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SESATS > General Thoracic > Flashcards

General Thoracic Flashcards

1
Q

How long post Esophagectomy does it take for resoution of QOL

A

9 Months

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2
Q

time course of post esophagectomy strictures

A

Within the first 9 months

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3
Q

Major causes of reflux following esophagectomy:

A
  1. Anastomosis
    1. Location:
      • The severity of reflux after esophagectomy is, in part, related to the location of the anastomosis.
        • Severe reflux is associated with the low intrathoracic anastomosis created with a left thoracoabdominal approach;
        • less common with a cervical anastomosis.
  2. Vagotomy/Pyloroplasty:
    • Vagotomy is required for esophageal cancer resections, and inadequate pyloroplasty, incomplete pyloromyotomy, or denervation of the pylorus may cause functional gastric outlet obstruction.
    • Pyloric Drainage:
      • A meta-analysis of three randomized trials reported:
      • a significant benefit in favor of pyloric drainage versus no drainage in terms of early gastric outlet obstruction, which may contribute to early satiety.
      • In this review, delayed emptying was a difficulty for approximately one third of the patients who had no pyloric operation.
  3. Ivor-Lewis = Redundant Sigmoid Gastric conduit
    1. sigmoid gastric tube that may fall into the right costophrenic gutter with resulting delayed emptying.
  4. This problem is known to follow colon interposition as well, but it is rarely seen after transhiatal esophagectomy. However, obstruction of any of the conduit choices at the level of the hiatus is possible
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4
Q

Flail Chest:

  • What is the Determinant of the underlying pathophysiology:
A
  • Determinant of the underlying pathophysiology:
    • underlying pulmonary contusion
      *
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5
Q

Flail chest - what is the optimal treatment in the current era …

A

optimal treatment principles include:

  1. avoidance of fluid overload
  2. vigorous pulmonary toilet
  3. effective analgesia.
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6
Q

Small cell lung cancer linked to smoking?

A

Yes

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7
Q

Small cell lung cancer

what % of all lung cancers?

A

15-25%

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8
Q

90 year old patients with lymphoma presents with chest mass and biopsy below… appropriate step?

A

Likely extrapulmonary TB

PPD skin test next to see if active infection

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9
Q

Presentation of extrapulmonary TB

A

Painless “cold” abscesses

Should be suspicisous in patietns with immunocompramised or endemic areas

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10
Q

Chest wall osteocarcoma
typical associaiton ?

A

typically associated with:

  1. prior radiation
  2. chemotherapy
  3. Paget disease
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11
Q

Chest wall osteocarcoma
characteristic Radiology findings :

A

Radiology findings :
“Sunburst periosteal reaction”

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12
Q

Chest wall osteosarcoma

Characteristic Histology:

A

Malignant spindle cells
Mitoses
Excess ostoid

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13
Q

Chest wall osteocarcoma
% of primaiary chest wall tumors ?

A

overall osteosarcoma 10% of malignant primary chest wall tumors

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14
Q

Chest wall osteocarcoma
fraction that have metastais ?

A

1/3 have metastisis

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15
Q

Chest wall osteocarcoma
Rib and sternal lesions account for what percent of osteogenic sarcoma ?

A

Rib and sternal lesions account for only 5% of osteogenic sarcomas,

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16
Q

Chest wall osteocarcoma

Treatment?

A

Neoadjuvant protocols are typically recommended

  • efficacy of chemotherapy is frequently limited.
  • Aggressive 3-month regimens and their attendant toxicities are recommended for large and high-grade tumors.

complete resection with wide margins offers the best chance of cure

Radiation therapy is not routinely recommended, but it may help with pain management in palliative circumstances.

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17
Q

Prognosis of chest wall osteosarcoma

how does this compare with extremity osteosarcoma ?

A
  • Despite a multimodality approach osteosarcomas of ribs, sternum and thoracic spine have an overall 5-year survival less than 30%.
  • This compares to 65%-80% for extremity sarcomas, where neoadjuvant protocols and limb-sparing resection are goals
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18
Q

Chest wall tumors

what % are malignant ?

A

90% are malignant

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19
Q

Chest wall tumors

what are the most common malignant tumors?

A

Chest wall tumors

Most common malignant tumors are:

  1. chondrosarcoma
  2. Ewing sarcoma
  3. Osteosarcoma
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20
Q

Chest wall tumors

The most common benign tumors are:

A
  1. chondroma
  2. fibrous dysplasia
  3. osteochondroma
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21
Q

Chondroma

what is it ?

Epidemiology ?

Path?

Histo?

Management: ?

A

Chondroma: Benign chest wall lesion

Epidemiology :

  • 15% of benign rib tumors
  • occurs in the 2nd and 3rd decade of life

Path:

  • Gross: found at the costochondral junction
  • Histo:
    • difficult to differentiate from chroncdrosarcoma
    • lobules of hyaline cartilage

Management:

as a malignant lesion

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22
Q

CT of the chest

Rib lesion

expansile lesion with cortical thickening

Ground glass center

A

Fiberous dysplaisia

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23
Q

Osteochondroma:

A

occurs at the metaphysical area of the rib, bony stalk and cartilaginous cap

Occurs mainly in children and can undergo malignant transformation

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24
Q

Chondrosarcoma

what proportion of primairy malignant bone tumors

A

1/3

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25
Q

what is the most common primairy malignant bone tumor ?

A

Chondrosarcoma

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26
Q

Chondrosarcoma

Epidemiology

A

Most common malignant bone tumor

most common betwen 30-40 years old

M> F

may be assoaciated with history of trauma

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27
Q

Chondrosarcoma

treatment

5 year surival

predictors of survival

A

treatment is complete resection

65% five year survival

Predictors of survival : R0 ressection and the grade of the tumor

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28
Q

Ewing sarcoma

% of primairy malignant tumors of the chest

A

15%

29
Q

Ewing sarcoma

Gross Pathology

A
  1. flat bones
  2. midshart of the long bone
30
Q

Ewing sarcoma

Natural history

A

25% have Mets

70% will develop Mets during up-front chemotherapy

31
Q

Ewings sarcoma

treatment

A

chemotherapy followed by EBRT

surgery if residual tumor

32
Q

Ewings sarcoma

5-year survial

A

65%

33
Q

% of patients who devellop sarcoma forllowing radiation therapy ?

A

< 1%

34
Q

The mean latency after irridation for osteosarcoma

A

15 years, but may be as soon as 4 years

35
Q

Haller Index

A

Haller index:
It is the ratio of inner transverse diameter of the chest to the shortest distance between the vertebrae and the sternum (A/B in the figure = 4.4 in this example).
A normal index is 2.5, and a ratio greater than 3.25 is considered a severe pectus excavatum deformity.

36
Q

Pulmonary AVM

associated lesions

A

Up to 90% of patients with pulmonary AVM have: Hereditary hemorrhagic telangectasia (Osler-Webber-Rendu) syndrome

  • Conversely, only 50% of patients
37
Q

Blood supply to a pulmonary AVM

A

85% have a single feeding artery

38
Q

Sequale of pulmonary AVM

A

The natural history in untreated individuals entails substantial morbidity and mortality.

33% stroke
18% of a transient ischemic attack (TIA)
23% of a cerebral abscess
3% of hemothorax.

39
Q

Predictors of stroke in pulmonary AVM

A
  • Shovlin and colleagues found no correlation between any index of PAVM severity and the risk of brain complications.
  • the risk of ischemic stroke was associated with low mean pulmonary artery (PA) pressures.
40
Q

Treatment of pulmonary AVM

A

Embolization

41
Q

Comparison of presentation of ILS and ELS

A

Comparison of presentation:
Extralobar sequestration
typically present in infancy secondary to respiratory distress a sizeable, nonfunctional “accessory lung.”
ILS:

,a young adult patient with an intralobar BPS (the most common type) presents with recurrent infections.

42
Q

Concern with surgery for ILS

A

the abarent arterial supply must be addressed

43
Q

Vascular supply

  1. CCAM
  2. ILS
  3. ELS
A
  1. CCAM : Pulmonary
  2. ILS : Systemic
  3. ELS Systemic
44
Q

venous drainage

CCAM

ILS

ELS

A

CCAM : pulmonary

ILS : pulmonary

ELS Systemic

45
Q

laterality

CCAM

ILS

ELS

A

CCAM : 90% are unilateral , either side

ILS : 60% left

ELS : 90% left

46
Q

Gender predominance

CCAM

ILS

ELS

A

CCAM Male > Female

ILS Equal

ELS Male> Female

47
Q

laterality of Morgagni and Bochdaleck hernia

A

Morgagni hernias right-sided (>90%),
Bochdalek hernias are commonly left-sided (>90%).

48
Q

Bochdaleck hernia

frequency

A

1/5000

49
Q

Etiology of Bochdaleck hernia

A

Due to in uetro failure ofthe pleuro-peritoneal folds to join — >

Results in a left sided defect

50
Q

Presentation of Bochdaleck hernia

A

Adults – More common, and p/w poorly described pain

In utero – may result in pulmonary hypoplasia

51
Q

when should diaphragmatic hernia be ressected ?

A

repair should be considered beause of the potetial for intestinal obstruction or strangulation

Symptoms are not necessary to justify surgery.

52
Q

Bochdalek hernia

salient features of repair

A

Bochdalek: abdominal or transthoracic approach,
hernia sack must be ressected:

53
Q

Space of Larrey:

A
  • space through wich a Morgagni hernia is created.
  • between the xiphoid proscess and the distal body of the strum and the costochondral attachments of the diaphragm
  • trhough which the IMA passes
54
Q

Indicaiton for repair of a type III paraesophageal hernia

A

Type III paraesophageal hernia:
.
Due to the risk of incarceration of the non-sliding component, repair is advised in any patient with acceptable anesthetic risk.

55
Q

Lung Cancer Staging

Intrapulmonary Mets of the Same Lobe

A

T3

56
Q

Lung Cancer Staging

Intrapulmonary Mets - different lobe on the same side

A

T4

57
Q

Lung cancer staging

Mets to a contralatteral lung

A

M1a

Stage IV disese

58
Q

5 year survival for patient with mets within the same lobe

A

48%

59
Q

Radiation Therapy Oncology Group (R9309)

A

Stage III Lung Cancer:

after neoadjuvant therapy, patients operated for stage III lung cancer did poorly if they were not downstaged, had persistent multi-station disease, or if they required a pneumonectom

60
Q

Most common complication from Nissen fundoplication

what is the frequency

A

slippage of the wrap

a reported incidence of 0.7-20%.

61
Q

Lower esophageal Sphincter

Normal resting pressure and length

A

Normal resting pressure: 12-20mmHg

Normal Length of LES: 3-5 cm

62
Q

Dysfunctional LES

Resting pressure and length

A

LES

dysfunctional if the resting pressure < 6

dusfucntional if the length is < 2cm

63
Q

Treatment of patient with positive (PET and Biopsy) mediastinal lymphnodes (for lung cancer) and no parenchymal disease

A

by definition the patient is T3; therefore, the patient should be started on radiation chemotherapy

64
Q

8th Ed lung cancer Staging

T1c

A

Tumor > 2 cm but =< 3 cm

65
Q

8th Ed lung cancer Staging

Tumor involving the visceral pleurae

A

T2

66
Q

Gene mutations responsible for Critzotinib

A

ALK

ROS1

67
Q

Treatment of antenatal diagnosis of CCAM ?

A

most experts recommend:

resection of all cystic lesions in the first 10 months of life because of the risks of infection and malignant transformation.

68
Q

should be considered when unexplained dyspnea, pneumothorax, pleural effusion or infiltrative radiographic changes occurs in a woman of childbearing age.

A

I. Lymphangiomyomatosis (LAM)

SESATS (12 decks)

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