CHEST

Question 1

Borders of Mediastinum

Answer 1

Superior: thoracic outlet Inferior: diaphragm Anterior: Sternum Posterior: anterior surface of vertebral bodies Intrathoracic compartment (extrapleural) located between pleural cavities

Question 2

Anterior mediastinum components

Answer 2

Thymus Adipose tissue Aorta Brachiocephalic vessels LN

Question 3

Middle mediastinum components

Answer 3

Heart Pericardium All major vessels entering and leaving the heart Trachea Main bronchi Paratracheal and tracheobronchial LN Phrenic and upper vagus nerves

Question 4

Posterior mediastinum components

Answer 4

Descending aorta Esophagus Thoracic duct Posterior mediastinal LN Paravertebral tissues

Question 5

Superior mediastinum

Answer 5

Lies above aortic arch Subdivided into anterior, middle, and posterior zones

Question 6

Common tumors of anterosuperior mediastinum

Answer 6

Goiter Aneurysm Parathyroid tumor Esophageal tumor Angiomatious tumor Teratoma Thymoma Pericardial cyst Lymphoma Morgagni hernia Lipoma

Question 7

Common tumors of the middle mediastinum

Answer 7

Lymphoma Lymph node hyperplasia Bronchogenic tumor Bronchogenic cyst

Question 8

Mediastinal Tumors

Answer 8

> 75% in adults are benign 50% malignant in children Three common: neurogenic tumor, thymoma, benign cyst

Question 9

Mediastinal tumors in children

Answer 9

Neurogenic tumors (most common) Lymphomas Cysts Germ cell tumors Mesenchymal tumors Thymomas (rare)

Question 10

Dx approach

Answer 10

Imaging: CT scan is best option Biopsy: FNA, mediastinoscopy, thoracoscopy, open Barium studies of GI tract Radioactive iodine uptake scan

Question 11

VATS as curative tx

Answer 11

Middle and posterior tumors Moderate sized (

Question 12

Median sternotomy incision as tx

Answer 12

Large (> 6cm) anterior tumors

Question 13

Thymoma

Answer 13

Most common neoplasm of the anterior mediastinum Associated with myasthenia gravis 40-60 yo

Question 14

Thymoma therapy

Answer 14

Aggressive surgical approach– VATS Remove entire tumor with capsule in one piece Open mediastinal procedure if not

Question 15

Germ cell tumors

Answer 15

Teratomas, seminomas, choriocarcinoma, embryonal cell carcinoma, endodermal sinus tumors Anterior mediastinum 20-40 yo Benign more common in women, malignant more common in men Majority in mediastinum are teratomas

Question 16

Teratoma

Answer 16

Majority are benign Unicystic or multicystic Two or three embryonic layers– teeth, skin, hair, cartilage, bone, bronchial, intestinal, or pancreatic tissue Usually found via compressive sx Dx established from CXR (although CT is ideal)

Question 17

Seminoma

Answer 17

Most common malignant germ cell tumor Men in 30s-40s Primary in the mediastinum and not metastatic from testes CT scan +/- compressive sx

Question 18

Superior vena cava syndrome

Answer 18

Obstructive sx Facial edema Flushing

Question 19

Tx: Seminoma

Answer 19

Radiation Chemo -Poor prognosis: > 35 yo, fever, SVC syndrome

Question 20

Bronchogenic and Enterogenous Cysts

Answer 20

Middle mediastinum near large airways Subcarinal area Commonly discovered early in life on screening CXR CT Needle biopsy (sometimes that’s the tx)

Question 21

Pleueropericardial Cysts

Answer 21

Cardiophrenic angle, right side Single layer of mesothelial cells Usually asx CT diagnostic Needle aspiration

Question 22

Neurogenic tumors

Answer 22

Posterior mediastinal masses Arise from nerve sheath or nerve itself Higher malignancy in children Benign in adults Common in those

Question 23

Nerve sheath tumors

Answer 23

Benign: neurilemoma, neurofibroma, melanotic schwannoma, granular cell tumor Malignant: neurofibrosarcoma

Question 24

Ganglion cell tumors

Answer 24

Benign: ganglioneuroma Malignant: ganglioneuroblastoma, neuroblastoma

Question 25

Paraganglionic cell tumors

Answer 25

Benign: chemodectoma, pheochromocytoma Malignant: malignant chemodectoma, malignant pheochromocytoma

Question 26

Lung Cancer: Stats

Answer 26

Leading cancer killer, second most frequently diagnosed cancer in US 28% of all cancer deaths 1 in 13 men, 1 in 16 women RF: cigarette smoking, secondhand smoke, radon gas

Question 27

Lung Cancer– Diagnostic evaluation

Answer 27

-Hx of primary tumor location -Hx of signs/sx of metastatic disease -Exam– pulmonary, nodes, skin, neuro, voice -Radiology for primary tumor: CT chest w/contrast, +/- PET scan -Radiology for metastatic disease: + bone scan, head MRI, abdominal CT -Tissue analysis to subtype primary tumor -Tissue analysis for metastatic disease

Question 28

Clinical presentation of lung cancer: Pulmonary sx

Answer 28

Cough Dyspnea Wheezing Hemoptysis Pneumonia

Question 29

Clinical presentation of lung cancer: nonpulmonary thoracic sx

Answer 29

Pleuritic pain Local chest wall pain Radicular chest pain Pancoast’s syndrome Hoarseness Swelling of head and arms

Question 30

Pancoast’s Syndrome

Answer 30

Tumors originating in superior sulcus Apical chest wall and/or shoulder pain Horner’s syndrome Radicular arm pain

Question 31

Phrenic nerve palsy

Answer 31

Tumors at the medial lung surface or anterior hilum can directly invade the nerve shoulder pain (referred), hiccups, and dyspnea with exertion because of diaphragm paralysis

Question 32

Recurrent laryngeal nerve palsy

Answer 32

commonly occurs on the left side, (hilar location of left RLN as it passes under aortic arch)

Question 33

Broad classification of lung cancer

Answer 33

Non-small cell lung carcinoma– large cell, squamous cell, adenocarcinoma Neuroendocrine tumors– neuroendocrine hyperplasia, neuroendocrine carcinoma (NEC, grade I-IV)

Question 34

Non-small cell lung carcinoma: Large cell

Answer 34

10-20% of Lung CA’s (central or peripheral), cell diameter of 30-50micrometers, can be confused with large-cell variant of neuroendocrine CA, differentiate with stains

Question 35

Non-small cell lung carcinoma: squamous cell

Answer 35

30-40% of Lung CA’s (Central: main/lobar/first segmental Bronchi), smokers, cough/hemoptysis/wheezing-obstruction/dyspnea/pneumonia

Question 36

Non-small cell lung carcinoma: adenocarcinoma

Answer 36

-Most common Lung CA (peripheral), asymptomatic until invasion into pleura or chest wall -30% male smokers, 40% female smokers, 80/60% in non-smoker M/F -Classified as: pre-invasive (in situ), minimally invasive, invasive, or variant

Question 37

Neuroendocrine tumors: Neuroendocrine carcinoma (NEC) Grades I and II

Answer 37

I: classic carcinoid; 80% central; young, hemoptysis/hemorrhage II: atypical carcinoid; peripheral; smokers, lymph mets 50%

Question 38

Neuroendocrine tumors: Neuroendocrine carcinoma (NEC) Grades III and IV

Answer 38

III: Large cell type; mid-peripheral; heavy smokers IV: small cell/oat cell; central, widespread mets; 25% of all lung CAs

Question 39

Types of resections for lung cancer

Answer 39

Wedge resection Segmentectomy Lobectomy Pneumonectomy

Question 40

Post-op management

Answer 40

Chest tube: continuous suction (-20 cm H2O), off suction (water seal), monitor output, monitor for resolution of air leak

Question 41

When to remove chest tube?

Answer 41

-Normal healthy person: less than 500 mL over 24 h -After VATS: drainage less than 400mL over 24 h -Malignant pleural effusion, pleural space infection, or inflammation or pleurodesis: less than 100-150 mL over 24 h

Question 42

How much fluid should we allow to drain?

Answer 42

Limit to 1500 mL initially (rapid drainage can cause SOB, clinical instability, and postexpansion pulmonary edema)

Question 43

Air leaks

Answer 43

common after pulmonary resection, fibrosis and destroyed blood supply impairs healing of surface injuries

Question 44

Prolonged Air Leak (Lasting > 5 days)

Answer 44

-treated by diminishing or discontinuing suction, by continuing chest drainage, or by instilling a pleurodesis agent (doxycycline or talcum powder) -Pleurodesis of the lung within the chest cavity - minimize the possible collapse of the lung due to persistent air leak

Question 45

Bronchopleural fistula

Answer 45

-if the leak is moderate to large -flexible bronchoscopy is performed to evaluate the bronchial stump -Management includes prolonged chest tube drainage, reoperation, and reclosure (with stump reinforcement with an intercostal muscle flap or a pedicled serratus muscle flap)