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SESATS > General Thoracic 2.0 > Flashcards

General Thoracic 2.0 Flashcards

1
Q

Lower esophageal sphincter

Normal and abnormal resing pressure amplitude

A

LES:

Normal pressure : 12 - 20 mmHg

Abnormal < 6

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2
Q

LES - normal and abnormal length

A

Normal length is 3-5 cm

Abnormal is < 2cm

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3
Q

Components of the DeMeester Score (6)

A

Data to calculate the score

  1. Presence of time pH<4
  2. percent supine pH< 4
  3. percent upright pH< 4
  4. Number of reflux episodes
  5. Number of reflux episodes > 5 min in duration
  6. Longest reflux episode
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4
Q

Demeester Score consistent with Reflux

A

score is >14.7
percent time pH < 4 is > 4%

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5
Q

Length of the cervical esophagus

what does this mean for surgical options for esophageal cancer ?

A

The cricopharyngeas is at 15cm from the incisors - the length of the cervial esophagus

For a tumor to be removed from here surgicall would require a pharyngolaryngoesophagectomy which high associated morbidity

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6
Q

Esohophageal anatomy

how far from the incisions to the thoracic inlet / sternal notch

A

20 CM

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7
Q

Esophogeal anatomy

how far from the incisors to the azygous Vein

A

25cm

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8
Q

Esophageal anatomy

How far from the incisors to inferior pulmonary vein

A

30 cm

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9
Q

Esophageal anatomy

How far from the incisors to the EGJ

A

40cm

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10
Q

Treatment of SCC of the cervical esophagus

A

Behave more like H&N cancers

Respond well to Radiation and Chemotherapy

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11
Q

pharyngolaryngoesophagectomy

A

would be needed for esophageal cancer of the cervical esophagus

Problems:

  • deforming
  • poor long-term outcomes
  • poor QOL
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12
Q

General Defenition of Barrett’s esophagus

A

squamocolumnar junction is cephalad to the GE junction
Adaptive reponse to esophageal mucosal injury from gastric acid or bile reflux

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13
Q

Barretts is found in what percent of patient with GERD

A

6-12%

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14
Q

Histology of Barretts esophagus

A

Columnar mucosae (intestinal metaplasia)

Goblet cells

Progressive disorganization of cells and glands above the GE junction

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15
Q

What percent of Barrett’s esophagus progress to adenocarcinoma ?

How higher fold of a risk is it ?

A

1%

30-120 fold higher risk

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16
Q

what percent of Barrett’s esophagus will progress to some form of dysplasia ?

A

5-10%

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17
Q

What percent of Barrett’s esophagus progress to LGD

A

15-25%

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18
Q

Barrett’s esophagus - what percent of patients will progress to HGD

A

5-10%

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19
Q

Barrett’s Esophagus

Management of patients with metaplasia wtihout dysplaisa

A

Endoscopy every 2-3 years with 4 quadrant biopsies at 2 cm intervals

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20
Q

Management of Barrets esophagus with Low grade dysplasia

A

4 quadrant biopsies at every 2cm

Every 6 months for 1 year

then annually if still LGD

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21
Q

Managements of barrets esophagus found to have high grade dysplasia

A

Confirm diagnosis with repeat endoscopy and two separate pathologists

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22
Q

treatment of patients with high grade dysplasia

A

Flat and unifocal:

  • may be treated with endoscopic techniques

Mutifocal ./ HGD with displasia associated lesion or masses (DALM) / long segments of dysplasia

  • Esophagectomy
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23
Q

Varriants of HGD that are indications for Esophagectomy

A
  • Mutifocal
  • HGD with displasia associated lesion or masses (DALM)
  • Long segments of dysplasia
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24
Q

Technic of PDT for Barrett’s esophagus

A

injection of photosentitizing ageng followed by tx with 630nm laser – causes ox rad dependent tissue necrosis

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25
Complications of Photodynamic therapy
30% esophageal stricture rate 10% sunburn dysphagia
26
Key limitations of photodynamic therapy
_Depth of penetration_ is limited to the **submucosa** **Invasive cancers** are inadequately treated
27
RFA treatment of Barrett's esophagus
Ablates the tumor to the level of the muscularis mucosa Does not provide intact histology architechture
28
_EGFR targeted drugs:_
_EGFR targeted drugs:_ * Erotinib * Afatinib * Crizotinib * Certinib * Gefitinib
29
what Genes should be looked for in squamous cell lung cancer in non-smokers
EGFR and ALK
30
Lung cancer Which patients should be offered up front surgery
Stage 1 and II
31
Lung Cancer For which patients should one recieve adjuvant based chemotherapy:
Stage IIA and IIB
32
Lung cancer TNM of patients who should get adjuvant chemotherapy
IIA : T1, T2a, N1 ; T2bN0 IIB: T2b N1, T3 N0
33
patients who should recive neoadjuvant radiochemotherapy
1. IIIA (N2) positive lung cancer * This is : T1-T2a N2 disease 2. Best for non-bulky disease (\<3cm)
34
**Lung cancer** Next step in treatment for patients who have recieved neoadjuvant chemotherapy ?
Patients in whom an *R0 ressection* can be performed with a **lobectomy** **Pneumonectomy** *does not* provide a survival advantage
35
Lung cancer survival of patients who have recieved neoadjuvant therapy 5 year survival of lobectomy vs omm
1. 5 year survival benefit to the lobectomy group vs OMM (36 vs 18%)
36
Eosinophilic esophagitis Epidemiology * Age * Ethnic
1. Typical **Age** at presentation: 1. It can occur in all ages 2. typically presents in the **third or fourth decade.** 2. **Ethnic** predisposition 1. has predominance in **non-Hispanic males**
37
How to make the diagnosis of Eosinphilic Esophagitis
1. Currently, the only reliable diagnostic method is endoscopy with biopsy, and sampling both the proximal and distal esophagus is recommended. 2. Endoscopic findings include nonspecific inflammatory changes, and "rings" and/or "corrugations" are present in most patients (see figure).
38
Histologic diagnosis of eosinphilic esophagitis
1. **\>= 15 eos /HPF in the _squamous_ mucosa** of the esophagus 2. Biopsies of the mucosa of the _gastric antrum or duodenum should ***not***_ show similar findings.
39
Eosinophilic esophagitis Rx
1. Swallowed topical fluticasone or budesonide 2. oral systemic prednisone 3. dietary elimination of food antigens
40
number of lung segments
18
41
Domperidone
_Domperidone_ Dopamine antagonist (can cause lactation) used outside theUS as a prokinetic pharmacotherapy for reflux. I augments muscle contractions in the esophagus, stomach, and intestines. Domperidone passes into breast milk in small amounts.
42
what causes a forshortened esophagus
Reflux with a reultant inflammatory reaction to the lamina propriata leads to a forshortened esophagus and may lead to a type III hernia
43
Esophagus; varriations of High Grade Dysplasia to consider in reccomending treatment
_Endoscopic_: * Flat and unifocal: _Esophagecomy_ : * Mutifocal . * HGD with displasia associated lesion or masses (**DALM**) * Long segments of dysplasia
44
esophagus with a ‘corkscrew’ appearance
Diffuse esophageal spasm
45
​esophagus with a ‘rosary bead’ appearance
Diffuse esophageal spasm
46
Diffuse esophageal spasm 1. _Pathology/Pathophysiology_ :
Diffuse esophageal spasm 1. _Pathology/Pathophysiology_ : 1. Degenerative changes in the vagus 2. Muscle hypertrophy 3. Simultaneous contractions in the esophagus leading to a ‘corkscrew’ or ‘rosary bead’ appearance 4. Epiphrenic diverticulum
47
Esophageal condition clinical history related to anxiety or psychiatric disorders
Diffuse esophageal spasm
48
Diffuse esophageal spasm 1. _Presentation_:
Diffuse esophageal spasm 1. _Presentation_: 1. Substernal atypical pain 2. Similar to anxiety and angina 3. High association with psychiatric disorders
49
Diffuse esophageal spasm Manometry
Manometry **LES**: normal or hypertensive, normal relaxation **High amplitude esophageal contraction**
50
Treatment of DES
1. _Rx_: 1. Nitrates and CBB- tried for symptom relief but infrequent success 2. Endoscopic botox to LES relieves dysphagia 3. Long Esophageal myotomy – refractory cases
51
* Tarceva
* **Erotinib** (Tarceva) - EGFR blocker
52
What type of mutation is EGFR mutation when related to lung cancer
Driver mutation
53
What trials evaluated tarceva
Tarceva = Erolotinib = EGFR blocker 1. BR-21 2. EUROTAC
54
Br - 21
_Trial evaluating tarceva (Erotonib)_ Evaluated Erlotonib in NSCLCA Erlotonib vs placebo
55
EUROTAC
Clinical trial evaluating Tarceva (Erolotonib) Erotinib vs standard chemo improved disease free survival
56
Iressa
* EGFR blocker * Gefitinib (Iressa) * Initially removed by FDA in 2003 for lack of efficacy * TRANSCOG – efficacy of Irressa in Esophageal Cancer * 2015 FDA approved it for the use of NSCLC
57
**Pseudoachalsia** what is it? consequently, what is the best diagnostic strategy ?
Pseudoachalsia Behaves like achalsia from a manometric findings, but there is no loss of the myenteric plexus. EUS with Bx is the best diagnostic modality
58
Esophageal cancer - sub types of T4 disease
* **T4a** tumors are _resectable_ cancers invading adjacent structures such as pleura, pericardium, or diaphragm. * **T4b** are _unresectable_ cancers invading other adjacent structures, such as aorta, vertebral body, or trachea.
59
Esophageal cancer - what is **_A regional lymph node_**:
**_A regional lymph node_**: has been redefined to include any paraesophageal lymph node extending between cervical nodes and celiac nodes. Supraclavicular nodes are M1 celiac nodes are considered regional
60
Esophageal cancer what stage are supraclavicular lymph nodes?
Supraclavicular nodes are M1 celiac nodes are considered regional
61
esophageal lung cancer what station are celicac lymph nodes?
Supraclavicular nodes are M1 ***celiac* nodes are considered _regional_**
62
Blunt chest trauma factors that impact mortality Factors that impact the length of stay
A. Adverse outcome for flail chest patients correlates with: a) Injury Severity Score b) Associated injuries. B. Length of Hospitalization (But not Mortality) is dependent on: a) Age, b) hemopneumothorax c) mechanical support ​
63
how long can it take for Myasthenia gravis symptoms to improve after thymectomy
up to two years
64
what type of myasthenia gravis tends to not improve after thymectomy
Some reports suggest that non-thymomatous myasthenia patients with antibodies to muscle-specific tyrosine kinase (MuSK) tend not to benefit from thymectomy.
65
Most common causes of idiopathic phrenic nerve paralysis and what does that mean for surgery?
Idiopathic phrenic nerve paralysis, possibly due to viral infection or associated with acute brachial plexus neuritis (neuralgic amyotrophy, Parsonage-Turner syndrome) tends to resolve over time. Surgery (diaphragm plication) should be delayed at least 18-24 months to allow for potential spontaneous resolution.
66
PFT improvements with diaphragm plication
Dynamic values tend to get better because aggregate diaphragm strength and muscle recruitment both improve. Residual volume, however, is not altered.

SESATS (12 decks)

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