General Thoracic 3.0 Flashcards
2017 Lung Cancer Staging
T0 –
T0 – no primary tumor
T1a (mi) – Minimally invasive adenoma
T1a ss –superfical spreading in central airways (any size but confined to the tracheal or bronchial wall)
T1a Tumor =< 1cm
T1b tumor > 1 but =< 2 cm
T1c Tumor > 2 but =< 3cm
Lung Cancer 2017 Staging
T1a (mi) –
Lung Cancer 2017 Staging
T1a (mi) – Minimally invasive adenoma
Lung Cancer 2017 Staging
T1a ss
Lung Cancer 2017 Staging
T1a ss:
superfical spreading in central airways
(any size but confined to the tracheal or bronchial wall)
Lung Cancer 2017 Staging
T1a
Lung Cancer 2017 Staging
T1a Tumor =< 2cm
Lung Cancer 2017 Staging
T1b
tumor > 2, but =< 3cm
Lung Cancer 2017 Staging
T1c?
Tumor > 2 but =< 3cm
ACOSOG Z0050 trial
Trial purpose
Trial Conclusion
ACOSOG Z0050 trial (2011)
- Examined the utility of PET for staging patents with potentially operable NSCLC
- The authors concluded that their study validated that mediastinoscopy (prior to the widespread use of EBUS) is the gold standard for mediastinal staging when compared to the CT and/or PET interpretations.
- Therefore: N2 disease should be confirmed pathologically.
Specificty of PET for N2/N3 disease ?
ACOSOG Z0050 trial (2011)
PET for N2/N3
Specificity: 84%
PPV of PET for mediastinal lymph nodes
ACOSOG Z0050 trial (2011)
The PPV (positive predictive value) of PET in that study was only 56%.
Comparison of VATS vs. Thoracotomy
Mortality
No differences in mortality
Comparison of VATS vs. Thoracotomy
Respiratory issues:
Perioperative respiratory complications (12.2% vs. 7.6%, p=0.0001)
Comparison of VATS vs Thoracotomy
Atrial arrhythmia:
Comparison of VATS vs Thoracotomy
Atrial arrhythmia:
atrial arrhythmias (11.5% vs. 7.3%, p=0.0004) were higher in the thoracotomy group.
Comparison of VATS vs Thoracotomy
Lymph Node Status and Up Staging
Mediastinal and hilar lymph node staging
Mediastinal Lymph nodes
no difference in the number of mediastinal stations sampled or of upstaging of mediastinal nodes (5.0% with thoracotomy vs. 4.9% with VATS; p = 0.52).
Peribronchial lymph nodes
There was, however, a difference in the rates of hilar and peribronchial upstaging for N1 disease favoring thoracotomy (9.3% vs. 6.7%, p<0.001).
This was assumed to indicate variability in the completeness of hilar and peribronchial lymph node dissection during the VATS cases.
Cameron’s Ulcers
- Patients with a type III hernia may have an associated unexplained anemia.
-
Aetiology
- The blood loss is from the stomach moving up and down through the hernia ring leading to irritation of the gastric mucosa and subsequent bleeding. This may or may not be seen on endoscopy. These erosions are referred to as Cameron’s erosions or Cameron’s ulcers.
-
Epidemiology
- It occurs in 20%-30% of patients with large type III hernias.
-
Work up
- A full investigation of other sources of gastrointestinal blood loss is warranted. This usually involves a colonoscopy and CT scan to rule out other causes of bleeding.
Incidence of Cameron’s ulcer
-
Epidemiology
- It occurs in 20%-30% of patients with large type III hernias.
Quantification of AFB and B-HCG in young patient with anterior mediastinal mass
? how much is too high?
Any elevation of alpha-fetoprotein (αFP) and elevation of beta human chorionic gonadotropin(βhCG) elevation > 100 mIU/mL is diagnostic for a primary mediastinal nonseminomatous germ cell cancer.
IHC staining for germ cell tumors
ALK
- Eighty percent of seminomatous germ cell cancers stain positive for placental alkaline phosphatase, which is also diagnostic.
what is more comminon
Seminoma or non-seminoma
Seminoma
what has a better prognosis ? seminoma or non-seminoma
Seminoma - 5 year survival 80%
Non seminoma 50-60%
Most common malignant germ cell tumor in the mediastinum
Seminoma
###
A.Seminoma
1.Epidemiology
- Frequency of mediastinum
- Gender prevlance
- Age?
###
- Most common malignant germ cell tumor in the mediastinum
- Occurs almost exclusively in Males
- 30’s – 40s
###
Seminoma
Diagnosis
Lab and Imaging ?
###
a) Serum Tumor markers are slightly elevated.
b) CT: reveal characteristically large, homogenous math with smooth boaders
c) Eighty percent of seminomatous germ cell cancers stain positive for placental alkaline phosphatase, which is also diagnostic.
###
Seminoma
Treatment
- Radiation therapy: traditionally the primary treatment.
- Cisplatin-based chemotherapy is used for metastatic disease
- Surgical resection is reserved for any residual disease that is manifested as the local growth of a residual mass.
Non-seminomatous germ cell tumors
Epidemiology
Age and gender
###
A.Non-seminomatous germ cell tumors
Epidemiology
a)most often in young men 20 to 30 years old
###
Non-seminomatous germ cell tumors
pathologic subtypes
###
(1) yolk sac carcinoma
(2) embryonal carcinoma
(3) choriocarcinoma
###
Most common side effects to Cisplatin
The most common side effects of cisplatin are:
nausea and vomiting
arthralgias
nephrotoxicity
sensory polyneuropathy
electrolyte abnormalities
(hypomagnesemia, hypocalcemia, hypokalemia), ototoxicity,
anemia and leukopenia (usual onset after 10 days, with nadir between 14-23 days, and recovery after 21-39 days).
Bronchopleural Fistula
Epidemiology
- incidence of bronchopleural fistula (BPF)following pneumonectomy: 0.8% to 15%?
Bronchopleural Fistula
Epidemiology
- incidence of bronchopleural fistula (BPF)following pneumonectomy: 0.8% to 15%
*
Bronchopleural Fistula
Risk factors?
Pneumonectomy
Neoplastic disease
Right >> Left
neoadjuvant chemotherapy or radiation
hypoalbuminemia
long residual bronchial stump
more severe chronic obstructive lung disease
the need for postoperative mechanical ventilation.
B
CTA findings consistent with chronic pulmonary HTN
- A CT-determined main pulmonary artery diameter greater than 29 mm predicts PHTN with a sensitivity of 87% and specificity of 89%.
- The specificity reaches 100% if additionally an artery-to-bronchial ratio greater than 1:1 is found at the segmental level in at least three lobes.
Stages of BOS
1 - 3
Grade 1 BOS
10% reduction in FEV1
Lung biopsy results consistent with BOS
intraluminal fibromyxoid granulation tissue and submucosal eosinophilic infiltrates
You have sent a specimen after a lung biopsy. The fresh sample shows hyphae branching at right angles. The most likely diagnosis is
- mucormycosis
In Blunt chest trauma with fractured ribs what factors are predictive of morality ?
A. The adverse outcome for flail chest patients correlates with:
a) Injury Severity Score
b) Associated injuries.
In blunt chest trauma with fractured ribs: what impacts the length of stay (but not mortality)?
Length of Hospitalization (But not Mortality) is dependent on:
a) Age,
b) hemopneumothorax
c) mechanical support
In blunt chest trauma with fractured ribs,
what does Injury Severity Score correlate with?
Mortality
Recommendations for medical therapy for Mycobacterium Tb
- 2010 WHO recommendations:
a) 2HZRE/4HR
(1) 2 months of isoniazid (H) Pyrazinamide (Z), Rifmapin, Ethambutol (E)
(2) 4 months of Isoniazid and rifampin
(3) ethambutol is maintained in areas of high resistance
Ranking of disease on LAS
-
Rank of Favoring Diseases on LAS
-
Highest
- End-stage fibrotic lung disease
- (e.g., idiopathic pulmonary fibrosis-IPF, usual interstitial pneumonitis-UIP)
-
Middle:
- supportive lung disease (eg, CF, bronchiectasis)
- Least favored:
-
Highest
obstructive lung disease emphysema, alpha1 antitrypsin deficiency
highest ranked primary lung diseases in LAS
- Rank of Favoring Diseases on LAS
-
Highest
- End-stage fibrotic lung disease
- (e.g., idiopathic pulmonary fibrosis-IPF, usual interstitial pneumonitis-UIP)
2.
-
Highest
Middle ranked diseases on LAS
Middle:
supportive lung disease (eg, CF, bronchiectasis)
Least favored lung diseases in LAS
Least favored:
obstructive lung disease emphysema, alpha1 antitrypsin deficiency
Double vs single lung transplant for primary pulmonary htn
in older patients (>65 yrs) double lung transplantation has proven to be high risk, single lung transplantation for patients with moderate pulmonary hypertension (mean 35 mmHg) has equivalent outcomes.
Proximal Acinar Emphysema -
typical anatomic location
Proximal acinar emphysema (centrilobular) typically located in the upper airways
Proximal acinar emphysema
- with what is it associated (etiology)
Smoking
Inflammatory lung conditions
Pan acinar emphysema
typical anatomic location ?
typically located in the lower lung zones
Pan-acinar emphysema
with what disease states is it associated?
associated with
alpha-1-at deficiency
PI deficiency
Distal acinar emphysema
Sub pleural fibrosis
Nearly everyone will get
Study design of the NETT 2003 study
randomized patients into either
- OMM + Pulmonary rehab
- or*
- LVRS
Inclusion criteria in the NETT trial
-
Inclusion criteria:
- FEV1 < 45%
- Pt with FEV1<20% with either (a) homogeneous lung disease distribution or (b) DLCO < 20% were excluded
- pCO2 < 60 and PO2> 45
- 4 months of smoking cessation
- FEV1 < 45%
Exclusion criteria for the NETT trial
-
Exclusion criteria –
- Pt with FEV1<20% with either (a) homogeneous lung disease distribution or (b) DLCO < 20% were excluded
- PAH (mean > 35)
- O2 requirement > 6L
- Pulmonary nodule requiring surgery
NETT Trial results for
Upper lobe predominant
High Exercise capacity
No improvement in Survival
Improved QOL
NETT Trial Results
Upper Lobe predominant
Low exercise Capacity
50% decrease in 2 year mortality
NETT Trial Results
Lower Lobe predominant
High exercise capacity
2x increase in mortality
NETT Trial Results for
Lower Lobe predominant
Low exercise capacity
No improvement in survival
No improvement in QOL (although still better than OMM)
Nett trial criteria for low exercise capacity
Women < 25 Watts
Men < 40 Watts
How long should one be off of PPI’s and h2 blockers before having PH monitoring?
7 days off of PPI
48 hours off of H2 blocker
Thymoma Masaoka Stage I
Macroscopically encapsulated with no microscopically detectable capsular invasion
Thymoma Masaoka Stage II
Macroscopic invasion of the fatty tissue or Mediastinal pleura
or
Microscopic invasion into the capsule
Thymoma Masaoka Stage III
Macroscopic invasion of structures
(pericardium, great vessels, lung)
Thymoma Masaoka Stage IVA
Pleural or pericardial dissemination
Thymoma Masaoka Stage IVb
Lymphogenous or hematogenous spread
Epidemiology association between
- Lymphangiomyomatosis
and
- Tuberous sclerosis
- 1% of patients with LAM have tuberous sclerosis complex;
- 30-40% of adult women with tuberous sclerosis have LAM
Esophageal cancer- N- Stage
N0:
Esophageal cancer- N- Stage
N0: no lymph nodes
Esophageal cancer-N- Stage
N1:
Esophageal cancer-N- Stage
N1: 1 or 2 lymph nodes
Esophageal cancer- N- Stage
N2:
Esophageal cancer- N- Stage
N2: 3 to 6 lymph nodes
Esophageal cancer- N- Stage
N3:
Esophageal cancer- N- Stage
N3: 7 or more regional lymph nodes are involved
ZOO60 TRIAL
ZOO60 TRIAL To clarify the role of FDG-PET in staging potentially resectable esophageal cancer, Z0060 to determine if FDG-PET could detect metastatic lesions that would preclude esophageal resection in patients believed to be surgical candidates after standard imaging procedures.
- PET scan identified M1 disease in 4.8% of cases and N1 nodal disease in 31% of the patients.
- named packets of nodal material by the surgeon resulted in 16 ± 9 nodes per case, as opposed to 10 ± 8 nodes for routine processing by the pathology team (P <0.001).
Predictive values of lymph nodes
Recent analysis demonstrated that number of regional lymph nodes containing metastases (positive nodes)
- is the most important prognostic factor in resectable esophageal cancers.
- also predictive of distant metastases,
- survival of patients with 9 or more positive nodes is equivalent to that of patients with the distant metastatic disease.
iHC markers for squamous cell cencer
- IHC P40 (p63, CK 5/6)
IHC to ddx meso and andeno ca of the lung
- Calretinin, cytokeratin 6/5 (or WT-1): both + for mesothelioma and negative for adeno)
- CEA and MOC-31 (or BEP-EP4, BG-8): + for adeno and negative for meso
EGFR
Lung tumor associated
phenotype
Adenocarcinoma
typically in non-smoking asians
What is Ludwigs Angina ?
Necrotizing crevical myofascitis
thoracic surgical treatment of Ludwig Angina
Radical debridment .\
May require a sternotomy
