Esophagus, thoracic & Breast Flashcards
How far does the esophagus extend
Extend from the laryngopharynx to the cardiac offices of the stomach
What are the 4 divisions of the esophagus
Cervical
Upper thoracic
Middle thoracic
Lower thoracic
How are the divisions of the esophagus measured
Measure from the patient’s incisors
Describe the cervical esophagus
Starts roughly at C6-T2/3
18cm from incisors
Begins at cricoid cartilage to thoracic inlet at suprasternal notch
Where is the thoracic esophagus
Begins at the suprasternal notch and extends to the carina
24cm from incisors
Roughly 6cm long
Where is the middle thoracic esophagus
Begins at the carina and extends down to the EG junction of stomach
Roughly 32cm from incisions
Roughly 8cm long
Where is the lower thoracic esophagus
The abdominal esophagus
Roughly 8cm long
40cm from incisors
What’s is the esophagus’s location in reference to the trachea and vertebral column
Esophagus is posterior of the trachea and anterior of the vertebral column
What are the layers of the esophagus
Mucosa (innermost)
Muscularis mucosa
Sub-mucosa
Thin loose connective adventitia (no serosal) - outer most
Esophageal wall greater then ______ is considered abnormal
5mm
T/F
Esophageal cancer is 3 times greater in female than males
False
Esophageal cancer is 3 times greater in males than females due to drinking and smoking
Esophageal cancer that are found in the upper and middle thoracic is what type of cell (histology)
Squamous cell carcinoma
Esophageal cancer that are found in the distal 1/3 of the esophagus is what type of cance (histology)
Distal 1/3 esophagus is Adenocarcinoma
Why is esophageal cancer more common in Asia
More common found in asia due to diet
What is Barrette’s esophagus
Is commonly due to GERD
It’s a change in the distal esophagus from stratified squamous epithelium to columnar epithielium
Associated with Adenocarcinoma (distal 1/3 esophagus)
What is Achalasia
The lower 2/3 of the esophagus loses peristaltic activity
EG junction sphincter fails to relax and food fails to pass into the stomach
5-20 percent risk for squamous cell carcinoma
What s the EG Junction
Junction where the esophagus meets the stomach
When treating a patient with esophageal cancer, why might consider treating the patient in prone position?
So that gravity can pull the esophagus away from the spinal cord and other critical structures
What are the radiation treatment fields for esophageal cancer
AP/PA with posterior obliques with wedges or laterals
Come off the cord at 45Gy
Total of 50Gy; patient and stage dependent
The thyroid/thyroid cancer is cancer of what gland
Endocrine gland
Thyroid produces what kind of hormones
Several kind but the most common is T3 and T4 for metabolic regulations
What regulates thyroid function
Thyroid functions are regulated by the pituitary gland and hypothalamic hormones
What is TSH
It is a thyroid stimulating hormone (TSH)
TSH stimulates the thyroid cells to produce and releases hormones that are critical for carbohydrate and protein metabolism
Describe the location of the thyroid gland
It’s located inferior to the larynx at the level of the cricoid cartilage
Connected at the midline by the isthmus
Consist of right and left lobes (lateral lobes)
What and where are the parathyroid glands
Parathyroid glands are located on the posterior aspect of the thyroid lobes
It’s involved with the metabolism of calcium and phosphorus
What are examples of hyperthyroidism
Grave’s disease ( muscular weakness, abnormal weight loss, exophthalmos- bulgy eyes)
Goiter disease (enlarge thyroid gland caused by enlarged thyroid cells caused by overstimulation of TSH)
Thyroid cancer is the most common type of endocrine cancer. 2 percent of all cancer is papillary but ___________ is the most common
Mixed papillary follicular
What is the only documented factor that causes thyroid cancer
External radiation at a young age (multiple dental X-rays or some diagnostic X-rays)
What are the treatment type for thyroid cancer
Surgery
Radioactive iodine I-131 for papillary, mixed papillary follicular or follicular
XRT combined with I-131 and/or surgery (3DCRT or IMRT to include entire gland, neck and superior mediastinal nodes
XRT for grave’s disease
Use to treat the inflammation of the eye muscles due to hyperthyroidism to shrink the muscles
Using opposed fields
2000cGy (20Gy) for 2 weeks
What and where is the thymus gland
It is a triangular shaped bi-lobed gland of the lymph tissues and is located. In the superior mediastinal behind the sternum
What is the function of the thymus gland
Responsible for cellular immunity
Site for T-lymphocytes to mature
Produces Thymosin- responsible for the development/maturation of the lymphocytes
What happens to the thymus as one ages?
It’s reaches it maximum size during puberty
It diminishes as an adult and is replaced by mediastinal fat
What is the most common mediastinal tumor in adults and how is it treated
Thymoma
Usually with just surgery
May require chemo or XRT but treatment is based upon CT biopsy
What are the muscle associated with respiration
Inter costal
Serratus
Diaphragm
How does the intercostal muscles aid in respiration
Consist of 3 layers (external, internal, innermost)
The intercostal muscles help elevate the ribs and expand thoracic cavity
How does the serratus muscle aide in respiration
The serratus posterior SUPERIOR muscle assists in forced INSPIRATION. The serratus posterior INFERIOR muscle assist in forced EXPIRATION
How can you tell the difference between the serratus posterior superior muscle to the serratus posterior inferior muscle on a CT
SP Superior- no lungs visible
SP Inferior- lungs are visible
________ is the chief muscle of respiration
Diaphragm
What and where is the diaphragm
A dome shaped muscle spans entire thoracic outlet.
It separates thoracic and abdominal cavities
And is attached to the lumbar spine via the 2 tendinous structures (CRURA) or left and right crus
CT Scan of normal diaphragm shows the diaphragm is at the level of the _____
Xiphoid
What other muscle aid in the expansion of the thoracic cavity on deep inspiration besides the thoracic muscles
Pectoralis major
Pectoralis _______ connects the sternum and clavicle with the humerus while pectoralis ______ connects ribs 3-5 to the coracoid process of the scapula
Major- sternum and clavicle to humerus
Minor- ribs 3-5 to the coracoid process of scapula
The breast is a _____ gland that overlies on the _______ muscle
Breast is a mammary gland that overlies the pectoralis major muscle
The breast consist of how many quadrants
4 quadrants (Upper inner, upper outer, lower inner, lower outer) plus the Tail of Spence
Main function of the breast
To produce and store milk. Dispenses milk during breast feeding
What are the 3 layers of the Breast
Subcutaneous- skin and subcutaneous fat
Mammary- glandular tissue, lactiferous ducts and connective tissue
Retro-mammary- muscle, deep connective tissue and retromammary fat
An adult female breast is consisted with ____ lobes per breast
15-20 lobe per breast
An adult female breast consists of _______ lobules per breast
20-40 lobules per breast
The lobules drain into the _____ which leads the milk to the surface of the nipple
Ducts
The axillary lymph nodes drain lymphatics from __–
Breast, arm, and ski of back
The axillary lymph nodes frequently clustered around
The axillary vessels and the low portion of pectoralis major
The fat plane between the pectoralis major and minor houses the ______ lymph nodes
The interpectoral lymph nodes (Rotter’s nodes)
When breast cancer spreads, it is frequently spreads to heat lymph nodes
Axillary
Intermammary
Supra-clavicular
What is a PAB breast field
Posterior axillary boost field. It is a field posteriorly tha uses the same isocenter but the field is smaller to treat deep axillary nodes
How much dose is normally given to a supra-clavicular
45-50 Gy
How does DBH for breast help
The lung volume expands and this moves the heart posteriorly, away from the chest wall, so decreases does to the heart (especially the left ventricle) and even lung
How are sentinel lymph node identify
2 ways
Weak radioactive dye (technetium labeled sulfur colloid)
Blue dye (isosulfan blue)
_____ is the removal of the entire breast, nipple/areolar region, pectoralis major and minor and also all lymph nodes. It’s rarely performed today
Radical mastectomy
What is the difficulty a patient have encounter with radial mastectomy
Lymphedema to the arm and hand of the breast removal. This is due to no lymph nodes being available to drain fluids. No needle sticks or BP measurements can be done to that arm/hand
_____ is the most common form of mastectomy performed today
Modified radical mastectomy
______ is the removal of entire breast, nipple/areolar region and lymph nodes
Modified radical mastectomy
_____ is a wide excision. It’s the removal of breast cancer tumor and margin of normal tissue
Lumpectomy
How are breast implants placed
Sub-glandular placement
Sub-muscular placement
______ implant is positioned posteriorly to the pectoral muscles
Silicone implants
What is a TRAM flap technique
Transverse rectus abdominis musclocutaneous flap technique. It is the most common surgical procedure for autologous tissue breast reconstruction.
A ______ is an accumulation of fluid in a tissue or organ that can occur after surgery or sometimes after a nut trauma and some times requires aspiration (removal of fluid)
Seroma
_____ is a very aggressive breast cancer. It affects the lymphs and thickens the skin it is warm to the touch and will require a Bolus during XRT
Inflammatory breast
“Peau d’orange”
A pitted or dimpled appearance of the skin, like that of an orange especially a characteristic of inflammatory breast cancer.
______ is a 2cm or more subareolar tissue in a non-obese male. It’s not cancer. Instead is associated with prostate cancer. Amle will be given female hormones to help with the prostate cancer and hence lead to this.
Gynecomastia
How is gynecomastia treated
With low dose radiation to reduce swelling from the hormonal therapy. Normally treated with 3-5 fractions with electrons.
What are the level one lymph nodes
Anterior pectoral
Posterior sub scapular
Lateral humeral
What are the level 2 lymph nodes
Central
Some apical
Rotter’s
What are level 3 lymph nodes
Apical
