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ABSITE 2022 > Chapter 25 - Thoracic++ > Flashcards

Chapter 25 - Thoracic++ Flashcards

1
Q

What is the path of the azygos vein?

A

Runs along the right side and dumps into superior vena cava in the superior chest

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2
Q

What is the path of the thoracic duct?

A

Runs along the right side, crosses midline and dumps into left SCV at junction with IJ

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3
Q

Which mainstem bronchi is longer?

A

Left

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4
Q

Which pulmonary artery is longer?

A

Right

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5
Q

Which nerve runs anterior to hilum? Which runs posterior to hilum?

A

Anterior – phrenic; posterior – vagus

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6
Q

What percentage of total lung volume is the right lung volume? What is the left lung volume?

A

55%; 45%

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7
Q

What percent of the work is done by the diaphragm during quiet inspiration?

A

80%

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8
Q

What are the accessory muscles of respiration?

A

Sternocleidomastoid, levators, serratus posterior, scalenes

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9
Q

What is the function of type I pneumocyte? Type II pneumocytes?

A

Type I: gas exchange; type II: surfactant production

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10
Q

What is the purpose of pores of Kahn?

A

Direct air exchange between alveoli

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11
Q

What FEV1 is needed before surgery?

A

Greater than 0.8L or 40% of predicted value

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12
Q

What value of pCO2 or CO2 is needed prior to resection?

A

pCO2 greater than 45, CO2 less than 50. This is not an absolute contraindication in itself, but it likely correlates w/ a poor FEV1 or poor exercise performance.

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13
Q

Persistent air leak is most common after what operation?

A

Segmentectomy, wedge

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14
Q

Symptoms of lung cancer?

A

Most common symptom is persistent cough.

Asymptomatic with findings on routine chest x-ray, pneumonia, pain, weight loss.

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15
Q

What is the most common cause of cancer related death in the United States?

A

Lung cancer

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16
Q

What aspect of lung cancer has the strongest influence on survival?

A

Nodal involvement

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17
Q

What is the single most common site of lung cancer metastasis?

A

Brain

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18
Q

How does lung cancer recurrence present? What percent of recurrences are within the first three years?

A

Most commonly appears as disseminated metastases; 80%

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19
Q

What is the overall five-year survival rate of lung cancer? With resection?

A

10%; 30%

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20
Q

Which stages of lung cancer are resectable?

A

Stage I and II

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21
Q

What is the most common lung cancer?

A

Adenocarcinoma

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22
Q

What percent of lung cancer is non-small cell carcinoma?

A

80%

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23
Q

What type of non-small cell carcinoma is associated with more peripheral lesions and distant metastases?

A

Adenocarcinoma - described as ground-glass and hazy appearing

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24
Q

What type of non-small cell carcinoma is associated with local recurrence and more central lesions?

A

Squamous cell carcinoma - spiculated and irregular appearing, cavitation with resultant central scar

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25
Q

What percent of lung cancer is small cell carcinoma?

A

20%

  • bulky nodal disease can be a diagnostic clue
  • often has distant mets
  • more commonly have paraneoplastic syndromes
  • manage like NSCLC if presents as SPN
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26
Q

What is the overall five-year survival rate for small cell carcinoma?

A
  • Very poor, less than 5% are candidates for surgery.
  • 10-13% for limited disease and 1-2% for extensive disease.
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27
Q

What paraneoplastic syndrome is associated with squamous cell carcinoma?

What two are associated with small cell carcinoma? Which is most common?

A

Squamous cell – PTH related peptide

Small cell – ACTH (most common), ADH

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28
Q

What is the most malignant lung tumor?

A

Mesothelioma

  • extrapleural pneumonectomy best achieves local control
    • higher recurrence-free survival
    • no difference in overall survival, however
  • chemo or radx is not a first choice tx
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29
Q

Chemotherapy used for non-small cell carcinoma stage II or higher?

A

Carboplatin, Taxol

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30
Q

What chemotherapy is used for small cell lung cancer?

A

Cisplatin, etoposide

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31
Q

What findings would prompt use of mediastinoscopy?

A

Centrally located tumors, patients with suspicious adenopathy, ipsilateral and contralateral mediastinal nodes

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32
Q

What is the Chamberlain procedure?

A
  • mediastinoscopy through L 2nd rib cartilage
  • aortopulmonary window nodes (station 5/6)
  • LUL cancers go through these nodes, but cannot often be reached by other MIS methods
  • used to stage these cancers if suspected nodes in this area
  • EBUS is first for central tumors/nodes
  • percutaneous is first for peripheral
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33
Q

What is a Pancoast tumor (aka superior sulcus tumor)?

A

Tumor invades apex of chest wall and patients have Horner’s syndrome or ulnar nerve symptoms

  • eval for brachial plexus involvement: contraindx to surg if extensive
  • mediastinoscopy: eval for mediastinal nodes
  • nodes involved: no resection (N2)
  • uninvolved: en-bloc resection, don’t resect brachial plexus, ok to resect sympathetic chain, chest wall involvement likely (often involves ribs 2-4)
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34
Q

Which cancers’ mets to the lung may be resected if isolated and not associated with any other systemic disease?

A

Colon, renal cell cancer, sarcoma, melanoma, ovarian or endometrial cancer

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35
Q

What are the characteristics of a carcinoid tumor?

A

Neuroendocrine tumor, central, 50% with symptoms

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36
Q

What is the five-year survival of a typical carcinoid? Atypical carcinoid?

A

90%, 60%

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37
Q

What bronchial adenomas are malignant?

A

Adenoid cystic adenoma, mucoepidermoid adenoma, mucous gland adenoma

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38
Q

What is the spread of adenoid cystic adenoma?

A

Spread along perineural lymphatics, beyond endoluminal compartment; slow-growing, can get 10 year survival with incomplete resection

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39
Q

What is the most common benign adult lung tumor?

A
  • Hamartomas - 75% of all benign tumors. Men > women.
  • PSX: SPN w/ very slow growth
  • DX: well-circumscribed nodule w/ popcorn calcification; needle aspx
  • TX: if symptomatic, resect
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40
Q

What do hamartoma lesions look like on chest CT?

A

Have calcifications, appear as popcorn lesion, with fat within the lesion

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41
Q

Do hamartomas require resection?

A

No; repeat chest CT in six months to confirm diagnosis

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42
Q

What is the most common mediastinal tumor in adults and children?

A

Neurogenic

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43
Q

What is the most common site for mediastinal tumor?

A

Anterior

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44
Q

What tumors can be found in the anterior mediastinum?

A

Lots of “Ts”:

  • Thymoma
  • Thyroid cancer
  • paraThyroid adenoma
  • T-cell lymphoma
  • Teratoma
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45
Q

What is the number one anterior mediastinal mass in adults?

A

Thymoma

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46
Q

What tumors can be found in the middle mediastinum?

A

Lots of cysts:

  • bronchiogenic cyst
  • pericardial cyst
  • enteric cyst
  • lymphoma
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47
Q

What tumors can be found in the posterior mediastinum?

A

Enteric cyst, neurogenic tumor, lymphoma

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48
Q

What percent of thymomas are malignant? What percent have symptoms? What percent are associated with myasthenia gravis?

A

50%, 50%, 50%

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49
Q

What percent of patients with myasthenia gravis have thymomas?

A

10%

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50
Q

Treatment of thymomas?

A
  • All need resection (may include pericardium or lung)
  • Neoadj chemo if not/potentially resectable
  • Stage II or III requires postop RT
    • (thymic cancer always requires PORT)
  • If myasthenia gravis, tx preop: anti-cholinesterase medications, plasmapheresis, steroids
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51
Q

What is the most common type of lymphoma?

A

T cell non-Hodgkin’s lymphoma

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52
Q

What type of Hodgkin’s lymphoma is most common?

A

Nodular sclerosing

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53
Q

What is the treatment for lymphoma?

A

Chemo and radiation

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54
Q

What is the most common germ cell tumor in the mediastinum? What is the most common malignant germ cell tumor in the mediastinum?

A

Teratoma, seminoma

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55
Q

Treatment for germ cell tumors?

A
  • Sx: due to mass effect
  • Dx: AFP, b-HCG; CT
  • Tx mature teratoma: resection (sternotomy or post/lat thoracotomy); relatively insensitive to chemo/radx
  • Tx immature teratoma: neoadj chemo and resx
  • Tx seminoma: platinum based chemo and radx, can resect small ones
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56
Q

What percent of nonseminoma tumors have elevated beta hCG and alpha-fetoprotein?

A

90%

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57
Q

What are bronchiogenic cysts? Where are bronchiogenic cysts? What is their treatment?

A
  • Arise from anomalous budding of the foregut.
  • Psx: 20 yr w/ hard to tx coughing, wheezing, PNA
  • Dx: CXR shows air-fluid lvl if infx, CT demonstrates cystic nature; do not communicate w/ bronchial tree
  • Posterior to carina in middle medx`iastinum
  • Tx: Partial or total lobectomy - likely to be symptomatic, can become malignant
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58
Q

Where are pericardial cyst found? What is their treatment?

A
  • At right cardiophrenic angle
  • Psx: SoB, R HF; asx incidental finding
  • Tx: resection if sx or unsure of dx, can be observed if found incidentally and asx
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59
Q

What is the most common neurogenic tumor? Treatment?

A

Neurolemmoma, resection

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60
Q

Paragangliomas produce what?

A

Catecholamines

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61
Q

Nerve sheath tumors are associated with what syndrome?

A
  • Von Recklinghausen’s, AKA NF1
  • cafe-au-lait spots, cutaneous neurofibromas, Lisch nodules, axillary/inguinal freckling
  • autosomal dominant, neurofibromin
  • mediastinal neurofibromas are very rare
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62
Q

What percent of symptomatic mediastinal masses are malignant?

A

50%

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63
Q

What percent of asymptomatic mediastinal masses are benign?

A

90%

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64
Q

What are benign tumors of the trachea in adults? children?

A

Adults – papilloma, children – hemangioma

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65
Q

What are malignant tumors of the trachea?

A

Squamous cell carcinoma

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66
Q

What is the most common early complication after tracheal surgery? Late?

A

Laryngeal edema; granulation tissue formation

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67
Q

Where is post-intubation stenosis?

A

At stoma site with tracheostomy, at cuff with ET tube

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68
Q

Where does a tracheostomy need to be placed so as not to risk tracheoinnominate fistula?

A

Between the first and second tracheal rings, not lower than third rings

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69
Q

Treatment for tracheoinnominate fistula?

A
  • overinflated balloon or stick your finger in the tracheotomy and compress the innominate
  • resect innominate and place graft
  • use new tracheostomy site
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70
Q

Management of benign tracheoesophageal fistula?

A
  • Hx: large bore NGT/ETT/trach for long period, perc trach
  • Sx: aspiration, cuff leak, bile/saliva from ETT, recurrent/persistent PNA
  • Dx: swallow study or CT w/ panendoscopy
  • Tx: NPO, decompress stomach, elevate HoB, define size
    • stent can temporize, DC causing agent
    • clip for poor OR candidate
    • small: divide and repair w/ covering over NGT
    • large: +/- decompressing gastrostomy
      • +/- tracheal resection, recon
      • +/- sternohyoid flap
      • may require delayed repair
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71
Q

Lung abscesses are most commonly associated with what? What segment of the lung are they most commonly in?

A

Aspiration; posterior segment of RUL and superior segment of RLL

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72
Q

Treatment for lung abscess?

A
  • Antibiotics that include anaerobe coverage are 95% successful. Can take months.
  • CT guided drain if meds fail.
  • Surgery if drain fails or cannot rule out cancer. Usually not needed.
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73
Q

What causes empyemas?

A

Secondary to pneumonia and subsequent parapneumonic effusion (staph, strep)

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74
Q

Symptoms of empyema?

A

Pleuritic chest pain, fever, cough, SOB

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75
Q

What will the pleural fluid show in empyema?

A

WBCs >500 cells/cc, bacteria, positive G stain

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76
Q

3 phases of empyema?

A

Exudative (1st week), fibroproliferative phase (2nd week), Organized phase (3rd week)

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77
Q

Treatment of empyema in the exudative phase?

A
  • Uncomplicated parapneumonic effusions can be tx w/ thoracentesis
  • Otherwise, chest tube w/ flushes
  • Abx to include anaerobes
  • CT w/in 24 hrs
  • remove when draining <50ml/day
  • failure requires VATS
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78
Q

Treatment of empyema in organized phase?

A

Likely decortication of fibrous peel around lung causing failure of re-expansion. Usually not needed unless pleural restriction present after 6 months.

More adhesions, larger pleural thickness, larger cavity may favor open decortication.

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79
Q

What is an Eloesser flap?

A

Direct opening to external environment

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80
Q

Chylothorax fluid characteristics?

A

Milky white; high lymphocytes and TAGs (>110), Sudan red stains fat. Will also have high lymphocytes w/ normal pH.

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81
Q

What is the cause of chylothorax?

A

50% trauma/iatrogenic injury to thoracic duct, 50% tumor (lymphoma most common)

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82
Q

What level injury causes left sided chylothorax? Right sided?

A

Thoracic duct injury:

  • Left: above T5-6
  • Right: below T5-6
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83
Q

Treatment for chylothorax?

A

3-4wk conservative: CTb, octreotide, low-fat diet or TPN; if fails: surgery with ligation of thoracic duct on R. low in mediastinum

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84
Q

What is considered massive hemoptysis?

A

>600cc/24h

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85
Q

What is the bleeding from in massive hemoptysis?

A

High pressure bronchial arteries

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86
Q

What is the most common etiology of massive hemoptysis?

A

In US, 2/2 bronchectasis from CF.
In devloping countries, 2/2 TB.
Cancer and aspergilloma are other causes.

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87
Q

Treatment of massive hemoptysis?

A
  • place bleeding side down
  • OR rigid bronch to ID side and tx if possible
    • consider angio if unable to ID bleeding side
  • mainstem intubation to side opposite bleeding
  • no go: FEV <40% predicted, unable to localize, unresectable cancer/metastasis, coagulopathy, bilateral
  • OR for lobectomy or pneumonectomy
  • bronchial artery embolization if not good for OR
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88
Q

What is the recurrence risk of spontaneous pneumothorax after 1st? 2nd? 3rd?

A

1st: 20%, 2nd: 60%, 3rd: 80%

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89
Q

Treatment for spontaneous pneumothorax?

When is surgical intervention warranted?

A

Chest tube

Surgery for recurrence, large blebs on CT, air leak >7d, nonreexpansion

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90
Q

What does surgery for spontaneous pneumothorax entail?

A

Thoracoscopy, apical blebectomy, mechanical pleurodesis

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91
Q

What are bronchiogenic cysts?

A

Abnormal lung tissue outside lung; did not get connected to bronchial system

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92
Q

Where does sequestered lung tissue get its blood supply?

A

From anomalous systemic arteries, usually off of thoracic aorta; can also come from abdominal aorta through inferior pulmonary ligament

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93
Q

Who is extralobar sequestration more common in?

A

Children; more likely to have systemic venous drainage

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94
Q

Who is intralobar sequestration more common in?

A

Adults; more likely to have pulmonary vein drainage

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95
Q

Treatment for sequestration?

A

Lobectomy

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96
Q

What condition is most likely to cause arrest after blunt trauma due to impaired venous return?

A

Tension pneumothorax

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97
Q

What is a catamenial pneumothorax and what is it caused by?

A

Occurs in temporal relation to menstruation, caused by endometrial implants in the visceral lung pleura

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98
Q

What are bronchioliths usually caused by?

A

Secondary to infection

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99
Q

When does mediastinitis usually occur?

A

After cardiac surgery

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100
Q

What causes white out on chest x-ray with midline shift toward white out? Midline shift away from white out? No shift?

A

Toward whiteout: collapse from obstruction, need bronchoscopy to remove plug

Away: effusion, place chest tube

No shift: possibly contusion w/ trauma hx; CT to figure out

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101
Q

What are the characteristics of tuberculosis lung disease?

A

Lung apices, calcifications, caseating granulomas

102
Q

What is a Gohn complex?

A

Parenchymal lesions plus enlarged hilar lymph nodes

103
Q

What are characteristics of exudative effusions on cytology?

A

Protein greater than 3, SG greater than 1.016, LDH ratio (plural fluid to serum) greater than 0.6, low glucose

104
Q

What is the treatment for recurrent pleural effusions?

A

Mechanical pleurodesis, talc pleurodesis for malignant effusions

105
Q

What are airway fires usually caused by? What is the treatment?

A

Associated with the laser; stop gas flow, remove ET tube, can use water or saline, re-intubate for 24 hours, laryngoscopes and bronchoscopy

106
Q

What are AVMs? Where are they located in the lung?

A

Connections between the pulmonary arteries and pulmonary veins, usually in lower lobes

107
Q

What are symptoms of AVMs? What is the treatment?

A

Hemoptysis, SOB, neurologic event; embolization

108
Q

What is the most common benign chest wall tumor?

A

Osteochondroma

109
Q

What is the most common malignant tumor of the chest wall?

A

Chondrosarcoma

110
Q

What are the two general forms of dysphagia based on anatomy?

A

esophageal, orophyaryngeal

111
Q

DDx in oropharyngeal dysphagia?

A
  • mechanical - cancer, webs, radiation, scarring
  • intrinsic/motor - diverticulum (Zenker)
  • systemic - CVA, myesthenia gravis
  • inflammatory - eosinophilic, HSV/CMV/candida, caustic
112
Q

DDx of esophageal dysphagia

A
  • mechanical - cancer, stricture, webs
  • motor - achalasia, spasm
  • systemic - scleroderma, DM
  • inflammatory - eosinophilic, HSV, CMV, candida, caustic
113
Q

When swallowing, immediate coughing, choking, regurgitation suggests what general location of the cause of dysphagia?

A

orophyaryngeal

114
Q

Odynophagia is associated with what conditions?

A

Usually NOT dysphagia. Usually associated with inflammation - pharyngitis, mucositis (s/p radiation), caustic ingestion.

115
Q

For chronic conditions associated with dysphagia, what are four important questions that need to be answered in the history?

A
  • location (patients can identify location with accuracy)
  • solid/liquid/both
  • progression
  • association with weight loss/anorexia
116
Q

In suspected caustic ingestion causing dysphagia, what is the first diagnostic test?

A

upper flexible endoscopy - assess anatomic extent of damage, grade the injury

117
Q

In most cases of dysphagia, what is the first test?

A
  • barium swallow - readily available, safe, cost-effective, rapid
  • information gathered includes anatomic relations, esophageal transit, mass lesions, diverticular
  • subsequent upper endoscopy is safer and has higher diagnostic yield after barium
118
Q

If GERD is suspected in the dysphagia workup, what test can confirm this?

A

24-hr pH monitoring study - assesses presence and severity with DeMeester score >14

119
Q

If motility disorder is suspected in dysphagia workup, what test can be used to confirm this?

A

esophageal manometry

120
Q

If extrinsic compression is suspected in dysphagia, what test can be used to identify masses or vascular anomalies?

A

CT or MRI

121
Q

What is the pathophysiology of achalasia?

A

loss of inhibitory neurons in Auerbach plexus altering LES relaxation

122
Q

What is the characteristic presentation of achalasia?

A

middle-aged person with progressive dysphagia to both solids and liquids, now with regurgitation, chest pain, and some weight loss

123
Q

What are the manometry findings diagnostic of achalasia?

A

aperistalsis and failure of LES relaxation in response to food bolus

124
Q

What cancer is at risk of developing with long-standing achalasia?

A

esophageal SCC

125
Q

What are the three types of achalasia? How do they differ?

A
  • Type I - 100% failed peristalsis, no contractile activity, no pressure >30 mmHg
  • Type II - same as 1 except, pan pressurization >30 mm Hg; best prognosis
  • Type III - no peristalsis, preserved fragments of contraction, worst prognosis
126
Q

What is the role of botulinum toxin injections in achalasia?

A

Not a long-term solution, used in elderly with short life-span or those who cannot tolerate surgery

127
Q

What is the most effective nonsurgical management of achalasia

A

balloon dilation; not calcium channel blockers or nitrates

128
Q

What is the standard treatment for a patient with achalasia?

A

lap Heller (esophagomyotomy) w/ Dor (partial anterior) fundoplication

129
Q

What does manometry in a patient with diffuse esophageal spasm show?

A

periodic, prolonged, multipeaked, high-amplitude contraction in more than 1 of 5 swallows; classically, there is a corkscrew appearance

130
Q

What does manometry show in nutcracker esophagus?

A

esophageal peristalsis with extremely high pressure amplitudes (>180 mm Hg), normal peristalsis is not observed within trains of high-pressure waves

131
Q

Is Zenker diverticulum a true or false diverticulum?

A

false

these occur in the pharyngoesophageal area after pulsion pressure just superior to the cricopharyngeus, the mucosa herniate through the muscular layers due to dyscoordination in a more distal part of the esophagus

132
Q

How is Zenker diverticulum diagnosed?

A

barium swallow WITHOUT endoscopy (risk perforation)

133
Q

How is Zenker diverticulum treated?

A

surgery - include division of the cricopharyngeus muscle, excision of the diverticulum (if >2cm)

134
Q

What are the characteristics of mid-esophageal diverticulum?

A

not associated with dysphagia, true diverticulum caused by traction in the setting of extraesophageal inflammation (granulomatous disease in subcarinal nodes); treated by focusing on the underlying inflammation

135
Q

What are the characteristics of epiphrenic diverticula?

A

pulsion type, associated with underlying dysmotility; usually managed conservatively, unless dysphagia is present - treat with excision of the diverticulum, myotomy, antireflux procedure

136
Q

How are esophageal webs and rings managed?

A

the same way

diagnose with barium swallow and treat with mechanical dilation using Savary bougies or balloons; associated with anemia in Plummer-Vinson syndrome - assess and manage this as well

137
Q

How do you manage peptic strictures?

A
  • maintain high suspicion for Barrett or invasive cancer
  • endoscopic biopsy
  • acid suppression and dilation after biopsy
  • surgery is uncommon
138
Q

How is eosinophilic esophagitis diagnosed? How is it managed?

A
  • symptoms of esophageal dysfunction
  • 15 eosinophils on mucosal biopsy
  • no response to PPI
  • no GERD on pH

barium swallow is usually normal

no surgery - give steroids, avoid inciting foods, dilate strictures

139
Q

What are the most common causes of chronic cough?

A
  • chronic cough lasts >8 wks
  • GERD
  • post-nasal drip
  • asthma
  • bronchiectasis
140
Q

What are some characteristics of carcinoid lung cancer?

A
  • CT: central endobronchial tumors that obstruct the bronchial lumen
  • bronch: smooth, round, fleshy, pink/purple, friable, intact epithelium, vascular
  • Path: uniform polygonal cells w/ round nuclei and fine granular chromatin within vascular stroma
141
Q

How do you manage a patient with a malignant fistula between the esophagus and the airway?

A
  • cancers eroding through or radiation damage
  • present with copious secretions and foul breath
  • palliate with stents in the airway and/or esophagus
142
Q

To determine cause of hemoptysis in a stable patient what is often the initial workup?

A
  • ABCs and resuscitation
  • CXR
  • CT chest w/ contrast
  • lay the patient on the affected side if possible
143
Q

In a patient w/ severe hemoptysis, what tool can be used to determine the site and side of bleeding?

A
  • rigid bronchoscopy if severe hemoptysis
  • selective ventilation with double-lumen tube may temporize
  • if bronchoscope doesn’t treat, do arteriography
144
Q

If bronchoscopy fails to ID the source of hemoptysis, what can be used next?

A

angiography - may show blush or just hypertrophy, tortuosity, or aneurysm

145
Q

What are the contraindications to surgical resection for massive hemoptysis?

A

often relies on you knowing the patient’s history

  • FEV <40% of predicted
  • unable to localize at bronchoscopy
  • unresectable cancer
  • metastatic cancer
  • coagulopathy
  • systemic disease
  • bilateral lung involvement
146
Q

What are the pathophysiologic mechanisms that create the differential for pleural effusions?

A
  • Starling equilibrium imbalances
    • high capillary/lymph hydrostatic P: CHF, CKD
    • low capillary oncotic P: hypoproteinemia
    • low intrapleural hydrostatic P: atelectasis
    • high pleural oncotic P: inflammation, lymphatic obsx
  • Increased permeability: infection, cancer, AI
147
Q

What is the difference between transudative and exudative pleural effusions?

A
  • transudative - result of change in hydrostatic P with low protein count
  • exudative - results of increased permeability likely related to inflammation
148
Q

What is the role of imaging in pleural effusion workup?

A
  • CXR: upright shows 150 ml of effusion, lateral can show 50 ml
  • US: detects smaller effusions, used to guide thoracentesis
  • CT: can detect size and give hints to etiology
    • fluid-fluid layering - blood
    • pleural thickening, loculations, enhancement - infection
    • calcified plaques - asbestosis
    • diffuse irregular nodularity - mets or mesothelioma
  • MRI: no use
149
Q

What are the different characteristic effusions and possible causes?

A
150
Q

What tests can be run for pleural effusions after a thoracentesis? What could they suggest for diagnosis?

A
151
Q

What are contraindications to thoracentesis?

A

lack of cooperation, instability, coagulopathy, high-pressure ventilation

152
Q

In a patient with an exudative effusion without a diagnosis after pleural fluid analysis, what is the next step?

A
  • exudative: high protein, high LDH
  • pleural biopsy: needle biopsy, VATS
153
Q

What does pleural fluid neutrophilia in the cell count usually point to?

A

infection, does not exclude malignancy

154
Q

What is lymphocytosis in the pleural effusion cell count indicative of?

A

malignancy, TB, or chylothorax

155
Q

Discuss the role of thoracentesis in the ICU patient.

A
  • many potential causes of effusion: sepsis, CHF, CKD/AKI, over-resuscitation, malnourishment, cancer
  • use liberally - early infection detection, maximize hemodynamics and respiratory status
156
Q

How do you manage malignant effusions?

A
  • palliation: relieve dyspnea, reduce hospital days
  • if cause can be treated, do thoracentesis
  • if cause is untreatable, do tunneled catheter
  • prevent with pleurodesis w/ sclerosants (talc)
  • the better prognosis/functional status, the more invasive pleurodesis - VATS pleurodesis has better outcomes
  • don’t do VATS if trapped lung
  • risk of ALI, do not do bilaterally
157
Q

What are the stages of parapneumonic effusion or pleural space infection?

A
  • exudative phase: permeability, initially sterile
  • fibrinopurulent: fibrin and WBC, proliferation, loculation
  • organizing: collagen, lung entrapment, peel develops
158
Q

What kinds of pleural effusions require drainage?

A

those with moderate to high risk of poor outcomes

  • anatomy: >50% hemithorax, loculation, thickened pleura
  • clinical status: dyspnea
  • bacteriology: positive gram stain/culture, pus
  • the more complicated (loculated), the more likely VATS will improve outcomes - hospital days, chest tube days
159
Q

Discuss bronchopleural fistulas

A
  • these are infected by definition
  • most likely after right pneumonectomy
  • operative management required
160
Q

What are the causes of chylothorax?

A

trauma, malignancy (non-Hodgkin lymphoma), left subclavian vein thrombosis (unlikely)

161
Q

How do you diagnose chylothorax?

A

pleural fluid triglyceride levels:

  • >110 mg/dL is highly suggestive
  • <50 rules out
  • pleura to serum ratio >1 is indicative
  • chylomicron presence is synonymous
162
Q

How do you manage chylothorax?

A
  • determine output: >500 ml/d is predictive of nonop failure
  • if high o/p or nonop fails, do R side thoracoscopic duct ligation
    • give PO heavy cream 2-3 hrs before OR
  • can attempt NPO, TPN, octreotide
  • lymphangiography can ID if above fails
163
Q

What metastatic SPNs may be cured/gain survival benefit with resection?

A

sarcoma, testicular carcinoma, head and neck, melanoma, colorectal

  • multiple, bilateral foci can undergo staged wedge resections if PET shows no other mets
164
Q

What can a growing SPN in a patient with joint pain and an elevated RF mean?

A

rheumatoid nodule

165
Q

How does sarcoidosis often present?

A
  • rarely as SPN
  • often as hilar/mediastinal lymphadenopathy w/ diffuse parenchymal involvement in a young African-American woman
  • lab: elevated ACE levels
  • path: noncaseating granulomas
166
Q

If a patient with an SPN is suspected to have granulomatosis with polyangiitis, what can be tested to help confirm?

A

C-ANCA (highly sensitive)

give cyclophosphamide +/- steroids

167
Q

Which infectious pulmonary granulomas have a cavitary appearance on CT scan?

A
  • atypical mycobacteria
  • histoplasmosis
  • coccidiomycosis
  • aspergillosis - can show shifting of positon of the cavity content w/ CXRs in different positions, can have crescent of air around the mass (mycetoma of aspergillosis)
168
Q

In the setting of infectious granuloma causing hemoptysis without significant pulmonary function loss, what is often required to manage?

A

resection

169
Q

Discuss echinococcus in the setting of SPN

A
  • sheep and cattle associated hydatid tapeworm
  • ingested and travel to lung
  • labs: eosinophilia
  • confirm: hemagglutinin test
  • mgmt: do not aspirate or biopsy d/t anaphylaxis risk, use antihelminthics, consider resection
170
Q

What presentation would make an SPN more likely to be malignant?

A
  1. spiculated margins on CT
  2. age >70
  3. size >2cm
  4. rapid growth
  5. smoking
171
Q

What is the role of CXR in the management of SPNs?

A

poor for screening, but if no change in appearance over 2 years, then the SPN is 90% benign and can be followed w/ yearly CXRs

172
Q

What is the recommendation for screening for lung cancer?

A
  • 30 pack-year history
  • 55-80 years
  • smoked within the last 15 years
  • annual low-dose CTs
  • ACCP recommends CT at 3, 12, and 24 mo if SPN is 8 mm; no follow up if lesion is stable after this
173
Q

What are ground glass opacities? What should be done with them?

A
  • areas of diffuse high attenuation on CT that don’t obstruct vasculature or produce air bronchograms
  • can be premalignant
  • slow growing - follow yearly with CT x3 yrs
174
Q

How do neuroendocrine tumors present on CT?

A

>50 HU, rounded lesions, can cause airway obstruction producing atelectasis

175
Q

For SPNs greater than 8mm and an intermediate pre-test probability, what is a cost-effective test to help determine malignancy?

A

PET-CT, though this test is most useful in staging

176
Q

SPNs between 1-3 cm and that are peripheral should be considered for what diagnostic test?

A
  • transthoracic needle biopsy
  • PTX is complication - do not treat unless sx, otherwise observe w/ serial CXRs
177
Q

SPNs that are centrally located should be considered for what diagnostic study?

A

bronchoscopy

178
Q

What is your algorithm for managing an SPN?

A
  • should be at least 8mm; compare to previous imaging
  • risk stratify:
  • low risk, <1cm - CT at 3, 12, 24 mo (+36 if GGO)
    • resect if growth
  • >1cm and indeterminate - PET
    • negative: f/u CTs
    • positive, risky pt - TTNB vs bronch
    • positive, healthy pt - VATS bx
  • high-risk: old smoker w/ 2cm spiculated mass - OR bx vs lobx
179
Q

In a patient w/ SPN who is biopsied and found to have cancer, what further testing is required?

A
  1. PFTs - to determine tolerance of lobectomy
  2. bronchoscopy - can be intraoperative
  3. mediastinal eval - EBUS vs mediastinoscopy
  4. PET/CT

of note, cardiac eval is not standard preop for lung surgery

180
Q

Summarize the management of the most common cancer worldwide for men and women.

A
  • differentiate NSCLC vs small cell
  • NSCLC: stage clinically, assess for surgery
    • ​​stage Ia: resect
    • >stage Ia: resect w/ adjuvant chemo
    • positive margins: RT, then chemo
    • stage III: med onc/rad onc/ CTS
  • small cell: usually disseminated
    • stage I: resect, then…
    • combo chemo: platinum-based, RT
181
Q

In a patient with isolated SCC of the lung, what do you do with a…

  • single brain met?
  • single adrenal met?
  • second lesion in the same lobe?
  • malignant pleural effusion?
  • invasion of parietal pericardium?
A
  • assess if can be tx w/ definitive therapy, can resect
  • assess if can be tx w/ definitive therapy, can resect
  • T3 dz: can be stage II (resect), or stage III (resect w/ chemorad)
  • stage IV - unable to resect
  • T3 dz: can be stage II (resect), or stage III (resect w/ chemorad)
182
Q

What is the diagnostic workup for patients with suspected aortic dissection?

A
  • Psx: anterior chest pain in ascending aortic dissection or severe, sharp, or “tearing” posterior chest or back pain when the dissection progresses distal to the left subclavian artery. HTN more common w/ type B.
  • Dx: depends on stability
    • stable - CT; if equivocal, do TEE or MRA
    • unstable - TEE (most sensitive)
183
Q

What is the exposure of choice for a patient with a precordial stab wound?

A
  • ABCs first
  • median sternotomy in OR is ideal: pt must be able to be resuscitated; allows access to heart, vessels
  • if the patient arrests in ED, do ED thoracotomy through left anterolateral thoracotomy
184
Q

How is neurogenic thoracic outlet syndrome usually diagnosed?

A

history and physical

  • imaging can help rule out other issues
  • look for wasting of lateral thenar muscles
  • shoulder girdle and arm pain radiating down the medial aspect of the arm with paresthesias and numbness in the ulnar distribution of the forearm in a young asthenic woman with poor posture is highly suggestive
  • EMG can help establish dx
185
Q

What is the curative management of malignant tracheal tumors?

A

surgical resection and mediastinal radiation

  • assess for ability to recon before resection
  • laser therapy is palliative
  • radiation alone is palliative
186
Q

Pt has persistent opacity on CXR after tube thoracostomy placed for hemothorax, what is the next step?

A
  • CT to eval for retained hemothorax
  • early VATS
  • fibrinolytics are second line after surgery or if surgery contraindicated
  • risk empyema without surgery
187
Q

What is the preferred approach for atrial myxomas?

A

median sternotomy and left and right atriotomies

188
Q

When should patients quit smoking preoperatively?

A

4 wks

189
Q

If a thoracic surgery patients has preop FEV/DLCO less than 30%, what should be done next?

A

cardiopulmonary exercise testing with measurement of maximal oxygen consumption

less than 10 ml/kg/min - nonop management

190
Q

Given a patient with delayed evacuation of empyema, a thick pleural rind that is difficult to remove, and incomplete lung reexpansion at the end of the case, what should be done?

A

can attempt to continue thoracoscopically (depending on surgeon comfort), but if there is no progression, conversion to open thoracotomy is often required to achieve complete empyema drainage, full decortication, and complete lung re-expansion (required before leaving the OR)

191
Q

Determining the maximum fluid volume that can be safely removed during therapeutic thoracentesis is uncertain. To avoid procedure-related pneumothorax or reexpansion pulmonary edema, it is recommended that fluid removal be discontinued when?

A

at the onset of chest pain or when the total fluid removed reaches 1000 to 1500 mL

192
Q

In a trauma patient, when should an ED thoracotomy be done?

A
  • penetrating chest wound with loss of vitals w/ CPR less than 15 mins
  • blunt trauma and loss of vitals w/ CPR in transit
  • contraindications: no signs of life at scene, asystole without tamponade, other nonsurvivable injuries
193
Q

In an asymptomatic patient with a small pneumothorax (apex-to-cupola distance < 3 cm), what is an appropriate approach?

A

Observation with repeat chest x-ray in 6 hours is an appropriate approach. In a patient who has reliable access to short-interval follow-up, a stable chest x-ray after 6 hours of observation warrants discharge home.

194
Q

What does the visceral pleura adhere to?

A

pulmonary parenchyma surface

195
Q

What is the parietal pleura innervated by (generally)?

A

Somatic

196
Q

Fluid production and absorption rates in the pleural space max out at what?

A
  • production: 100 ml/hr
  • absorbption: 300 ml/hr
197
Q

Describe the factors leading to a pleural effusion.

A

Sterling’s law of capillary exchange

  • increased hydrostatic pressure
  • increased negative intrapleural pressure
  • increased capillary permeability
  • decreased plasma oncotic pressure
  • decreased lymphatic drainage
198
Q

How do you distinguish between exudative/transudative effusions?

A

Light’s criteria defines exudative effusions

  • pleural/serum protein ratio: >0.5
  • pleural/serum LDH ratio: >0.6
  • pleural LDH > 2/3 normal serum LDH
199
Q

In a patient with a parapneumonic effusion or empyema, be able to identify common causative agents.

A
  • Streptococcus milleri
  • Streptococcus pneumonia
  • Staphylococcus aureus
  • Enterobacter
  • Gram-negative organisms
  • Anaerobes
200
Q

What can cause increased permeability of pleural membranes and capillaries?

A
  • Sepsis
  • Malignancy
  • Pulmonary embolism
  • Pancreatitis
201
Q

What can cause increased hydrostatic pressure in the pleural space?

A
  • Congestive heart failure
  • Renal disease
  • Iatrogenic fluid overload
202
Q

What can cause hypoalbuminemia leading to pleural effusion?

A
  • Cirrhosis
  • Nephrotic syndrome
  • Malnutrition
203
Q

Be able to describe the typical presenting symptoms of a patient with an empyema.

A
  • Constitutional symptoms:
    • Malaise
    • Fever
    • Loss of appetite
    • Weight loss
  • Cough and dyspnea
  • Pleuritic chest pain
  • History of recent pneumonia or other lung infection
  • Pleural effusion
204
Q

Be able to correctly describe thoracentesis for sampling and drainage of pleural fluid.

A
  • Thoracentesis is indicated only in simple effusions or in the exudative/acute phase of empyema.
  • It should be performed with ultrasound guidance.
  • Direct the needle above the selected rib to avoid the neurovascular bundle.
205
Q

Discuss application of tube thoracostomy for pleural effusions or empyema in exudative or fibropurulent stage.

A

Complete and dependent drainage is required. Therefore, a chest tube is useful in large effusions, those not completely drained by thoracentesis or are recurrent.

Early empyema (exudative phase) is usually treated with drainage alone. Sometimes, in early fibrinopurulent empyema, fibrinolytic agents (tPA + DNase) can be effective in select circumstances.

206
Q

Understand indications for video-assisted thoracoscopic surgery (VATS) or thoracotomy and decortication and be able to describe the operative technique and relevant anatomy pertaining to the procedure.

A
  • VATS or thoracotomy and decortication are performed in the organizing phase of empyema or, if conservative management has been unsuccessful, in the fibropurulent stage.
  • Identify and preserve significant anatomy including:
    • Subclavian artery apically
    • Phrenic nerve and pericardium medially
    • Aorta and esophagus posteriorly
    • Diaphragm inferiorly
  • Adequate decortication to allow complete lung expansion
  • Obliteration of space should be performed while avoiding excessive injury to the lung tissue.
  • Critically ill and/or septic patients or those with chronic empyema may require dependent drainage via rib resection and creation of an Eloesser flap/window for packing.
207
Q

Secondary pneumothoraces arise from an array of underlying medical conditions that affect the lung parenchyma, including:

A
  • Chronic obstructive pulmonary disease (most common)
  • Asthma
  • Bullous disease
  • Cystic fibrosis
  • Infection/pneumonia
  • Congenital cysts
  • Idiopathic pulmonary fibrosis
  • Pulmonary embolism
  • Malignancy
  • Thoracic endometriosis
208
Q

Be able to articulate the symptoms and physical examination signs consistent with pneumothorax and independently describe those that suggest a tension pneumothorax.

Most common?

Signs of tension?

A
  • The most common are acute onset of chest pain and dyspnea.
  • Signs and symptoms of a tension pneumothorax include:
    • Anxious, uncomfortable appearance with inc WoB
    • Decreased breath sounds on the affected side
    • Tracheal deviation away from the affected side
    • Tachycardia
    • Hypotension
    • Jugular venous distention
209
Q

What is the role for surgery in pneumothorax?

A
  • In the setting of persistent air leak (defined by the ACCP as beyond 4 days), thoracoscopy to close the leak with subsequent pleurodesis to prevent recurrence should be undertaken.
  • Aside from a persistent air leak, surgery should be deferred to the second recurrence of a primary spontaneous pneumothorax. Such surgery should include bullectomy (if blebs are visualized at surgery) in addition to pleurodesis to prevent recurrence
  • Failure to fully expand after CTb placement
  • High-risk profession (scuba diver, pilot)
  • Limited access to follow up
210
Q

Describe pigtail catheter placement

A
  • Apply local anesthetic to the chosen site (2nd intercostal site).
  • Under constant aspiration, slowly insert a needle through the chest wall along the superior aspect of the inferior rib until air is briskly aspirated.
  • Thread the guidewire via a Seldinger technique.
  • Dilate the tract over the wire using the dilator provided in the kit.
  • Insert the catheter over the guidewire along the dilated tract within its obturator, taking care to remove the obturator when curling the catheter.
  • Remove the obturator and wire as a unit and suture the catheter.
  • Place a sterile dressing.
  • Connect the catheter to a water-seal device.
  • Obtain a chest x-ray to confirm placement.
211
Q

What are the principles of surgery for pneumothorax?

A
  • Video-assisted thoracoscopy is the standard approach
  • Identify apical blebs and resect them.
  • Pleurodesis should be performed to create adhesions between the parietal and visceral pleura, with eventual obliteration of the pleural space.
  • Options for pleurodesis include:
    • Mechanical
    • Chemical: doxycycline, bleomycin, talc
    • Pleurectomy
    • Indwelling intrapleural catheter
212
Q

What patient factors can reduce recurrence rate in PTX?

A

Smoking cessation is the only modifiable risk factor shown to reduce recurrence rate.

213
Q

Where does the thoracic duct originate?

A

The thoracic duct originates at the cisterna chyli from the second lumbar vertebra. It terminates and empties into the venous system at the junction of the left internal jugular and subclavian veins.

214
Q

What increases chyle flow?

A

The volume of chyle increases with intake of dietary long-chain triglycerides.

215
Q

What is the most common cause of nontraumatic chylothorax?

A

malignancy

216
Q

In a patient with suspected chylothorax, be able to perform the necessary workup to confirm or exclude the presence of chylothorax.

A
  • If no chest tube is present, place a pleural drainage catheter to determine the quality of fluid and allow for lung reexpansion.
  • Send pleural fluid for analyses, including triglyceride and chylomicron levels.
  • A triglyceride level greater than 110 mg/dL with a predominance of lymphocytes is strongly suggestive of chylothorax.
  • A triglyceride level less than 50 mg/dL is not suggestive of chylothorax.
  • For an intermediate triglyceride level (50-110 mg/dL), obtain repeat fluid measurements after a high-fat diet. Chylomicron detection by lipoprotein electrophoresis provides a definitive diagnosis.
217
Q

Determine the appropriate time to perform surgical intervention and describe the therapeutic procedure.

A
  • Conservative therapy should be attempted for at least 5 to 7 days, at which point surgical intervention should be performed.
  • Thoracic duct ligation can be performed via video-assisted thoracoscopic surgery (VATS) or open thoracotomy procedures.
  • Thoracic duct embolization can be performed for poor surgical candidates with difficulty, requiring specialized interventional radiology techniques.
  • Concurrent pleurodesis should be considered for etiologies at high risk of failure, especially malignancy.
218
Q

Describe the important principles of conservative therapy for management of chylothorax.

A
  • Conservative therapy is first-line treatment for chylothorax.
  • Management consists of bowel rest with total parenteral nutrition.
  • Pleurodesis can be considered in patients who can achieve pleural apposition with adequate drainage.
  • Low-volume leak can be managed with exclusion of long-chain triglycerides and inclusion of medium-chain triglycerides.
  • High-volume or persistent leak on oral diet should be given TPN.
  • Somatostatin can be used as an adjunct therapy to reduce chyle production.
219
Q

A 76-year-old woman with type II diabetes mellitus underwent coronary artery bypass grafting (CABG) utilizing the left internal mammary artery (IMA) and one saphenous vein graft. On POD #5, she complains of increased chest discomfort and dyspnea. Physical exam reveals fever, wound erythema, sternal instability and purulent drainage from the old mediastinal chest tube site. What is the most appropriate management?

A
  • Postoperative mediastinitis should be suspected in any postoperative patient with sternal instability or unexplained findings of infection.
  • Increased chance of sternal wound infections in patients who are elderly or with diabetes undergoing CABG with use of IMA grafts.
  • Diagnostic workup for mediastinitis.
  • Principles of management: reoperation to debride sternum and wound closure with pectoralis or rectus muscle flaps.
220
Q

A 34-year-old male presents to the ED 1 week after dental extraction with temp 102.5°F, WBC 23K, and progressive chest pain. How will you evaluate and manage this patient?

A
  • The differential diagnosis of this patient should include descending acute mediastinitis of odontogenic origin.
  • The diagnostic workup should include CT imaging, and should rule out tracheal and esophageal perforation.
  • Resuscitation and preparation for thoracic surgical intervention – OR for mediastinal irrigation, debridement and drainage.
221
Q

What are the types of chronic mediastinitis and their causes?

A

Chronic

  • two types of fibrosing: granulomatous and not
  • granulomatous: histo and TB cause recurrent abscesses
  • non-granulomatous: radiation, idiopathic drug rxn
222
Q

In a patient with suspected acute mediastinitis, what is the ideal study for diagnosis?

A

CXR may happen first, but CT scan of the neck and chest, ideally with contrast if the renal function is normal, is the best test.

It will show mediastinal fluid collections that may contain air bubbles.

223
Q

Why does elderly age and diabetes increase risk for postop sternal wound infection?

A

poor blood supply to the sternum; same reason those s/p CABG by IMA have increased risk

224
Q

In a patient undergoing bronchoscopy, identify important bronchial anatomic structures.

A

There are ten bronchopulmonary segments in the right lung and eight bronchopulmonary segments in the left lung. There can be anatomic variants.

At the carina, the right mainstem bronchus is more cephalad-caudad oriented than the left, which requires a deliberate turn to enter. On the right, the first branch point is the takeoff of the right upper lobe bronchus (3 o’clock). The bronchus intermedius is a continuation of the right mainstem bronchus, followed by the takeoff of the right middle lobe bronchus (9 o’clock), and the takeoff of the right lower lobe superior segmental bronchus (3 o’clock) and the basilar segments of the right lower lobe (12 o’clock).

The left mainstem bronchus is more horizontally oriented and divides into the left upper lobe bronchus (9 o’clock) and the left lower lobe bronchus (6 o’clock).

225
Q

What muscles insert into the first and second ribs that may be encountered with thoracotomy?

A

The anterior and middle scalene muscles insert onto the first rib, whereas the posterior scalene muscle inserts onto the second rib.

226
Q

What muscles may be involved in a posterior thoracotomy?

A

Other muscles that may be involved in posterior thoracotomy include the trapezius, rhomboideus major and minor, infraspinatus, and teres major and minor muscles.

227
Q

What is the prognosis of lung cancer based on stage?

A

Lung cancer survival is directly linked to stage. Five-year survival is 45% to 50% at stage I, 30% at stage II, 5% to 14% at stage III, and less than 5% at stage IV.

228
Q

What preop test should be ordered if FEV1 is <80% or DLCO is <80%? What does it mean?

A

predicted postoperative (PPO) pulmonary function

  • calculate the number of segments to be resected or with perfusion nuclear imaging
  • PPO FEV1 or DLCO less than 40% are at increased perioperative risk of mortality and cardiopulmonary complications
  • PPO FEV1 or DLCO greater than 60% are acceptable candidates for lobectomy
229
Q

Discuss the types and patterns of mets to the lung.

A
  • Sarcomas and melanoma tend to metastasize to the lung as solitary nodules.
  • Head and neck, breast, colon, renal cell, and other ipsilateral or contralateral lung carcinomas tend to metastasize to the lung as multifocal lesions.
  • Tumors usually spread hematogenously to the lung, depositing in small distal vessels.
230
Q

Describe the modalities of acquisition of tissue for a suspicious lung nodule.

A
  • The modality for acquisition of tissue is dependent on nodule location.
  • Bronchoscopic biopsy and transthoracic needle aspiration are commonly used to sample suspicious nodules.
  • Nonanatomic wedge resection (with confirmation of carcinoma on frozen pathology section) can precede subsequent oncologic resection in otherwise undiagnosed but suspicious nodules after physiologic evaluation for lung resection has been completed.
231
Q

Are patients with malignant effusion candidates for resection?

A

Most likely not. This is considered M1 disease.

232
Q

Describe T staging for tumors.

A
  • T1 tumors: ≤ 3 cm in diameter
  • T2 tumors: > 3 but ≤ 5 cm in diameter
  • T3 tumors: > 5 but ≤ 7 cm in diameter (or invading the parietal pleural/chest wall, phrenic nerve, or pericardium, or two tumors in the same lobe)
  • T4 tumors: > 7 cm in diameter (or invading the mediastinum, diaphragm, heart, great vessels, trachea/carina, esophagus, recurrent laryngeal nerve, or spine, or separate nodules within the same lung but separate lobes)
233
Q

After determining the T stage on cross-sectional imaging and tissue biopsy, effectively address lymph node staging.

A
  • CT and PET imaging together can help identify suspicious lymphadenopathy, with PET having a negative predictive value of 87%.
  • Palpable supraclavicular or cervical lymph nodes portend a poor prognosis with N3 disease if positive, and they can be sampled with fine needle aspiration.
  • Mediastinoscopy and endobronchial ultrasound (EBUS) can be used to biopsy bilateral paratracheal (levels 2 and 4) as well as subcarinal (level 7) lymph node basins. They can be utilized with frozen pathology section analysis prior to formal resection of the tumor under the same anesthetic.
  • EBUS, endoscopic transesophageal ultrasound, and video-assisted thorascopic surgery (VATS) can be used for many other lymph node basins.
  • Preoperative imaging concerning for lymphadenopathy should guide the decision to proceed with the above biopsy modalities.
234
Q

Given a patient with a newly diagnosed NSCLC, identify common locations of metastatic foci.

A
  • Lung cancer can spread hematogenously and to lymphatics (pulmonary and mediastinal lymph nodes).
  • Common hematogenous sites: brain, adrenal glands, lungs, and bone.
  • Up to 7% of lung cancer patients have an adrenal metastasis.
235
Q

Given a patient with newly diagnosed lung cancer who has been adequately staged, accurately determine whether the patient may be appropriately treated with resection, should be referred for neoadjuvant therapy, or is not a surgical candidate.

A
  • Stage I and II tumors may be completely resected, and some small stage I tumors are amenable to stereotactic radiotherapy alone when patients cannot tolerate surgery because of comorbidities.
  • Stage IIIa and IIIb locally advanced tumors can be resected if they involve resectable mediastinal structures or N2 ipsilateral lymph node disease after neoadjuvant chemoradiotherapy.
  • Stage IIIb disease with either T4 tumors that involve nonresectable structures or N3 contralateral lymph nodes is treated with chemoradiation in most cases.
  • Stage IV tumors due to metastatic spread to the brain or adrenal glands can be treated with resection of the primary lung cancer in conjunction with oligometastasis control via radiation or resection. Otherwise, stage IV cancer is widely metastatic and therefore not resectable.
  • Resectability must also be determined in the context of a patient’s predicted postoperative pulmonary function and if the operative mortality is lower than the expected stage-specific 5-year overall survival.
  • Mediastinal lymphadenectomy should be performed during all resections. It is considered adequate if lymph nodes are obtained from stations 2R, 4R, 7, 8, and 9 for right-sided cancers and stations 4L, 5, 6, 7, 8, and 9 for left-sided cancers.
236
Q

While evaluating a patient with a superior sulcus (Pancoast tumor), predict the extent of resection required based on clinical symptoms and preoperative imaging.

A
  • Upper arm, forearm, and hand parasthesias indicate likely C8/T1 compression by the tumor, most commonly in the ulnar distribution. Such a tumor can be resected, but the C8 nerve root should be spared if possible to avoid hand weakness.
  • Weakness of the intrinsic muscles of the hand, wrist, or arm more likely indicates nerve root invasion and is commonly a contraindication to aggressive surgery.
  • Horner syndrome (ptosis, miosis, and anhidrosis) indicates invasion of the sympathetic chain.
  • Chest wall pain can be severe in the C8/T1 nerve distribution.
  • Resection of the tumor often involves multiple rib resections (commonly 2, 3, and/or 4).
  • The patient should be treated with neoadjuvant chemoradiation prior to surgical resection.
237
Q

During a lung cancer resection, identify anatomic landmarks to perform a safe thoracotomy or safe port position for VATS/robotic minimally invasive surgery.

A

The intercostal neurovascular bundle courses underneath the above rib in the anterior and posterior chest, but posteriorly falls away toward the central intercostal space.

The number of port sites varies according to surgeon preference and patient anatomy.

Port site incisions for VATS resection usually include triangulation between a low anterior camera port, a low more posterior working port, and an approximately 5-cm upper anterior utility incision at the apex of the triangle.

238
Q

In a patient with locally invasive, nodal, or distant metastatic disease, understand the commonly used chemotherapeutic agents.

A

Most regimens include paclitaxel and platinum-based therapy.

Vascular endothelial growth factor inhibitors such as bevacizumab can be added to chemotherapy regimens.

Tumors are often tested for biomarkers such as epidermal growth factor receptor (EGFR), which can be treated with the EGFR tyrosine kinase inhibitor erlotinib.

Anaplastic lymphoma kinase (ALK)–positive tumors can be treated with ALK inhibitors such as crizotinib and alectinib.

239
Q

In a patient with a primary sarcoma with metastatic lesions in the lung, enumerate the criteria required for consideration of metastectomy.

A

There must be adequate control of the primary tumor (resection and/or chemoradiotherapy), and a long disease-free interval is associated with longer survival.

There should not be any extrathoracic metastatic lesions on imaging such as PET.

The patient must be able to tolerate metastectomy of all lesions (there is no survival advantage to incomplete metastectomy).

240
Q

In a patient undergoing metastectomy of lung metastases, describe the goal of pulmonary metastectomy.

A

There must be complete resection of all lesions suspicious for pulmonary metastases.

The entire lung must be examined, which often necessitates thoracotomy for physical palpation of the lung surface.

Healthy lung tissue should be spared with use of wedge resections achieving negative margins.

Metastectomy is generally done in a staged procedure if bilateral lungs are involved.

241
Q

In a patient with metastatic lung cancer, develop a multimodality treatment plan.

A

Discussion of complex patients at a multidisciplinary tumor board conference helps determine appropriate treatment.

Involvement of thoracic surgery, medical oncology, radiation oncology, radiology, pathology, and palliative care teams enables coordination of a team-based treatment plan.

Community oncology specialists can participate in multidisciplinary tumor board discussions at tertiary/quartenary care centers via telehealth conferencing.

242
Q

Understand and be able to implement the stage-specific postdefinitive therapy surveillance required for lung cancer patients.

A

Stage I to II: history and physical examination (H&P) with chest CT every 6 months for 2 to 3 years, followed by annual H&P and noncontrast chest CT thereafter

Stage III to IV: H&P with chest CT every 3 to 6 months for 3 years, followed by H&P with chest CT every 6 months, followed by annual H&P and noncontrast chest CT thereafter

PET and brain MRI: not routinely recommended for surveillance

243
Q

What do you do if either PPO FEV1 or PPO DLCO is <30 percent?

A

If either PPO FEV1 or PPO DLCO is <30 percent, a formal cardiopulmonary exercise test can be performed with measurement of maximal oxygen consumption.

244
Q

What do you do for patients with either postoperative predictive (PPO) forced expiratory volume in one second (FEV1) or PPO diffusing capacity for carbon monoxide (DLCO) <60 percent predicted, but both >30 percent predicted?

A

a low technology exercise test (either stair climb or a shuttle walk test) should be performed

245
Q

What are some causes of transudative pleural effusions?

A

heart failure, liver failure, kidney failure

246
Q

What lymph nodes are an EBUS usually able to visualize?

A

EBUS is able to visualize superior and inferior mediastinal lymph nodes at stations 2R/2L, 4R/4L and 7, as well as stations 10, 11 and even 12.

247
Q

Explain V/Q ratio.

A
  • V - ventilation - air that gets to alveoli
  • Q - perfusion - blood that gets to alveoli
  • These two are main determinants of blood oxygenation
  • Can be measured by V/Q scan
  • Upright pt - apex has high V/Q ratio, base has low V/Q ratio
  • Low - asthma and pulmonary edema
  • High - PE (oxygenates, but no blood) and COPD
  • V/Q of 0 - loss of ventilation; ie shunting
248
Q

Pancoast tumor management

A
  • chemoradiotherapy
  • surgical excision if no distant mets or local progression (N2-3)
  • postop chemotherapy platinum based
  • if unresectable, definitive chemoradx and adj immunotherapy
  • RT can tx sx d/t Pancoast tumor

(UpToDate)

249
Q

Describe superior vena cava syndrome

A

PATH: caused by compression of SVC from malignant mediastinal masses; eg lymphoma or lung cancer, also TB and CV stenosis 2/2 catheters and pacemaker leads

PSX: swelling of head, neck, arms; headache and edema of conjunctiva; dysphagia and dyspnea

DX: CT chest or MR venography; Duplex can rule out thrombus

TX: malignancy - dx and do RT; secure airway if threatened; thrombus removal is individualized but all need heparin; stents may help long-term; SCLC gest systemic chemo

250
Q

Describe primary or idiopathic pulmonary hypertension management.

A
  • PSX: SoB and dizziness increasing in frequency and severity; widely split S2, peripheral edema and clubbing
  • 2/2: heart dz, lung dz, artery obsx, unclear and/or multifact mech
  • fluid retention - diurese
  • arterial obstruction - anticoagulation
  • hypoxemia - supplemental oxygen

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