General Thoracic Flashcards
How long post Esophagectomy does it take for resoution of QOL
9 Months
time course of post esophagectomy strictures
Within the first 9 months
Major causes of reflux following esophagectomy:
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Anastomosis
-
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.
- The severity of reflux after esophagectomy is, in part, related to the location of the anastomosis.
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Location:
-
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.
- Ivor-Lewis = Redundant Sigmoid Gastric conduit
- sigmoid gastric tube that may fall into the right costophrenic gutter with resulting delayed emptying.
- 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
Flail Chest:
- What is the Determinant of the underlying pathophysiology:
- Determinant of the underlying pathophysiology:
- underlying pulmonary contusion
*
- underlying pulmonary contusion
Flail chest - what is the optimal treatment in the current era …
optimal treatment principles include:
- avoidance of fluid overload
- vigorous pulmonary toilet
- effective analgesia.
Small cell lung cancer linked to smoking?
Yes
Small cell lung cancer
what % of all lung cancers?
15-25%
90 year old patients with lymphoma presents with chest mass and biopsy below… appropriate step?
Likely extrapulmonary TB
PPD skin test next to see if active infection
Presentation of extrapulmonary TB
Painless “cold” abscesses
Should be suspicisous in patietns with immunocompramised or endemic areas
Chest wall osteocarcoma
typical associaiton ?
typically associated with:
- prior radiation
- chemotherapy
- Paget disease
Chest wall osteocarcoma
characteristic Radiology findings :
Radiology findings :
“Sunburst periosteal reaction”
Chest wall osteosarcoma
Characteristic Histology:
Malignant spindle cells
Mitoses
Excess ostoid
Chest wall osteocarcoma
% of primaiary chest wall tumors ?
overall osteosarcoma 10% of malignant primary chest wall tumors
Chest wall osteocarcoma
fraction that have metastais ?
1/3 have metastisis
Chest wall osteocarcoma
Rib and sternal lesions account for what percent of osteogenic sarcoma ?
Rib and sternal lesions account for only 5% of osteogenic sarcomas,
Chest wall osteocarcoma
Treatment?
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.
Prognosis of chest wall osteosarcoma
how does this compare with extremity osteosarcoma ?
- 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
Chest wall tumors
what % are malignant ?
90% are malignant
Chest wall tumors
what are the most common malignant tumors?
Chest wall tumors
Most common malignant tumors are:
- chondrosarcoma
- Ewing sarcoma
- Osteosarcoma
Chest wall tumors
The most common benign tumors are:
- chondroma
- fibrous dysplasia
- osteochondroma
Chondroma
what is it ?
Epidemiology ?
Path?
Histo?
Management: ?
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
CT of the chest
Rib lesion
expansile lesion with cortical thickening
Ground glass center
Fiberous dysplaisia
Osteochondroma:
occurs at the metaphysical area of the rib, bony stalk and cartilaginous cap
Occurs mainly in children and can undergo malignant transformation
Chondrosarcoma
what proportion of primairy malignant bone tumors
1/3
what is the most common primairy malignant bone tumor ?
Chondrosarcoma
Chondrosarcoma
Epidemiology
Most common malignant bone tumor
most common betwen 30-40 years old
M> F
may be assoaciated with history of trauma
Chondrosarcoma
treatment
5 year surival
predictors of survival
treatment is complete resection
65% five year survival
Predictors of survival : R0 ressection and the grade of the tumor
Ewing sarcoma
% of primairy malignant tumors of the chest
15%
Ewing sarcoma
Gross Pathology
- flat bones
- midshart of the long bone
Ewing sarcoma
Natural history
25% have Mets
70% will develop Mets during up-front chemotherapy
Ewings sarcoma
treatment
chemotherapy followed by EBRT
surgery if residual tumor
Ewings sarcoma
5-year survial
65%
% of patients who devellop sarcoma forllowing radiation therapy ?
< 1%
The mean latency after irridation for osteosarcoma
15 years, but may be as soon as 4 years
Haller Index
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.
Pulmonary AVM
associated lesions
Up to 90% of patients with pulmonary AVM have: Hereditary hemorrhagic telangectasia (Osler-Webber-Rendu) syndrome
- Conversely, only 50% of patients
Blood supply to a pulmonary AVM
85% have a single feeding artery
Sequale of pulmonary AVM
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.
Predictors of stroke in pulmonary AVM
- 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.
Treatment of pulmonary AVM
Embolization
Comparison of presentation of ILS and ELS
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.
Concern with surgery for ILS
the abarent arterial supply must be addressed
Vascular supply
- CCAM
- ILS
- ELS
- CCAM : Pulmonary
- ILS : Systemic
- ELS Systemic
venous drainage
CCAM
ILS
ELS
CCAM : pulmonary
ILS : pulmonary
ELS Systemic
laterality
CCAM
ILS
ELS
CCAM : 90% are unilateral , either side
ILS : 60% left
ELS : 90% left
Gender predominance
CCAM
ILS
ELS
CCAM Male > Female
ILS Equal
ELS Male> Female
laterality of Morgagni and Bochdaleck hernia
Morgagni hernias right-sided (>90%),
Bochdalek hernias are commonly left-sided (>90%).
Bochdaleck hernia
frequency
1/5000
Etiology of Bochdaleck hernia
Due to in uetro failure ofthe pleuro-peritoneal folds to join — >
Results in a left sided defect
Presentation of Bochdaleck hernia
Adults – More common, and p/w poorly described pain
In utero – may result in pulmonary hypoplasia
when should diaphragmatic hernia be ressected ?
repair should be considered beause of the potetial for intestinal obstruction or strangulation
Symptoms are not necessary to justify surgery.
Bochdalek hernia
salient features of repair
Bochdalek: abdominal or transthoracic approach,
hernia sack must be ressected:
Space of Larrey:
- 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
Indicaiton for repair of a type III paraesophageal hernia
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.
Lung Cancer Staging
Intrapulmonary Mets of the Same Lobe
T3
Lung Cancer Staging
Intrapulmonary Mets - different lobe on the same side
T4
Lung cancer staging
Mets to a contralatteral lung
M1a
Stage IV disese
5 year survival for patient with mets within the same lobe
48%
Radiation Therapy Oncology Group (R9309)
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
Most common complication from Nissen fundoplication
what is the frequency
slippage of the wrap
a reported incidence of 0.7-20%.
Lower esophageal Sphincter
Normal resting pressure and length
Normal resting pressure: 12-20mmHg
Normal Length of LES: 3-5 cm
Dysfunctional LES
Resting pressure and length
LES
dysfunctional if the resting pressure < 6
dusfucntional if the length is < 2cm
Treatment of patient with positive (PET and Biopsy) mediastinal lymphnodes (for lung cancer) and no parenchymal disease
by definition the patient is T3; therefore, the patient should be started on radiation chemotherapy
8th Ed lung cancer Staging
T1c
Tumor > 2 cm but =< 3 cm
8th Ed lung cancer Staging
Tumor involving the visceral pleurae
T2
Gene mutations responsible for Critzotinib
ALK
ROS1
Treatment of antenatal diagnosis of CCAM ?
most experts recommend:
resection of all cystic lesions in the first 10 months of life because of the risks of infection and malignant transformation.
should be considered when unexplained dyspnea, pneumothorax, pleural effusion or infiltrative radiographic changes occurs in a woman of childbearing age.
I. Lymphangiomyomatosis (LAM)
