Lung Surgery Flashcards
Staging of lung cancer
- Stage 1: Just the lung
- Stage 2: Hilar adenopathy
- Stage 3:
- 3a: Ipsilateral mediastinal adenopathy
- 3b: Contralateral mediastinal adenopathy
- STage 4: Metastatic
Malignant massive pleural effusion occurs in stage ___ lung cancer
Malignant massive pleural effusion occurs in stage 4 lung cancer
So if this is the presentation, surgery basically is not an option. Also, when you tap this, it will recur – you need to pleurodese.
Four most common sites of lung cancer metastasis
- Bone
- Brain
- Liver
- Adrenals
Lung cancer screening guidelines
Subpleural bullae
- Most common cause of spontaneous pneumothorax in otherwise healthy individuals
- Mostly occurs in young, lanky males (Marfanoid body habitus)
- If one side ruptures, the other side usually also has blebs at risk of rupture that need prophylactic management
- Sx more mild than other cases of pneumothorax since there is typically no underlying lung disease
- Treat with video assisted thorascopic surgery (VATS) with bleb lysis
__ is responsible for 70% of secondary spontaneous pneumothoraces
COPD is responsible for 70% of secondary spontaneous pneumothoraces
Pneumothorax in patients with AIDS in the US is usually due to ___.
Pneumothorax in patients with AIDS in the developing world is usually due to ___.
Pneumothorax in patients with AIDS in the US is usually due to pneumocystis pneumonia.
Pneumothorax in patients with AIDS in the developing world is usually due to tuberuclosis pneumonia.
ACCP definition of “small” pneumothorax
Apex of the lung is < 3 cm away from its typical position by CXR due to the presence of air
ACCP guidelines for which pneumothoraces can be safely observed
For primary pneumothorax, < 3 cm (small) and asymptomatic
For secondary pneumothorax, < 1 cm (very small) and asymptomatic
Placing patients on ___ improves the resolution of pneumothorax
Placing patients on supplemental oxygen improves the resolution of pneumothorax
This is because oxygen diffuses more readily through lung tissue than nitrogen or carbon dioxide.
Surgical operations to treat recurrent spontaneous pneumothorax
- Bleb ablation (if blebs are present)
- Pleurodesis (with talc or doxycycline)
With each episode of spontaneous pneumothorax, the odds of recurrence. . .
. . . increase
Simple tube thoracostomy vs aspiration for pneumothorax
- Aspiration is associated with shorter length of hospital stay
- HOWEVER, if aspiration fails then tube thoracostomy is indicated
Therefore, aspiration is first-line, thoracostomy is second line
Spontaneous pneumothorax is unlikely to progress to ___
Spontaneous pneumothorax is unlikely to progress to tension pneumothorax
Current lung cancer screening guidelines
- Screen with low-dose CT scan
- Eligibility:
- > 20 pack year smoking history
- Current smoker or < 15 years since quit
- Age 55 - 80
- Frequency:
- Every year
CT protocol for evaluating solitary pulmonary nodule
Should include full view of the chest and the upper abdomen to the adrenals
Adrenal cancer and liver cancer commonly metastasize to the lung
Technical definition of “solitary pulmonary nodule”
- < 3 cm in maximal diameter on radiographic imaging
- < 1 cm for “small solitary pulmonary nodule”
- At least moderately well-marginated
- Roughly round in shape
Second leading cause of lung cancer in the US
radon
Staging of lung cancer
PET-CT
Lung adenocarcinoma
- Most common lung cancer
- Also occurs in non-smokers (only LC that does this)
- Peripherally placed within lung parenchyma
- Metastasize earlier than squamous cell carcinomas, but not at time of diagnosis like small cell carcinomas
- Often metastasize to CNS
Lung squamous cell carcinoma
- Tend to be more centrally located in the lungs
- More likely to undergo necrosis and cause compression of airways
Small cell lung cancer
- Highly smoking associated
- Presumed metastatic at time of diagnosis
- Has a diffuse “cloudy” pattern on CXR rather than discrete nodules
- Often involves mediastinal lymph nodes at time of diagnosis
Common lung cancer metastasis sites
Hilum/mediastinum
Brain
Adrenals
Bones
A new lung nodule in a smoker has a ___ chance of being cancerous
A new lung nodule in a smoker has a 70% chance of being cancerous
Anatomic vs nonanatomic (wedge) resection for lung cancer
Anatomic follows natural lobar/lung segmental lines and is associated with greater disease free survival
However, wedge resections better preserve pulmonary reserve in individuals with poor lung function.
Evaluation is necessary prior to surgery to determine whether anatomic resection can be tolerated. If so, it is the safer option.
In a patient with stage I-II lung cancer, ___ is the next step to determine whether or not they are a candidate for surgical oncology.
In a patient with stage I-II lung cancer, pulmonary function testing is the next step to determine whether or not they are a candidate for surgical oncology.
What diameter of small pulmonary nodule are we not worried about possibly being lung cancer, even in smokers
> 0.5 cm / 5 mm
Something this small has < 1% chance of being a lung cancer
Lung resection is still a consideration for patients with a different primary cancer who present with ___
Lung resection is still a consideration for patients with a different primary cancer who present with oligometastatic disease
Typically a single nodule in the lung after having been in remission for > 2 years
Shortcoming of V/Q scans
They can identify V/Q mismatch, but cannot tell you what is causing it
Could be a PE, could be atelectasis, could be pneumonia, etc. If there is no other obvious cause, PE is most likely, but pre-existing lung pathology can make this test less uesful.
Way to improve CT angiography sensitivity for PE
Combine with a CT venography of the pelvis
Pulmonary angiography
Gold standard for diagnosis of PE, with sensitivity of 96% and false negative rate of 0.6%.
Catheter-directed treatments may also be delivered, however drawbacks are the delays for preparation of the study and major procedural complications of the study (complication rate 1.3%, mortality rate 0.5%)
Thrombolytic therapy for PE
- tPA (delivered IV or angiographically)
-
Contraindications:
- Major surgery within 10 days
- Traumatic brain injury within 10 days (DOES NOT include concussion or other TBI with normal CT)
Who is a candidate for catheter-directed or surgical pulmonary thrombectomy?
- Patients with PE w/ hemodynamic instability who failed initial thrombolytic therapy
Provoked vs unprovoked VTE
Provoked: Attributable cause, can treat with short, defined course of prophylactic anticoagulation
Uprovoked: No attributable cause or known disorder of coagulation, often treated with life-long anticoagulation
Well’s Criteria
Practical aspects of using unfractionated heparin vs LMWH
-
Unfractionated:
- Intravenous delivery
- Requires monitoring and titration to aPTT of 2.0-2.5
-
LMWH:
- Weight-based dosing
- Does not require monitoring
- Subcutaneous delivery
Indications for vena cava filter
- VTE recurrence or propagation in the face of therapeutic anticoagulation
- VTE and contraindication to systemic anticoagulation
Efficacy of IVC filter vs systemic anticoagulation for prevention of PE
About the same, ~95%
IVC filter is obviously more invasive though, and has local complications including IVC thrombosis and erosion.
When an IVC filter is indicated, typically a ___ should be used
When an IVC filter is indicated, typically a retrievable filter should be used
This reduces the rate of filter-related complications
ABG of someone with a pulmonary embolism should basically never show ___
ABG of someone with a pulmonary embolism should basically never show hypercapnia
1972
2 7 9 and 10
The vitamin-K dependent clotting factors
Direct oral anticoagulants should never be used in. . .
. . . patients with APLS or patients with prosthetic heart valves
Idarucizumab
Purified Fab fragment that sequesters dabigatran, reversing its effects.
Adexanet
Factor Xa inhibitor sink. Sequesters factor Xa inhibitors and rescues factor Xa activity.
Stratifying anticoagulation prophylaxis period for patients with DVT/PE
- Patients with femoral-popliteal DVT without persistent risk factors: 3 months
- Patients with provoked PE and no genetically determined hypercoagulable condition: 6 months
- Patients with unprovoked VTE: 12 months or longer
- Patients with strong genetic predisposition to VTE: Lifelong
Anticoagulation safe in pregnancy
Any heparin product, but nothing else
V/Q scan NPV
Pretty poor
If someone has high prior probability of PE, their posterior probability can still be as high as ~40% even with a normal V/Q scan.
So, V/Q scan cannot rule out PE.
Trauma patients with history of large blood loss are. . .
. . . extremely high risk for VTE
Somewhat paradoxically, we need to anticoagulate these patients once they have been stabilized through surgery. LMWH is the drug of choice for this indication, and should be started 36 hours after obtaining hemostasis.
Notably, pneumatic compression boots are not effective for DVT prophylaxis in this population.
Elevation in INR after massive hemorrhage
Generally reflects a coagulopathy, and so it does not confer any protective benefits against development of DVT/PE
DVT/PE risks for laporoscopic surgery
Generally quite low in patients without risk factors and surgeries without complications
HIT and heparin products
HIT is a 100% contraindication to giving any heparin product
Upper extremity DVT and PE
While less common than lower extremity DVTs, upper extremity DVTs carry a much higher risk of PE than lower extremity DVTs
Safe criteria for VTE ruleout
Low Well’s score (<2) and normal D-dimer
Malignant pericardial effusion
Complicated vs uncomplicated parapneumonic effusion
Bronchial carcinoid tumor
Bronchial mucus plugging following intubation
- Will present as lobar-pattern atelectasis following extubation
- Mediastinal shift can suggest atelectasis and the pattern of atelectasis clues into the diagnosis
- Smoking is a risk factor
Even if someone has a small pneumothorax and good oxygen saturation on room air, you still put them on supplemental oxygen. Why?
Because it accelerates the resolution of the pneumothorax.
Mediastinal compartment stuff
Triad of Pancoast tumor syndrome
- Shoulder pain
- Horner’s syndrome
-
Ulnar neuropathy (weakness of hand muscles, paresthesias in 4th and 5th digits, radiating pain in ulnar distribution)
- Note: in someone with a significant smoking history
