Dr Hugo Ford, Dr James Rudd, Dr Helen Simpson, Dr Prina Ruparelia and Dr Alison Cluroe, Addenbrookes Hospital
Next, pathologist Dr Alison Cluroe dissected the lungs to see whether this might hold the key to the cause of death with Chris Smith...
Alison - So what I have here is the thoracic organs and what youíre seeing me do at the moment is Iím just opening up his gullet to make sure there is no food in there. And then Iím just opening up his voice box, the larynx, and then beyond the voice box weíre going into the windpipe or trachea, and then it splits, it divides into two. One going to one lung and one going to the other - these are the bronchi and, in fact, in this gentleman's right main bronchus we have pus.
Chris - The fact that you can see pus there, thatís immediately telling us that thereís something wrong with this personís lungs?
Alison - Absolutely. The other thing I can see are more of these white nodules that we discussed on the lining of the ribcage, and you can see more of them on the surface of the lung here.
Chris - This persons lungs are about football sized, arenít they? If you were to put the whole block of tissue together, itís about the size of a football. Are they very heavy?
Alison - They are unnaturally heavy. Sometimes lungs fill up with fluid because the heart isnít working to pump fluid away from the lungs and itís like a very wet sponge, soaked up with water and, if you look now as I just press the lung tissue, thereís lots, and lots, and lots of fluid.
Chris - Itís frothy.
Alison - Itís frothy, itís pouring out of the lung tissue.
Chris - And if that lung was full of fluid instead of being full of air, it would have meant the lung didnít work as well as it should do. He would have been short of breath.
Alison - Absolutely. So heís going to be having trouble breathing and thatís all a consequence of his heart failure.
Chris - Anything jumping out at you at this stage that you can see?
Alison - Not a great deal at the moment. There does appear to be a suggestion of some infection which, actually, looking at it now closely, having touched it, I wondered if it was infection, but now I can see that itís a plaque. Itís a white plaque of tissue. That is very typical of the sort of plaque one might see in asbestos exposure.
So Iím just going to move on to the vessels of the lungs and cut down thereÖ
Chris - These are the arteries and the veins that bring blood to and from the lungs. Why are you interested in the vessels?
Alison - Well, Iím particularly looking for evidence of pulmonary embolism, that is blood clots to the lungs, particularly because of two reasons. This gentleman has evidence of swelling of his lower legs and that increases the predisposition to blood clots developing in the veins inside the calf muscles of the legs. But also he has a disseminated malignant process which also makes the blood more sticky and, therefore, increases the risk of you developing blood clots, and I canít see any evidence of that.
Now Iím going to slice these lungs because I can feel some large lumps inside the lung tissueÖ
Chris - In both of them?
Alison - In both of themÖ As I open it up, you can see at the very top part of the left lung,thereís this great big cream and pink mass - itís about the size of an apple, and this is a tumour.
Chris - The rest of the lung tissue is pinky brown. Thereís some blackness which I presume is carbon, which is in there from when perhaps this personís been a smoker, but there is this very well defined, big, round, apple sized blob.
Alison - Now what Iím most interested in is thisÖ now cutting the other side.. Is another lump of tumour, which I had actually thought was within the lung, Iím now thinking it might be a lymph node thatís got tumour in it.
Chris - Lymph node being - these are our glands. They drain fluid away from different tissues. So if cancer breaks away from one place in the body, one of the places it can go is into these glands.
Alison - Thatís right. Now we also have a bit of pus, so we have got a little bit of what I think would be bronchial pneumonia developing here. Not surprisingly, because weíve got this great big tumour and I think, given that location, itís likely to be a lung adenocarcinoma and I think, although they can sometimes they can be associated with exposure to asbestos, there also not uncommon in people who have a history of smoking.
Chris - Dr Alison Cluroe. So a number of pathologies there. Weíve got these frothy lungs, we have an apple sized cancerous tumour, and also a lot of black carbon was visible in the lungs. So let's start there...
Prina - how do you end up with black lungs if you smoke?
Prina - Cigarette smoke has lots of different chemicals in it. Thereís over 700 different chemicals in cigarette smoking including tar so, if you chronically smoke, you will deposition of those chemicals.
Chris - Donít the lungs clean themselves out?
Prina - They do, but smoking in itself can damage the cilia, which are these little hair-like structures in the airways which gives a mechanisms to clear things from your lungs. If you smoke it damages those cilia and so you canít clear it.
Chris - So itís a bit like the cleaners all going on strike and no-one to empty the rubbish bins so stuff just accumulates, and the accumulation of the stuff then accelerates other sorts diseases and disease risk, I suppose, things like cancers?
Prina - Yes, exactly, cancers. And equally this gentleman has COPD, and that has also been shown to cause damage to the cilia and inflammation within the lungs which may also have predisposed him to tumour development.
Chris - And Hugo - the spread from this, what we presume to be the primary cancer in the lung around the body, both to the glands tissue and to the liver, does that fit?
Hugo - That would be an absolute classic characteristic of the way that lung cancer would affect the body, spreading through the lymphatic system (the lymph glands) and through the bloodstream to those other areas.
Chris - And he didnít have a known history of lung cancer when we reviewed his notes. Is this a pretty common thing to just discover like this?
Hugo - Well it is certainly common that lung cancer is advanced at the time that itís diagnosed.
Chris - Why?
Hugo - Well thereís a combination of features. The first thing is, of course, that the symptoms can be quite non-specific, so most of us would get a cough and wouldnít think too much of it. Often the tumour has to be quite large before it would give you the more serious symptoms that one would get. For example pain, coughing up blood which is a very important symptom. For a tumour to actually cause you to cough up blood, often theyíre quite large cancers and, by that time, itís much more difficult to treat them.
On the other hand, for the amount of disease that this man has, I would be surprised if he wasnít having some symptoms from it, and I think it would be interesting to know whether for the few months before his death he actually did have symptoms which, in retrospect, would have been attributable to his lung cancer.
Prina - Alison - used the word bronchopneumonia. She said there was some pus coming out of the airways and this gentleman had clearly had some signs of infection, what is bronchopneumonia?
Prina - So, pneumonia is an infection within the lungs. It is usually due to either a bacteria or a virus on occasion. We breathe these things in all the time, the lungs can usually clear them but, in some cases, that can cause an overwhelming infection and then, in a bid to try and fight that infection, there'll be a lot of inflammatory cells coming into the lungs and so that causes a buildup of pus. And bronchopneumonia is an infection within the main airways.
Chris - Would the cancer this gentleman had have made it more likely for him to develop that condition?
Prina - Yes, for a number of reasons. As heís got cancer his immune system may have been suppressed. Equally itís possible that there may have been a tumour deposit that was affecting the clearance mechanism of the lung. And equally we already heard that heíd probably had steroid treatment as well. So all these three factors could have contributed.
Chris - Because steroids reduce your immune response, donít they, so that would increase his risk of succumbing to an infection?
Prina - Yes, exactly.
Chris - What about the fluid? These lung, I picked them up and theyíre very, very heavy. Twice, three times the weight they should have been. Where was all that fluid coming from?
Prina - Because of his heart failure you will get a back pressure in the blood vessels in the lungs and they will become leaky. Just as his legs were swollen you would get fluid leaking into the lungs for that same reason. Equally because heís got infection, that may have made his blood vessels a bit more leaky as well.
Chris - And Hugo - one of the things we didnít find here, but Alison specifically went looking for, was a pulmonary embolus, a blood clot that lodges in one of the main blood vessels supplying the lung. And she made the point that people with cancer are more likely to suffer from what she dubbed sticky blood. Whatís the background and basis of that?
Hugo - So there are a number of reasons why people with cancer are more likely to have blood clots. And those range from a local effect from actually a cancer in the pelvis which is pressing on a blood vessel reducing the flow, and that means when the flow in the blood vessel is less, and slower, itís more likely to sludge up and clot. To the fact that people with cancer often donít eat and drink very well and can get very dehydrated and thatís another thing, which again, makes their blood more likely to sludge up. And finally, actually some of the treatments that we use for the cancer themselves can make the blood more sticky, more likely to clot.
So there are a number of reasons we do see, not infrequently in people with cancer, blood clots either in the veins lower down in the body or in the lungs.