What are the main types of lung cancer. How does lung cancer develop in the respiratory system. What are the primary risk factors for lung cancer. How is lung cancer diagnosed and staged. What is the role of the lymphatic system in lung cancer spread.

Understanding Lung Cancer: An Overview

Lung cancer is a serious health condition that develops when abnormal cells in the lungs grow uncontrollably, forming tumors. It is the third most common cancer in the UK, with approximately 48,500 new cases diagnosed annually. This disease can originate in various parts of the respiratory system, including the windpipe (trachea), main airway (bronchus), or lung tissue itself.

There are two main categories of primary lung cancer:

• Non-small cell lung cancer (NSCLC)
• Small cell lung cancer (SCLC)

NSCLC is the more prevalent type, accounting for the majority of lung cancer cases. It’s crucial to distinguish primary lung cancer from secondary lung cancer, which occurs when cancer cells from other parts of the body spread to the lungs.

The Anatomy of the Respiratory System

To comprehend lung cancer, it’s essential to understand the structure and function of the respiratory system. This complex network of organs and tissues works together to facilitate breathing and gas exchange.

Key Components of the Respiratory System

• Nose and mouth
• Windpipe (trachea)
• Airways to each lung (left and right bronchus)
• Lungs

The right lung is divided into three sections: upper, middle, and lower lobes. The left lung, slightly smaller to accommodate the heart, has two lobes: upper and lower.

The Pleura: Protective Covering of the Lungs

The pleura consists of two fibrous sheets of tissue that envelop the lungs, offering protection and facilitating smooth breathing. The space between these membranes, known as the pleural space, contains a lubricating fluid that allows for effortless lung expansion and contraction during respiration.

The Role of the Lymphatic System in Lung Cancer

The lymphatic system plays a crucial role in the spread of lung cancer. This network of vessels and nodes filters body fluids and helps fight infections and diseases, including cancer.

How does the lymphatic system contribute to lung cancer progression?

1. Cancer cells can detach from a lung tumor and enter nearby lymph nodes.
2. These cells can then travel through the lymphatic system to other parts of the body.
3. During diagnosis, doctors examine lymph nodes for the presence of cancer cells to determine the extent of the disease.

The Mechanics of Breathing and Lung Function

Understanding how the lungs work is crucial for grasping the impact of lung cancer on respiratory function. The process of breathing involves a complex series of events:

1. Air enters through the nose or mouth and travels down the windpipe (trachea).
2. The trachea divides into two main bronchi, one for each lung.
3. These bronchi further split into smaller tubes called secondary bronchi and then into even smaller bronchioles.
4. At the end of the bronchioles are tiny air sacs called alveoli.
5. In the alveoli, oxygen from inhaled air passes into the bloodstream, while carbon dioxide from the blood is expelled during exhalation.

How does lung cancer affect this intricate breathing process? Tumors can obstruct airways, impair gas exchange in the alveoli, and reduce the overall efficiency of the lungs, leading to symptoms such as shortness of breath and chronic cough.

Risk Factors and Causes of Lung Cancer

While anyone can develop lung cancer, certain factors significantly increase the risk. Understanding these can help in prevention and early detection efforts.

Smoking: The Primary Culprit

What is the most significant risk factor for lung cancer? Smoking is by far the leading cause, responsible for more than 70% of lung cancer cases in the UK. This includes both active smoking and exposure to secondhand smoke.

Other Notable Risk Factors

• Age: Lung cancer risk increases with age, with about 45% of diagnoses occurring in people 75 and older.
• Exposure to radon gas: This naturally occurring radioactive gas can accumulate in buildings and increase lung cancer risk.
• Occupational exposure: Certain workplace chemicals and substances, such as asbestos, arsenic, and diesel exhaust, can elevate risk.
• Family history: Having a close relative with lung cancer may increase your susceptibility.
• Previous lung diseases: Conditions like chronic obstructive pulmonary disease (COPD) and pulmonary fibrosis can increase risk.
• Previous cancer treatments: Radiation therapy to the chest for other cancers may increase lung cancer risk.

Diagnosis and Staging of Lung Cancer

Early detection and accurate staging are crucial for effective lung cancer treatment. The diagnostic process typically involves several steps:

1. Initial symptoms assessment
2. Physical examination
3. Imaging tests (X-rays, CT scans, PET scans)
4. Biopsy to confirm the diagnosis and determine the cancer type

What factors do doctors consider when staging lung cancer?

• Tumor size
• Lymph node involvement
• Presence of metastasis (spread to other parts of the body)

Early-stage lung cancer is typically confined to the lung, while advanced stages involve spread to surrounding tissues or distant organs.

The Impact of Lung Cancer on Respiratory Function

Lung cancer can significantly impair respiratory function, leading to various symptoms and complications:

• Shortness of breath: Tumors can obstruct airways or reduce lung capacity.
• Chronic cough: Irritation of the airways by the tumor can cause persistent coughing.
• Pleural effusion: Cancer cells can cause inflammation of the pleura, leading to fluid buildup in the pleural space.
• Reduced oxygen exchange: Tumors can interfere with the normal gas exchange in the alveoli.
• Recurrent respiratory infections: Impaired lung function can make patients more susceptible to pneumonia and other infections.

How does pleural effusion affect breathing? When fluid accumulates in the pleural space, it can prevent the lung from fully expanding, leading to shortness of breath and discomfort.

Prevention and Risk Reduction Strategies

While not all cases of lung cancer are preventable, there are several strategies to reduce risk:

Smoking Cessation

What is the most effective way to reduce lung cancer risk? Quitting smoking is the single most important step smokers can take to protect their health. For those who have never smoked, avoiding secondhand smoke is crucial.

Radon Testing and Mitigation

Testing homes and workplaces for radon gas and implementing mitigation measures if levels are high can significantly reduce exposure risk.

Occupational Safety

Adhering to workplace safety guidelines and using appropriate protective equipment can minimize exposure to carcinogenic substances.

Healthy Lifestyle Choices

• Maintaining a balanced diet rich in fruits and vegetables
• Engaging in regular physical activity
• Limiting alcohol consumption
• Managing stress

Regular Health Check-ups

Routine medical examinations and discussing any persistent respiratory symptoms with a healthcare provider can aid in early detection.

Advancements in Lung Cancer Research and Treatment

The field of lung cancer research is rapidly evolving, with new discoveries and treatment options emerging regularly. Some notable areas of progress include:

Targeted Therapies

These treatments target specific genetic mutations or proteins involved in cancer growth, offering more precise and potentially less toxic options for some patients.

Immunotherapy

This approach harnesses the body’s immune system to fight cancer cells, showing promising results in some lung cancer cases.

Early Detection Techniques

Advancements in imaging technologies and biomarker testing are improving our ability to detect lung cancer at earlier, more treatable stages.

Personalized Medicine

Genetic profiling of tumors allows for more tailored treatment plans, potentially improving outcomes and reducing side effects.

How are these advancements changing the landscape of lung cancer treatment? These innovations are leading to improved survival rates, better quality of life for patients, and new hope for those affected by this challenging disease.

Living with Lung Cancer: Support and Quality of Life

A lung cancer diagnosis can be overwhelming, but various support systems and strategies can help patients and their families cope:

Multidisciplinary Care Teams

Comprehensive care involving oncologists, pulmonologists, surgeons, and other specialists ensures all aspects of treatment and support are addressed.

Palliative Care

This specialized medical care focuses on providing relief from symptoms and stress of serious illness, improving quality of life for both the patient and family.

Support Groups

Connecting with others facing similar challenges can provide emotional support, practical advice, and a sense of community.

Psychological Support

Professional counseling and mental health services can help patients and families navigate the emotional impact of a lung cancer diagnosis.

Lifestyle Adjustments

• Adapting daily activities to conserve energy
• Implementing breathing techniques to manage shortness of breath
• Maintaining a nutritious diet to support overall health and treatment efficacy
• Engaging in appropriate physical activity as recommended by healthcare providers

What role does a support system play in lung cancer treatment? A strong support network can significantly improve a patient’s quality of life, treatment adherence, and overall outcomes.

The Global Impact of Lung Cancer

Lung cancer is not just a personal or family issue; it has far-reaching effects on society and healthcare systems worldwide:

Economic Burden

The costs associated with lung cancer treatment, lost productivity, and premature deaths place a significant economic strain on individuals, families, and healthcare systems.

Public Health Initiatives

Governments and health organizations worldwide are implementing tobacco control measures, environmental regulations, and cancer screening programs to combat lung cancer.

Research Funding

Substantial resources are being devoted to lung cancer research, driving innovations in prevention, detection, and treatment.

Global Disparities

Access to advanced lung cancer treatments and screening programs varies widely across different countries and socioeconomic groups, highlighting the need for global health equity efforts.

How can society contribute to the fight against lung cancer? Public awareness campaigns, support for smoking cessation programs, and advocacy for research funding are crucial ways communities can make a difference.

Future Directions in Lung Cancer Management

As our understanding of lung cancer continues to evolve, several promising areas are shaping the future of diagnosis, treatment, and prevention:

Liquid Biopsies

These blood tests can detect cancer DNA circulating in the bloodstream, potentially allowing for earlier and less invasive diagnosis and monitoring of lung cancer.

Artificial Intelligence in Imaging

AI algorithms are being developed to assist radiologists in detecting lung nodules and characterizing lung cancer more accurately and efficiently.

Combination Therapies

Researchers are exploring various combinations of targeted therapies, immunotherapies, and traditional treatments to enhance efficacy and overcome drug resistance.

Cancer Vaccines

Therapeutic vaccines designed to stimulate the immune system against lung cancer cells are in development and clinical trials.

Precision Prevention

Advances in understanding genetic susceptibility and environmental risk factors may lead to more personalized and effective prevention strategies.

What potential impact could these emerging technologies have on lung cancer outcomes? These innovations hold the promise of earlier detection, more effective treatments, and potentially even prevention of lung cancer in high-risk individuals.

The Importance of Lung Cancer Awareness and Education

Raising public awareness about lung cancer is crucial for improving prevention, early detection, and support for those affected by the disease:

Destigmatization

Efforts to reduce the stigma associated with lung cancer, particularly its link to smoking, can encourage earlier medical consultation and reduce feelings of guilt or shame among patients.

Symptom Recognition

Educating the public about early signs and symptoms of lung cancer can lead to earlier diagnosis and potentially better treatment outcomes.

Risk Factor Awareness

Increasing understanding of both modifiable and non-modifiable risk factors can empower individuals to make informed decisions about their health.

Policy Advocacy

Informed citizens can advocate for policies that support lung cancer research, improve access to care, and reduce environmental risk factors.

Community Support

Greater awareness can foster more supportive communities for lung cancer patients and their families, improving quality of life and social support.

How can individuals contribute to lung cancer awareness? Participating in awareness events, sharing accurate information on social media, and supporting lung cancer charities are all effective ways to make a difference.

As we continue to advance our understanding of lung cancer, from its molecular origins to its societal impact, we move closer to more effective prevention, earlier detection, and better treatments. While the challenge of lung cancer remains significant, the combined efforts of researchers, healthcare providers, patients, and the public offer hope for a future where this disease no longer poses such a formidable threat to global health.

What is lung cancer? | Cancer Research UK

Lung cancer starts in the windpipe (trachea), the main airway (bronchus) or the lung tissue. Cancer that starts in the lung is called primary lung cancer.

There are 2 main types of primary lung cancer:

• non small cell lung cancer
• small cell lung cancer

The most common type is non small cell lung cancer.

Primary lung cancer differs from cancer that spreads to your lungs from somewhere else in your body. This is called secondary lung cancer.

Transcript

Lung cancer can start in the windpipe, the main airway or the lungs.

It develops when there is uncontrolled growth of abnormal cells inside one or both lungs. These cells grow to form tumours.

More than 8 out of 10 cases of lung cancer in the UK are caused by smoking. If you’re a smoker, quitting is the best thing you can do for your health. Passive smoking also increases the risk.

Lung cancer is more common in older people and in people with previous chest problems or lung diseases such as emphysema.

Other risk factors include exposure to radon gas, air pollution and chemicals in the workplace.

A cancer that starts in the lung is called a primary lung cancer, while a cancer that starts in another part of the body and spreads to the lungs is called a secondary lung cancer.

The stage of a cancer refers to its size and how far it has spread. Doctors look at the size of the tumour, whether it is in the lymph nodes and whether it has spread to another part of the body.

A small cancer that is just in the lung is likely to be an early stage cancer. One that has spread into the surrounding tissue or to another part of the body is an advanced cancer.

You can find out more information about lung cancer by visiting the Cancer Research UK website.

The lungs

The lungs are part of the breathing system, which is also called the respiratory system. The breathing system includes:

• the nose and mouth
• windpipe (trachea)
• airways to each lung (left and right bronchus)
• lungs

The right lung is divided into 3 sections called the upper, middle and lower lobes. The left lung is divided into 2 sections called the upper and lower lobes.

The pleura (covering of the lungs)

The pleura or pleural membranes are 2 fibrous sheets of tissue. They cover the lungs and help to protect them. 

The gap between the pleura is called the pleural space. The pleura make a lubricating fluid. The fluid keeps the membranes moist, so they slide easily over each other as we breathe in and out.

Lung cancer cells can spread to the pleura. The cancer cells inflame the pleural membranes and they then make too much fluid. The fluid collects in the pleural space and stops the lung from expanding fully. This can make you feel breathless. Build up of fluid between the pleura is called a pleural effusion.

The lymph nodes

Lymph nodes (also called lymph glands) are close to the lungs and airways. They are part of the lymphatic system. This a network of tubes and glands in the body that filters body fluid and fights infection and illnesses like cancer.

Lymph fluid circulates through body tissues. Cancer cells may be released from a lung tumour and trapped in nearby lymph nodes. 

When you are diagnosed, your surgeon or cancer specialist (medical oncologist) checks your lymph nodes for cancer cells.

How the lungs work

Your lungs have a system of tubes that carry oxygen in and out as you breathe. 

The windpipe divides into two tubes, the right bronchus and left bronchus. These split into smaller tubes called secondary bronchi. They split again to make smaller tubes called bronchioles. The bronchioles have small air sacs at the end called alveoli.

In the air sacs, oxygen passes into your bloodstream from the air breathed in. Your bloodstream carries oxygen to all the cells in your body. At the same time carbon dioxide passes from your bloodstream into the air sacs. This waste gas is removed from the body as you breathe out.

Where lung cancer starts

Lung cancer can start in any part of the lungs or airways.

How common is lung cancer?

Lung cancer is the third most common cancer in the UK. Around 48,500 people are diagnosed in the UK each year.

Who gets lung cancer?

Lung cancer is more common as you get older. Around 45 out of 100 people (around 45%) diagnosed with lung cancer in the UK are aged 75 and older.

In the UK each year:

• around 25,300 men are diagnosed
• around 23,300 women are diagnosed

More than 70 out of 100 (more than 70%) of lung cancer cases in the UK are caused by smoking.

Other causes or risk factors include:

• exposure to radon gas
• exposure to certain chemicals in the workplace
• a family history of lung cancer
• certain cancer treatments for other types of cancer

Related cancers

A rare cancer called mesothelioma starts in the protective sheets that cover the lungs (pleura). This is very different to lung cancer.

Cancer can spread into the lung from other parts of the body. This is called secondary lung cancer.

• Cancer Incidence from Cancer Intelligence Statistical Information Team at Cancer Research UK  (2016 – 2018 UK average) 
  Accessed December 2022

• Lung cancer diagnosis and management
  National Institute for Health and Care Excellence, 2019 (updated 22 September 2022)

• Management of lung cancer
  Scottish Intercollegiate Guideline Network, 2014

• Cancer: Principles and Practice of Oncology (11th edition)
  VT DeVita, TS Lawrence, SA Rosenberg
  Wolters Kluwer, 2019

• Ross and Wilson Anatomy and Physiology in Health and Illness (13th edition)

  A Waugh and A Grant

  Elsevier, 2018

• Cancer and its Management, 7th Edition

  JS Tobias and D Hochhauser

  Wiley-Blackwell, 2015

Last reviewed: 

07 Dec 2022

Next review due: 

07 Dec 2025

Print page

Sarcoidosis – NHS

Sarcoidosis is a rare condition that causes small patches of swollen tissue, called granulomas, to develop in the organs of the body. It often affects the lungs and lymph nodes, and can also affect your skin.

The symptoms of sarcoidosis depend on which organs are affected, but typically include:

• tender bumps on the skin
• shortness of breath
• a persistent cough

For many people with sarcoidosis, symptoms often improve without treatment within a few months or years. In these cases, the symptoms are not usually severe.

However, some people find their symptoms develop gradually and get worse over time, to the point where their health becomes severely affected. This is known as chronic sarcoidosis.

There is currently no cure but symptoms can usually be managed with medicine.

Symptoms of sarcoidosis

It’s impossible to predict how sarcoidosis will affect a person, as the condition can affect any organ and the symptoms vary widely depending on which organs are involved.

Most people with sarcoidosis develop symptoms suddenly, but these usually clear within a few months or years and the condition does not come back. This is known as acute sarcoidosis.

Some people do not have any symptoms at all, and the condition is diagnosed after an X-ray carried out for another reason.

A few people find their symptoms develop gradually and get worse over time, to the point where they become severely affected. Lots of granulomas may form in an organ and prevent it from working properly. This is known as chronic sarcoidosis.

Sarcoidosis most often affects the lungs, skin and lymph nodes (glands).

Lung symptoms

The lungs are affected in about 9 out of 10 of people with sarcoidosis. This is known as pulmonary sarcoidosis.

The main symptoms are shortness of breath and a persistent dry cough. Some people with pulmonary sarcoidosis experience pain and discomfort in their chest, but this is uncommon.

Skin symptoms

Credit:

CNRI/SCIENCE PHOTO LIBRARY https://www.sciencephoto.com/media/262539/view

The skin is also affected in many people with sarcoidosis.

This can cause tender bumps or patches to develop on the skin (particularly the lower legs and arms), as well as bumps on the upper body. These can be reddish-brown or purple, depending on your skin colour and the type of sarcoidosis you have.

Other symptoms

If other organs are affected, you may also have some of the following symptoms:

• tender and swollen glands in the face, neck, armpits or groin
• tiredness and a general feeling of being unwell
• painful joints
• red or sore eyes
• an abnormal heart rhythm (arrhythmia)
• a blocked or stuffy nose
• pain in the bones
• kidney stones
• headache

Causes of sarcoidosis

The body’s immune system normally fights off infections by releasing white blood cells into the blood to isolate and destroy the germs. This results in inflammation (swelling) of the body tissues in that area. The immune system responds like this to anything in the blood it does not recognise, and this dies down when the infection has been cleared.

It’s thought that sarcoidosis happens because the immune system has gone into overdrive, where the body starts to attack its own tissues and organs. The resulting inflammation then causes granulomas to develop in the organs.

There are many similar conditions, such as rheumatoid arthritis and lupus, that are caused by the body attacking its own tissues. These are collectively known as autoimmune conditions.

It’s not known why the immune system behaves like this.

It’s possible that some environmental factor triggers the condition in people who are already genetically susceptible to it.

Sarcoidosis can occasionally occur in more than one family member, but there’s no evidence that the condition is inherited. The condition is not infectious, so it cannot be passed from person to person.

Who’s affected

Sarcoidosis can affect people of any age, but usually starts in adults aged between 30 and 40. It’s rare in childhood.

The condition affects people from all ethnic backgrounds. It’s also more common in women than men.

Diagnosing sarcoidosis

A number of different tests may be carried out to diagnose sarcoidosis, depending on which organs are affected.

If your symptoms suggest you have pulmonary sarcoidosis (sarcoidosis affecting the lungs), you may have a chest X-ray or a CT scan of your lungs to look for signs of the condition.

In some cases, doctors may want to examine the inside of your lungs using a long, thin, flexible tube with a light source and a camera at the end (an endoscope) that’s passed down your throat. A small sample of lung tissue may also be removed during this test so it can be studied under a microscope. This is known as a biopsy.

If doctors think you may have sarcoidosis affecting other organs – such as the skin, heart or eyes – scans or examinations of these areas will usually be carried out.

How sarcoidosis is treated

Many people with sarcoidosis do not need treatment as the condition often goes away on its own, usually within a few months or years.

In this case, simple lifestyle changes and over-the-counter painkillers (such as paracetamol or ibuprofen) are often all that’s needed to control the pain of any flare-ups.

Doctors will monitor your condition to check if it’s getting any better or worse without treatment. This can be done with regular X-rays, breathing tests and blood tests.

Medicines

If treatment is recommended, steroid tablets are usually used.

This helps relieve symptoms and prevent damage to affected organs by reducing inflammation and preventing scarring.

However, steroid tablets can cause side effects such as weight gain and mood swings if taken in high doses. Other side effects, such as weakening of the bones (osteoporosis), can also develop if steroids are taken for a long time. Therefore, they’re only used when necessary.

You may initially be given a high dose of steroid medicine for a short period of time, before switching to a low dose for the months or years that follow. Your condition will be monitored during this time to see how well the treatment is working.

In some cases, taking calcium or vitamin D supplements can help reduce the risk of osteoporosis caused by long-term use of steroid medicine. However, you should only take these if advised to by a doctor. Some people with sarcoidosis may have an increased risk of developing complications, including kidney stones, while taking steroid medicine.

Other medicines may sometimes be used if steroids are not enough or there are concerns about side effects. In these cases, a medicine called an immunosuppressant might be recommended. This may help to improve your symptoms by reducing the activity of your immune system.

Living with sarcoidosis

The following lifestyle measures may help if you have sarcoidosis:

• stop smoking, if you smoke
• eat a balanced diet
• maintain a healthy weight
• try to reduce stress
• get regular exercise
• get enough sleep

Find a support group on the Sarcoidosis UK website

Outlook

Symptoms of sarcoidosis may come and go, and can often be managed with over-the-counter painkillers so they do not affect everyday life.  Most people with the condition find their symptoms have disappeared within a few years of their diagnosis.

However, for some people the condition slowly gets worse over time and they end up with organ damage. For example, their lungs may stop working properly, causing increasing breathlessness.

Help is available for people with severe, persistent sarcoidosis. Ask your doctor for advice and visit the Sarcoidosis UK website (which has a list of support groups) or the Asthma + Lung UK website.

Information about you

If you have sarcoidosis, your clinical team will pass information about you on to the National Congenital Anomaly and Rare Disease Registration Service (NCARDRS).

This helps scientists look for better ways to prevent and treat this condition. You can opt out of the register at any time.

Find out more about the register on the National Disease Registration Service website

Page last reviewed: 06 October 2022
Next review due: 06 October 2025

cervical, axillary, thoracic, inguinal lymph nodes – indications, procedure, features, price

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Ultrasound of the pelvic organs (uterus, appendages) during pregnancy up to 10 weeks	4000.00
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Ultrasound of pregnant women (includes assessment of anatomical structures, including the fetal heart) Dr. I.V.	5000.00
Ultrasound of the pelvic organs in women (uterus, appendages) (expert)	7000.00
Ultrasound of the pelvic organs during pregnancy up to 10 weeks (Professor Panina O.B.)	7000.00
Ultrasound of pregnant women (includes assessment of anatomical structures, including the fetal heart) (expert)	7000.00
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Fetal Doppler	1800.00
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Ultrasound folliculometry	1700.00
Ovarian ultrasound	1400.00
Ultrasound of the location of the placenta	1200.00
Ultrasound determination of the amount of amniotic fluid	1400. 00
Fetal heart rate ultrasound	1400.00
Cervical ultrasound	1400.00
Uterine tone ultrasound	1400.00
Ultrasound of the lower uterine segment	1400.00
Endometrial ultrasound	1400.00
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Vascular ultrasound
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Duplex scanning of brachiocephalic arteries (neck vessels) Dr. Grigoryeva M.A..	3200.00
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Duplex scanning of vessels of the lower extremities (veins and arteries) Dr. Grigoryeva M.A.	5800.00
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Retroperitoneal ultrasound (adrenals, abdominal aorta, retroperitoneal lymph nodes)	2400.00
Small bowel ultrasound	1700.00
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transrectal ultrasound of the prostate (TRUS) Dr. Sevostyanov V.I.	2800.00
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Duplex vascular scanning of the scrotum	2400.00
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Neurosonography (children)	2200.00
Neurosonography with vascular dopplerography (children)	3800.00
Ultrasound of the hip joints (children)	2500.00
Reproductive ultrasound (children)	2600.00
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Ultrasound of the thymus (thymus)	2200.00
Ultrasound of hollow organs (children)	2200.00
Ultrasound of the parotid glands (children)	2200.00
Vascular Doppler (during neurosonography)	1600. 00
Ultrasound examination of the esophagus in a child	1600.00
Ultrasound examination of the small intestine in a child	1600.00
Ultrasound examination of the colon in a child	1600.00
Ultrasound examination of the prostate in a child	1800.00
Doppler ultrasound of the vessels of the spermatic cord in a child	1600.00
Ultrasound examination of the adrenal glands in a child	1200.00
Ultrasound examination of the child’s brain	2600.00
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Ultrasound examination of peripheral nerves (one anatomical region) in a child	2600.00
Ultrasound determination of fluid in the child’s abdomen	1100.00
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Sholokhov V.N. • Ultrasound anatomy of the parasternal region in patients with breast cancer

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Introduction

In clinical practice, to assess the condition of the chest cavity, including the parasternal region, the most commonly used diagnostic methods are radiography, computed tomography (CT), magnetic resonance imaging (MRI), scintigraphy, positron emission tomography (PET/CT) [1]. This article presents the experience of using ultrasound tomography in the assessment of superficially located anatomical structures of the parasternal region.

The purpose of this study is to evaluate the possibility of performing an ultrasound examination of the parasternal region, as well as to study ultrasound anatomy to improve the results of diagnosing breast cancer metastases.

Materials and methods

The study included 55 patients aged 29 to 89 years who were treated at the N.N. N.N. Blokhin” with a diagnosis of breast cancer and localization of tumors in the central and medial sections. All women underwent ultrasound examination (ultrasound), including examination of the breast, axillary, subclavian and supraclavicular areas, additionally, all patients underwent an examination of the parasternal region. In addition, all patients underwent mammography in two projections. In all patients, the diagnosis was verified morphologically. The study was performed on expert-class devices using high-frequency linear sensors with a frequency of 4 to 9MHz.

Normal topographic anatomy of the peristernal region

The parasternal region is a triangular gap located along the edge of the sternum. The base is turned to the edge of the sternum, and the apex of the triangle is to the place where the cartilaginous part of the ribs passes into the bone. It is bounded anteriorly by the costal cartilages and intercostal muscles lined by the fascial plate, and posteriorly by the internal thoracic fascia and parietal pleura. The contents of the parasternal space are the internal thoracic artery, the internal thoracic vein (one or two), lymph nodes and vessels surrounded by adipose tissue [2]. Parasternal lymph nodes are located along the edge of the sternum or in the area of ​​the cartilaginous part of the ribs, from the first to the fifth intercostal space, in the form of a chain along the internal thoracic arteries and veins [3]. The number of lymph nodes in the parasternal zone found in preparations after extended mastectomy on each side ranges from 1 to 10 [4, 5]. The size of the parasternal lymph nodes ranges from 1 to 10 mm, but can reach 20 mm in diameter (Caceres E., 1966).

Ultrasound anatomy

The skin on ultrasound has the appearance of a thin hyperechoic linear structure 1–3 mm thick (Fig. 1–5), which is visualized directly under the ultrasound transducer [6, 7].

Fig. 1. Transverse scan. 1 – skin, 2 – subcutaneous fat, 3 – muscle (m.pectoralis major), 4 – internal thoracic vein, 5 – internal thoracic artery, 6 – edge of the sternum.

Fig. 2. Longitudinal scan. 1 – skin, 2 – subcutaneous fat, 3 – muscle (bundles of intercostal muscles), 4 – internal thoracic artery, 5 – ribs, 6 – pleura, 7 – lung.

Fig. 3. Transverse scan. 1 – skin, 2 – subcutaneous fat, 3 – internal thoracic vein, 4 – internal thoracic artery, 5 – perforating branch of the internal thoracic artery, 6 – sternum, 7 – lung.

Fig. 4. Transverse scan. 1 – skin, 2 – subcutaneous fat, 3 – muscle (m.pectoralis major), 4 – internal thoracic artery, 5 – internal thoracic vein, 6 – lymph node of intact structure, 7 – pleura, 8 – lung.

Fig. 5. Longitudinal scan. 1 – skin, 2 – subcutaneous fat, 3 – rib, 4 – internal thoracic artery, 5 – lymph node of intact structure, 6 – pleura.

Under the dermis is subcutaneous fat (SFA), which in the upper sections is permeated with collagen fibers of the reticular layer, forming an extensive network consisting of wide loops, which, in turn, are filled with lobules of adipose tissue. On ultrasound tomograms, the pancreas is visualized as a tissue layer consisting of hypoechoic lobules separated by thin hyperechoic bands of connective tissue (Fig. 1–5) [6, 8].

The next anatomical area includes several layers of muscle bundles. A characteristic ultrasound picture of muscle fibers during longitudinal scanning is a parallel arrangement of hypoechoic fibers – muscle bundles separated by thin hyperechoic linear structures – the perimysium, which is the stroma between the muscle bundles [8–10]. In contrast to the SJ, which practically does not change its ultrasonic characteristics when the scanning plane changes, muscle tissue during transverse scanning (relative to muscle fibers) is visualized as a hypoechoic layer with multiple hyperechoic dot
inclusions (Fig. 1, 2, 4). At the level of I-V ribs (rarely I-VI), the pectoralis major muscle (m. pectoralis major) and the transverse muscle of the chest (m. trans verses thoracis) originate from the edge of the sternum. In the intercostal spaces, it is possible to clearly visualize the bundles of the external and internal intercostal muscles.

Behind the pectoralis major muscle there are ribs, which are visualized as anechoic oval structures, behind which an acoustic shadow is formed (Fig. 2, 5). The seven upper pairs of ribs are attached by cartilage to the sternum, however, the 1st rib is not connected by a joint, but by means of the so-called synchondrosis. In the thickness of the costal cartilages, areas of calcification can be visualized, which are normal and should not be considered as a manifestation of the pathological process. The sternum is a flat bone that consists of a handle, body and xiphoid process. On ultrasound, it is visualized as an anechoic formation with echoes behind (Fig. 1, 3).

The anterior chest wall is supplied bilaterally by the internal thoracic artery and vein (arteria at vena thoracica interna). In the intercostal spaces, along the edge of the sternum, both with longitudinal and transverse scanning, it is quite clearly possible to see
visualize both of the aforementioned vessels. As a rule, the diameter of the internal mammary artery is 1.5–2 times the diameter of the vein of the same name. Perforating branches of the internal thoracic artery are visualized in the intercostal spaces along the edge of the sternum (Fig. 1–5).

Lymph nodes of the chest cavity are divided into 2 groups: parietal, located along the inner surface of the chest wall, along the pleura (intercostal, parasternal, pleural), and organ, or visceral, located parabronchially, near the esophagus, paraaortal, pericardial. Parasternal, or parasternal, lymph nodes (nodi lymphatici parasternales) are located along a. thoracica interna and are closely related to the latter. In the parasternal collector, lymph outflow occurs mainly from the central and medial sections of the mammary gland (usually deep sections) through the chest wall to the lymph nodes of the first to fifth intercostal space.

The minimum size of the visualized lymph nodes was 0.3–0.4 cm. The lymph nodes looked like hypoechoic elongated oval formations closely adjacent to the parietal pleura and the internal thoracic vascular bundle (Fig. 4, 5).

In this study, out of 55 patients, parasternal lymph nodes were visualized in 16 (29.1%). Fine-needle aspiration biopsy was performed from all visualized lymph nodes. In 8 (50%) cases, the lymph nodes had a rounded shape, reduced echogenicity, the differentiation of the anatomical structures of the lymph node was difficult, in the elastography mode, the lymph nodes had a hard consistency. This ultrasound picture was typical for lymphatic
ski nodes with a metastatic nature of the lesion. In the other 8 cases, the rim, the central echo complex and the hilum of the lymph node were clearly visualized; in the elastography mode, the lymph nodes had a soft consistency – the described changes are characteristic of the lymph nodes with benign reactive hyperplasia.

Even with a small size of the lymph node, when examined with a high-frequency probe, the region of the hilum of the lymph node differentiates well, but in obese patients, the differentiation of the structures of the lymph node is difficult.

Discussion

Evaluation of the condition of peripheral lymph nodes, including the parasternal lymphatic collector in patients with malignant neoplasms of the mammary glands, should be a mandatory step before starting treatment. In a study published by U. Veronesi et al. [14], the overall survival rate of patients without metastases for 10 years was 80.4%, patients with affected internal thoracic lymph nodes – 53%, and with combined damage to the axillary and parasternal lymph nodes – 30%. Also, according to the seventh current TNM classification [15], metastases in the parasternal lymph nodes are classified as N2b, that is, metastases that are clinically determined (according to the examination or using ultrasound, CT, MRI, PET, but without the use of lymphoscintigraphy), internal thoracic (parasternal) lymph nodes, in the absence of clinically detectable metastases in the axillary lymph nodes on the side of the lesion. Accordingly, with metastatic lesions of the parasternal collector, the clinical stage from II changes to IIIA, regardless of the size of the tumor (Table 1). A tumor in stage IIIA is initially inoperable and requires drug therapy at the first stage of treatment.

Table 1 . Classification of stages of breast cancer TNM.

Note: *T1 includes T1mi.

CT and lymphoscintigraphy are non-invasive diagnostic methods that provide anatomical and functional picture of the state of the internal thoracic lymph nodes. In addition to imaging the parasternal lymph nodes, CT provides a comprehensive examination that includes the axillary region, mediastinum, lung parenchyma, and pleura. However, CT is relatively expensive and is associated with radiation exposure. CT has a number of limitations in patients with a history of allergic reactions to iodine-containing drugs and in patients with kidney disease. Lymphoscintigraphy with Te-99 ^m is a time-consuming process that requires delayed studies 3 and 6 hours after injection, and in 9% of studies has a false negative result.

Ultrasound can be a useful and effective complementary tool in assessing the parasternal lymphatic collector. Experience shows that ultrasound can visualize lymph nodes ranging in size from 0.3–0.4 cm. In the lymph nodes of this group, it is possible to differentiate structural elements: the gate and the cortical layer. If a metastatic lesion of the lymph node is suspected, it is possible to safely perform a fine-needle biopsy under ultrasound guidance in order to obtain material for cytological examination. Despite the fact that ultrasound is a technically simple and affordable method, however, it has a number of limitations. Firstly, ultrasound is an operator-dependent technique, and secondly, anomalies of the costosternal joints can interfere with the qualitative assessment of the parasternal lymphatic collector. Severe obesity can also interfere with obtaining a complete ultrasound picture of the area under study. Lymph nodes located behind the sternum may not be included in the scan area. Finally, as with other diagnostic methods, micrometastases not associated with enlargement of the involved lymph node may be missed by this test. Thus, ultrasound of the parasternal zone is a promising method for assessing internal
thoracic lymph nodes. The technique is easily reproducible using linear sensors. Our preliminary experience shows that visualization of the internal thoracic lymph nodes is not difficult, except in the cases described above (severe obesity and anomalies of the costosternal joints). If a specific lesion is suspected, ultrasound navigation allows you to safely collect material for cytological examination in a short time.

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