Cardiothoracic Disorders

Question 1

What are the different types of coin lesions you can see on CXR?

Answer 1

Smooth walled (benign), calcium spicules (granuloma, malignant tumors are rarely calcified), bull’s eye (benign), spiculated surface (malignant, especially if > 3cm) and popcorn (benign hamartoma).

Question 2

Chance of malignancy in a coin lesion in a patient age 50

Answer 2

50%. It increases with age.

Question 3

Regions with coin lesions commonly due to coccidioidomycosis

Answer 3

SW USA

Question 4

Regions with coin lesions commonly due to histoplasmosis

Answer 4

Mid Atlantic and Ohio Valley.

Question 5

Tumors that commonly metastasize to the lungs and their 5-year survival

Answer 5

Testicular, breast (27-50%), renal (24-54%) and colon cancer (13-38%)

Question 6

Next step in a patient with a SPN that is new from a prior CXR

Answer 6

CT to better characterize the lesion and look for lymphadenopathy. If suspicious CT-guided biopsy gets definitive dx 90% of the time.

Question 7

Next step when CXR and CT reveal bronchial tree mass

Answer 7

Bronchoscopy for tissue sample and mediastinoscopy for assessment of lymph node involvement

Question 8

What lung masses can simulate malignancy? How do you r/o malignancy with these masses?

Answer 8

ACTINOMYCOSIS: associated w/dental or sinus abscess and involves chest wall. COCCIDIOMYCOSIS: thin-walled cavity w/air-fluid level. HISTOPLASMOSIS: concentric or homogenous calcifications. BLASTOMYCOSIS: associated w/chronic skin ulcers. CRYPTOCOCCUS: superinfection in immunocompromised patient, meningeal involvement. ASPERGILLOSIS: mycetoma w/air crescent sign. HAMARTOMA: well defined border with slight lobulations (popcorn). ROUND ATELECTASIS: adjacent to thickened pleura w/comet tail vessel pattern.

Question 9

Staging for non-small cell lung cancer and associated 5-year survival rates

Answer 9

Stage IA (50%): T1a/T1bN0M0 (< 3 cm across, only involves lung parenchyma and is > 2cm from main bronchus)

Stage IB (45%): T2aN0M0: 3-5cm, involves a main bronchus but > 2cm distal to carina, involves visceral pleura and/or partially obstructing airway.

Stage IIA (30%): T1a/T1bN1M0: < 3cm, does not involve visceral pleura or mainstem bronchi w/+ ipsilateral hilar LNs. OR T2aN1M0: 3-5cm, involves mainstem brochus but > 2cm distal to carina, involves visceral pleura and/or partially obstructing airway w/+ ipsilateral hilar LNs. OR T2bN0M0: 5-7cm, involves mainstem bronchus but > 2cm distal to carina, grown into visceral pleura and blocks the airways w/o LN spread.

Stage IIB (30%): T2bN1M0: 5-7cm, involves mainstem bronchus but > 2cm distal to carina, grown into visceral pleura and blocks the airways w/+ ipsilateral hilar LNs. OR T3, N0, M0: > 7cm, involves chest wall, diaphragm, mediastinal pleural, parietal pericardium, main bronchus < 2 cm from carina, airway obstruction leading to lung collapse or 2+ separate tumor nodules in same lobe. No +LNs.

Stage IIIA (15%): T1-T3N2M0: Any size, does not involve mediastinum, heart, great vessels, trachea, esophagus, spine, carina or different lobes. + ipsilateral hilar and/or mediastinal LNs. OR T3N1M0: > 7cm, involves chest wall, diaphragme, mediastinal pleura, parietal pericardium, main bronchus < 2cm to carina, 2+ nodules in same lobe, obstruction leading to lung collapse. +ipsilateral hilar LNs. OR T4N0/N1M0: Any size involving mediastinum, heart, great vessels, trachea, esophagus, spine carina and/or 2+ nodules in different lobes of same lung. +/- ipsilateral LNs.

Stage IIIB (5%): TanyN3M0: any size, obstruction leading to lung collapse, + supraclavicualr contralateral/ipsilateral mediastinal and hilar LNS. OR T4N2M0: any size involving mediastinum, heart, great vessels, trachea, esophagus, spine, carina, 2+ nodules in different lobes of same lung w/+ peribronchial LNs.

Stage IV (1%): TanyNanyM1a: metastasis to pleural and/or pericardial fluid. OR TanyNanyM1b: Metastasis to distant LNs, bone, brain, liver etc.

Question 10

Lung cancer type with chemotherapy as the primary treatment

Answer 10

Small-cell carcinoma is a systemic disease at diagnosis because it has usually already spread beyond the lung and is not amenable to resection.

Question 11

Lung cancer type with surgical resection as the primary treatment

Answer 11

Non-small cell carcinoma (adenocarcinoma and epidermoid carcinoma…aka squamous-cell carcinoma) are local diseases that spread to local and region LNs before becoming systemic.

Question 12

What patients require a pneumonectomy over a lobectomy?

Answer 12

Centrally located tumors that involve mainstem bronchi. Note that pneumonectomy has a higher initial mortality rate and sleeve lobectomy, although more difficult, is an option if local invasion of the main pulmonary artery is not present.

Question 13

Tx for stage I and II lung cancer

Answer 13

Surgical resection

Question 14

Tx for stage III and IV lung cancer

Answer 14

Chemotherapy + radiation, then resection if chemoradiation sufficiently shrinks the tumor.

Question 15

What is a pancoast tumor?

Answer 15

A tumor that grows in the superior sulcus of the lung. It invades the chest wall, lower cords of brachial plexus, subclavian artery and sympathetic ganglia. This can result in SOB, radiculopathies, peripheral limb ischemia and Horner’s syndrome.

Question 16

Work up of a pancoast tumor

Answer 16

CT then bronchoscopy to check for bronchial invasion and get tissue if possible, mediastinoscopy to assess for LN spread and needle biopsy if tissue is still needed.

Question 17

Tx for pancoast tumors

Answer 17

6 weeks radiation followed by surgical resection, patients do surprisingly well

Question 18

Differential for small hemoptysis in a 25 year old non-smoker

Answer 18

Bronchial adenoma, atelectasis and Tb. These can all cause obstruction of a bronchus and bleeding.

Question 19

Types of bronchial adenomas

Answer 19

These actually have considerable malignant potential: 1) Carcinoid, more benign when originating in lung, more malignant when originating from small bowel, may present with carcinoid syndrome. 2) Adenocystic carcinomas, which tend to invade locally.

Question 20

Tx for bronchial adenomas

Answer 20

Lobectomy tends to be curative (except for when carcinoid metastasizes widely)

Question 21

What do you worry about when you see a pleural effusion in an elderly patient?

Answer 21

Although effusions from CHF are more common, this is cancer (bronchogenic carcinoma or mesothelioma) until proven otherwise. After r/o cancer with thoracentesis and pleural biopsy you can consider other diagnoses like pneumonia, empyema or tuberculosis.

Question 22

Mesothelioma on CT

Answer 22

Thick-walled tumor that is pleurally based

Question 23

Tx for mesothelioma

Answer 23

En bloc pneumonectomy w/parietal and visceral pleura +/- pericardium and diaghragm. Morbidity and mortality rates are greater than 10%, but 30% of patient can recover. Chemorads is not an option.

Question 24

How do you place a chest tube (tube thoracostomy)?

Answer 24

Make an incision between ribs 4 & 5 (at nipple line) above the rib. Finger dissect into the extrapleural space, then place a 24 Fr chest tube directed toward the apex and attach it to a water-seal-type drainage. If it is a patient’s 1st time pneumothorax you can consider a polyethylene tube with a one-way valve (Heimlich) over the 24 Fr tube and water seal.

Question 25

Most common cause of the lung not expanding after placement of chest tube for pneumothorax?

Answer 25

Improperly placed chest tube. Try replacing the chest tube. If this does not fix the problem you then need to consider a parenchymal cause like leaking from large blebs/bronchi that need to be treated with pleurodesis to cause visceral and parietal pleura to adhere to each other.

Question 26

Most common cause of empyema in the elderly

Answer 26

Strep pneumo in the community setting, Staph and gram-negs in the hospital setting. Anaerobes if pt has hx of aspiration pneumonia.

Question 27

How do you treat a patient with empyema?

Answer 27

Abs, pus evacuation and lung re-expansion

Question 28

Why is rapid tube thoracostomy important in the treatment of empyema

Answer 28

Over time the empyema can become loculated as fibrin organizes. If this occurs, the patient will require thoracotomy and decortication to re-expand the lung.

Question 29

A patient presents with unstable angina. How do you treat him initially and how do you work him up?

Answer 29

Start with bed rest, sedation, 02, beta-blockers, nitroglycerin, aspirin and/or heparin. Check cardiac enzymes to r/o MI then do cardiac cath to check patency of coronary vessels.

Question 30

Normal EF

Answer 30

90% in kids, 70-80% in young adults and 50-60% in older people. < 40-50% is abnormal

Question 31

What is meant by three vessel disease? How do you treat a patient with three vessel disease and reduced EF?

Answer 31

Occlusion of the right coronary, LAD and the circumflex arteries (LAD and circumflex both branch off the left main). Treat with coronary bypass. This tx is indicated for left main disease (widowmaker) and 3-vessel disease w/reduced EF because it also has high mortality rates and these patients benefit more than any other group from bypass.

Question 32

How does PTCA compare to CABG?

Answer 32

In PTCA 30-60% of lesions reobstruct within 1 year so reoperation rates are higher early on.

Question 33

Best artery to use for CABG

Answer 33

Internal thoracic artery (internal mammary). 90%+ patency rates at 10 years.

Question 34

How does cardiopulmonary bypass work?

Answer 34

1) Clamp great vessels 2) Hyperosmolar (Na/Glc) w/K+ infused into heart for cardioplegia (blood and other buffers can be added to reduce ischemic acidosis and ROS damage). 3) Hypothermia to 86F (30C) in body, 59F (15C) in the heart. This combination allows the heart to be stopped for 2+ hours.

Question 35

Why would you ever consider off bypass coronary surgery with arterial anastomoses instead of the cardiopulmonary bypass machine?

Answer 35

The machine can generate a general infalmmatory response leading to respiratory, hemorrhagic and myocardial complications post-op. This is only considered in patients that are high-risk and patients with 1-2 easily accessible obstructed coronary arteries.

Question 36

Mortality rate for CABG

Answer 36

~3%

Question 37

What causes mitral valve regurgitation typically?

Answer 37

Myxomatous degeneration of the valve from ischemia to the mitral valve apparatus.

Question 38

Barlow syndrome

Answer 38

Mitral valve prolapse

Question 39

Common causes of mitral valve stenosis

Answer 39

Rheumatic and scarlet fever, this is why mitral valve stenosis is relatively rare in the US. Antibodies to group A strep also recognize the leaflets of the mitral valves. This causes fusion at the commissures and obstruction with late calcification. Increased left atrial pressure eventually leads to pulmonary HTN and right heart failure.

Question 40

How do we treat symptomatic mitral valve disease?

Answer 40

Commissurotomy can be done for stenosis if cought before calcifications of leafelets occurs. Annuloplasty (excising redundant leaflet and narrowing/reinforcing mitral annulus) is appropriate for prolapse. For either condition you can replace with a prosthetic valve.

Question 41

Causes of aortic stenosis

Answer 41

Congenital (from bicuspid valve), arteriosclerosis and deterioration.

Question 42

A patient presents with SOB, unstable angina and syncope. Echo shows aortic stenosis. What is this guy’s life expectancy if you don’t operate?

Answer 42

Dead within 2 years

Question 43

Work up in a patient with aortic stenosis

Answer 43

Cardiac cath to determine coronary circulation status, aortic valve lumen size, pressure gradient and ventricular function. You also need to do carotid doppler u/s to r/o carotid stenosis as the cause of syncope.

Question 44

Possible 1st symptom of aortic stenosis

Answer 44

Death in 5th or 6th decade.

Question 45

What determines the succes of aortic valve replacement in a patient with symptomatic high grade aortic stenosis?

Answer 45

Results of the catheterization…elderly patients typically do well regardless of age as long as they have preserved ventricular function.

Question 46

Options for aortic valve replacement

Answer 46

Mechanical (plastic/metal): durable, efficient and require anticoagulation for life. Tissue (human, porcine or bovine): do not require anticoagulation but require replacement around 7 years.

Question 47

Prognosis for patients suffering from dilated cardiomyopathy after a viral infection?

Answer 47

1/3 get better, 1/3 stay the same, 1/3 get worse

Question 48

Tx for dilated cardiomyopathy

Answer 48

Beta-blockers for symptomatic management. If condition continues to worsen, the patient will need a heart transplant.

Question 49

Prognosis for a patient receiving a hear transplant

Answer 49

Immediate survival = 90%. With immunosuppression (tacrolimus, cyclosporine and steroids) survival is 85-90% at 1 year and 75% at 2 years. Most deaths are due to infection from immunosuppression or rapid coronary atherosclerosis due to chronic rejection.

Question 50

Next step in a patient with recurrent regurgitation of undigested food

Answer 50

Barium swallow or upper endoscopy

Question 51

How do you get a Zenker diverticulum?

Answer 51

It is a pulsion diverticulum, meaning that pressure from swallowing causes mucosa to pouch out between the inferior pharyngeal constrictor superiorly and the cricopharyngeal inferiorly.

Question 52

Where in the esophagus can you get a pulsion diverticulum aside from Zenker?

Answer 52

Distal esophagus near the GE junction, called an epiphrenic diverticulum. At attachments outside of esophagus, called a traction diverticulum.

Question 53

Tx for esophageal diverticuli

Answer 53

Transection of the cricopharyngeal muscle to relax the esophageal entrance. Excision and esophageal myotomy are necessary with epiphrenic diverticuli.

Question 54

Why is a bird’s beak esophagus so characteristic of dysphagia?

Answer 54

Whatever the etiology (T. cruzi, stress, trauma or weight loss), there is loss of the Auerbach plexus (parasympathetic ganglion in esophageal smooth muscle) which prevents esophageal peristalsis and LES relaxation. Food then gets stuck and the esophagus becomes an adynamic sac.

Question 55

What is the treatment for achalasia?

Answer 55

Ca-channel blockers can induce LES relaxation; however, correction is typically surgical w/ Heller myotomy (100% relief) or endoscopically w/ balloon dilation (60% relief)

Question 56

Esophageal tumors typically found in the upper and middle 1/3 of the esophagus

Answer 56

Squamous cell carcinoma

Question 57

Esophageal cancers typically found in the lower 1/3 of the esophagus

Answer 57

Can often be squamous cell, but incidence of adenocarcinoma is increasing b/c of GERD -> squamous cell dysplasia to columnar cells -> Barrett’s esophagus (shown below) -> Adenocarcinoma.

Question 58

How is squamous cell esophageal carcinonma staged?

Answer 58

T, N, M, G.

Stage 0: Tis, N0, M0, GX or G1; any location: This is the earliest stage of esophageal cancer. It is also called high-grade dysplasia. The cancer cells are found only in the epithelium (the layer of cells lining the esophagus). The cancer has not grown into the connective tissue beneath these cells (Tis). The cancer has not spread to nearby lymph nodes (N0) or other organs (M0). The tumor is well differentiated (G1) or grade information is not available (GX), and it can be anywhere along the esophagus.

Stage IA: T1, N0, M0, GX or G1; any location: The cancer has grown from the epithelium into the layers below, such as the lamina propria, muscularis mucosa, or submucosa, but it has not grown any deeper (T1). It has not spread to nearby lymph nodes (N0) or to distant sites (M0). The tumor is well differentiated (G1) or grade information is not available (GX). It can be anywhere along the esophagus.

Stage IB: Either of the following:

T1, N0, M0, G2 or G3; any location: The cancer has grown from the epithelium into the layers below, such as the lamina propria, muscularis mucosa, or submucosa, but it has not grown any deeper (T1). It has not spread to nearby lymph nodes (N0) or to distant sites (M0). It is moderately (G2) or poorly differentiated (G3). The tumor can be anywhere in the esophagus.

T2 or T3, N0, M0, GX or G1; location lower: The cancer has grown into the muscle layer called the muscularis propria (T2). It may also have grown through the muscle layer into the adventitia, the connective tissue covering the outside of the esophagus (T3). The cancer has not spread to nearby lymph nodes (N0) or to distant sites (M0). It is well differentiated (G1) or grade information is not available (GX). Its highest point is in the lower part of the esophagus.

Stage IIA: Either of the following:

T2 or T3, N0, M0, GX or G1; location upper or middle: The cancer has grown into the muscle layer called the muscularis propria (T2). It may also have grown through the muscle layer into the adventitia, the connective tissue covering the outside of the esophagus (T3). The cancer has not spread to nearby lymph nodes (N0) or to distant sites (M0).The cancer is in the upper or middle part of the esophagus and is well differentiated (G1) or grade information is not available (GX).

T2 or T3, N0, M0, G2 or G3; location lower: The cancer has grown into the muscle layer called the muscularis propria (T2). It may also have grown through the muscle layer into the adventitia, the connective tissue covering the outside of the esophagus (T3). The cancer has not spread to lymph nodes (N0) or to distant sites (M0).The cancer is in the lower part of the esophagus and is moderately (G2) or poorly differentiated (G3).

Stage IIB: Either of the following:

T2 or T3, N0, M0, G2 or G3; location upper or middle: The cancer has grown into the muscle layer called the muscularis propria (T2). It may also have grown through the muscle layer into the adventitia, the connective tissue covering the outside of the esophagus (T3). The cancer has not spread to nearby lymph nodes (N0) or to distant sites (M0). It is in the upper or middle part of the esophagus and is moderately (G2) or poorly differentiated (G3).

T1 or T2, N1, M0, any G; any location: The cancer has grown into the layers below the epithelium, such as the lamina propria, muscularis mucosa, or submucosa (T1). It may also have grown into the muscularis propria (T2). It has not grown through to the outer layer of tissue covering the esophagus. It has spread to 1 or 2 lymph nodes near the esophagus (N1) but has not spread to lymph nodes further away from the esophagus or to distant sites (M0). It can be any grade (G) and can be anywhere along the esophagus.

Stage IIIA: Any of the following:

T1 or T2, N2, M0, any G; any location: The cancer has grown into the layers below the epithelium, such as the lamina propria, muscularis mucosa, or submucosa (T1). It may also have grown into the muscularis propria (T2). It has not grown through to the outer layer of tissue covering the esophagus. It has spread to 3 to 6 lymph nodes near the esophagus (N2) but it has not spread to lymph nodes farther away from the esophagus or to distant sites (M0). It can be any grade (G) and can be anywhere along the esophagus.

T3, N1, M0, any G; any location: The cancer has grown through the wall of the esophagus to its outer layer, the adventitia (T3). It has spread to 1 or 2 lymph nodes near the esophagus (N1), but it has not spread to lymph nodes farther away from the esophagus or to distant sites (M0). It can be any grade (G) and can be anywhere along the esophagus.

T4a, N0, M0, any G; any location: The cancer has grown all the way through the esophagus and into nearby organs or tissues (T4a) but still can be removed. It has not spread to nearby lymph nodes (N0) or to distant sites (M0). It can be any grade (G) and can be anywhere along the esophagus.

Stage IIIB: T3, N2, M0, any G; any location: The cancer has grown through the wall of the esophagus to its outer layer, the adventitia (T3). It has spread to 3 to 6 lymph nodes near the esophagus (N2), but has not spread to lymph nodes farther away from the esophagus or to distant sites (M0). It can be any grade (G) and can be anywhere along the esophagus.

Stage IIIC: Any of the following:

T4a, N1 or N2, M0, any G; any location: The cancer has grown all the way through the esophagus and into nearby organs or tissues (T4a) but still can be removed. It has spread to 1 to 6 lymph nodes near the esophagus (N1 or N2), but it has not spread to lymph nodes farther away from the esophagus or to distant sites (M0). It can be any grade (G) and can be anywhere along the esophagus.

T4b, any N, M0, any G; any location: The cancer cannot be removed with surgery because it has grown into the trachea (windpipe), the aorta (the large blood vessel coming from the heart), the spine, or other crucial structures (T4b). It may or may not have spread to nearby lymph nodes (any N), but it has not spread to lymph nodes farther away from the esophagus or to distant sites (M0). It can be any grade (G) and can be anywhere along the esophagus.

Any T, N3, M0, any G; any location: The cancer has spread to 7 or more nearby lymph nodes (N3), but it has not spread to lymph nodes farther away from the esophagus or to distant sites (M0). It can be any grade and can be anywhere along the esophagus.

Stage IV: Any T, any N, M1, any G; any location: The cancer has spread to distant lymph nodes or other sites (M1). It can be any grade (G) and can be anywhere along the esophagus.

Question 59

How is adenocarcinoma of the esophagus staged?

Answer 59

Stage 0: Tis, N0, M0, GX or G1: This is the earliest stage of esophageal cancer. It is also called high-grade dysplasia. The cancer cells are found only in the epithelium (the layer of cells lining of the esophagus). The cancer has not grown into the connective tissue beneath these cells (Tis). The cancer has not spread to nearby lymph nodes (N0) or other organs (M0). It is well differentiated (G1) or grade information is not available (GX).

Stage IA: T1, N0, M0, GX, G1, or G2: The cancer has grown from the epithelium into the layers below, such as the lamina propria, muscularis mucosa, or submucosa, but it has not grown any deeper (T1). It has not spread to nearby lymph nodes (N0) or to distant sites (M0). It is well (G1) or moderately differentiated (G2), or grade information is not available (GX).

Stage IB: Either of the following:

T1, N0, M0, G3: The cancer has grown from the epithelium into the layers below, such as the lamina propria, muscularis mucosa, or submucosa, but it has not grown any deeper (T1). It has not spread to nearby lymph nodes (N0) or to distant sites (M0). It is poorly differentiated (G3).

T2, N0, M0, GX, G1, or G2: The cancer has grown into the muscle layer called the muscularis propria (T2). It has not spread to nearby lymph nodes (N0) or to distant sites (M0). It is well (G1) or moderately differentiated (G2), or grade information is not available (GX).

Stage IIA: T2, N0, M0, G3: The cancer has grown into the muscle layer called the muscularis propria (T2). It has not spread to nearby lymph nodes (N0) or to distant sites (M0). It is poorly differentiated (G3).

Stage IIB: Either of the following:

T3, N0, M0, any G: The cancer has grown through the wall of the esophagus to its outer layer, the adventitia (T3). It has not spread to nearby lymph nodes (N0) or to distant sites (M0). It can be any grade.

T1 or T2, N1, M0, any G: The cancer has grown into the layers below the epithelium, such as the lamina propria, muscularis mucosa, or submucosa (T1). It may also have grown into the muscularis propria (T2). It has not grown through to the outer layer of tissue covering the esophagus. It has spread to 1 or 2 lymph nodes near the esophagus (N1), but it has not spread to lymph nodes farther away from the esophagus or to distant sites (M0). It can be any grade.

Stage IIIA: Any of the following:

T1 or T2, N2, M0, any G: The cancer has grown into the layers below the epithelium, such as the lamina propria, muscularis mucosa, or submucosa (T1). It may also have grown into the muscularis propria (T2). It has not grown through to the outer layer of tissue covering the esophagus. It has spread to 3 to 6 lymph nodes near the esophagus (N2) but it has not spread to lymph nodes farther away from the esophagus or to distant sites (M0). It can be any grade (G).

T3, N1, M0, any G: The cancer has grown through the wall of the esophagus to its outer layer, the adventitia (T3). It has spread to 1 or 2 lymph nodes near the esophagus (N1), but it has not spread to lymph nodes farther away from the esophagus or to distant sites (M0). It can be any grade (G).

T4a, N0, M0, any G: The cancer has grown all the way through the esophagus and into nearby organs or tissues (T4a) but still can be removed. It has not spread to nearby lymph nodes (N0) or to distant sites (M0). It can be any grade (G).

Stage IIIB: T3, N2, M0, any G: The cancer has grown through the wall of the esophagus to its outer layer, the adventitia (T3). It has spread to 3 to 6 lymph nodes near the esophagus (N2), but it has not spread to lymph nodes farther away from the esophagus or to distant sites (M0). It can be any grade (G).

Stage IIIC: Any of the following:

T4a, N1 or N2, M0, any G: The cancer has grown all the way through the esophagus and into nearby organs or tissues (T4a) but still can be removed. It has spread to 1 to 6 lymph nodes near the esophagus (N1 or N2), but it has not spread to lymph nodes farther away from the esophagus or to distant sites (M0). It can be any grade (G).

T4b, any N, M0, any G: The cancer cannot be removed with surgery because it has grown into the trachea (windpipe), the aorta (the large blood vessel coming from the heart), the spine, or other crucial structures (T4b). It may or may not have spread to nearby lymph nodes (any N), but it has not spread to lymph nodes farther away from the esophagus or to distant sites (M0). It can be any grade (G).

Any T, N3, M0, any G: The cancer has spread to 7 or more nearby lymph nodes (N3), but it has not spread to lymph nodes farther away from the esophagus or to distant sites (M0). It can be any grade (G).

Stage IV: Any T, any N, M1, any G: The cancer has spread to distant lymph nodes or other sites (M1). It can be any grade (G).

Question 60

What esophageal cancers are resectable.

Answer 60

Stages I and II. Most stage IIIs are resectable as long as the cancer has not grown into the trachea, the aorta, spine, or other nearby crucial structures. Many stage IIIs that are potentially resectable are not because patients are not healthy enough.

Question 61

What are the 5 year survival rates for esophageal cancer?

Answer 61

Localized to esophagus = 40%. Regional spread = 21%. Distant spread = 4%.

Question 62

By what physical means is esophageal cancer staged?

Answer 62

Endoscopic u/s to assess tumor depth and local LN involvement. Chest and abdomen CT to assess for celiac node spread and abdominal involvement. Note the layers of the esophagus on the endoscopic u/s below: 1st hyperechoic layer: interface between lumen and mucosa, 2nd hypoechoic layer: deep mucosa and muscularis mucosa, 3rd hyperechoic layer: submucosa, 4th hypoechoic layer: muscularis propria, 5th hyperechoic layer: adventitia/fat interface

Question 63

Treatment for esophageal cancer

Answer 63

If upper 1/3 of esophagus = chemoradiation followed by resection of obstruction persists. If middle 1/3 of esophagus = neoadjuvant chemoradiation followed by surgical resection if tumor shrinks appropriately (because these tumors often invade local structures). If lower 1/3 of esophagus = esophagectomy and proximal gastrectomy with intrathoracic esophagogastric anastamosis.

Question 64

What are the 2 types of esophagectomy that can be performed for esophageal cancer? Why choose one over the other?

Answer 64

Formal esophagectomy (Ivor Lewis): upper abdominal incision + right thoracotomy -> gastroesophageal anastamosis in chest, can also convert to neck, advantage of keeping most gastric mucosa. Transhiatal esophagectomy: incision in neck + incision in upper abdoment -> upper esophagectomy + sleeve gastrectomy -> anastomosis of stomach and esophagus in neck, this procedure is good because risk of anastomosis leak is 10% and if it leaks in the chest there is a higher risk for infection and pulmonary complications.

Question 65

How do you confirm your diagnosis in a patient presenting with signs and symptoms of dysphagia that are concerning for esophageal cancer?

Answer 65

Barium swallow, esophagoscopy and biopsy

Question 66

Why might a patient with squamous cell esophageal carcinoma have a cough as an associated symptom?

Answer 66

Erosion of esophageal mucosa can create a TEF and cause aspiration

Question 67

Since 80% of patients will die in their first year after diagnosis of esophageal cancer, what measures can you do that are not curative, but palliative?

Answer 67

Feeding gastrostomy (G-tube), esophageal stents, radiation or palliative resection. Just know that mortality rate and complications increase with each of these procedures.

Question 68

What tumors commonly originate in the anterior mediastinum and how do they present?

Answer 68

Thymus tumor 33% (+/- myasthenia gravis), lymphoma 19% (most common is Hodgkin lymphoma in young people), germ cell 17% (teratomas most common = calcium deposits, hair, primitive teeth), carcinoma 11%, cysts 8%, mesenchymal 4%, and endocrine 6%.

Question 69

When is surgery appropriate for a tumor in the anterior mediastinum?

Answer 69

Thymomas and other non-lymphoma tumors. Lymphomas are treated with chemoradiation.

Question 70

What are the common tumors of the middle mediastinum? How do you manage them?

Answer 70

Cysts account for 61% of them. Bronchiogenic cysts (from foregut remnants, lined w/columnar epithelium) and pericardial cysts (water bottle appearance). Because cysts can become inflammed, symptomatic and form fistulas, surgical excision is appropriate. Lymphomas 21%, mesenchymal 8% and carcinoma 6% of tumors.

Question 71

What are the common tumors of the posterior mediastinum? How do you treat them?

Answer 71

Neurogenic tumors (53%) adjacent to vertebral bodies (neurilemoma is most common and most are benign (41%)). Cysts (32%), mesenchymal tumors (9%) and endocrine tumors (2%) also occur. Tumors can be dumbell-shaped, inside the spinal canal or outside the spinal canal. After confirming tumor w/imaging, removal by thoracic and neurosurgical approach are warranted.