General Thoracic 2.0 Flashcards
Lower esophageal sphincter
Normal and abnormal resing pressure amplitude
LES:
Normal pressure : 12 - 20 mmHg
Abnormal < 6
LES - normal and abnormal length
Normal length is 3-5 cm
Abnormal is < 2cm
Components of the DeMeester Score (6)
Data to calculate the score
- Presence of time pH<4
- percent supine pH< 4
- percent upright pH< 4
- Number of reflux episodes
- Number of reflux episodes > 5 min in duration
- Longest reflux episode
Demeester Score consistent with Reflux
score is >14.7
percent time pH < 4 is > 4%
Length of the cervical esophagus
what does this mean for surgical options for esophageal cancer ?
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
Esohophageal anatomy
how far from the incisions to the thoracic inlet / sternal notch
20 CM
Esophogeal anatomy
how far from the incisors to the azygous Vein
25cm
Esophageal anatomy
How far from the incisors to inferior pulmonary vein
30 cm
Esophageal anatomy
How far from the incisors to the EGJ
40cm
Treatment of SCC of the cervical esophagus
Behave more like H&N cancers
Respond well to Radiation and Chemotherapy
pharyngolaryngoesophagectomy
would be needed for esophageal cancer of the cervical esophagus
Problems:
- deforming
- poor long-term outcomes
- poor QOL
General Defenition of Barrett’s esophagus
squamocolumnar junction is cephalad to the GE junction
Adaptive reponse to esophageal mucosal injury from gastric acid or bile reflux
Barretts is found in what percent of patient with GERD
6-12%
Histology of Barretts esophagus
Columnar mucosae (intestinal metaplasia)
Goblet cells
Progressive disorganization of cells and glands above the GE junction
What percent of Barrett’s esophagus progress to adenocarcinoma ?
How higher fold of a risk is it ?
1%
30-120 fold higher risk
what percent of Barrett’s esophagus will progress to some form of dysplasia ?
5-10%
What percent of Barrett’s esophagus progress to LGD
15-25%
Barrett’s esophagus - what percent of patients will progress to HGD
5-10%
Barrett’s Esophagus
Management of patients with metaplasia wtihout dysplaisa
Endoscopy every 2-3 years with 4 quadrant biopsies at 2 cm intervals
Management of Barrets esophagus with Low grade dysplasia
4 quadrant biopsies at every 2cm
Every 6 months for 1 year
then annually if still LGD
Managements of barrets esophagus found to have high grade dysplasia
Confirm diagnosis with repeat endoscopy and two separate pathologists
treatment of patients with high grade dysplasia
Flat and unifocal:
- may be treated with endoscopic techniques
Mutifocal ./ HGD with displasia associated lesion or masses (DALM) / long segments of dysplasia
- Esophagectomy
Varriants of HGD that are indications for Esophagectomy
- Mutifocal
- HGD with displasia associated lesion or masses (DALM)
- Long segments of dysplasia
Technic of PDT for Barrett’s esophagus
injection of photosentitizing ageng followed by tx with 630nm laser – causes ox rad dependent tissue necrosis
Complications of Photodynamic therapy
30% esophageal stricture rate
10% sunburn dysphagia
Key limitations of photodynamic therapy
Depth of penetration is limited to the submucosa
Invasive cancers are inadequately treated
RFA treatment of Barrett’s esophagus
Ablates the tumor to the level of the muscularis mucosa
Does not provide intact histology architechture
EGFR targeted drugs:
EGFR targeted drugs:
- Erotinib
- Afatinib
- Crizotinib
- Certinib
- Gefitinib
what Genes should be looked for in squamous cell lung cancer in non-smokers
EGFR and ALK
Lung cancer
Which patients should be offered up front surgery
Stage 1 and II
Lung Cancer
For which patients should one recieve adjuvant based chemotherapy:
Stage IIA and IIB
Lung cancer
TNM of patients who should get adjuvant chemotherapy
IIA : T1, T2a, N1 ; T2bN0
IIB: T2b N1, T3 N0
patients who should recive neoadjuvant radiochemotherapy
- IIIA (N2) positive lung cancer
- This is : T1-T2a N2 disease
- Best for non-bulky disease (<3cm)
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
Lung cancer
survival of patients who have recieved neoadjuvant therapy
5 year survival of lobectomy vs omm
- 5 year survival benefit to the lobectomy group vs OMM (36 vs 18%)
Eosinophilic esophagitis
Epidemiology
- Age
- Ethnic
- Typical Age at presentation:
- It can occur in all ages
- typically presents in the third or fourth decade.
-
Ethnic predisposition
- has predominance in non-Hispanic males
How to make the diagnosis of Eosinphilic Esophagitis
- Currently, the only reliable diagnostic method is endoscopy with biopsy, and sampling both the proximal and distal esophagus is recommended.
- Endoscopic findings include nonspecific inflammatory changes, and “rings” and/or “corrugations” are present in most patients (see figure).
Histologic diagnosis of eosinphilic esophagitis
- >= 15 eos /HPF in the squamous mucosa of the esophagus
- Biopsies of the mucosa of the gastric antrum or duodenum should *not* show similar findings.
Eosinophilic esophagitis
Rx
- Swallowed topical fluticasone or budesonide
- oral systemic prednisone
- dietary elimination of food antigens
number of lung segments
18
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.
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
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
esophagus with a ‘corkscrew’ appearance
Diffuse esophageal spasm
esophagus with a ‘rosary bead’ appearance
Diffuse esophageal spasm
Diffuse esophageal spasm
- Pathology/Pathophysiology :
Diffuse esophageal spasm
-
Pathology/Pathophysiology :
- Degenerative changes in the vagus
- Muscle hypertrophy
- Simultaneous contractions in the esophagus leading to a ‘corkscrew’ or ‘rosary bead’ appearance
- Epiphrenic diverticulum
Esophageal condition
clinical history related to anxiety or psychiatric disorders
Diffuse esophageal spasm
Diffuse esophageal spasm
- Presentation:
Diffuse esophageal spasm
-
Presentation:
- Substernal atypical pain
- Similar to anxiety and angina
- High association with psychiatric disorders
Diffuse esophageal spasm
Manometry
Manometry
LES: normal or hypertensive, normal relaxation
High amplitude esophageal contraction
Treatment of DES
-
Rx:
- Nitrates and CBB- tried for symptom relief but infrequent success
- Endoscopic botox to LES relieves dysphagia
- Long Esophageal myotomy – refractory cases
- Tarceva
- Erotinib (Tarceva) - EGFR blocker
What type of mutation is EGFR mutation when related to lung cancer
Driver mutation
What trials evaluated tarceva
Tarceva = Erolotinib = EGFR blocker
- BR-21
- EUROTAC
Br - 21
Trial evaluating tarceva (Erotonib)
Evaluated Erlotonib in NSCLCA
Erlotonib vs placebo
EUROTAC
Clinical trial evaluating Tarceva (Erolotonib)
Erotinib vs standard chemo
improved disease free survival
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
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
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.
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
Esophageal cancer
what stage are supraclavicular lymph nodes?
Supraclavicular nodes are M1
celiac nodes are considered regional
esophageal lung cancer
what station are celicac lymph nodes?
Supraclavicular nodes are M1
celiac nodes are considered regional
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
how long can it take for Myasthenia gravis symptoms to improve after thymectomy
up to two years
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.
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.
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.
