Lung Cancer Flashcards
What neoplasm is associated with Eaton-Lamberts myasthenia crisis?
SCLC
Paraneoplastic syndromes associated with SCLC?
Eaton-Lamberts
Cushing’s (ectopic ACTH production)
SIADH
Neurologic syndromes (SCLC and Squamous)
Recurrent hypercalcemia after cancer resection. What’s going on?
PTHrp made by squamous cell cancer. Recurrent hyperCA = recurrent cancer
T stage for tumor that involves bronchus <2cm from carina
T3 (>2cm is T2, <2cm is T3). Involvement of carina is T4
T stage for tumor that invades pleura
T3 (includes invasion of chest wall, pericardium, phrenic)
T stage if 2 nodules in same lobe
separate Tumor nodules in same lobe is T3. satellite nodule in ipsilateral non-primary lobe is T4
Staging for contralateral lobe tumor?
M1
Tenets for determining tumor stage
All M1 –> Stage 4
N0 –> 1a (T1), 1b (T2), 2b (T3), 3a (T4); except T2b (4-5cm) is 2a
N1 –> 2b (T1, T2) or 3a (T3, T4)
N2 –> 3a (T1, T2) or 3b (T3, T4)
N3 –> 3b (T1, T2) or 3c (T3, T4)
When do you get invasive mediastinal staging?
Anything not T1 (>3cm) or anything with suspected mediastinal disease
(Nodes >1cm)
Any T3 lesion or central tumor needs routine mediastinoscopy
What is the sump node exception?
LUL cancer drains to 5 and 6, so can resect in this situation (despite N2)
What is the basic lung nodule workup?
Basic labs
PFTs
CT IV contrast and thin cuts
PET
Head CT Or MRb if Stage II or greater
EKG
Stress test to assess for operative suitability
Workup for SOLID incidental nodule:
<6mm: (nothing if low risk, 12 mo stability scan If high risk)
6-8mm: CT 6-12mo; if stable rpt scan at 18-24
> 8mm: CT 3mo vs PET vs bx
Pre-operative studies to order for Pancoast tumor?
After confirmed on biopsy for tissue diagnosis:
1. PET/CT
2. Brain MR
3. EBUS/Mediastinoscopy
4. MR chest to assess for brachial nerve/foramenal involvement
5. PFTs
6. Stress Test
Initial therapy for Pancoast tumor
Induction chemoradiation (cisplatin/etoposide + 45Gy, concurrent for 3 cycles)
60Gy radiation is tx for unresectable Pancoast
Which nerve roots can you resect for Pancoast tumors?
T1 nerve root (No residual motor deficit, some numbness/weakness of intrinsic hand muscles)
C8 nerve root resection will leave motor dysfunction (can partially overcome with PT)
Contraindications to resection of Pancoast tumors?
- N2 or N3 disease
- Extensive vascular invasion
- Brachial plexus involvement more extensive than C8-T1
- Transverse process involvement (T4) is resectable but vertebral body involvement (T4) is unresectable
Suspected diagnosis and treatment of headache after pancoast tumor resection?
Suspect CSF leak
Tx: bedrest, antibiotics, CT myelogram (air in ventricles also diagnostic)
If leak, treat with spinal drain and chest tube. If persists, then thoracotomy and intercostal muscle flap and chest tube. If dural tear, NSGY for dural patch
Surgical approach to carina
R chest or median sternotomy w/ transpericardial approach
Suspicion in post-pneumonectomy patient with wet cough post-op?
BPF, confirm with CXR showing air-fluid level
then place chest tube and OR for evaluation and repair
Operative treatment for fresh post-op BPF?
bronch to evaluate stump. reopen thoractomy. If small dehiscence → direct repair
If large dehiscence → trim and reclose bronchus
Cover stump with well-vascularized pedicel (pectoralis flap, serratus, or omentum). If stump too short, suture flap circumferentially around defect
Place 2 chest tubes for irrigation and close (daily antibiotic irrigation and daily pleural fluid cultures post-op until negative)
Options for post-pneumonectomy empyema? (3)
Systemic abx and chest tube drainage. Bronchoscopy to determine size and location of defect
- Claggett: open pleural drainage/pack, obliteration of cavity (once granulation tissue formed) with debridement antibiotic solution and close
- If won’t tolerate muscle flap, can do Eloesser flap: upside down U at level of cavity, marsupialize flap, pack
- If even worse, definitive reduction is thoracoplasty (rib resections to collapse chest wall)
Questions to ask when suspicious for lung cancer?
Risk:age, smoking history, h/o previous cancer, exposure, travel history, common cancer screening results
Lung sx: unremitting cough, chest pain, hemoptysis, dyspnea/stridor
Consitutional: fever/chills, weight loss, fatigue
CNS: headache, n/v, mental status changes
Physical exam: diminsted breath sounds, lmited chest wall excuriosn, LAD, clubbing, ypertrophic osteoarthropathy
Describe a Chamberlain procedure:
prep chest from chin to umbilicus. Small transverse incision in 2nd ICS just lateral to edge of sternum. Remove costochondral cartilage with rongeur
Retract or transect IMA
Retract pleura laterally to explose mediastinum ad PA nodes
Place mediastinoscope for visualization. Biopsy nodes with forceps and confirm adequate sampling with frozen section analysis
How would you approach tumor invading SVC?
T3. resect and primary repair if 30% involved, patch repair if 50% involved, resection and spiral vein or 12mm Gore Tex tube if unrepairable
How do you approach solitary brain met?
resect brain lesion first to decrease risk of neurologic compromise over time. If lung tumor symptomatic or bleeding, then resect lung first. 10-30% 5 year survival
What features suggest a lesion is a metastatic lesion from other primary?
well-circumscribed, spherical, sub-pleural, or multiple lesions
Work-up for metastatectomy?
PET (moderately accurate for RCC) to rule-out extrapulmonary disease PFTs
Include Brian MR if propensity for brain mets (breast cancer, melanoma)
Describe a wedge resection?
- Double-lumen ETT and lateral decubitous position
- Place camera port at 8th interspace along anterior axillary line
- Introduce camera to ensure lung isolation, place 2 working ports along posterior axillary line and one anteriorly
- Examine visceral and parietal pleura for lesiosn
- Identify lesion, retract with ringed clamp, staple with Endo-GIA blue load 45mm stapler with at least 1cm margins
- Extract using bag to prevent trocar site seeding
Consideration for pulmonary metastatectomy for primary head and neck cancer?
Susceptible to lung primaries and histology is difficult to distinguish
Tumors occurring >2 years from primary should be considered a new lung primary requiring anatomic resection
Consideration for pulmonary metastatectomy for primary renal cell cancer?
Limited sensitivity to systemic chemo and therefore are often considered for aggressive resection
Simple Lung Cancer Staging
for N0/N1/N2/N3
T1: 1A, 2B, 3A, 3B
T2: 1B, 2B, 3A, 3B (except the 2a for T2 4-5cm)
T3: 2B, 3A, 3B, 3C
T4: 3A, 3A, 3B, 3C
Immunologics for ALK and EGFR mutations
- Immune therapy should not be used if EGFR or ALK mutation
ALK+: alectinib, brigatinib are first line (crizotinib also an option)
EFGR+: Osimertinib is first-line, erlotinib (“Tarceva”)
ALK-/EFGR- (or unknown or treatment failure with above regimen:
cisplatin-based doublet +/- bevacizumab (“Avastin”)
For metastatic double negative tumors → bevacizumab + atezolizumab + carboplatin + paclitaxe
What do you do if work-up for lung metastatectomy has extrapulmonary disease on PET
Must biopsy to prove extra-pulmonary disease prior to ruling patient out for lung resection
Indications for rib plating
- 3 or more acutely displaced rib fractures
- flail segment
- failure of optimal medical management
- thoracic surgery for diff reason
How do you calculate a Haller Index? what is significant?
Distance from inner surface of lateral ribs / distance from posterior sternal table to anterior vertebral body at point of maximal depression
> 3.25-3.5 is significant and indication for repair
How long do you leave Nuss bars in?
2 years in younger patients
>3 years for adults (greater recurrence rates)
Operation of choice for penetrating lung injury??
Pulmonary tractotomy
- place linear end of GIA stapler through tract and divide to surface of lung. Now can repair exposed and injured vessels/airway/parenchyma
Presentation and management of solitary fibrous tumor?
-Has malignant potential
- broad based sessile parietal pleural lesion or stalk based visceral pleural lesion
- need resection to neg margin
- may recur many years later, so need yearly surveillance CT
- strongest predictor of metastatic potential is >4 mitoses/10HPF
- systemic therapy if systemic disease (no indication for adjuvant therapy)
How to manage ground glass tumor?
no rush to resect if no solid component (low risk of nodal/metastatic spread) - monitor until grows over time or 8-10 mm
when resect - wedge positioned to make resection possible
if part-solid, resect when solid component 5mm or 1/2 size of part solid nodule
Role of ADA in tuberculous effusions?
correlates with mycobacerial burden
ADA needed for lymphocytes to work
may also be elevated in empyema, rheumatoid, lymphomatous effusions
confirm TB with thoracoscopic pleural bx (80% yield on histopath)
no need to drain effusions for TB - selectively drain based on sx
How much of PA can you resect during lobectomy?
25%. Anything greater needs sleeve with end-to-end reconstruction or tangential pericardial patch reconstruction
to retain flow and avoid thrombosis
Treatment of pancoast tumor?
Induction chemoradiation
Surgery via posteriolateral thoractomy or anteriro dartevelle approach
lobectomy with hilar/mediastinla lymphadenectomy (NOT wedge)
subclavian artery resection/reconstruction if involved
Pt going for LVRS with bad COPD codes on induction? High index of suspicion for?
Auto-PEEP (hyperinflation/lung trapping –> prevent venous return)
disconnect ETT from vent, pressure should return in 30-60 seconds. then can try vent a lower pressure and longer expiraotry time
Criteria for LVRS?
FEV1 20-45% predicted
DLCO > 20 % predicted
6 min walk >140m
No smoking 4 months
Sucessful completion of pulmonary rehab
No limiting cardiac risk or sig pHTN
Criteria for lung transplant for COPD?
- FEV1 <20% predicted
- DLCO < 20% predicted or homogenous emphysema
- BODE (body mass, airflow obstruction, dyspnea, exercise intolerance) score >7
- Hospitalization for exacerbation with hypercapnea (pCO2>50)
- Pulmonary HTN
Rate of nodal spread for T1 esophageal cancer?
<5%, this is why surgery is appropriate (can follow with chemo when appropriate)
For nodal involvement, chemoradiation alone has same survival as surgery alone. Surgery just offers better sx palliation
Rate of nodal spread for T3 esophageal cancer?
50%
Prefer neoadjuvant chemoradiation then surgery in T3 or known nodal disease but only local regional extent (40-60% survival with combined tx vs 15-18% with CRT alone)
What is pembrolizumab? What study showed its effects and when is it recommended?
PD-1 inhibitor (monoclonal antibody)
KEYNOTE 024 - pts with advanced NSCLC and PDL1>50% had prolonged overall and progression free survival with pembrolizumab. Also fewer adverse events than platinum based chemo.
Pembro is standard of care first-line for metastatic NSCLC with PD-L1 >50%
First steps in dx/tx for venous TOS?
Dx: initial diagnosis with US followed by venography to delineate venous anaatomy
Tx: thrombolysis and initial AC, then early first rib resection (with at least 3 mo AC postop)
Treatment of stage IV lung adeno with EGFR mutation?
tyrosine kinas inihbitor (erlotinib, gefitinib, etc) with no chemotherapy
Standard of care to treat completely resected stage II and stage III adeno with platninum based chemo
TKIs lose effectiveness after 1-2 years of therapy, so more beneficial to save in case later metastasis
What is crizotinib? (what gene does it work on)
ALK inhibitor
Trauma pt with ptx. Place chest tube and huge airleak. Next step?
Suspect disruption of bronchial tree. Flexible bronch to determine presence and location of injury and possible reposition ETT in other mainstem. Semi-elective repair after evaluating other trauma injuries
R thoracotomy - distal trahceal, carina, either prox mainstem
L thoracotomy - distal L mainstem, left lung lobar injuries
How to evaluate barrett’s seen on endoscopy?
Seattle protocol:
forceps biopsies in each quadrant every centimeter from EGJ to level of normal squamous mucosa
Also bx any suspiciious iregular or raised areas
EGD for HGD or very superficial cancer within barrett’s segment but ONLY after establishing diagnosis and identifying areas of specific concern
Treatment for T1c squamous that path now shows 2 positive peribronchial lymph nodes but neg mediastinal nodes
platinum-based adjuvant chemo (due to peribronchial lymph nodes) T1cN1M0
Most reliable landmark for EGJ?
proximal extent of gastric rugal folds
How to treat infected pleural catheter for malignant effusion
Abx (average 3 weeks); don’t need to remove/replace catheter
How does a hamartoma appear on XR? When to operate?
lobulated nodule with “popcorn” calcifications and fat density
follow if asx
resect if growing at rate that may cause sx in near future by involvement of contiguous structures
What tumors are associated with synaptophysin and chromogranin expression?
Neuroendocrine tumors (typical/atypical carcinoid, small cell, large cell)
take clinical hx into account. suspect small cell if smoking hx
Mgmt of HGD vs T1a vs T1b esophageal cancer?
HGD -> RFA
If nodular areas, must EMR these bc 40% will have invasive cancer depsite bx with HGD
T1a -> EMR with RFA of remaining barretts (low risk of nodal spread)
T1b –> (21-24% risk of nodal spread), esophagectomy
What trials support lytics?
MIST1 - streptokinase did not decrease need for surgery
MIST2 - DNase alone caused greater need for surgery; TPA + DNAse reduced need for surgery and hospital LOS
Primary tx for schwannoma?
Firm/well encapsulated. 5% neural sheath tumors are malignant. Surgically completely resect all. Usually benign and rarely recur (rarely ever need adjuvant therapy)
Radiation and chemo doesn’t work on neurogenic tumors
Must get MR to assess tumor extension into neural foramina
Management of esophageal submucosal lesion?
Most are leiomyoma. Observe asymptomatic ones. Enucleation for symptomatic ones. Can FNA bx symptomattic larger marginally resectable/unresectable ones.
How would you surgically approach distal esophgeal leiomyoma?
Can reach from chest but usually easier/less pain for pt via abdomen
When can you use Endoscopic submucosal dissection for leiomyoma?
if small <2cm, subepithelial lesion
At how much narrowing in tracheal stenosis do pts experience sx?
50-74% narrowing before dyspnea/wheezing
8mm = DOE
5mm = dyspnea at rest
Options for ventilation for trachea-obstructing tumor
Laryngeal mask airway
jet ventilation
Heliox
Flexible/rigid bronch
ETT various sizes
Tracheostomy
ECMO
Chemo vs radiation for tracheal ACC?
Adjuvant radiation for R1 resection
Best chemo regimen not identified yet; for metastatic progressive ACC, can use cytotoxic chemo
How to treat PTLD? When does it occur?
Most common malignancy in first year post-txp. associated with EBV
More common after lung txp. Higher risk if EBV neg recipient (should get ganciclovir)
Pulmonary/intrathoracic disease more common first year after txp with extrathoracic presentations later
Early lesions - polyclonal B cell proliferation –> lower immunosuppression, resolve 3-5 weeks
If can’t reduce immunosuppression or CD20+, give rituximab
Chemo (cyclophophamide, doxorubicin, vincristine, prednisone) if refractory of CD20-/EBV-
Radiation for localized disease/CNS involvment. Surgery also possible if localized
4 types: early, Polymorphic, monomorphic, classic Hodgkin’s lymphoma-type
Lung txp indications for CF?
FEV1<30% or rapid decline
Exacerbation requiring ICU stay
Inc freq of exacerbations
Recurrent/refractory ptx
Inc O2 req
Hypercapnea
Pulm HTN
No Burkholderia Cepacia allowed
Strongest predictor of surviial for chest wall osteosarcoma?
Tumor biology/grade
Treatment of “fluid filled mediastinal mass abutting esophagus” at level of inferior pulm vein?
Esophageal duplication cyst (pericardial or bronchogenic cyst also on differential)
Surgically resect
don’t drain (infection risk) or marsupialize (recurrence risk)
Appearance of esosinophilic esophagitis on EGD and tx?
dx: >40 eosinophils/hpf, typically will see rings and furrowing on egd
Tx: PPIs and topical steroids (swallow, then wash out mouth to prevent oral candidiasis), serial dilations if fibrosis/narrowing
How would you treat cT3N2+ squamous esophageal cancer
definitive concurrent chemoradiation (can aslo do surgery after, but recent european trials show no benefit to adding surgery)
(for T3N2 adeno, must do surgery after)
systemic therpay for stage IV
Pt with new pleural met after thymoma resection 2 year ago? what if can’t tolerate surgery?
Surgical resection is mainstay of treatment
if can’t tolerate, sterotactic ablative therapy
Suspect mallory weiss tear and see mucosal tear. what do you do?
thin contrast esopahgram to r/o full thickness tear
no role for stent; maybe role for clips but only after r/o full. thickness tear
Treatment for aspergilloma?
Surgical resection; has high morbidity/mortality
Must make sure neg for TB first (esp if didn’t finish all 9 months of RIPE). Get AFP, cultures, TB PCR
Large pleural based mass in pt with hypoglycemia. What do you suspect?
Doege-Potter Syndome
Solitary fibrous tumor, secrete insulin-like growth factor 2
resect with wedge of lung
Pt present with occasional diplopia and you see ptosis on exam? Dx and workup?
myasthenia gravis
Confirm with autoantibodies against ACh receptor or muscle-specific tyrosine kinase; can also confirm with electrodiagnostic tests
must get CT bc 15% have thymoma
Treatment of functional heartburn?
TCA, SSRIs, SNRIs, trazodone, also 5-HT3 antagonists/5HT4 agonists
treatment for obese pt with significant reflux?
Roux-en-Y
Nonseminomatous tumor s/p chemo with residual mass. What do you do?
Surgically resect mass - may harbor malignancy
regardless of tumor marker high vs low
don’t do salvage chemo or radiation
Strongest risk factors for development of esophageal adenocarcinoma?
Male sex (6x more likely)
Advanced Age
Also obesity, GERD, tobacco useE
Esophageal adeno that is HER2 positive. What do you do before surgery?
Combined chemo and radiation
Trastuzumab is not approved yet for perioperative tx
Screening intervals for Barrett’s esophagus per American Gastroenterology Association?
No dysplasia: 3-5 years
LGD: 6-12 mo
HGD without therapy: 3 months
Describe TNM staging for thymic malignancies?
T1 - no invasion
T2 - invades pericardium
T3 - invades adjacent resectable structures (lung, innominate vein, SVC, phrenic)
T4 - invades nonresectable structures
N1 - anterior perithymic lymph nodes
N2 - nodes outside perithymic area (cervical/supraclvicular)
Young man, large mediastinal mass, elevated tumor markers. next step?
nonseminomatous
chemo (cisplatin, etoposide, and bleomycin/ifosfamide)
surgery for residual mass
Progressive dysphagia for years with bx findings of hyperkeratosis, acanthosis, parakeratosis. tx?
verrucous carcinoma
esophagectomy
if locally advanced/invasion into adjacent structures, combined chemo and radiation
What genes are implicated in esophageal adeno?
KRAS, ERBB2, EGFR, SMAD4, VEGFA
What genes are implicated in esophageal squamous cell cancer?
PTEN, FGFR1, RB1, NOTCH1
Most common source for descending mediastinitis?
Odontogenic infection (used to be phargyneal infection before abx era)
How to decide transcervical vs transthoracic drainage for mediastinitis?
If infection extends below level of carina or if pleural space involved, then both
If not, transcervical but early monitoring/reimaging to assess extent of drainage
Treatment of fibrosing mediastinitis?
Usually related to prior histoplasma
Tx palliative when begin to develop sx. No surgery. Endovascular stent placement if needed
idiopathic immune variant can be treated with glucocoriticoids (combats infiltration fo IgG4 plasma cells)
Same treatment for benign or fibrotic SVC syndrome
How do you prevent air embolus during lung transplant?
Must adequately de-air left atrium while in trendelenbug position before removing atrial clamp
Partially inflate lung prior to reperfusion to aid with perfusion/de-airing
Pt presents with symptomatic pleural efffusion and RUL adeno EGFR+. On thoracocopy, pleural mets.What do you do?
pleurodesis for sx relief and osimertinib
What trial validated osimertinib and when is osimertinib used?
FLAURA trial
Better progression-free survival in EGFR+ Stage IV cancer than earlier generation drugs and than standard chemo
Osimertinib (3rd gen TKI) is first line Stage IV adeno with EGFR mutation
Alternative to surgery for lung cancer?
Stereotactic ablative radiation is alternative for pts who are inoperable (if clinically node neg, and tumor up to 5cm)
very high rate of radiation pneumonitis 30-50% and 6% mortality in ILD pts
Which lung adeno subtypes have worst prognosis?
Micropapillary and solid have highest rates of local/nodal recurrence after sublobar resection
2.1 cm peripheral small cell lung tumor with no nodes/distant mets on imaging. Tx?
Must do mediastinal staging with EBUS or mediastinocopy
then surgery - full lobectomy and adjuvant systemic/radiation usually indicated
Definition of minimially invasive lung adenocarcinoma on path?
Less than or equal to 5mm invasive component (solid component on imaging)
Stage II lung adeno tx?
surgery then adjuvant radiation
When do you do definitive chemo/rad for cancer?
definitive chemo/rads followed by immune checkpoint inhibitor for inoperaable IIIA and IIIB
Loss of tidal volumes during dissection in trashiatal esophagectomy. What do you do?
if volumes maintained and ventilation/oxygenation adequate - may be able to complete dissection
if minor loss in volumes - pack to see if stomach can eventually buttress injury enough to prevent thoractotomy
if sig loss of volumes - bronch to find injury, ETT into L mainstem, R thoracotomy to repair primarily (poss pericardial patch to buttress repair with pericardial fat)
Describe 3 types of achalsia?
Type 1 (Classic): no pressurization, absent peristalsis
Type 2: absent peristalsis, pan-esophageal pressurizatoin
Type 3: impaired LES, rapidly propagating or spastic simultaneous contractions in distal esophagus in at least 20% swallows
How much of esophageal anastomosis must be involved to necessitate mossi takedown and cervical esophagostomy?
> 2/3 (or if contorl of spesis required)
Malignant TEF in esophageal cancer. Tx?
Tx goal is avoid soliage of lungs and provide nutrition
Esophageal covered stent preferred - well tolerated if place at or below cricopharyngeus
Then can do stent diet but must also provide feeding access for nutrition/hydration
This is terminal event; need GOC talk
Pt with esophageal adeno s/p definitive CXR 22 mo ago now with stricture adn new T1N0. Regional control on PET
salvage esophagectomy if demonstrated locoregional control
endoscopic stents don’t help bc not dilatable enough to stent and usually responds by progression of stricture
Early satiety and regurgitation after esophagectomy?
Need pyloric dilation
Must confirm diagnosis with EGD first (scope will have trouble passing), then bougie or balloon dilation). if works, can try botox at later time
Stanfard of care for T2aN3 disease
Stage IIIb: definitive chemo and radiation (can be curative)
just offering sysetmic is palliative, while radiaion + chemo is curative
What did PACIFIC trial show?
RCT for Stage III lung cancer that led to FDA approval for immunotherapy.
Durvalumab after chemoradiation (without progression) improves survival
Patient with advanced esophageal cancer undergoing therapy and has dysphagia bc tumor. tx?
Endoscopic dilation, stent placement (as long as can control secretions), and G tube (less expensive and easier to maintain than J tube)
Carcinoid tumor resection margins? When to use systemic therapy?
Resect to neg margins (no distance recommended, same for typical/atypical)
Systemic therapy for endocrine sx or advanced/unresectable doseqse
Management of loculated malignant effusion with lung trapping
Thoracoscopy to break loculations and drain effusion
If lung expands, pleurodesis
If lung trapped, tunneled pleural catheter
When is fundiplocation indicated for peptic strictures?
Initial tx is high dose PPI and dilation (most respond to 1-3 dilations). Steroid injections considered for recalcitrant strictures
No stent- lengths stricture
Fundo if recurrence after initial successful stricture management
Best and worst tx options for type III Achalasia?
Pneumatic dilation is worst
LHM and Dor work for all
POEM is best tx for type III bc can adjust myotomy proximally to degree and length of spasm as seen in HRM
Raynauds + dysphagia. Suspect what?
Scleroderma
These pts have true gerd- can confirm
With 24 hr pH probe monitoring
Scleroderma dx needs combination of signs/sx and labs (anti-top isomers I, ANA, anticentromere (ACA) ab)
Next step for epiphanic diverticulum
Epidemic diverticulum is pulsing diverticulum - usually distal 10 cm of esophagus
Associated with motility disorders and impaired LES relaxation
Need HRM
What are the 3 stages of achalaisa
onset - pain, dysphagia, regurtation
silent - sx improvement due to esopahgela diatoin and food retnetion in dilated esophagus
end-stage - severe weight loss, malnutrition, respiratory infection
Esophageal injury during hiatal hernia repair. How do you manage?
scope to see if full thickness
primary repair in 2 layers (mucosa, muscle)
repeat leak test
Re-inforce site of repair with fundolplication (dor anteiror, toupet posteior)
Presentation and treatment for CPAM?
all infants with prenatal diagnosis need neonatal CXR (even if asx or lesion appears resolved)
Sx - contrast CR or MRI to futher eval lesion
Asx - also CT or MR to confirm dx by 6 month age
Bochladek vs Morgagni. Where in diaphram? When do they present?
Bochladek - posterolateral, R side, more common but present in infants
Morgagni - anterior, central, adults, incidental
Esophageal mucosal injury during leiomyoma resection. What do you do?
Primarily repair mucosa and muscle and buttress with vascularized flap (pleura or pericardial fat)
First and 2nd line treatment for sarcoid?
Glucocorticoids (prednisone)
If refractory to steroids, immunomodulators like methotrexate or azathioprine
can observe asymptomatic
Enhancing middle mediastinal mass in pt with tachycardia/HTN
Hormonally active paraganglioma
Test with 24 urine adn plasma studies for catecholamines adn metanephrines, MIBG scan can diagnose and localize thesel lesions
mEdically stablize before surgery. Alpha blocker like phenoxybenzamine first, then beta blcoker
Achalasia Pt with prior POEM and now intractable reflux and narrowing above EGJ on scope. dx adn tx?
peptic stricture after POEM
laparoscopic partial fundoplication
Peristalsis req for magnetic sphincter augmentation?
Normal peristalsis >70% of time
Frothy unilateral secretions after lung txp?
Pulmonary venous stenosis (or torsion, thrombosis, back-wall suture)
Confirm with TEE
Pt with critical tracheal stenosis? How do you manage sedation/paralysis during intubation?
Inhalational anesthesia (sevo considered least irritating), maintain spontaneous breathing
Rigid bronch pass beyond obstruction
then paralyticW
Workup when you suspect diaphragmatic paralysis
Give 6 months for any neuropraxia to resolve
PA/lat CXR, PFTs (restrictive pattern), sniff test
St George’s Respiratory Questionnaire can objectively confirm level of dyspnea
Post-esopahgectomy paraconduit hernia. When to repair?
Immediate repair if intestinal obstruction or resp sx
Otherwise still repair all bc risk of incarceration/strangulation
How to manage Ewing sarcoma relapse?
Resect recurrence in lung if disease free interval> 2 years and completely resectable disease
if not, give chemo +/- radiation
Tx for mixed germ cell tumors with incomplete resopnse?
Incomplete response = elevated serum markers OR persistent radiographic evidence of disease
Must surgically resect all residual massses - usually teratoma or necrosis. If surgery not persued, must observe
If embryonal, yolk sac, seminoma, or choriocarinoma elements –> 2 additional cycles platinum-based chemoW
Halitosis, dysphagia, regurgitation of undigested food. what test do you order?
Barium esophagram
Adverse effect of infection after esophagectomy?
Post-esophagectomy infections reduce overall survival and progression-free survival
thought that inflammatory TGFa, IL1, IL6, cytokines promote cancer growth
infectious also worsens general health (decreasing non-cancer death) and may makes pt less able to get palliative chemo after recurrecne
What is regimen for pre-op mupirocin
self-administered topical abx that eliminates staph (including MRSA) in nares for up to 1 year
topical nasal twice daily for 5 days before surgery
Most common casue of readmission after lobectomy
infection
usually pneumonia, surgical site breakdown, empyema
Pt discharged home after lobectomy with chest tube with for airleak. returns with fevers, chills, exudative drainage. tx?
Suspect empyema, possible BPF
Admit, abx and fluid for sepsis, thoracoscopy for drainage of empyema and decort
must bronch after ETT to protect other lung and see if BPF present
ICU pt with resp failure with new LUL opacfiation on XR and CT with opacificaiton and LUL cavitary process? high vent setting. next step?
Ddx: virulent pneumonia, opportunist infection, abscess, cancer
too sick for IR or surigcal bx, also may not heal from airleak when in ICU
next do flex bronch lavage and brushings
Tx of actinomyocis?
IV penilin G (4-6 weeks)
PO peniilin B 6-12 weeks
sulfur granules and filaments on gram stain are diagnostic
from poor oral dentiition; inhale secretions wiht actinomycosis (obligate aneraobe, gram pos filamentous shape)
Anatomy of thoracic duct?
enters at aortic hiatus at T12, ascends R lateral to esophagus, crosses to L lateral near inlet, join nears L IJ/subclavian confluence
Treatment for adenoid cystic carcinoma with microscopically positive margins on resection?
Adjuvant radiation
Surgery + adjuvant radiaion for R1 resection has best survivall
Radiation alone (no surgery) has worst survival
Blood supply of trachea
Upper trachea: Inferior thyroid artery
Lower: branches from subclavian, innominate, ITA, bronchial artery
Do you need myotomy for mid esopahgeal diverticulum
No
traction diveritulum due to inflammed mediastinal nodes
operate when sx via R chest
free culprit nodes, staple esophagus w/ bougie in place, pleural/muscle flap to prevent recurrentce/leak
Treatment for epiphrenic diverticulum?
transthoracic L chest or transabdominal
staple divertiulcum w/ bougie in place, myotomy contralaterally 2-3 cm onto stomach to prevent dysphagia, partial fundo
Surgical tx steps for zenkers?
L neck incision along anterior border of SCM
diverticulopexy to pre-cervical fasica if <2cm divertiulua, larger shoudl have stapled resection
criopharyngeal myotomy from base of dovertulum to thoraci inlet to relieve obstriiction
Causes for generalized hyperhidrosis?
Usually excesive heat due to systmic diseases or medications
Uaually occurs as adults adn sweatihgn while awake & sleeping
evaluate for systmic causes
Dxsx: infectious (HIV, TB, Endocarditis), malignancy (lymphoma), endocrinopahty (carcinoid, pheochromocytoma, hyperthryoid)
Most common complication of sympathectomy?
Compensatory sweating (torso, thighs, legs)
risk factor for compensatory sweating: divition at or above R2, multiple level sympathectomy, axillary component of swating, BMI>28, age >30
What level to divide for hyperhidrosis?
R2 denotes division of chain at TOP of rib 2, etc
Facial: R3
Isolated palmar: R4
Axillary or any combo of ax, palm, plant: R4+R5
First line tx for hyperhidrosis?
topical antiperspirant (ususally contains aluminnum)
can also try oral or topical anticholinergics or botox injection (less effective than antiperipersants)
surgery if refractory
What type of stent to use for benign vs malignant esoohageal diseae?
self expanding metal for malignant disease
slef expanding plastic only in benign
most common complicatoin after metal stent is pain, then tissue ingrowth, migration, bleeding perforaiton
How much to dilate esophageal stricture?
opening fo at least 6mm
serial dialtiosn until 18mm opening (allows solid food swallowing without dysphagsia)
dilate no more than 2mm per session reduce perforation risk
Most common etiology fo esophageal perf?
Iatrogenic
What is boerhave syndrome?
caused by forceful vomiting taht causes longitudinal rent on left posterolatearl wall fo thoracic esophagus
Most common cauuse of caustic esophageal injury?
80% are accidentla by small children
in adults, most comon is suidicie
alkli - liqufactive nceoriss, wihch causes deeper mucosal peentraiton and inc risk of perf
acid - coag necoris -limted to superviical mucosa
surgical approach for esohpgael perg?
cervical - heal w/out reapir but requre aggressive drainage ot prevent mediastinitsi
upper and milddle thir - R thoroactomy
lower - L thoractomy
longitudnial myotomy to explosre ful extnetnof mucosal defect
primary rpair w/ muslce flap buttressB
test withhighest sensitivty for esophageal perf?
CT with oral contrast (>95%)
What causes pain in nutcracker esophagus?
inability to transmit bolus
pain does not corelate with high amplitude contractios - these are marker for a hypersensitive esopahgus
chest pain correlating with high amplitudes is typical for diffuse esophageal spasm
Definiton of ineffective esophageal motiliy?
failed distal propagaiotn of contraction in >30 % swallows
First like tx for Diffuse esophhageal spams and nutcracker?
medical
(nitrates)
What criteria need to be met before surgical therapy for GERD?
Failure of medical therapy
Demonstration fo loss of barrier funciton at LES
surgery successful in 80-90% cases
Which is better? PPI or H2 blocker?
PPIs more effective than H2 blcoker at sx/esopahgitis resolution but do not reduce risk of Barrett’s or cancer
Workup for GERD?
if typical heartburn sx and resposnive to PPI, don’t need anything else
EGD first test
manometry adn 24 hr pH important to r/o motility issues adn confirm GERD
Surgical apporach for leiomyoma?
R chest
bx w/ frozen section to confirm benign lesion
enucleation
Origin of granular cell tumor of esophagus? GIST? Small cell?
Granular cells from schwann cells
GIST from interstitial cells of cajal
Small cell from neuroendocrine cells
Leiomyoma from smooth muscle
Risk of photodynamic therapy for barretts?
involves use of photosensitizing agent followed by light probe in esophagus
importnat risk of “buried glands” that escape surveillance and progress to cancer
Conversation rate of barrett’s esophagus to cancer?
0.5%
Most common diaphgram tumor?
very rare - usualyl mesenchymal (90%) or neurogenic (10%) in orgine
usually benign and cystic
most common solid primary is lipoma
most common malignnat mesenchymal is fibrosarcoma
Where are morgagni hernias?
Anterior, to the right (bochladek is mroe common)
Most common method ot predict survival when congenial diaphragmatic hernia diagnosed in utero?
ultrasound lung-to-head ratio (bigger lung volumes a/w better survival)
Where is bochladek’s hernia?
Posterior to the left
Treatment of catamenial ptx?
chest tube, pleurodesis, resection of endometrial implants (usually on visceral pleura adn diagphragm), and closure of porous defects in diaphragm primarily or w/ meshM
most common demographic for TOS?
women (4:1)
20-40 yo
neurogenic most common
Where does lymphatic drainage from head and neck drain?
R thorax, head, neck, dome of liver, and R diaphgragm lmyph drains into R sided lymphatic duct - terminates into posterior confluence of R subclavian and jugular veins
Cut off for TGs in pleural fluid for chylothorax
> 110 diagnostic
50-110 - need additional tests
<50 - neg with 95% probability
spontanoues closore of thoracic duct fistulas occurs in 50% cases
Why do we use medium chain TG in chylothorax?
fatty acids w/ <10 carbon atoms mostly enter portal circulation directly, avoiding lymphatics (Medium chain TG can reduce throacic duct flow)
Most common cause of neoplastic chylothroax?
lymphoma
62 yo shipyard worker with loculated effusion and thickened pleura. next best step
suspect mesothelioma 2/2 asbestos
pleural biopsy
how to treat mild vs mod vs severe rejection on lung txp bx?
mild: no therapy
mod: IV steroid pulse therapy
sev: Ab therapies
Survival after lung txp?
5 yr survival 54%
worst outcomes:
short term - pHTN
mid-term- pulm fibrosis
long term (10y) - emphysema
Most commonly affected extrapulmonary sites of sarcoid?
Eyes and skin
Unique feature of lymphoid interstitial pneumonia?
Highest reported rates of regression
responds to corticosteroid therapy
low rate of malignant transformation (5%)
Initial diagnostic intervetions if suspicious for ILD?
PFTs
HRCT
serologic testing
BAL if above tests inconclusive and suspect sarcoid, eosinophilic pna, or infection
Which type of pneumonia has a mononucelar infiltrate?
NSIP - mononuclear infiltrate w/ or without fibrosis
How does doubling time affect diferential for solitary pulm nodule?
Doubling time <10 days usually infectious, while >450 days usually benign
SPN is any rounded intraparenchymal lesion <3cm discovered in absence of other active disease
LVRS vs valve benefits?
FDA hasn’t apporved valves
short term, valves dont have as much benefit as LVRS showed in NETT trial
need complete fissures
Who gets survival benefit from LVRS, per NETT trial?
Upper lobe predominant and low exercise toleranceH
Healthy newborn with cystic mass in L hemithorax. next best step?
upper GI to differentiate CCAM vs congenital diaphragmatic hernia
CCAM should be resected (tx is lobectomy) between 3-12 mo age in asx pts as can give rise to malignant lesions
Which vascular ring accounts for most resp sx?
double arotic arch accounts fot 50% of rings w/ resp sx
anomalous R subclavian is overall most common ring
upper vs lower lobe predominance for CCAM vs CLE?
cong lobar emphysema is upper lobe predominant
CCAM is lower lobe predominant
Intubated pt with type C TEF who needs urgent cardiac procedure but inc abdominal distneiosn?
G tube to decompress
How to confirm dx of EA TEF in newborn?
8 or 10 Fr OG tube placement
if resistance at 8-12 cm from lip and coiling in esophgus on XR, dx is confirmed
What lung lesion asssociated with congenital diaphragmatic hernia?
extralobar pulm sequestration (in 5-15% of CDH pts)
Which cancer has worst prognosis after pulm metastatectomy?
Melanoma
complete lymph node dissection during metastatectomy offers best long-term survivial
In which population is post pneumonectomy syndrome more common?
Children
inc mobility of mediastinum and lung compliance
How does post pneumonectomy cardiac herniation vary based on side?
L -LV herniates through pericardial defect and strangulates, impairing diastole, systole, adn coronary perfusion
R- RV torsion occludes inflow from SVC and IVC
Can you resect multilevel vertebral involvement of lung cancer?
yes, so long as no spinal cord involvement
high morbidity rate
R0 resection ahs 5 yr survival fo 25%
Tricks to reduce anastomotic tension after sleeve lobectomy?
IPL release
pre-op mediastinoscopy
suprahyoid laryngeal release
hilar release (U shaped pericardial incision below IPL)
Which nerve root can you NOT take in superior sulcus tumor?
C8
very poorly tolerated b/c Klumpke’s paralysis (of hand AND forearm muscles)
TUmor found to be invading diaphragm intra-op. what do you do?
Resect en bloc w/ 5 cm margins and reconstruct w/ prosthetic material
R0 reseciton gives only 20-30% 5y survival
Diaphragm invasion is T4
What did NSLT show?
National Lung Cancer Screening Trial showed low dose CT had 20% relative risk reduction in lung-cancer specific mortality compared to CXR screening
NCCN lung cancer screening guidelines?
Anyone > age 50
>20 pack year hx
functional status amenable for curative intent tx
Serratus anterior vascularization and innervation?
Long thoracic NERVE
Lateral thoracic and thoracodorsal ARTERIES
Where can you consistently find R PA?
junction of the fissures
R PA begins anterior and inferior to bronchus
LPA wraps posteriorly around upper lobe bronchus
Border for region of upper paratracheal nodes?
Inferior border of innominate vein on R
superior border of arch on L
Association of thymoma?
anemia
Correct order of tracheal release maneuvers?
- Pre-tracheal dissection
- Neck flexion
- Suprahyoid release
- IPL release
- Hilar release of R lung
How far away from incisors should upper esophageal stent be?
15 cm
How far away from incisors should upper esophageal stent be?
15 cm
How far proximally and distally shoudl esophagela stent extend from lesion?
2-4 cm
Best test to evaluate esophagus after caustic ingestion?
Endoscopy
Diong a nissen and completed dissection to pulmonary veins but still tension in intraabdominal portion of esopahgus w/ 1.5 cm length. next step?
Collis gastroplasty
What are “typical” symptoms of GERD (typical sx have better surgicla outcomes than atypical)
Heartburn, regurgitation, dysphagiA
What age to reconstruct in infants with long gap atresia?
2-3 months
Which gene creates membrane between trachea and esophagus
Shh
Which gene creates membrane between trachea and esophagus
Shh
What features favor resection of leiomyoma?
Size >4cm
Irregular margins
Mixed echo characteristics
Associated regional lymphadenopajty
Do not need biopsy to enucleate
Treatment and association of esophageal cysts
80% diagnosed in childhood
Associated with vertebral and spinal cord abnormalities
If asx, tx is enucleation for simple cysts and excision for duplication cysts - to prevent growth and obstruction
Treatment for GIST
Derived from pacemaker cells of my enteric plexus (interstitial cells of Cajal)
Associated with ckit- codes a tyrosine kinase inhibitor
Tumors not in stomach and small bowel have worse prognosis
3 yrs adjuvant imatinib for intermediate and high risk to prevent recurrence
High risk: nongastric GIST <=5cm with > 5 mitoses per 50 hpf
Small cell histology
Little cytoplasm
Hyperchromatic nuclei that are Round with classic granualr appearanfe
Expression chromogranin A and synaptophysin on IHC
Pathophysiology of diaphragmatic eventrarion?
Failure of migration of myoblasts into muscular portion of diaphragm
In utero
What did rematch trial show
48% Dec in Al cause death in LVad pts ba medical Management
Most common reason for LVAD exchange?
Lead damage, followed by driveline infection and pump thrombosis
Sequence of Lvad with PFO and sec TR
Bicaval venous cannulation
Repair Pfo and TR (if greater than moderate) - do before LVAD so it’s easier to de air left heart
Implant LVAD
What tumor is associated with Gardner and Lynch syndrome?
Chrondrosarcoma
Which subtype has best outcome for malignant pleural mesothelioma?
Epitheliod has best vs sarcomatoid and desmoplastic or mixed
Minimum acceptable P/F ratio for donor lungs?
> =300
How to assess donor lung compliance during procurement?
Disconnect from vent and watch lungs deflate
Should you harvest nodes for carcinoid?
Typical - no, just wedge w/ neg margin
Atypical - 50% nodal involvement so get nodes
Next step for endobronchial lesion?
Bronch/bx is gold standard in dx of carcinoidsP
ARDS PF ratio cutoff of when to consider prone/paraylsis adn ECMO
P/F<150 = prone and paralyze
PF<80 = VV ECMO
