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Thoracic Surgery > NSCLC > Flashcards

NSCLC Flashcards

0
Q

NSCLC accounts for ___% of all new lung cancer diagnoses.

A

80%

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1
Q

What is the gold standard of mediastinal lymph node evaluation?

A

Mediastinoscopy

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2
Q

___% of patients diagnosed with NSCLC are eligible for resection.

A

35%

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3
Q

What is the five year survival of a complete resection if stage I disease?

A

70%. 80% of these patients never have a recurrence. 15-20% die within five years from causes unrelated to their NSCLC.

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4
Q

What is the five year survival of a complete resection if stage IIa disease?

A

About 55%.

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5
Q

What is the five year survival of a complete resection if stage IIB disease?

A

40%

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6
Q

What is the five year survival of a complete resection if stage IIIA disease?

A

25-39%

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7
Q

What is the five year survival of a complete resection if stage IIIB disease?

A

About 6%

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8
Q

What is the five year survival of a complete resection if stage IV disease?

A

1-7%. Rami-Porta did report a survival of 25%, but the number of patients was low (n=27). A much larger series by Mountain (n=1427) had only a 1% survival.

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9
Q

How often does PET prevent no therapeutic thoracotomy?

A

6.3%

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10
Q

What is the positive predictive value of PET for mediastinal lymph node disease?

A

56%

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11
Q

Is mediastinoscopy necessary for IA disease?

A

No. The overwhelming majority will not have N2 disease.

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12
Q

What percentage of T2-4 patients with a negative mediastinum in CT/PET have occult nodal metastasis?

A

15%.

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13
Q

How does lobectomy compare to lesser resections (wedge or segmentectomy) for stage I disease in the Lung Cancer Study Group?

A

Local recurrence better in lobectomy (6.4 vs 17.2%). Overall survival also better with lobectomy. Long term survival was reduced by 30% in the group receiving lesser resections.

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14
Q

How does 5Y survival of sleeve lobectomy compare to pneumonectomy.

A

Sleeve 52% vs pneumonectomy 31%

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15
Q

How does operative mortality of sleeve lobectomy compare to pneumonectomy.

A

Sleeve 1.6% vs pneumonectomy 5.3%

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16
Q

Operative mortality of completion pneumonectomy?

A

21%

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17
Q

Keenan and colleagues reported 4 year survival of anatomic segmentectomy vs lobectomy?

A

67 vs 62%. The text doesn’t say whether they were randomized or not.

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18
Q

How does wedge resection generally compare to lobectomy?

A

Higher rate of local recurrence despite negative margins and a trend toward reduced survival.

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19
Q

What are contraindications to VATS Lobectomy?

A

Inability to tolerate one lung ventilation, large tumor >4cm, a fused pleural space, established N2 disease.

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20
Q

Is there a difference in LN met detection in LN sampling vs dissection?

A

ECOG group: They are equivalent for detecting N1 and N2 disease, but dissection detected more levels of N2 disease and suggested a survival advantage for stages II and IIIA NSCLC.
This was corroborated by a Chinese study demonstrating median survival of complete dissection being 59 months vs 34 months in the nodal sampling group (P<.05).

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21
Q

What % of patients without metastatic disease in CT are found to have metastatic disease on PET?

A

6%

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22
Q

How often does PET give a false positive?

A

6.6%

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23
Q

How does the sensitivity of PET compare to CT in detection of lymph node metastasis?

A

42 v 13% (P=.02)

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24
Q

What is the negative predictive value of PET for mediastinal node disease?

A

87%

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25
Q

Should stage IB or II receive chemotherapy after complete resection?

A

Yes. There is a significant improvement in recurrence free and overall survival. This effect seems to be true for rumors 4cm or greater. The 15% improvement in survival is more than that observed for many other cancers for which adjuvant chemotherapy has become routine.

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26
Q

After completely respected stage I disease, how many develop a recurrence?

A

20-30%

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27
Q

After completely respected stage I disease, how many develop a solitary brain met?

A

20%

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28
Q

What percentage of stage II patients require pneumonectomy for complete resection?

A

30% Memorial Sloan Kettering series of 214 patients.

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29
Q

Is there a role for adjuvant radiation in R0 Stage II resection?

A

Yes, radiation decreases risk local and regional recurrence, but there is no impact on survival.

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30
Q

Is there a role for adjuvant chemotherapy in R0 Stage II resection?

A

Yes. Medically fit patients should receive adjuvant chemotherapy. A prospective randomized trial in patients with stage II completely resected non-small cell lung cancer have a large survival advantage when treated with postoperative vinorelbine plus cisplatin.
The median survival time was 41 months in the observation group and 80 months in the chemotherapy group (P=.004). NEJM 352:2589, 2005.

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31
Q

Difference in 5 year survival between single or multiple positive lymph nodes in stage two disease?

A

Single: 45%
Multiple: 31%

JTCS 109:120, 1995

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32
Q

T1

A

3 cm or less

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33
Q

T1a

A

2 cm for less

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34
Q

T1b

A

2 to 3 cm

35
Q

T2 size? Location?

A

3 to 7 cm
-or-
Involves main bronchus, visceral pleura involvement, atelectasis or attractive pneumonitis that extends to the hilar region but does not involve the entire lung

36
Q

T2a

A

3 to 5 cm

37
Q

T2b

A

5 to 7 cm

38
Q

T3 size? Location?

A
  • 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
39
Q

T4

A

Any size that invades the mediastinum, heart, great vessels, trachea, recurrent laryngeal nerve, esophagus, vertebral body, carina, separate tumor in different ipsilateral lobe.

40
Q

Ipsilateral hilar nodes are?

A

N1: ipsilateral peribronchial and/or ipsilateral hilar lymph nodes and intrapulmonary notes, including involvement by direct extension

41
Q

Subcarinal lymph nodes represent? Minimum stage?

A

N2, IIIA

N2: ipsilateral mediastinal (two, four, seven, eight, nine) or subcarinal lymph nodes.

42
Q

Ipsilateral scalene lymph nodes represent? Minimum stage? Most aggressive treatment?

A

N3, IIIB

N3: contralateral mediastinal, contralateral hilar, ipsilateral or contralateral scalene, or supraclavicular lymph nodes

43
Q

What structure separates level two from level for lymph nodes?

A

Innominate vein

44
Q

What level are the lymph nodes on the anterior surface of the SVC?

A

3a (prevascular)

45
Q

What station are the lymph nodes in the tracheoesophageal groove?

A

3p (retrotracheal)

46
Q

What station are the lymph nodes in the aortopulmonary window around the ligamentum arteriosum?

A

5 (subaortic)

47
Q

What station on the lymph nodes on the a sending aorta and or phrenic nerve?

A

6 (para-aortic)

48
Q

What station are the lymph nodes along the esophagus below the level of the carina?

A

8 (paraesophageal)

49
Q

What station of the lymph nodes in the pulmonary ligament?

A

9

50
Q

What station would a lymph node be at the division of a lobar bronchus?

A

12 (lobar)

N1- minimum stage 2a

51
Q

What station would a lymph node be at the division of a segmental bronchus?

A

13 (segmental)

N1- minimum stage 2a

52
Q

What station would a lymph node be at the division of a subsegmental bronchus?

A

14 (subsegmental)

N1- minimum stage 2a

53
Q

What station are hilar lymph nodes?

A

10

N1- minimum stage 2a.

54
Q

What station are interlobar lymph nodes? (Those in the fissure)

A

11

N1- minimum stage 2a

55
Q

What are the five-year survival completely resected T4N0

A

Survival 50%

56
Q

What does MSK say about parietal pleural invasion and extent of resection?

A

Extrapleural mobilization of the tumor with development of subpleural plane. If margins were negative, no chest wall resection was performed. Of note, 50% of patients in their series had positive margins.

57
Q

What does Pairolero say about the need for chest wall resection? How does their survival compare to MSK?

A

They stress the need for routine for thickness chest wall resection. They advocate palpation through a rip space above or below the tumor. If the tumor is adherent to the Perot, they respect the overlying ribs and intercostal muscles en block with a margin of 1 to 2 cm. if the adhesions are flimsy, extrapleural resection can be performed.
44% vs 50% for T3 N0 disease. There’s no detectable difference.

58
Q

What percentage of non-small cell lung cancer is involved chest wall invasion?

A

5 to 8%

59
Q

Is there any evidence to support the use of adjuvant or neoadjuvant radiation therapy for chest wall invasion?

A

Not outside of Pancoast tumors. The majority of studies have not demonstrated any improvement in survival.

60
Q

Evidence supporting adjuvant chemotherapy for chest wall invasion?

A

No significant data to support use either way.

Induction chemoradiation improves resectability and overall survival in Pancoast tumors.

61
Q

What are the main reasons to reconstruct the chest wall?

A
  1. Protect underlying structures

2. Prevent paradoxical chest wall motion and respiratory compromise

62
Q

What is the best material for reconstruction of large defects with chest wall and stability?

A

Combination of Marlex mesh and methylmethacrylate

63
Q

What is the best material for chest wall reconstruction of smaller defects (less than three ribs or 5 cm)?

A

Taught Marlex mesh or gortex patch closure

64
Q

At what rib level on the posterior chest do you need to reconstruct in order to prevent the scapula from falling into the chest?

A

5th rib or lower

65
Q

Does the chest wall resection of two ribs spaces require reconstruction?

A

No. Very small defects of 1 to 2 ribs and defects located posteriors or beneath the scapula usually do not require reconstruction

66
Q

What is the most common presenting symptom for patients with superior sulcus tumors?

A

Shoulder or chest wall pain.

67
Q

Which nerve roots are most likely invaded by superior sulcus tumors? What symptoms are elicited?

A

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.

68
Q

What is Horner’s syndrome? What anatomic structure is responsible for these findings? Is it on the ipsilateral or contralateral side of pathology?

A 
Ipsilateral miosis (constricted pupil), ptosis (droopy eyelid), enophthalmus (posterior eye displacement, +/- anhydrosis. 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).
69
Q

What structures are frequently invaded by superior sulcus tumors?

A

Brachial plexus, subclavian vessels, or spine

70
Q

What is the best imaging study to identify brachial plexus or spine invasion?

A

MRI

71
Q

What is the easiest way to obtain a diagnosis of a superior sulcus tumor?

A

Transcutaneous needle biopsy under CT guidance.

72
Q

What percentage of superior sulcus tumors are non-small cell lung cancer?

A

95%. 5% are small cell carcinoma with vastly different therapeutic options.

73
Q

Why is tissue biopsy for superior sulcus tumors necessary?

A

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.

74
Q

Is surgical mediastinal staging necessary prior to defend your perception of superior sulcus tumors?

A

Yes. Many centers routinely perform mediastinoscopy and supraclavicular lymph node biopsy to rule out N2 or N3 disease which would preclude surgical resection.

75
Q

Your superior sulcus tumor has received chemo radiation. What now?

A

Restage with PET/CT, brain MRI and mediastinal lymph node evaluation if suspicious.

76
Q

How long after neoadjuvant therapy should you wait to proceed with definitive resection?

A

4 to 6 weeks after induction therapy as long as restaging rules out metastatic disease.

77
Q

What are absolute contraindications to resection of a superior sulcus tumor?

A

N2/3 disease, extensive vascular invasion, brachioplexus involvement > than C8 and T1, and multiple level spinal involvement with extension into the spinal canal.

78
Q

What structures should be included in the en bloc resection of a superior sulcus tumor?

A

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.

79
Q

Name the three surgical approaches to superior sulcus tumor resection.

A

Shaw Paulson
Dartevelle
Hemiclamshell

80
Q

Describe the Shaw Paulson exposure.

A

Posterolateral thoracotomy, 4th rib space, pleural examination & cytology. If respectable, the incision is extended superiorly toward the midline to the base of the neck. Divide trapezius, rhomboid, and posterior serratus muscles. Elevate the scapula. Divided anterosuperior attachments to the serratus anterior muscle. Divide scalene attachments to first and second ribs. Dissect subclavian artery over midportion of first rib.

81
Q

Describe the first (anterior) portion of the Shaw Paulson chest wall resection.

A

After exposure, 3 cm of Chestwall margin is marked for resection (up to 5 ribs w/ intercostal muscle below). Start anteriorly from lowest to first rib. Develop subperiosteal plane and remove a 2 cm segment of bone (mark orientation for margin). Ligate neurovascular bundles. Develop plane between subclavian vessels and first rib. Use gigli saw to cut first rib.

82
Q

Describe the second (posterior) portion of the Shaw Paulson resection.

A

Posteriorly, the paraspinous musculature elevated from transverse processes. If rib or vertebral body are not involved, the rib is disarticulated. Be careful to ID and ligate the T1 neurovascular bundle which traverses from inferior to superior across the first rib neck. If involved, divide the TP flush to lamina. Posterior retraction of the paraspinous muscle exposes the costotransverse junction. The perverse ram fascia is then liberated caudally. The chest wall should be free at this point to allow anatomic upper lobectomy.

83
Q

What structures are at risk during interior division of the first rib during the Shaw Paulson resection?

A

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.

84
Q

Name the structures found immediately superior to the first rib, anterior to posterior.

A

Subclavian vein, phrenic nerve, anterior scalene, subclavian artery, brachial plexus, middle scalene, long thoracic nerve, posterior scalene, levator scapulae.

85
Q

Where is the stellate ganglion?

A

Posterior to the brachial plexus on the surface of the C7 and T1 vertebrae

86
Q

Describe the incision for the Darteville approach.

A

Anterior approach with an interior transferred one station curved under the head of the clavicle and continuing to fingerbreadths below the clavicle. Resection of the medial half of the clavicle is described in the original operation, however, the sternoclavicular joint can be spared and the clavicle can be elevated with a segment of manubrium to be reattached later. This provides a less morbid resection with a better functional result.

Thoracic Surgery (2 decks)

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