NSCLC Flashcards
What is the gold standard of mediastinal lymph node evaluation?
Mediastinoscopy
What is the positive predictive value of PET for mediastinal lymph node disease?
56%
Is mediastinoscopy necessary for IA disease?
No. The overwhelming majority will not have N2 disease.
What percentage of T2-4 patients with a negative mediastinum in CT/PET have occult nodal metastasis?
15%.
How does 5Y survival of sleeve lobectomy compare to pneumonectomy.
Sleeve 52% vs pneumonectomy 31%
How does operative mortality of sleeve lobectomy compare to pneumonectomy.
Sleeve 1.6% vs pneumonectomy 5.3%
Operative mortality of completion pneumonectomy?
21%
How does wedge resection generally compare to lobectomy?
Higher rate of local recurrence despite negative margins and a trend toward reduced survival.
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T3 size? Location?
- 7 cm
- separate nodule, same lobe
- Parietal pleura, chest wall, diaphragm, phrenic nerve, mediastinal pleura, parietal pericardium, main bronchus less than 2 cm from the carina
T4
Any size that invades the mediastinum, heart, great vessels, trachea, recurrent laryngeal nerve, esophagus, vertebral body, carina, separate tumor in different ipsilateral lobe.
Ipsilateral hilar nodes are?
N1: ipsilateral peribronchial and/or ipsilateral hilar lymph nodes and intrapulmonary nodes, (including involvement by direct extension)
Subcarinal lymph nodes represent? Minimum stage?
N2, IIIA
N2: ipsilateral mediastinal (two, four, seven, eight, nine) or subcarinal lymph nodes.
Ipsilateral scalene lymph nodes represent? Minimum stage? Most aggressive treatment?
N3, IIIB
N3: contralateral mediastinal, contralateral hilar, ipsilateral or contralateral scalene, or supraclavicular lymph nodes
What structure separates level two from level four lymph nodes?
Innominate vein
What level are the lymph nodes on the anterior surface of the SVC?
3a (prevascular)
What station are the lymph nodes in the tracheoesophageal groove?
3p (retrotracheal)
What station are the lymph nodes in the aortopulmonary window around the ligamentum arteriosum?
5 (subaortic)
What station on the lymph nodes on the a sending aorta and or phrenic nerve?
6 (para-aortic)
What station are the lymph nodes along the esophagus below the level of the carina?
8 (paraesophageal)
What station of the lymph nodes in the pulmonary ligament?
9
What station would a lymph node be at the division of a lobar bronchus?
12 (lobar)
N1- minimum stage 2a
What station would a lymph node be at the division of a segmental bronchus?
13 (segmental)
N1- minimum stage 2a
What station would a lymph node be at the division of a subsegmental bronchus?
14 (subsegmental)
N1- minimum stage 2a
What station are hilar lymph nodes?
10
N1- minimum stage 2a.
What station are interlobar lymph nodes? (Those in the fissure)
11
N1- minimum stage 2a
Is there any evidence to support the use of adjuvant or neoadjuvant radiation therapy for chest wall invasion?
Not outside of Pancoast tumors. The majority of studies have not demonstrated any improvement in survival.
Evidence supporting adjuvant chemotherapy for chest wall invasion?
No significant data to support use either way.
Induction chemoradiation improves resectability and overall survival in Pancoast tumors.
What are the main reasons to reconstruct the chest wall?
- Protect underlying structures
2. Prevent paradoxical chest wall motion and respiratory compromise
What is the best material for reconstruction of large defects with chest wall and stability?
Combination of Marlex mesh and methylmethacrylate
What is the best material for chest wall reconstruction of smaller defects (less than three ribs or 5 cm)?
Taught Marlex mesh or gore-tex patch closure
At what rib level on the posterior chest do you need to reconstruct in order to prevent the scapula from falling into the chest?
5th rib or lower
Does the chest wall resection of two ribs spaces require reconstruction?
No. Very small defects of 1 to 2 ribs and defects located posteriors or beneath the scapula usually do not require reconstruction
What is the most common presenting symptom for patients with superior sulcus tumors?
Shoulder or chest wall pain.
Which nerve roots are most likely invaded by superior sulcus tumors? What symptoms are elicited?
C8-T1
Radicular pain or ulnar neuropathy.
C8 dermatome is posteromedial arm down to fingers 4/5. Contributes to sensory portions of all nine median nerves. Also supplies dorsal motor nerves of the arm and shoulder.
T1 is medial arm down to the wrist.
What is Horner’s syndrome? What anatomic structure is responsible for these findings? Is it on the ipsilateral or contralateral side of pathology?
- ptosis (droopy eyelid),
- +/- anhydrosis.
- Ipsilateral miosis (constricted pupil),
- enophthalmus (posterior eye displacement)
Oculosympathetic palsy.
Usually related to invasion of the Stellate ganglion (@C7, superior to the neck of the first rib- fusion of inferior cervical ganglion and first thoracic ganglion).
What structures are frequently invaded by superior sulcus tumors?
Brachial plexus, subclavian vessels, or spine
What is the best imaging study to identify brachial plexus or spine invasion?
MRI
What is the easiest way to obtain a diagnosis of a superior sulcus tumor?
Transcutaneous needle biopsy under CT guidance.
What percentage of superior sulcus tumors are non-small cell lung cancer?
95%.
5% are small cell carcinoma with vastly different therapeutic options.
Why is tissue biopsy for superior sulcus tumors necessary?
Induction therapy has become the standard of care for superior sulcus tumors.
Large bore (core needle) biopsies may allow for immunohistochemical or genetic mutation studies to guide therapy.
Is surgical mediastinal staging necessary prior to defend your perception of superior sulcus tumors?
Yes.
Many centers routinely perform mediastinoscopy and supraclavicular lymph node biopsy to rule out N2 or N3 disease which would preclude surgical resection.
Your superior sulcus tumor has received chemo radiation. What now?
Restage with PET/CT, brain MRI
and mediastinal lymph node evaluation if suspicious.
How long after neoadjuvant therapy should you wait to proceed with definitive resection?
4 to 6 weeks after induction therapy
as long as restaging rules out metastatic disease.
What are absolute contraindications to resection of a superior sulcus tumor?
- N2/3 disease,
- extensive vascular invasion,
- brachioplexus involvement > than C8 and T1,
- multiple level spinal involvement with extension into the spinal canal.
What structures should be included in the en bloc resection of a superior sulcus tumor?
Upper lobe en-bloc with involved ribs and other structures including transverse processes, the lower roots of the brachioplexus, the stellate ganglion, and the upper dorsal sympathetic chain.
What structures are at risk during interior division of the first rib during the Shaw Paulson resection?
Brachial plexus comes over first rib superior to the intersection of the scalene and serratus anterior muscle attachments. The subclavian artery is anterior to the brachial plexus.
Name the structures found immediately superior to the first rib, anterior to posterior.
Subclavian vein, phrenic nerve, anterior scalene, subclavian artery, brachial plexus, middle scalene, long thoracic nerve, posterior scalene, levator scapulae.
Where is the stellate ganglion?
Posterior to the brachial plexus on the surface of the C7 and T1 vertebrae
NSCLC accounts for ___% of all new lung cancer diagnoses.
80%
