Surgical management of lung cancer

Question 1

What might be included in the history for someone with lung cancer ?

Answer 1

Pain
Headaches
Neurological symptoms
Haematuria

Question 2

What might you notice during an examination of someone with lung cancer ?

Answer 2

Recurrent laryngeal nerve palsy 
Brachial plexus palsy 
SVCO
Supraclavicular LN
Soft tissue nodules
Chest wall masses 
Pleural/pericardial effusion
Hepatomegaly

Question 3

What can a chest X-ray indicate ?

Answer 3

Pleural effusion
Chest wall invasion
Phrenic nerve palsy
Collapsed lobe or lung

Question 4

What can blood tests indicate ?

Answer 4

Anaemia
Abnormal LFTs (liver function tests)
Abnormal bone profile

Question 5

What does a CT scan show you ?

Answer 5

The size of the tumour
Mediastinal nodes
Metastatic disease (other parts of the lungs, liver, adrenals or kidneys)
Proximity to mediastinal structures
Pleural/pericardial effusion
Diaphragmatic involvement

Question 6

What other tests besides X-ray, blood tests and CT scans might help a diagnosis ?

Answer 6

MRI:
- determining the degree of vascular and neurological involvement in Pancoast tumour
Bone scan:
- chest wall invasion and for bony metastases
ECHO:
- demonstrate presence or absence of significant pericardial effusion

Question 7

What are the surgical methods of lung cancer staging ?

Answer 7

Bronchoscopy

Mediastinoscopy

Question 8

What considerations would you have to make before operating ?

Answer 8

CVS-angina
        - HBP
        - PVD
        - stroke
        - TIA
        - bruits 
        - murmurs 
Respiratory- barrel chested 
                   - COAD
                   - smoker
                   - asthmatic
                   - URTI
Psych-mental illness
          - anxiety 
          - social background
          - chronic pain problems 
Others- pulmonary hypertension
            - permenant tracheostomy 
            - rheumatoid arthritis 
            - cirrhosis

Question 9

What are the respiratory function tests needed to assess fitness for surgery ?

Answer 9

Spirometry
Diffusion studies
ABG on air/SLV
Fractioned V/Q scan

Question 10

How do you assess someone’s heart before surgery ?

Answer 10

ECG - (electrocardiogram)
ECHO - echocardiography - ultrasound of the heart
CT scan
ETT - (exercise tolerance test, exercise ECG)
Coronary angiogram

Question 11

If in doubt ?

Answer 11

Do not operate

Question 12

What is the goal of surgery ?

Answer 12

Curative resection, removing minimal tissue

Question 13

What must be determined before resection ?

Answer 13

Firm diagnosis of malignancy

Question 14

Is resection of the parietal structures possible ?

Answer 14

Yes, feasible

Question 15

What is peri-operative death ?

Answer 15

Death within 2 weeks of a surgical procedure

Question 16

What are the reasons for peri-operative death?

Answer 16

ARDS
Bronchopneumonia
Myocardial Infarction
PTE
Pneumothorax
Intrathoracic bleeding

Question 17

What non-fatal complications exist after an operation ?

Answer 17

Pain
Empyema
BPF
Wound infection
AF
MI
Post-op respiratory insufficiency
Gastroparesis/constipation.

Question 18

When is it difficult to assess the size of a tumour ?

Answer 18

Because of collapse of a lobe or lung

Question 19

What are the commonest problems with staging of lung cancer ?

Answer 19

Presence of another pulmonary nodule
Retrosternal thyroid
Adrenal Nodule

Question 20

When might be confused for cancer ?

Answer 20

Infection:
    - TB
    - lung abscess
Benign tumour:
    - hamartoma
Granuloma:
    - sarcoid
    - Wegener's rheumatoid nodule
    - inflammatory pseudotumor
Fibrosis:
    - PMF
    - organising pulmonary infarct
Other:
    - paraffinoma