NMS Thoracic Flashcards
what are chances that coin lesion on CXR is malignant
50% at 50. under 50 chances decrease, over 50 chances increase
what do benign lesions look like vs. malignant
benign has smooth surfaces, malignant has irregular or spiculated surfaces
what are other benign lesions
Bulls’ eyes, hamartomas which have popcorn appearance on CXR
which area of U.S. are coin lesions common
SW U.S. where coccidiomycosis is common and mid-Atlantic and OH valley where Histo occurs
most common mets to the lung are from
colorectal, breast, liver
if a lung lesion looks malignant what do you do
get a CT to characterize lesions and to look for enlarged lymph nodes in mediastinum, then do CT-guided needle bx
what do you do for a lesion with cough and hemoptysis and mediastinal enlarged lymph node
bronchoscopy for tissue diagnosis and to determine location of lesion and mediastinoscopy to determine state of mediastinal LNs
what do you do if needle bx shows malignant or indeterminate (lung)?
resection
what doubling time favors benign status vs. malignant status
if doubling time is 465 days then it favors benign. if doubling time is 5 wks to 280 days, favors malignant
what type of lung cancer usually presents late and not amenable to resection
small cell carcinoma
cure rate for Stage I lung tumors w resection
70%
Stage II lung cancer 5y survival
40-50%
surgical options for metastatic lesion involving mainstem bronchus
pneumonectomy (easier) or sleeve lobectomy (safer). sleeves not feasible if mainstem pulmonary artery involved
perioperative death rate from pneumonectomy
5-10% especially in those over 70 and those with cardiac or obstructive airway dz
at what stages can lung tumors be resected
stages I and II
at what stages are chemo and radiation the only treatments
stages III and IV
ipsilateral hilar lymph nodes are what stage
stage II
mediastinal lymph nodes are what stage
stage III
can a tumor undergo chemo and be downstaged and resected (lung)
yes
imaging modality good for detecting lung cancer mets
PET scan
symptoms of Pancoast tumor
Horner’s syndrome, pain in ulnar area of elbow and wrist
how to verify superior sulcus tumor
CT, bronchoscopy, mediastinoscopy, needle bx
what are 5y survivals for stage II, IIIa, and IIIb lung cancer
stage II 44%
stage IIIA 22%
stage IIIB <10%
tx of pancoast tumor
- irradiation over course of 6 wks then
2. surgical resection of chest wall and lung
in young healthy pt with hemoptysis and atelectasis, what would be suspect
bronchial adenoma thats obstructing bronchus
2 types of bronchial adenomas
- carcinoids (malignant potential if originated in small bowel)
- adenocystic carcinomas (invade locally)
how to dx bronchial adenoma
bronchoscopy with bx, careful bc they bleed!
how to treat bronchial adenomas
lobectomy. usually curative
carcinoid syndrome sxs?
flushing, diarrhea, wheezing from bronchospasm, facial telangiectasia, tricuspid regurg and pulmonary stenosis bc serotonin increases collagen production in valves
ddx for effusion (pleural)
cancer: bronchogenic carcinoma, mesothelioma
benign: CHF, viral/bacterial pneumonia, empyema, TB
how to dx pleural effusion
thoracentesis and pleural bx. you can cx the fluid and examine histology of bx for malignancy.
prognosis for mesothelioma
terrible. most die within a year. not responsive to chemo/radiation.
:(
only surgical tx for mesothelioma
extrapleural pneumonectomy. takes out lung, both visceral and parietal pleura, pericardium, and diaphragm at times.
etiology of spontaneous pneumothorax
rupture of apical blebs, pleural cavity pressure becomes same as atm, causing lung collapse and trachea deviated to side of collapse
etiology of tension pneumothorax
penetrating trauma to the lungs, pleural tear that allows air only to go into the pleural space, trachea deviates to contralateral side
tx of a pneumo
chest tube
what do you do if a patient is unresponsive to chest tube s/p pneumothorax
must investigate persistent air leaks from lung parenchyma with thoracoscope and surgical intervention
how to treat persistent or recurrent pneumo
- thoracoscopic excision of blebs and pleurodesis (pleural abrasion to adhere visceral and parietal pleura)
what do you suspect with chest pain, cough, recurrent fever, and pleural effusion after a pneumonia treatment
Empyema!
most common causes of empyema
s.pneumo, staph and gram neg in hospitals; anaerobes if aspiration suspected or alcoholism or recent operation
how often empyema culture neg
35% bc of previous abx tx
how to treat empyema
- empiric abx
2. chest tube for drainage
what happens if you dont treat an empyema
- exudative phase
- fibropurulent stage (loculation of fluid pockets)
- organizing stage (scarring and inflammatory tissue)
how do you fix an untreated empyema
thoracotomy and decortication
how to manage unstable angina
- admit and bed rest
- oxygen
- beta blockers, nitro, ASA, heparin, morphine is questionable
- cardiac enzymes
- cath or thrombolysis if MI+
3 major coronary arteries
- RCA
- LAD
- Circumflex
(LAD and Circumflex from left main)
whats an abnormal EF
<55% (she said 40-50%)
how to treat left main dz
coronary artery bypass
alternative to bypass?
PTCA with stents, danger of reobstruction
sources of bypass grafts
internal mammary artery has best patency, reversed greater saphenous vein also used
what solutions used to help performance of bypass
cardioplegia solution, blood cardioplegia solution, hypothermia
operative mortality for bypass surgeries
3%, but less for low riskers
etiology of MVR
myxomatous degeneration of mitral valve; thought to be due to ischemia of mitral valve apparatus
how is MVP different from MVR
prolapse is eccentric closure and doesnt have to regurg!
common in young women, but in men it can be sign of severe mitral valve dz.
etiologies of mitral stenosis
rheumatic fever, scarlet fever. you get inflammation of connective tissues, leaflets progressively fuse, LA pressure goes up, R heart enlargement, pulmonary htn
treatment of mitral valve dz
can try to repair regurg by excision of redundant portion of leaflets and reinforcing mitral annulus with annuloplasty ring, but can replace if not successful
3 etiologies of aortic stenosis
- congenital (bicuspid valve)
- arteriosclerotic
- deteriorative
aortic valve area less than what is severe stenosis
0.8 cm sq
workup for aortic stenosis
- cardiac cath to detect aortic valve size, pressure gradient, ventricular function, check for CAD
- carotid doppler to rule out internal carotid obstruction
when do pts with aortic stenosis usually present
late in life. extreme risk for sudden death
pros and cons of mechanical vs. tissue valves
mechanical valves need anticoagulation bc theyre thrombogenic; tissue valves nonthrombogenic but deteriorate. require replacement at 7 yrs
what can give you dilated cardiomyopathy if you’ve got normal coronary arteries
post-respiratory illness, etiology unclear
wtf??
prognosis for dilated cardiomyopathy
1/3 get better, 1/3 stay the same, 1/3 get worse
tx for dilated cardiomyopathy
steroids, diuretics, immunosuppressives, beta blockers, transplant
prognosis with transplant
immediate survival >90%
survival at 1 yr 85-90%
survival at 2 yrs 75%
immunosuppressives for transplants
cyclosporine, tacrolimus
most deaths from transplants happen from what
infection from immunosuppressive drugs and accelerated coronary atherosclerosis as a form of chronic rejection
what do we suspect with regurgitated undigested food and dysphagia
Zenker’s diverticulum or pharyngeal diverticulum
etiology of pharyngeal diverticulum
abnormal uncoordinated constriction of cricopharyngeal muscle during swallow results in outpouching bw lower pharyngeal constrictor and cricopharyngeal muscle
where else can a pulsion diverticulum occur
distal esophagogastric junction: epiphrenic diverticulum. food can regurgitate and can be aspirated.
tx for pharyngeal diverticulum
- excision if diverticulum is large
2. transect cricopharyngeal muscle to relax esophageal entrance and prevent uncontrolled contraction
tx for epiphrenic diverticulum
esophageal myotomy at esophageal gastric junction
sxs and etiology of achalasia
dysphagia, WL due to poor peristalsis of body of esophagus and failure of LES to relax. loss of smooth muscle ganglionic cells of Auerbach plexus
how to dx achalasia
barium swallow
associated conditions w achalasia
emotional stress, physical trauma, WL, Chagas
tx for achalasia
Heller myotomy or pneumatic dilation. maybe Ca channel blockers
types of cancers in different areas of esophagus
top 2/3 is squamous cell carcinoma, bottom 1/3 adenocarcinoma
esophageal cancer a/w what
alcohol, tobacco, Barrett’s (40x w severe dysplasia)
how do you stage esophageal cancer
endoscopic ultrasound for wall penetration and LN spread. CT abdomen and chest for celiac node involvement. mediastinal or celiac node mets automatically stage III and incurable.
complication with middle third esophageal cancers
invasion of tracheobronchial tree
tx for esophageal ca
stage I (just to submucosa) can be resected but not in upper third of esophagus. Stage II and beyond is chemoradiation. but you can downstage then try to resect
two types of esophagectomies and types of incisions
transhiatal (cervical and upper abdominal incision). we want the anastomosis at the cervical area for easy access in case of complications
what do we do after an esophagectomy anastomosis
pyloroplasty to prevent gastric outlet obstruction
why would a person with esophageal cancer have constant cough
tracheoesophageal fistula from tumor invasion
palliative methods for esophageal cancer
esophageal stent, gastrostomy tube, radiation, palliative resection, supportive care
what type of tumor a/w weakness and double vision (in thorax/mediastinum)
thymoma a/w Myasthenia gravis
lymphoma tx
rad + chemo
common tumors of anterosuperior mediastinum
thymomas, lymphomas, germ cell tumors
common tumors of middle mediastinum
cysts (bronchiogenic/pericardial), lymphomas, mesenchymal
common tumors of posterior mediastinum
neurogenic neurilemomas from nerves and nerve sheaths
