A male patient, 80 years of age presented to his general practitioner with a persistent cough. The practitioner suspected symptoms of the chronic obstructive pulmonary disease or early congestive cardiac failure (CCF). The chest X-ray of the patient was done and it has shown a COPD, right-sided consolidation and pneumonia on the right side of the lung. The Computed tomography scan of the chest was done to ascertain how much consolidation is there, exacerbation of COPD and small – lesions in lungs.
Adequacy- according to PIER mnemonic the adequacy of film can be asses:-
Position- Typically, PA and lateral view.
Inspiration- good inspiratory effect with 10 to 12 ribs.
Exposure – the exposure is adequate to demonstrate both soft and bony tissues.The thoracic spine can be through the heart show, indicating that penetration is sufficient.The only artifact present is from the L marker, which is overlying the distal end of the right clavicle; this could potentially be obstructing bony lesion located behind it.
Rotation- there is some degree of rotation. The PA view of the chest shows the medial end of the clavicle is not equidistant to the thoracic spinous processes. On the lateral view, ribs are not superimposed. These positional errors do not make images un-diagnostic.
Bones and soft tissues – bony structure appears normal on PA chest. There is some osteophyte lipping seen on the anterior aspects of the vertebrate of a thoracic spine. Thoracic discs appeared narrowed (Jones, 2011)
Diaphagram – The right diaphragm is raised, with large gas bubble (bowel and or stomach) seen inferiorly to it. The left costophrenic and cardiophrenic angles appear sharp
Effusion- The right costrophrenic angle is slightly blunted suggesting small pleural effusion. There is small right basal effusion.
Hilum – The cardiothoracic ratio is towards the upper limit. The hilum appears normal. There are two masses located within the right lung, the larger mass is shown in mid to upper zone abutting the right hilum, and the second, smaller mass, which is round in shape, is shown in the middle zone of the lung. The trachea is deviated to the right due to the presence of the mid-upper zone mass lesion. The right hilum is difficult to assess due to the presence of the right-sided mass
The patient was experiencing persistent cough. The chest X-ray of the patient was performed The chest X-Ray reports have shown that patient is suffering from COPD. A routine chest series was performed, which included both Postero-anterior views and left lateral view. COPD includes emphysema and chronic bronchitis. Emphysema causes shortness of breath due to abnormal enlargement of terminal bronchioles that block air flow. Chronic bronchitis is inflammation of bronchioles. Patient suffering from COPD have blunted costophrenic angles which are caused due to pleural effusions. COPD results in flattering of diaphragm and narrowing of tracheal tubes. Chest X-ray of COPD Patient demonstrates abnormal images only in 16 % of cases which is limited mainly to signs of pulmonary congestion or inflammatory infiltrate. Due to these reasons chest, X-Ray is not recommended on daily routines other than cases of massive pleural effusions, pulmonary edema, pneumothorax and suspected pneumonia. The benefits of chest X-ray are no radiation remains in the patient body which decreases the chances of cancer, they have no side effect in the diagnosis, it is inexpensive and widely available in nursing homes, physician offices and other locations which makes it convenient for both physician and patient. Limitations of Chest X-Ray are normal chest X-Ray does not find out pulmonary problems. In some cases, airway interstitial and pulmonary vascular disease cannot be detected by X-Ray (Luppi, Begh? & Roversi, 2012)
There is large left bronchitis. ar and anteromedial left upper lobe soft tissue mass which is approximately 11 cm in length and around 6 cm transverse diameter and 6 cm AP diameter. There is second rounded mass measuring 4 cm diameter in left mid zone. There are small right pleural effusion and mild elevation of right hemidiaphragm. There is small nodules or rolled atelectasis in the right lower lobe.
The right lung seems normal and there is no right pleural fluid. No pleural calcifications or plaques is noticed.
The cardiac size is normal. The superior mediastinum and trachea are shifted to the right of midline. There is no obvious tracheal narrowing.
No obvious ribs destruction is seen. No thoracic crush fractures are seen.
Chest X-Ray has shown that there is hilar and pulmonary masses. There is small pleural effusion. These findings may indicate a sign of malignancies.
Additional CT chest/Abdo/pelvis is done to further evaluate these masses within the chest and to determine whether one of these masses are metastatic or primary or if both are metastatic tumors. A CT scan of chest/Abdo/pelvis with intravenous contrast was performed which has shown that larger superior lesion is a primary malignancy. The patient has large retroperitoneal nodes in the right upper abdomen. After CT scan results, biopsy of patient lung lesions has been done to determine the grade of masses in the left lung. The biopsy samples of large, para-hilar regions have shown small- cell lung carcinoma.
The patient was referred to an oncologist and his chemotherapy was started. After completing three courses of chemotherapy the CT scan was again performed. The CT scan has shown that the growth of lung masses has not stopped.
Chest X-Ray or chest film is a chest radiograph used to diagnose diseases affecting the chest and its nearby structures. They are most commonly used the radiological procedure. Chest X-Ray is the most common film used in medicine for diagnosis. They are difficult to interpret. The benefits of chest X-ray are no radiation remains in the patient body which decreases the chances of cancer, they have no side effect in the diagnosis, it is inexpensive and widely available in nursing homes, physician offices and other locations which makes it convenient for both physician and patient. Chest X-ray of COPD Patient demonstrates abnormal images only in 16 % of cases which is limited mainly to signs of pulmonary congestion or inflammatory infiltrate (Weiss, 1995).
In this case, the patient is 80 years old having a persistent cough. The practitioner suspected symptoms similar to chronic obstructive pulmonary disease and a chest X-Ray was done. Chest X-ray has shown that there is small pleural effusion, left bronchitis, left hilar and pulmonary masses, costrophrenic angles are blunted and there is a zone of consolidation in lower ribs. Left hilar and pulmonary masses may indicate the sign of primary and metastatic malignancies. CT scan of lungs is performed to check the lesions in lungs. CT scan helps to diagnose the cause of shortness of breath, unexplained cough, chest pain, lesions, and small nodules in lungs. CT scanning is fast, noninvasive and painless. It is a standard for demonstrating pulmonary adenopathy. CT scan is very useful in detecting small lesions and area close to the diaphragm. CT scan identified larger superior lesion is a primary malignancy. A biopsy is performed after detecting lung lesions. The biopsy samples of large, para-hilar regions have shown that patient is having lung carcinoma (Brenner, 2012).
Small cell lung carcinoma (SCLC) is a type of cancer in which malignant cells form in the tissue of the lung.
Small cell lung carcinoma is a type of lung cancer in which cancer cells get deposited in tissues of lung.it is also called oat cell cancer. Sign and symptoms may result from paraneoplastic phenomena, compression of thoracic structures and distant metastases. The common symptoms of small-cell lung carcinoma are dyspnea, shortness of breath and persistent or worsening of a cough.The symptoms of SCLC involves compression of the oesophagus that leads to dysphagia, laryngeal nerves compression results in hoarseness, head, and neck superficial nerves get distended and superior vena cava compression results in facial edema. Th brain metastases or bone metastases may result in neurological defects or pain or personality change. The physical examination of SCLC patient may identify pneumonia, signs of chronic obstructive disease, supraclavicular lymphadenopathy, lobar collapse and pleural effusion. ("Small cell lung cancer", 1987). According to Australian government statistics 2013, lung cancer is 5th most commonly diagnosed cancer .in 2014 it was the leading cause of death due to cancer. In 2014 there were approximately 8,200 death from lung and which may increase to 9,000 in 2017 ("Lung cancer statistics | Lung cancer", 2017). The protocol which is followed to determine cancer includes physical examination, history, and routine laboratory tests. Conventional radiography uses X-Ray to visualize internal body parts .it evaluates abdomen, chest, spine, and abdomen. The X-ray consists produced electromagnetic radiation by passing high voltage in terminals of the vacuum tube. The energy of X-ray can be modulated by changing the voltage and current. The shadows after X-ray can be detected by using fluoroscopic systems or combinations of photographic films. The common technique used to visualize X-rays is to expose a single image on fluorescent screens which converts it into visible light. Density, the thickness of different tissues produce different levels of X-Ray attenuation. Lungs full of air appear black in color, calcified tissues such as bone appear white in color and soft tissues are of intermediate characteristics. In conventional radiography, four densities which can be soft tissue, air, calcified tissue, and fat can be determined. In case of normal chest, X-Ray mediastinal surface and heart appear clear with respect to black lungs (Medina & Blackmore, 2007). However, in case of consolidation more light is absorbed by lungs in chest X-Ray results in loss of outlines of the adjacent structure. There are various contrast agents used when natural contrast is not present in X-Ray. It is divided into positive contrast and negative contrast. Positive contrast is of high radiodensity such as barium and iodine while negative contrast is of low density such as air and carbon dioxide. To demonstrate structural abnormalities or derive functional information positive contrast is used. The positive contrast agents are water soluble which can form soluble compounds with lower toxicity. These agents can be either ionizing or nonionizing. In negative contrast, it is used as a double contrast to image colon, stomach, and colon (Dodd, 2007).
The various radiographic techniques are patient positioning. Inpatient positioning radiographs are taken using standard projections. Conventionally standard projections define according to the directions of X-Ray beams. The final projections are those that line in sagittal axis with the X-Ray beam. The lateral view is taken parallel to the coronal axis. In case of posterior-anterior view chest radiograph is taken against anterior chest while in anterior-posterior vie the X-Ray is taken against the posterior chest. A radiograph is a two-dimensional image, a three-dimensional structural image is recommended in minimum two planes for small lesions. The respiration phase is important in chest radiography, conventional inspiration shows lung field well as compare to expiratory view it shows pneumothorax. Various techniques can be used to improve the quality of chest radiography. A grid is used to improve image quality by filtering the obliquely scattered radiation. Restriction of the X-Ray beam to the area of interest helps to improve image quality and helps to reduce the dose of X-Rays. Computed tomography is highly efficient and prevents overexposure. It produces a higher proportion of diagnostic radiographs thus minimising radiation dose. Radiation dosage affects the person health (Chawla, 2015). X-Ray causes ionization of tissues which harmfully affect physiochemical properties of tissues. These effects are directly related to exposure. Approximately 87% of exposure to radiation is naturally while remaining is due to X-Rays. The radiation dose of X-Ray is varied from country to country. To minimize exposure to radiation, radiation to medical personnel and patient must be minimised. The radiation must keep reasonably low. Special considerations must be taken while performing X-Ray of abdomen and pelvis of women especially childbearing age women. The fetus is more susceptible to X-Ray radiation which may cause mutations (Hollingworth & Jarvik, 2007).
The diagnosis must be made based on evidence-based radiology. Evidence-based radiology is defined as a decision that must be based on the integration of clinical information from most appropriate image test available on the basis of patient’s expectations, physician’s experience, and best available evidence.Evidence-based radiology is based on five principles formulation of the question, efficient literature search, critical analysis of literature, application of search result’s and evaluation with respect to patient’s value and physician experience and evaluates the results available from the best diagnostic image. In diagnostic imaging, evidence-based radiology has received more attention(Hollingworth & Jarvik, 2007). The principles of evidence-based radiology help to promote proper use of resources, efficiently use of resources and benefits patients. Formulating a question in radiology is very important, it involves the majority of questions related to the superiority of diagnostic imaging over another related to specific pathology. The well-structured questions consist of Define patient, group of patients and their problem, intervention which is to be evaluated such as in this case Chest X-Ray and CT scan of the chest, comparison of the test result with the standard if any and evaluation of final result. After formulating a questioning look for best possible evidence, as the enormous volume of literature and books are available Haynes proposed a model of pyramid evidence which has six levels. The hierarchy of six level Haynes model includes studies- synopsis of studies - syntheses -synopsis of syntheses - summaries - systems. According to this model, the literature which appears in higher levels is considered scientifically better than lower levels. After formulating a question and finding best literature next is critically evaluate the literature. In critical evaluation the comparison between standard reference and test being evaluated. The procedure which used commonly is to use standard reference test on all patient regardless of test results evaluation. The staistical analysis is the major problems experienced by most clinicians. It is important to consider the scope of test which must be according to the patient problem (Smith, 2008). Test avilability, its risks and cost must be considered . Once the major question for clinical evidence is found next is a clinical experience which is applied to patient values and prefrences. Before the results of test apply to patient, assessment of diagnostic test reproducibility must be done, assessment of available alternatives, calculation of the probability that patient has the disease before a diagnostic test or performing the test and consideration of pros and cons of diagnostic test was done or performed. The last step is an evaluation of the results. Evaluate efficiency and effectiveness of diagnostic test or imaging performed as the tests performed in local and specialized labs varies, therefore they need to be evaluated. The specific resources available for evidence-based radiology includes books, journal articles, websites, workshops and conferences (Lilford, 1997).
Treatment options available for SCLC patients is based on stage, histology, general health, and comorbidities of the patient. The treatment for cancer may depend on the stage and general health. Surgery and chemotherapy are an available treatment for SCLC. Most commonly chemotherapy is used. Use of surgery for SCLC is rare. Radiotherapy can be used to treat StageI- Stage III of SCLC. Currently, there is no screening test available on routinely in Australia. Computed tomography is used to screen the patient suffering from lung cancer. Limited stage SCLC can be treated with concurrently using of chemotherapy and radiation therapy combination. In the advanced stage of lung cancer, palliative treatment is used to assess and manage pain, nausea and spreading of cancer. Prognosis of individual health will depend on their stage and type of cancer, age, and their general health. For patient’s who do not tolerate the combination of chemotherapy and radiation therapy, sequential therapy is given to them (S?rensen, 2009). The majority of patients treated with chemotherapy alone has higher locally relapse rate. In comparison, thoracic radiation therapy has very low local relapse rate. Combination of thoracic radiation therapy and chemotherapy has higher control on the overall disease. In patients with LD-SCLC thoracic radiation therapy in combination with chemotherapy is considered to be standard treatment. After initial treatment, chest radiation helps to reduce chances of cancer relapsing in the chest. Chest radiation is given after chemotherapy has been completed especially in those patients which have large tumors. The thoracic radiation must be given to a patient who has lymph node involvement in cancer. (End, 2006).
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