1. Identify what is the disease being manifested by the patient. - Lung Cancer.

It was a rare entity in the early 1900s but has since become far more prevalent. The prevalence of lung cancer is second only to that of prostate cancer in men and breast cancer in women. y the end of the 1900s! lung cancer had become the leading cause of preventable death in the "nited #tates! $%& and recently! it surpassed heart disease as the leading cause of smo'ingrelated mortality. (. )hat are the ris' factors of developing such disease* + oth e,posure -environmental or occupational. to particular agents and an individual s susceptibility to these agents are thought to contribute to one s ris' of developing lung cancer. In the "nited #tates! active smo'ing is responsible for 90/ of lung cancer cases. 0ccupational e,posures to carcinogens account for appro,imately 9-11/ of lung cancer cases. 2,posure to carcinogens -The development of lung cancer is directly related to number of cigarettes smo'ed! length of smo'ing history! and the tar and nicotine content of the cigarettes. 3is' is highest among current smo'ers and lowest among nonsmo'ers. 4 large trial showed that persistent smo'ers had a 15-fold elevated lung cancer ris'! which was further doubled in those who started smo'ing when younger than 15 years. $16& The age-ad7usted incidence rates range from 8.%-(0.% per 100!000 among nonsmo'ers to 180-95( among active smo'ers. -The most common occupational ris' factor for lung cancer is e,posure to asbestos. #tudies have shown radon e,posure to be associated with 10/ of lung cancer cases! while outdoor air pollution accounts for perhaps 1-(/. $10& In addition! pree,isting nonmalignant lung diseases! such as chronic obstructive pulmonary disease! idiopathic pulmonary fibrosis! and tuberculosis have all been shown to be associated with increased lung cancer rates. :enetic #usceptibility -3ecently! advanced molecular techni;ues have identified amplification of oncogenes and inactivation of tumor suppressor genes in <#CLC. The most important abnormalities detected are mutations involving the ras family of oncogenes. The ras oncogene family has 9 members= >-ras! ?-ras! and <-ras. These genes encode a protein on the inner surface of the cell membrane with :T@ase activity and may be involved in signal transduction. 0lder 4ge -Lung cancer occurs predominately in persons aged 10-60 years. The probability of developing lung cancer remains very low until age 99 years in both se,es. It then slowly starts to rise and pea's among those older than 60 years. The ris' of developing lung cancer remains higher among men in all age groups after age 80 years. :ender -the probability of developing lung cancer remains e;ual in both se,es until age 99 years -0.09/ or appro,imately 1 in 9!000.. It then starts to increase among men compared with women! reaching a ma,imum in those older than 60 years -5.68/ vs 8.51/ or 1 in 11 vs 1 in ((! among men and women respectively.. 3ace -Trends in 1-year survival rates in lung cancer from 1961-(009 revealed that while modest gains

occurred in 1-year survival rates among whites! survival rates remained unchanged in the 4frican 4merican population. Current 1-year survival rates are estimated to be 15/ among whites and 19/ among non-whites. 9. 2numerate the clinical manifestations of the patient describe in the situation. - complained of difficulty of breathing! dyspnea! persistent cough for ( years! - une,plained weight loss! - pain at the shoulder! chest and bac'. - verbaliAed occasionally coughing with blood strea' in the sputum. - wheeAing sound over the lung field from an obstructed air flow upon auscultation of the thoracic and bac' area. 8. )hat are the possible diagnostic procedures that will be order to the patient* Chest 3adiography 4 chest radiograph is usually the first test ordered in patients in whom a lung malignancy is suggested. If the tumor is clearly visible and measurable! chest radiography can sometimes be used to monitor response to therapy. Chest radiographs may show the following= -@ulmonary nodule! mass! or infiltrate -see the first image below. -Bediastinal widening -4telectasis ->ilar enlargement #putum Cytologic #tudies The diagnostic accuracy of sputum cytology is dependent on rigorous specimen sampling -at least 9 specimens. and preservation techni;ues! as well as on the location -central vs peripheral. and siAe of the tumor. $85& The test detects 61/ of central tumors but less than 10/ of peripheral tumorsC therefore! further testing must always follow a negative result. #everal large studies have not revealed that screening with sputum cytology and chest radiography is cost-effective in early detection. ronchoscopy )hen a lung cancer is suggested! bronchoscopy provides a means for direct visualiAation of the tumor! allows determination of the e,tent of airway obstruction! and allows collection of diagnostic material under direct visualiAation with direct biopsy of the visualiAed tumor! bronchial brushings and washing! and transbronchial biopsies. iopsy Transthoracic needle biopsy! guided by CT or fluoroscopy! is preferred for tumors located in the periphery of the lungs because peripheral tumors may not be accessible through a bronchoscope. 4 positive finding for cancer is reliableC however! the false-negative rate is high at (5/! and! thus! transthoracic biopsy is generally not useful in ruling out cancer. Thoracoscopy Thoracoscopy is usually reserved for tumors that remain undiagnosed after bronchoscopy or CTguided biopsy.

 Computed Tomography 4 chest CT scan is the standard for staging. The findings of CT scans of the chest and clinical presentation usually allow a presumptive differentiation between <#CLC and small cell lung cancer -#CLC.. Bassive lymphadenopathy and direct mediastinal invasion are commonly associated with small cell carcinoma. 4 mass in or ad7acent to the hilum is a particular characteristic of small cell cancer and is seen in about 6%/ of cases. Bagnetic 3esonance Imaging B3I is most useful when evaluating a patient in whom spinal cord compression is suggested. In addition! brain B3I has a greater sensitivity than CT scan for detection of central nervous system -C<#. metastasis. B3I may be used when findings of superior sulcus and brachial ple,us tumors are e;uivocal on CT scans. one #cintigraphy The s'eletal system is another common site of metastases for lung cancers. If patients report bone pain or if their serum calcium andDor al'aline phosphatase levels are elevated! a bone scan should be obtained to search for bone metastases Bediastinoscopy Bediastinoscopy may be used to obtain tissue from cancer that has infiltrated into the mediastinum. It is usually performed to evaluate the status of enlarged mediastinal lymph nodes -seen on CT scan. before attempting definitive surgical resection of lung cancer. <eedle Thoracentesis -"ltrasound :uided. <eedle thoracentesis is both diagnostic and therapeutic in patients presenting with respiratory distress. Thoracentesis has a sensitivity of only %0/ with a specificity greater than 90/. In patients suspected of having lung cancer who have an accessible pleural effusion! if the pleural fluid cytology finding is negative -after at least ( thoracenteses.! thoracoscopy is recommended as the ne,t step to aid in diagnosis. Thoracotomy Thoracotomy is indicated only for diagnosis and treatment of clearly resectable <#CLC. 1. )hat are the possible surgical management that will be performed to the patient* Lobectomy and pneumonectomy The standard surgical approach remains a lobectomy! which helps preserve pulmonary function! while allowing a good resection. >ilar and other pro,imal tumors may re;uire more e,tensive surgery! including a pneumonectomy! which carries significant operative mortality and long-term morbidity. In such patients! alternative approaches such as sleeve resection may be of value. 3etrospective data -#223. show lobectomy and segmentectomy have similar survival among patients with small lung cancer -E 1 cm.. This needs to be validated in a randomiAed phase III study. )edge resectionDsegmentectomy #ublobar resections are used for patients with poor pulmonary reserve and are increasingly being used in con7unction with video-assisted thoracoscopic surgery -F4T#.. 4n older Lung Cancer #tudy :roup trial! of stage I4 cancers randomiAed to standard lobectomy versus sublobar resections! suggested a much higher local recurrence rate -61/.! with a near-significant trend towards an increased cancer-specific mortality of 10/.

 Fideo-assisted thoracoscopic surgery F4T# is a minimally invasive surgical modality being used for both diagnostic and therapeutic lung cancer surgery. It offers low perioperative morbidity and mortality as well as decreased pain and hospitaliAation. Bediastinal lymphadenectomy The role of routine mediastinal lymphadenectomy versus lymph node sampling remains controversial. 4 large randomiAed trial comparing these modalities for patients with <0 or hilar <1 disease is still in progress.