CARDIOTHORACIC - Lung

Question 1

A 58yo patient with COPD complains of cough and hemoptysis. He is found to have a “coin lesion” on CXR.

1. Likely diagnosis
2. Dx
3. Tx

Answer 1

1. Malignant lung cancer
   - 80% chance of coin lesion on CXR being lung ca in pt >50yo; even higher with Hx of smoking
   - -> persistant cough, hemoptysis
2. Dx:
   CXR showing coin lesion or infiltrate
   Find old CXR (from 1-2 yrs ago)
   –if show same unchanged lesion, r/out cancer and avoid expensive & invasive work up
   Start with non-invasive tests from here:
   –Sputum cytology
   –CT scan (including chest & liver)
   If necessary, move to invasive modalities:
   –Bronchoscopy & biopsies (for central lesions)
   –Percutaneous biopsy (for peripheral lesions
   –Video-assisted thoracic surgery (VATS) & wedge resection if these biopsy unsuccessful
   *How far to go in diagnosis depends on…
   —if cancer likely (old, smoker, CT w/noncalcified lesion)
   —operability (residual lung fxn sufficient)
   –likelihood of cure (no mets)
3. Tx
   If small cell cancer: chemo & radiation (surgery assessment above not applicable)
   If non-small cell cancer: surgery

Question 2

How does one assess operability of a lung cancer?

Answer 2

Residual function after resection

• assuming pneumonectomy required (central lesions); less of an issue with lobectomy (peripheral lesions)
• if clinical findings (COPD, SOB) suggest this might be limited, get PFTs & determine fractions from each lung (V/Q scan)
• -> min FEV1 of 800mL predicted after surgery required to go ahead
• -> if

Question 3

How does one assess likelihood of cure from surgery for lung cancer?

Answer 3

Depends on extent of metastases:

• Hilar mets can be removed w/pneumonectomy
• Nodal mets @carina/mediastinum canNOT be removed
• ID nodal mets via
• –CT scan (also ID mets to liver, other lung)
• –PET scan
• –Endobronchial US sampling (more invasive)
• –Cervical mediastinal exploration (invasive, rarely needed)