Locally Advanced Lung Cancer Flashcards

Question

Bronchoplastic procedure options for broncial/carinal involvement

Answer 1

* Broncial involement * sleeve lobectomy * bilobectomy * Carinal involvement * sleeve resection * carinal pneumonectomy

Answer 2

Sleeve loectomy: * Improved operative morbidity and mortality * Comparable local recurrence rates * Similar long-term survival rates

Answer 3

* Sleeve pneumonectomy

Answer 4

* Negative proximal and distal bronchial margins * Tension-free anastomosis * Wrapping/butressing of anastomosis * pericaridial flap * pleural flap * pedicled intercostal flap

Answer 5

Anastomotic dehiscence * Initiate abx and tube thoracostomy. * For dehiscence of 5 mm or less, simple chest tube drainage may be all that is needed, particularly if there was tissue coverage of the anastomosis and minimal air leakage. * For larger segments of dehiscence and those with smaller defects but ongoing significant air leak or pleural contamination, completion pneumonectomy should be considered. * Early dehiscence (not clearly defined but occurring in the early postoperative period) may be treated with debridement, additional mobilization of the remaining lung/hilum, and re-anastomosis with tissue coverage in select cases.

Answer 6

Anastomotic stricture ## Footnote Anastomotic strictures may occur late and can typically be treated with balloon dilation. In rare cases, debridement of the stricture may be required with techniques such as laser therapy.

Answer 7

* Right sided carinal pneumonectomy: right posterolateral thoracotomy * Left sided carinal pneumonectomy: * median sternotomy * open posterior pericardium btw SVC and ascending Ao * left thoracotomy * bilateral (clamshell thoractomy)

Answer 8

* preoperative mediastinoscopy (loosens tissue) * neck flexed position * intrapericardial release

Answer 9

* Same lobe (T3): lobectomy, followed by adjuvant chemotherapy. * Different lobes, same lung (T4): lobectomy (for larger nodule) sublobar resection (for smaller nodule), as lung function permits. * Surgical resection (if no N2 disease) * 40-50% 5-year survival (comparable to M1 disease)

Answer 10

1. Paulson-Shaw posterior thoracic inlet tumors 2. Dartevelle for tumors invading the subclavian vein or artery

Answer 11

* **Must reconstruct:** 1. Posterior defects below 4th rib 2. All anterior defects \> 5 cm 3. Resection of three or more ribs 4. Removal of two or more ribs with baseline pulmonary compromise 5. Resection of the manubrium 6. Resection of the entire sternum * Options include: * Biological acellular dermal substitute (e.g., Strattice, AlloDerm) - * PTFE (2 mm thickness, easy to handle) - * Prolene mesh alone - * Prolene with methylmethacrylate sandwich (rigid, but harder to handle/implant) - * Soft tissue flap with the help of plastic surgery (latissimus – for posterior/anterior locations, pectoralis/transverse rectus abdominis (TRAM) – for anterior locations only) may be necessary if the defect is very large or if there is local radionecrosis from neoadjuvant or prior radiotherapy.

Answer 12

One strategy to manage these patients is to perform mediastinoscopy followed by resection of the smaller nodule in if the mediastinoscopy is negative. * If the mediastinoscopy is positive, assume M1 disease (the mediastinal nodal disease means the disease is in transit and the contralateral lung nodule is more likely to be a metastasis rather than a primary) and treat with chemotherapy. * If mediastinoscopy is negative, treat as two synchronous primaries and resect the smaller nodule. A second stage operation involves resection of the larger nodule. The amount of lung resected will depend on the patient’s lung function and which lobes are involved.

Answer 13

Tumor involving the chest wall, pericardium, focal vertebral body involvement and focal SVC involvement may be resected en bloc by surgeons with appropriate experience. Most surgeons would consider aortic or esophageal invasion a contraindication to proceeding. Clips should be placed to guide future radiotherapy if margins are close.

Answer 14

The nerve should be resected en bloc with the specimen. The patient should then be considered for vocal cord medialization in the immediate postoperative period. Strict aspiration precautions should be considered for the immediate postoperative period.

Answer 15

Common indications for sleeve resection include: 1. Lesions involving main bronchi or lobar bronchi close to the main bronchi 2. Benign or low-grade tumors (carcinoid being the most common) 3. Bulky peribronchial lymph node involvement 4. Tumors in the lateral aspect of the lower trachea or carina

Answer 16

1. Locally advanced T4 tumors 2. Patients with N2 or N3 disease * Note: the exception is in cases of carcinoid tumor, given that chemotherapy and radiation tend to be ineffective. The authors advocate proceeding with carcinoid resections despite advanced nodal disease for greatest chance of cure and for optimal management of existing and/or expected airway obstruction symptoms) 3. Inability to achieve negative margins

Answer 17

1. Traveling a further distance between bites on the larger sized bronchus should fix small size mismatches. 2. alternatively, a longitudinal wedge can be cut from the larger bronchus to allow tapering and better size match. 3. Telescoping is an advanced technique that can be considered by those with experience.