmental airways in black. And that's really important because in order for us to sample and treat, we need to know exactly which airway goes into which part of the lung. In order to diagnose and we can do resection, we can do biopsy. And therefore, this segmental anatomy is of utmost importance, but you don't need to know that for now. Um, now the other thing in the chest, aside from the lungs themselves is the mediastinum and you can't talk about the lungs without talking about the mediastinum. First of all, we are very, very hung up on the lymphatic drainage of the lungs because as we said, in the previous talk, the sort of, um, pleural space drains into lymphatic system, but also the lymphatic drainage for the lungs drain into the mediastinal lymph nodes. That is important because if you get lung cancer on one side, you need to know how it can be spread lymphatically. So for example, if I have a lung cancer in the right upper lobe, that is going to drain fast into my 10 R and then from my 10 R, it can go to seven and then that way it can spread to the 10 L and it can also spread upwards to four R and then once it crosses the other side, it can then spread upwards as well as well as down downwards. That's why it's important to note where the lymph nodes are and how they are in relation to other important fractures, that's really important as part of our diagnostic process. So as you will see soon, we do endobronchial ultrasound to sample these lymph nodes. And the order that we sample these lymph nodes is according to how the cancer is anticipated to spread. So we go from the most close to the cancer or distal to the mediastinum and we work backwards to avoid feeding the cancer. Now, you can see there are other important structures that are in the mediastinum. So that is your aorta, this is your aortic arch. You have your esophagus just in the posterior mediastinum. This is your spine and these are your anterior ribs and this is your heart. And here are some vasculatures including your vagus nerve, et cetera, et cetera. The mediastinum is divided into four main parts, superior, anterior, middle and posterior mediastinum. And a lot of times you can see masses or um cysts form in these different compartments. And that is visible both on chest X ray and CT scan. And these are all the different differentials that you will have to consider if you find a mass in the mediastinum. So just because it's in the chest does not mean it's lung cancer. It can be a variety of many other things. And in fact, we diagnosed a lot of lymphoma because that is where they first present. Now, that is just the basic of the anatomy. Um It's a lot but all you really need to know is how many lobes there are and that there's a lymphatic drainage and that there are some mediastinal structures. Now, we are going to work slowly through a case that is a real-life case that I have been working on um this year and um we shall begin. So this patient is called a and he's 53 years old. He first attended ed at my hospital in about July time with four weeks of back pain radiating down his right leg. So nothing really to do with the chest. But because we had lung cancer talk, this clearly will turn out to be a lung cancer. But, um, when you first see him, there is no reason to suspect that this is going to be anything to do with the lungs. So, back pain coming down, the right leg hasn't got any other symptoms, doesn't have features of cor equina doesn't cough, doesn't have breathlessness, no hemoptysis, no fever, nothing else. Just the back pain. He's got a history of asthma slash CO PD and he's been started on a PSA inhaler. He currently smokes between 5 to 20 a day. He insists to me that he's cut down from 20 down to five. But that story changes week on week, he smoked a total of 37 pack years. He's from Romania and he's currently working in the UK and in fact, contracted by my hospital to work as a builder. So there is some occupational exposure there. Po possibly he's not been exposed to TB and he's recently been back to Romania to see his family, but nobody is unwell. He's normally fit and independent and working still as a builder. Although the back pain is a relevant issue. Um However, when he was in A&E some very competent and very smart doctor noticed that on examination, he has got left basal wheezing crackles and there is reduced air entry on the left base. This is why you should always examine your patient thoroughly even though it might not be the presentation that you think it is. What is your top differential. So if I can get everyone to log on to slider.com and um put in this code or scan this QR code and it should come up as well. On the next page, here we go. You can scan this code or join here and um let me know what you think your differentials are and you will see that lung cancer is not part of this because we don't want you to think that this is lung cancer at present because there is no reason to suspect. So, so just to recap the history and examination, back pain radiating down the, I can't remember which leg it was, yeah, like it was the right leg. Um And um it's got reduced air entry crackles and wheeze in the left base. I'm gonna give everyone a couple more minutes. Choose your answers. Any other takers. Right. So, well. All right. Right. Go back. Mhm Right. So all of these answers are technically reasonable. That's why they're all in options. And there are two issues here. Number one is the presentation which is the back pain and the leg pain. And issue number two is the chest findings on examination. So options one into pneumonia and exacerbation, COPD or a combination of both can both explain the chest findings. However, how are we going to explain the fact that he has back pain? Now, pneumonia can cause pleuritic pain and it can irritate the pleura especially in the back. And that is entirely reasonable. If he's got a bit of a viral illness, he could have a bit of myalgia that is also reasonable, but he's come to A&E with back pain. So something is clearly going on there. It takes a lot for people to go to A&E with just back pain. Now, question number two, what investigations will you do next? Bearing in mind we need to figure out what's going on in the back and what's going on in the chest. And I think this is possibly a ranking thing or not. All right, anyone else still voting, put your vote in now. Ok. So the key to this question is, which investigation will you do next? So these are all very reasonable options and but the first investigation you would opt for as always, will be to work from bedside towards more complex investigation. So blood tests will always be fast, observations and blood tests will always be fast and then you move on gradually to the type of imaging that you think is useful. Now, I've put some things here that are all actually very important. So bone profile in this situation is important because, well, I've done something again. Um, because, um, if he's got back pain, there must be something going on in the musculoskeletal system. A simple blood test such as bone profile can actually tell us quite a lot of information. Um, inflammatory markers are helpful because we are suspecting exacerbation of COPD and pneumonia. Um Once see the chest X ray is definitely the investigation of choice to evaluate what's going on in that left lower lobe. At the same time, we probably would do an X ray of the spine as well. Just to rule out any fracture, an MRI scan is useful, but it will not be the first thing that you do and you are unlikely to get that within the next like 3 to 4 days anyway. And a sometimes is also helpful in cases where people have muscle pain. And for example, if you're suspecting dermatomyositis or any kind of myopathy, then a will be useful. Now, then he had some investigations done in A&E these are his bloods. So for a 53 year old man, he's a bit anemic. His white cell count is not raised and this is a normal cystic anemia. Sodium is a little bit on the lower side, but within reasonable range. Now, his alp is elevated without elevation in the rest of his liver enzymes. And you can see that actually his calcium is high. Now, this is suggesting a bony problem, as you would know, and I'm sure you'll get a talk on the bone profile, but this will suggest high turnover in the bones, high calcium, high LP. This is his X ray. So I'm sure you can all tell this is a bit of effusion in the left side. And um we're just gonna run through the X rays again. A is for airway. So you're looking at the trachea if it's central and if it bifurcates, normally into both sides, B is for breathing, you're looking at the lung, feels, looking at the lung markings. This looks like a bit of emphysema. Actually, you're looking for any upper lobe diversion in cases of pulmonary edema. You're looking at the top and bottom to look for any apical changes and any consolidation, any pneumothoraces and any pleural effusions, which you can see nicely has a meniscus hip C is for um cardiac or cardio cardiac cardiovascular. Uh So you're looking at the heart shadow. So this heart shadow doesn't look quite right. The left heart border is quite straight and it's definitely obscured by this bit, this effusion looking thing. So as you know, if the left heart border is too straight, you can see what's called a cell sign. This is not very definitively a cell sign. Um but it's worth considering that's definitely something going on here. Um D is a diaphragm. So normally you should be able to see the right hemidiaphragm and the left hemidiaphragm, the right hemidiaphragm tends to be a bit higher than the left hemidiaphragm. And you should be able to see the costal PHR angles on both sides to be crisp and clear. And this is not crisp and clear. The ee is for everything else. And you're looking at the soft tissue, the bones, the breast shadows underneath the diaphragm, check the apex, uh apex, see again just to make sure you're not missing anything. It's in the context of this pattern, having the range bone profile. We're definitely looking for any fractures in the bones or any sclerosis. And this is the main finding here, however, not to be missed is this bit. So um area that people tend to miss is the hila and you're comparing side to side, this is a bulky hila and that there looks like something there that should not be there. And this is very suspicious. So this man then ended up having a series of CT scans. So when you're suspecting cancer or if you're suspecting something abnormal going on in the lungs, the investigation of choice will be a CT chest with contrast in the venous face. So the venous face will allow us to see the media spinal structures a lot more clearly than a CTPA. And that's especially important because we want to see all the lymph nodes. We need to know whether the lymph nodes are enlarged so that we can sample them. This is in the bone window. This is in the lung window and this is in the abdomen window. So you can see on the lung window. First of all, the airways have the airway has bifurcated. So this is below the level of the carina. This is the left fissure and this is the lower lobe and this is the upper lobe. And you can see the upper lobe is occupying most of the anterior aspect of the lung. There is something going on here. This density here should not be there. And there is associated nodularity and thickening of this fissure. There is a trace of fluid here, but it's not that apparent and whatever is going on here seems to be blocking off some of these segmental airways. Now we move on to the same thing but in the uh abdominal window, now you won't be able to tell this. But this lymph node, which is a subcarinal lymph node is enlarged. Normally, lymph node should be less than a centimeter in the maximum diameter. And this is definitely bulky. And you can also see as the left main bronchus divides into the left upper lobe, bronchus and the left lower lobe bronchus. This lymph node here is called 10 L and this is also enlarged. So you are getting some kind of substance, some kind of cells infiltrating these lymph nodes. Now this is where the money is because the man has come in with the range bone profile and back pain. So we scanned him as well top to toe and in the bone window, I'm not a bone radiologist, but there are some lesions here and I think here that looks suspicious for bony metastases. Now, the imaging will suggest that this gentleman unfortunately has metastatic cancer of some sort. And then we will next go on to how we work him up, as we said in the beginning of the talk. Um it's a team effort and we involve a variety of many, many, many different people in the MDT. And that's why the MDT S go on for so long because everyone needs to have a say. So every person in this circle is extremely important for the diagnostic and management pathway. We get a lot of our referrals through the GP on the two week wait pathway either because the patient has symptoms or has abnormal imaging A&E sometimes refer us patients or other teams do because um they've incidentally found something and um it's been recommended by the radiologist to be referred to us. Obviously, respiratory is going to be there. Um And we have a variety of radiologists. So we have traditional CT, we have nuclear medicine, which is your pet scans. And we have interventional radiology, which is extremely helpful when we're looking to diagnose things to take biopsies. Then once we have the tissue sample, we send them to pathology to get looked at. And the pathologist can tell us what type of cancer it is and many, many different useful information surgery, not just a form of treatment, but also can be part of diagnosis. So actually we can do a wedge resection. So when it's something looks suspicious enough, we just go in, take out a wedge and then we look at that wedge POSTOP to see what it is. But then by the end of that surgery, that stuff is out already out of the patients, then you have your oncologist. So you have your medical oncologist who look after the chemotherapy side of things and your clinical oncologist who deal with more radiotherapy side of things. And if the patient is not eligible for active curative treatment, then you're looking at palliative care and not to be forgotten are all of these people, psychologists, physiotherapists, nutritionists and our oncology, nurses who are all extremely important in the patient's journey. The way I think about it is that there are four main things that we need to concern ourselves about in terms of lung cancer management. If you do not prepare appropriately before you start treatment, you will fail. Secondly, you need tissue tissue is the issue. It's something that my bosses love to say. Um but in cancer diagnosis without tissue, you can't really move forward. Number three, the right treatment for the right patient at the right time. What we get a lot is that patients are like, you know, why can't you just start treatment? Why can't you just start treatment, just give me chemo, give my dad chemo, just treat straight away. The thing is if you don't give people the tailored targeted therapy from the beginning, it's less likely to work and it subjects them to side effects that they sh shouldn't have to be subjected to. So if you take a bit longer, two weeks longer, for, for example, in your diagnostic process, you can avoid a lot of complications and unnecessary side effects for the patients. So it's always to get it right the first time. And finally, I'm sure you will know we always put the patient in the center, but don't forget about the family, managing families whose loved ones are having a cancer diagnosis and undergoing cancer treatment is not easy and it's very, very hard on the carers on the partners on the Children to handle the diagnosis and also to look after their relative. So make sure you keep them in your mind. And there are lots of really helpful charities um that help out on for the psychological counseling, for families and help them with financial support as well, right? So when you're looking at the patient's cancer work up, there are a few things that we need to answer. What type is the cancer, what stage is the cancer and how fit the patient is. And these two often go hand in hand because we're not gonna, you know, stage it first before we type it or type it before we stage it because actually different types of cancer have different kinds of staging as we will discuss when you want to know what type the lung cancer is. The imaging and the history can help point you towards one diagnosis over another. But until you look at it under the microscope, you won't be able to tell. And that's why tissue is the issue. Then we need to look at how exactly we get that tissue. What is the safest least invasive way that is going to get us the highest yield of tissue. So if you came to the talk on Wednesday, you would know that cytology from pleural effusion has a very low yield for cancer. And what you really ideally want is a chunk of tissue either from the primary cancer or lymph node metastases or distant metastases to answer your question about what it is. And when you sample, you want enough tissue to allow you to test for biomarkers and what's called next generation sequencing in lung cancer. We now have options including targeted therapy and immunotherapy, which requires us to have a greater cell sample in order to test for these markers. And if we have those markers, if the patient has those markers, then it allows them to qualify for those immunotherapy. And it's much more effective than if you just whack them with some blanket chemotherapy that's been around for decades. The stage of the cancer is really, really important and you want to stage the cancer as early as possible. That's why when we work patients up, we always do a cross sectional imaging from chest down to the pelvis. Pet CT is especially helpful when we want to do uh biopsies to see what area lights up. And this is especially important for lymph node biopsies that we do via EBUS brain imaging. Also important just to check for brain metastases because that will rosely change your management. Now, it's all very well talking about what treatment the patient can have based on the histology and the staging. But your patient needs to be fit enough to undergo all of these tests and future treatments. If the patient is going to have surgery, you need to make sure that they're fit enough for surgery. It's a big ask, taking out a chunk of someone's lung. So that needs to be thoroughly discussed and thoroughly considered fitness is thought about in two different ways, functioning, which is a who performance status and physiologically. Now, lung function is something that we look at a lot and you have to have good lung function before you go for a lung biopsy as well as having surgery. Because if I'm going to take out part of your lung, the remaining parts of your lung need to be working enough for you to keep breathing with a chunk of your lung. Taken out the who performance status scale ranges from 0 to 44 is the least fit. So four is essentially somebody who is bed bound and not really getting out of bed and zero is fit and well, no problems. And so everyone will fall somewhere on that spectrum. And if your performance status is three or four, it makes you very unlikely to qualify for very aggressive treatment. And that will include things like immunotherapy chemotherapy and definitely surgery. However, just because someone is performance based two or three to begin with doesn't mean you can't make them better and doesn't mean that they won't get worse by the time you start treatment. So what's really sort of vogue at the moment is something called prehab as opposed to rehab. So before you send them off for whatever treatment they're gonna get, you're gonna get the phy physiotherapist there and you're gonna get them as fit as possible. What I always tell my patients is, but between diagnosis and starting treatment, you need to make sure you're the best version of yourself because if you don't start off fit, you're never going to end up anywhere near fit. So I always tell them walk 20 minutes, three times a day, eat healthy, make sure you exercise like not too, you know, not too intensely but exercise, keep fit, make sure that you can, you know, do a couple of flights of stairs without getting really out of breath. Then that means you will be eligible for more treatment. Then you will think about treatment, what options are available and that's why all of those people in that graph before are going to sit around a table or, you know, online on teams and hash it out be like, is the patient good enough for surgery or are they not for surgery? Should they have chemo, should they have chemotherapy? Should they have radiotherapy? What order are we going to do these things in? So we can, you know, do radiotherapy to shrink the tumor and then do surgery or we can debulk the tumor and then do adjuvant chemotherapy. That's also possible who is going to do it. So, different centers have different expertise, different centers have different treatments available. Radiotherapy is not available everywhere, immunotherapy is not available everywhere. Thoracic surgery is extremely hard to find. So we need to find the right people to do what you need to do. Then is the patient going to be able to go through treatment because of their fitness and also because of their willpower family support and traveling plans. I have had a lot of patients including patient a who are like, you know, I'm going abroad and I'm like, what are you going abroad for? You need to start your treatment now and then they're like, you know, I need to visit family. Someone said they want to go to Pakistan for a hip replacement. I'm like, no, no, no, no, no, you need to do this now. Hip replacement can wait. Then after treatment, how are we going to follow them up because you want to prevent recurrence? And if they're going to have a recurrence, you want to pick it up early and not when it's come back metastasized. And if none of these treatment options are available, whether it's because the patient is in a really advanced stage or that they are not fit enough, then what else can we do? Because cancer treatment is not just, you know, if you're not eligible, then that's it. You just go to a hospice and die. It's not like that. There are many things available now and we will discuss those as well. Now, back to diagnostic methods um as the respiratory clinician, our main role is in diagnostics. So we work people up to stage them and to get the tissue. So other people smarter people can then plan the treatment. So number one, this is a pet scan. So pet scan is a positive electron tomography scan and um it looks at sort of cell uptake of the glucose that we inject into them and it lights up in areas where the cells are higher metabolic activity. So as you can see again, this is just at the level of the pana and there's a lymph node here and there's a lymph node here that's lighting up. And these are areas that we can potentially sample with an endobronchial ultrasound. So we pass the bronchoscope down the airways and I pass a needle into this lymph node and I take a sample of it, which is exactly what is going on here. So here are some structures, the SVC, this is the lymph node that is four R and this is the AZ vein and this is tricare and this is the aortic arch. What you see endoscopically is this. So this is the pinna right side and left side. and this is what we see on ultrasound. So we have all of these views. 12 and three while we're doing the procedure. So once, once you're in there, you stick your camera and your probe close to the air wall, airway wall and then you'll get a nice cross sectional ultrasound image. And this is your lymph node and that is what you want to sample. And here you can see is different lymph nodes. So this is the lymph of interest, the four R and this is the SPC. So you don't want to go here, but you want your needle to go enough depth into here to get big chunk on this lymph node multiple times. So we take um at least five or six passes and that means five or six needles going through. And each time we jab it about 40 times in order to get enough sample and that's called fine needle aspiration. The other method you can get a sample from is a core biopsy. So this is a CT guided lung biopsy. This is only possible for very peripheral lesions because if you imagine the masses here, you're going through a whole load of lung before you get to the mass. And that is a very high risk of pneumothorax, very high risk of bleeding. So, anything peripheral, we can do a CT guided biopsy. Anything more centrally will have to go in endoscopically. Now, that's a little bit bit brief uh overview about how we diagnose. Now, this is the types of lung cancer that we think about small cell lung cancer and non small cell lung cancer. Small cell lung cancer makes up 10 to 15% of all lung cancers. Whereas the non small cell lung cancer makes up the rest small cell lung cancers are a lot more aggressive. And by the time they're detected, they're often quite extensive. Non small cell lung cancer are then subdivided into three main types. Adenocarcinoma, which is the commonest squamous cell carcinoma, which is the commonest in smokers. As you can see here, big chunk of this is smokers and large cell carcinoma, which is relatively rare, bronchoalveolar. Uh carcinoma is a variety of adenocarcinoma. So we put that on the adeno, but you can see adenocarcinoma mix up a whole load, almost half of the total number of cancers. Now, this is the different types of non small cells. Adenocarcinoma tends to be peripheral squamous cell carcinomas tend to be central and large cell carcinomas tend to grow aggressively. This I think is a really helpful diagram slash table about the different characteristics of the different types of non small cell carcinomas. And you can go have a read of the slides afterwards. But the take home message is adenocarcinomas are peripheral squamous cell carcinomas are central, they tend to look a bit different on CT imaging as well. Um But that only comes with experience if you've seen in million different CT S and I'm still working on that as well. Um Squamous cell carcinoma is more smoking, although smoking is a risk factor across board anyway, as you know, um yeah, and different type of cancer, especially squamous cell and adenocarcinoma are associated with different paraneoplastic syndromes. Um And that's something worth reading up about as well. Staging again, as we said is very, very important. The reason why it's helpful to have a sample of the tumor before your stage is because if it's small cell lung cancer, you're not staging the traditional way because it's so aggressive. What you can tell is that it's limited or extensive, limited means that the tumor and its lymph node metastases has not spread beyond the midline. So you're he within the ipsilateral lung. If you've got anything across to the other side or elsewhere, then you're by definition, in an extensive stage. This is staging for non small cell lung cancer and this is fresh of the breast. This is the ninth edition of the TNM staging. And you can tell it's quite complicated and this is T is for tumor size. N is for lymph node metastasis and M is for distant metastases. And then you group people into one A, one B, two A, 2 B3, A 3 B3 C four A and four B. And anyone in stages three and four will not be eligible mostly for curative management. The earliest stages of three is a bit debatable. Um But four definitely is not curative because it's been metastasized and it's very hard. It, it's like, for example, if you've got a um colorectal cancer and you've got a liver metastasis, sometimes you can do like, you know, um excision of the metastasis and then you can have adjuvant chemotherapy and that's got a very good chance of cure. But for lung cancer that has metastasized this, it's very difficult to get rid of it. And it's very important that we, we be realistic and honest with our patients and not give them any false hope. What I tell my patients is that we hope for the best, but we always prepare for the worst and that hopefully will give them a bit of, you know, realism about what's going on. Now, this is why staging is important. If you can look at one A versus four B is very, very different. And by the time you get to four years, stage four B, lung cancer has nearly a 0% survival by them. Whereas you can do pretty good in stage one, that's why we want to catch them early in stages one and two rather than three and four. So we can treat them and we can allow them to survive and have good quality of life in their survival. Treatment. Options were briefly mentioned. So you can do uh surgery which is just cut out the thing and um, you can cut out the cancer itself, do a segmentectomy, um or wedge resection. But most of the time what we want is cut out the whole lobe and do a lobectomy just to prevent any recurrence from cancer cells left in the area. Um, chemotherapy is an option. Radiation is another option. So if you've got something that is really hard to get to um by surgery, but it's quite limited. So for example, it's like very sort of contained within the mediastinum. You can do something called saber, which is a form of target targeted radiotherapy. And you can just concentrate your radiation beam on that very small area of cancer. And then that avoids radiating surrounding tissues. You can also have targeted medical therapy and immunotherapy. And that's why we were saying why tissue is so, so, so important, we often wait 4 to 6 weeks just for these biomarkers to come back. So then we can have the correct immunotherapy for the patient. And immunotherapy works extremely well and there's more and more research coming out all the time to say how good immunotherapy is especially for early stage cancers. Now, if there's nothing you can do to treat, to cure, you can still look at palliative care. You can do symptom management, symptomatic management as we do in all kinds of end of life and palliative conditions. But you can also actually treat some of these things. So you can treat peripheral metastases. So this would include things like brain mets, um bone mets, um We can give radiation to the bone radiation to the brain and steroids also help shrink the distant tumors. Um So patient a actually was planned to have radiation therapy, but then he sadly deteriorated prior to us being able to start that and he passed away before that, we can also do local symptomatic control. So some cancers that are growing next to the airways can obstruct the airways sometimes actually, when we do a bronchoscope, we can actually see the tumor and it's very obstructive and that's why you're not getting enough air through. And sometimes people get a wheeze because of that. So we can put in an endobronchial stent to open up the airway again and allow the patient to breathe. But that is obviously not a curative treatment and it's not without risk. And by the time you get to the stenting stage, your life expectancy is very, very short. Um I've admitted a patient from Bronchoscopy as well. Um He had an obstructive cancer. And then we referred him on for a end of bronchial stent to be inserted at a different hospital. He went over to a different hospital, had the stent done, but then within 24 hours deteriorated and passed away. The other thing is we can also do indwelling pleural catheters, which we briefly mentioned in the pleural effusion talk. So if you have a malignant pleural effusion that is going to keep coming back because the cancer is active and not being treated, then you can put in this tube. So this is a chest drain that sits in. So it goes into the pleural space. It runs along the subcutaneous tissue and then it comes up like this and then you just curl it around, put it on the dressing, stick it to the patient. So it just sits on the skin like that most of the time it doesn't, you don't do anything with it. The district nurses can come three times a week to take fluid off and that helps people feel better and you can do this for other things other than lung cancer. For example, liver failure, you can have this as well. And this is what the bottle looks like the bottle that you connect to the drain. So this spiky thing goes into this cap here and um you just, this is suction. So it this suction button for its negative pressure in the bottle and then you just suck out fluid and normally you can take out 500 to a liter each time. Um three times a week we were seeing before that we want to capture our cancer patients. Nice and early. So lung cancer screening is a really big thing happening. Right now. In England, there have been tons of studies that have been piloted to test the feasibility of cancer screening and it's now being rolled out in more cities. So this is only in England, unfortunately. Um, but hopefully it can get rolled out into Scotland, Ireland and Wales soon. Um, as anyone age 55 to 74 with a history of smoking, whether or not you're a current smoker or you're an exsmoker, you are invited to screening and at screening, you are also asked to stop smoking and you will be given the support that you need to help you stop smoking and we will talk about smoking in a little bit more detail in a bit. And these are the trucks that they park in your local Tesco ASDA Sainsbury's Lidl wherever. So they park the CT scan in the hospital in the supermarket, car park. And um, it's a low dose CT scanner. So it doesn't um, carry as much radiation as traditional CT, but it gives us enough information to look for lung cancer. So you just walk up here, have your CT scan chat to someone about stopping smoking and then you get a letter later on to say what we found following the rollout of lung cancer screening, we are now diagnosing 76% of patients at stages one and two compared to five years ago, it was just 30%. So this has gone up more than double. Um And this is so important, it just improves people's survival by immense amounts. And that's why it's so important. We catch them early. The we are aiming to reach 40% of all eligible population by 2025 and 100% by 2030. So you will see this happening um in your time now, smoking cessation, I can't stress enough how important it is for everyone to stop smoking. All your patients who smoke should be given advice to stop smoking and they will tell you, oh, but doctor I've already got emphysema. It's too late for me or I've already got lung cancer. It's too late for me or I'm already 75. It's too late for me. No, it's never too late. And I want to show you this really amazing um ad that was done actually in the trust of one of my friends, I can share a different screen. Mm Let me see if I can share when the ad finishes. You will have a overloaded. Mhm Black Friday. This next one from God. I'm sorry, I can't be with you on your special day. You have a wonderful future ahead of you. I just wish I could be part of it. Mm. Download the smoke free app and get the help you need to quit. I just think that's a really powerful as, um, how much people will miss out on if they don't stop smoking and then they start wheezing and then they will die from it. Um, all right. Back to, back to the slides. Stopping smoking is the single best thing you can do for your health and your family's health and it's not just related to chest, it's related to cardiovascular risk, cerebrovascular risk, um liver health, gut health, everything. So stopping smoking, super important. And here are some of my favorite grafts. So, on the right side, you can see this graph and this shows um age against lung function. So against value at 25 which is the peak of your lung function, which I am sadly past. Um So if you've never ever smoked and you've never been successful, susceptible to smokers, you are in this top bit. So your lung function will deteriorate over time as you get older. But you're still pretty good by the end of it. If you're a smoker and you continue to smoke, you're on this blue line, which is a steep trajectory towards sickness and death. So this is morbidity in the light pink and morbidity. Uh morbidity in the light pink and mortality in the uh darker pink. And um yeah, so if you keep smoking, you will die early if you stop smoking earlier. You can end up on this green line, which is a slightly less tragic um trajectory. If you stop smoking, even at 65 there is still time for you. You can extend your life expectancy and you can live more of your life in a healthier way. So this is very important. This is also uh very useful to know. So this is um a never smokers lungs. So 100% of these cells are near normal. A smoker's lung has um 4 to 10% near normal cells, but 90 to 96% abnormal cells. If you stop smoking, there is a chance of you going back to 20 to 40% normal cells. So if you stop smoking, the damage is not permanent and some of it can be reversed. Even after you've been diagnosed with lung cancer, there is a good improvement if you stop smoking after your diagnosis. So if you quit your five year survival rate is 60%. But if you continue to smoke, that is 48.6%. This is quitting. Smoking is better than any of the treatment we've got available. And this uh improvement is also seen in progression free survival. So you improve your progression free survival from 43% to 54%. So, well, if people say, you know, i it's too late for me, doctor, I've already got lung cancer. Not sure you can quote this to them. And say stop smoking. Now, your survival will be much better and you are much less likely to have progression of your cancer. And that is a whistle stop tour of lung cancer. Uh, please, um, shout any questions through the chat. Thank you so much, Doctor Maggie. Um, yes, we do have a couple of questions sent privately to me and I'll just read them out one by one if that's ok. So the first question is, is that for patient, a, what investigations would you do first as bone profile and inflammatory markers are also part of bloods? So for a, so we did the bone profile and I think at that stage, it's not unreasonable to complete the bone profile with things like Vitamin D thyroid, parathyroid, et cetera. But then once he's had the x-ray for his chest and the spine, then he went on to have the CT scan, it was pretty apparent that he had metastatic cancer to his bones. And that would explain the raised alp and raise um adjusted calcium. And at that time, you can, you know, you can choose to do a bone scan, but actually a pet scan or CT is equally good um at looking at bone mass. So then he never actually ended up having a pet scan or a bone scan. He just had a um full body CT and an MRI head. Ok. Super. Thank you so much. Now, compared to other lung cancers, what is the prognosis. Oh, sorry. Compared to other cancers, what is the prognosis of lung cancer? Um, I don't have a finger off the top of my head, but it's pretty poor. Um, it depends on what stage you get diagnosed at. Um, and then from there, let me see if I can change the screen share. So it depends on the stage of it. So if you look at this one, this is survival, um over five years and you know, it depends on what stage you get diagnosed at that affects your overall survival. Um But because lung cancer is often diagnosed even now, um somewhere around here, then that means your prognosis is really poor compared to prostate cancer and breast cancer, which are the other commonest types of cancers. Um is a lot poorer. Um And survival is a lot worse with lung cancer. Thank you so much, Doctor Maggie. Um The next question is what would happen if a patient had suffered from COPD and diagnosed with lung cancer, will they be eligible for surgery if they pass a lung function test as the COPD might get worse after the surgery? Yes. Um So yes, they will be eligible if they meet the lung function criteria. So the FEV one has to be good and the ratio has to be good and it depends on the distribution of the emphysema as well and how much like big blood they have. Um But COPD is not a sort of exclusion criteria for surgery. Some if people have pulmonary fibrosis, for example, it makes it a lot harder to do something like a wet resection. Um because the tissue is a lot stiffer and a lot stickier in surgery. So they tend to just take the whole lobe out, but they will be a bit more cautious into going surgery with fibrosis um as opposed to COPD and as opposed to normal lungs. Ok. Super. Thank you so much doctor. So the next question is, is that what is a paraneoplastic syndrome? And what is the importance of it to lung cancer? The paraneoplastic syndrome is um a variety of conditions that is a result of the primary cancer. So for example, one that is um pretty well known in lung cancer is um hyponatremia. Um and um pseudo A th I think it's ectopic ACTH secretion from the um cancer itself. Um Then it gives you low sodium. You can also have ectopic P th production which then pushes up your calcium as well. And that is independent of bony Mets. Um and there's tons of these paraneoplastic syndromes. So it's important to recognize um these syndromes because you can treat them and um it prevents morbidity and mortality in patients with cancer because if you treat their sodium, they might live a bit longer. If you treat their PT, they might live a little a bit longer. Ok. Thank you so much, doctor. Now, the Next question is in terms of lung tumors that are to be resected, you remove the tumor, but do you also re remove the lymph nodes as in all of them? Or can you take a single lymph node to observe whether there's a metastasis such as in breast cancer? Very good question. So, um what you're talking about there is um breast cancer um with wide local excision and axillary, axillary lymph node clearance, which gets rid of all the lymph nodes in the direct drainage area of your breast cancer. In lung cancer, you take out the tumor, you take out the margin around the tumor. And then when the histology comes back from the um resection, we also know how much of a clear margin they've got and they normally sample some of the lymph nodes or cut out some of the lymph nodes around it, not all of it. Um Just one or two that is particularly salient and we look for cancer in those lymph nodes. But hopefully, by the time that we get to surgery, we already sort of know which lymph nodes are involved via pet scan and EBUS. Ok. Thank you so much, doctor. Just a few more questions and then we'll be done. So, if the patient goes through lumpectomy, would that mean that there's no reoccurrence of the cancer as I read somewhere that they also produce stem cells? Um If they have a lobectomy, um you've got a quite a good chance of uh no recurrence. But anything is possible, there are sort of micro metastases that is not detectable at the stage of surgery. And that's why we follow these people up for five years, even after surgery and we scan them every six months. Just to watch out for any recurrence. We look for any nodules, any sites of cancer, any sort of incl of the cancer coming back and then as soon as we can detect it, we can get rid of it. Ok, super. Thank you so much doctor. And lastly as a respiratory doctor, if a patient does not want to have the nicotine patches or the gum, how else would you get them to stop smoking? Uh getting people to stop smoking? It is the bane of my life. Um I got my husband to stop smoking. That was very good of me. Um But uh nicotine replacement therapy, a lot of the smokers will say, oh, you know, I tried a patch, it doesn't work for me. I've tried the gum, it doesn't work. I've tried whatever the spray. It also doesn't work for me. We now more think of uh smoking as tobacco dependency. It like how people are addicted to drugs is that's how they get addicted to smoking is predominantly the nicotine. But on top of that, a lot of it is psychology, social pressures. So in addition to replacing the nicotine, which addresses the nicotine dependence side of things, they also need some kind of counseling, psychological input. And that is something that our community smoking cessation team gets on with. So they give them sort of motivation, goal setting, target setting. But you know, obviously this is a very complex area and II struggle quite a bit telling people to stop smoking as well. Um So if anyone's got any bright ideas, we always welcome more bright ideas about how to get people to stop. We talk about it in all of our conferences, how to get people to stop smoking. So please go into that research. We'll be immensely grateful. Thank you so much, doctor. Well, that's all the questions that were asked. Now, thank you so much, Doctor Maggie for such an incredible informative talk on lung cancer. I truly do think that we have learned quite a lot in the space of just one hour. Um Personally, I did quite like the quote of tissues is the issue and I found all the different diagnostic markers and methods for lung cancer and how they will be carried out useful as well and understanding the new addition of different staging of lung cancer, especially if it's earlier on, it can really tailor the management for that particular patient. And like you said, smoking is probably the main factor um contributing to lung cancer. Now, on the behalf of everyone, all the students and the medical and team, thank you so much, Doctor Mackey for giving up your time today for this talk, please, if I can ask everyone to fill out the feedback form if they have not done so yet, just so they can receive their certificates. And our next session will be next Monday at 5 p.m. on Radiology of breast cancer by Dr Canaria. Now, thank you once again, Doctor Maggie and we will look forward to seeing you soon. Thank you. Thank you, everyone. Take care.