Surgical management of cancer

Question 1

Why wouldn’t people be suitable for surgery?

Answer 1

Many reasons:
If tumour has spread (many metastases)
If tumour attached to main structures
If they aren’t fit enough other health wise e.g. smokers have increased risk of ischemic heart disease/COPD

Question 2

Of those that undergo surgery, how many are cured?

Answer 2

About 50%

Question 3

Where are hila lymph nodes?

Answer 3

Within the lung, located in the area where the bronchus enters the lung.

Question 4

Can lymph node involvement be responsible for phrenic nerve palsy and recurrent laryngeal nerve palsy?

Answer 4

yes

Question 5

What does the left recurrent larryngeal nerve hook around? What does it innvervate?

Answer 5

Ligamentum arteriosum - within the aorto-pulmonary window which links between arch of aorta and left pulmonary artery. Innervates the left vocal chord.

Question 6

Common metastases locations

Answer 6

Brain, bones, liver, adrenals, controlateral lung

Question 7

Are metastases painful? Can you get a personality change?

Answer 7

Yes, they can be v painful, esp brain and bones. You can get personality change if metastases in the brain.

Question 8

What is Pancost syndrome?

Answer 8

Tumour invades brachial plexus, leading to weakness/numbness down one arm.

Question 9

Chances of permanent cure for surgical removal metastases?

Answer 9

Low, about 25%

Question 10

If there is plural effusion what are your concerns? Would you perform surgery?

Answer 10

Is it malignant? If so surgery would not get rid of disease.

Question 11

Chest wall invasion resected reconstructed with?

Answer 11

Pericardial patch

Question 12

Is phrenic nerve palsy operable? Why?

Answer 12

No, because it means that there is extensive invasion of mediastinum

Question 13

Careful of what re collapsed lung?

Answer 13

What extent the tumour is - PET scanning can help with this.

Question 14

Bone marrow involvement signs?

Answer 14

Anaemia

Altered bone profile

Question 15

What goesup when there is liver met or bone met?

Answer 15

Alkaline phosphatase

Question 16

When can the diaphragm be resected?

Answer 16

Only if central portion is the part which has been invaded. Not if it is the costophrenic recess parts!

Question 17

What does an ECHO show for all patients who are being considered for surgery?

Answer 17

Heart health and if there is pulmonary hypertension., also any pericardial effusion, which could be malignant.

Question 18

Criteria for pneumectomy if tumour in bronchus

Answer 18

Approx 2cm clear of carina (down the way)

Question 19

What is mediastinoscopy?

Answer 19

Small incision in the sternal notch, telescope inserted adjacent, anteriorly and laterally to trachea - where we may find lymph nodes - can take biopsies.

Question 20

Factors affecting fitness for surgery

Answer 20

Cardiovascular health
e.g Angina/HBP/Smoking/Stroke/TIA/previous CABG (coronary artery bypass surgery)/angioplasty

Respiratory health
still smoking/exercise capacity/barrell chested/COPD/recent URTI/Asthmatic

Mental health.
due to severe pain after operation and on recovery

Others
eg pulmonary hypertension, chirrhosis, rheumatoid arthritis, immobile patient

Question 21

What is a well known cause of death in surgery and it risk factor, how is this picked up?

Answer 21

Damage to pulmonary arteries, as they are thinned walled, patient bleeds to death. Often in patients with pulmonary hypertension, which is picked up with an echo scan.

Question 22

Why is cirrhosis considered?

Answer 22

Liver excretes fat soluble poisons.
Surgery causes fat soluble poisons, a lot of cellular debris, which contains fats.
Additionally if become infected post op, bacteria release endotoxins, usually fat soluble substances broken down by liver. If not broken down, cause systemic vasodilation - shock - death.

Question 23

Lung function testing done before – what types and what expected

Answer 23

Spirometry
Diffusion studies

May do ABG on air/SLV
Fractionated V/Q scan (patient inhales Xenon- shows up as inhaled part on scan, and injected with technetium -shows blood distribution) - can work out what post operative lung function would be.

We want FEV of greater than 1 litre in an adult post operatively.

Question 24

What test for coronary arterty calcifications?

Answer 24

Coronary angiogram

Question 25

What are the different types of operations

Answer 25

Wedge
Segementectomy
lobar
pneumonectomy

Question 26

What are the common cause of deaths and reasons

Answer 26

#1 = Adult respiratory distress syndrome, most common cause = activated interstitial lung disease - mortality rate 50%
Infection - death from bronchopneumonia
Blood loss - intrathoratic bleeding
Myocardial infarction
Embolism and pneumothorax

Question 27

What other complications can occur post surgery

Answer 27

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

Question 28

What is Broncho pleural fistula?

Answer 28

Post pneumonectomy, negative pressure in chest, some fluid in. If air gets sucked in from negative pressure. Causes repeated chest infections due to leaky fluid, chronic chest strain and if air hole is large then inefficient breathing.

Question 29

Are most adrenal nodules cancerous?

Answer 29

No, they can often be benign

Question 30

What are the mortality rates post operatively

Answer 30

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

Question 31

Not lung cancer, what could it be?

Answer 31

Infection - TB, Lung abscess
Benign tumour - Hamartoma
Granuloma - Sarcoid, Wegener’s, Rheumatoid nodule, inflammatory pseudotumour
Fibrosis - PMF, organising pulmonary infarct
Other - Paraffinoma