Lung Cancer - Surgical Management

Question 1

How do you assess the patient for lung cancer?

Answer 1

Staging of the lung cancer.
Fitness of the patient.

Question 2

What is the clinical history of lung cancer?

Answer 2

Pain (esp. bone pain).
Headaches.
Neurological symptoms (including personality change).
Haematuria.

Question 3

What is the clinical examination of lung cancer?

Answer 3

Recurrent laryngeal nerve / brachial plexus palsy.
SVC syndrome.
Supraclavicular LNs.
Soft tissue nodules.
Chest wall masses.
Pleural/pericardial effusion.
Hepatomegaly.

Question 4

What does a CXR check for in lung cancer?

Answer 4

Pleural effusion.
Chest wall invasion.
Phrenic nerve palsy.
Collapsed lobe or lung.

Question 5

What is between the aortic arch and the left pulmonary artery?

Answer 5

The aorto-pulmonary window.
The connection between the two vessels is the ligamentum arteriosum.

Question 6

Why is the recurrent laryngeal nerve particularly susceptible to lymph node metastases?

Answer 6

The RLN hooks around the medial side of the ligamentum arteriosum to gain a gap between the trachea and oesophagus, where it rises up into the neck to innervate the left vocal cord.

Question 7

What blood tests are done for lung cancer?

Answer 7

Anaemia.
Abnormal LFTs or bone profile.

Question 8

What is CT used for in lung cancer?

Answer 8

Size of tumour.
Mediastinal nodes.
Metastatic disease (other parts of lungs, liver, adrenals, kidneys).
Proximity to mediastinal structures.
Pleural/pericardial effusion.
Diaphragmatic involvement.

Question 9

What is an MRI used for in lung cancer?

Answer 9

Useful in determining the degree of vascular and neurological involvement in a Pancoast tumour.

Question 10

What is a bone scan used for in lung cancer?

Answer 10

To see chest wall invasions and bony metastases.

Question 11

What is ECHO used for in lung cancer?

Answer 11

The presence or absence of significant pericardial effusion.

Question 12

What are the two main surgeries for lung cancer?

Answer 12

Bronchoscopy and mediastinoscopy.

Question 13

What respiratory aspects must be considered for fitness for surgery?

Answer 13

Barrel chest.
COPD.
Smoking.
Asthma.
Recent URTIs.
On O2.
Exercise capacity.
Previous thoracotomy or ICD.

Question 14

What cardiovascular aspects must be considered for fitness for surgery?

Answer 14

Angina.
Heart problems.
HBP / DM / PVD.
Smoking.
Stroke / TIA.
Carotid bruits.
Previous CABG / angioplasty.
Heart murmurs.

Question 15

What psychological aspects must be considered for fitness for surgery?

Answer 15

PMH of mental illness.
Severe anxiety.
Social background.
Chronic pain problems.

Question 16

What other aspects must be considered for fitness for surgery?

Answer 16

Pulmonary hypertension.
Permanent tracheostomy.
Rheumatoid arthritis.
Mobility.
Cirrhosis.
Heterotopic ossification (h/o) radiotherapy to the chest.

Question 17

What respiratory function tests are done for lung cancer?

Answer 17

Spirometry.
Diffusion studies.
ABG on air / SLV.
Fractionated V/Q scan.

Question 18

What cardiac assessment is done for lung cancer?

Answer 18

ECG.
ECHO.
CT.
ETT.
Coronary angiogram.

Question 19

What occurs in surgical treatment of lung cancer?

Answer 19

Curative resection of parietal structures.
Removing the least amount of lung tissue.
Firm diagnosis of malignancy is highly desirable before lung resection.

Question 20

What are causes of peri-operative death?

Answer 20

ARDS.
Bronchopneumonia.
MI.
PTE.
Pneumothorax.
Intrathoracic bleeding.

Question 21

What are non-fatal complications of lung cancer therapy?

Answer 21

Post-thoracotomy wound pain.
Empyema.
BPF / AF / MI.
Wound infection.
Post-op respiratory insufficiency.
Gastroparesis/constipation.

Question 22

What are common problems with lung cancer staging?

Answer 22

Collapsed lobes or lungs make tumour size difficult to assess.
Presence of another pulmonary nodule.
Retrosternal thyroid.
Adrenal nodule.
Head CT is not routinely performed pre-op.

Question 23

What are the different mortalities of lung cancer operations?

Answer 23

Pneumonectomy - 5-10%.
Open/close thoracotomy - 5%.
Lobectomy - 3-5%.
Wedge resection - 2-3%.

Question 24

What are the different 5YS post-op percentages for different lung cancer stages?

Answer 24

T1N0 - 70%.
T2N0 - 60%.
T3N0 - 50%.
T1N1 or T2N1 - 40%.
Any N2 - 16%.
Chance of a second primary - 5%.

Question 25

What are examples of non-lung cancers?

Answer 25

Infection - TB and lung abscess.
Benign tumour - hamartoma.
Granuloma - sarcoid, Wegener’s, rheumatoid nodule, inflammatory pseudotumour.
Fibrosis - PMF, organising pulmonary infarct.
Paraffinoma.