Surgical management of lung cancer Flashcards
What history signs help with staging lung cancer?
Pain (especially bone pain)
Headaches or neurological symptoms (e.g. personality changes)
Haematuria
What examination signs help with staging lung cancer?
Recurrent laryngeal nerve palsy
Brachial plexus palsy
SVCO
Supraclavicular LNs
Soft tissue nodules
Chest wall masses
Pleural/pericardial effusion
Hepatomegaly
What are you looking for on a CXR?
Pleural effusion
Chest wall invasion
Phrenic nerve palsy
Collapsed lob/lung
What does phrenic nerve palsy show?
Extensive invasion of the mediastinum
Not inoperable
What can collapsed lobe or lung show?
Extent of tumour via PET scanning
How much collapsed lung is tumour or normal tissue
What blood tests would you do when staging/diagnosing lung cancer?
Anaemia
Abnormal LFTS
Abnormal bone profile
What does anaemia show in terms of lung cancer?
If anaemic then likely metastasis to the bone, there would be abnormal uptake in the skeleton consistent with metastatic disease.
What does a PET CT scan show?
Areas of high metabolic activity
- Metastatic tumours
What other tests can be done to stage lung cancer?
MRI
Bone scan
ECHO
What does an MRI tell us about lung cancer?
Useful in determining the degree of vascular and neurological involvement in Pancoast tumour.
What can a bone scan tell us about lung cancer?
Checks for chest wall invasion and for bony metastasis
What does an ECHO show us?
Demonstrates presence or absence of significant pericardial effusion
What are the means of surgical staging?
Bronchoscopy
Mediastinoscopy
What is the most important factor in assessing fitness for surgery?
Do they have heart or respiratory problems
What heart problems are of note in terms of fitness?
Angina
HBP
Diabetes (DM)
Peripheral vascular disease (PVD)
Stroke
Carotid bruits
Previous CABG/angioplasty
Heart murmurs
What respiratory problems are of note in terms of fitness?
Barrel chested
COAD
Still smoke
Asthmatic
Recent URTI
On oxygen
Exercise capacity
Previous thoracotomy or ICD
What are the key psychiatric issues to determine before surgery?
History of mental illness
Sever anxiety
Social background
Chronic pain problems
What other factors need to be assessed in assessing fitness for surgery?
Pulmonary hypertension
Permanent tracheostomy
Rheumatoid arthritis
Immobile patient
Cirrhosis of liver - reject for surgery, suggest radiotherapy instead
h/o radiotherapy to chest
What routine lung function tests are done on surgery patients?
Spirometry
Diffusion studies
ABG on air/SLV
Fractionated V/Q scan
What investigations are done in cardiac assessment?
ECG
ECHO
CT scan
ETT (exercise test)
Coronary angiogram
What are the aims of surgical treatment?
Curative resection
Remove minimum amount of lung tissue
Resection of parietal structures is feasible
Firm diagnosis of malignancy is highly desirable before lung resection
What are some reasons for pre-operative death?
ARDS - adult respiratory distress syndrome
Bronchopneumonia
Myocardial infarction
PTE
Pneumothorax
Intrathoracic bleeding
What are some non-fatal complications of surgery?
Wound pain
Empyema
BPF = broncho pleural fistula
Wound infection
AF
MI
Post-operative respiratory insufficiency
Gastroparesis/constipation
What are some common problems encountered when staging tumours?
Collapse of a lobe or lung makes tumour size difficult to assess
Presence of another pulmonary nodule
Retrosternal thyroid
Adrenal nodule
What are the common 4 procedures performed on lung cancer patients and what are the mortality rates?
Pneumonectomy 5-10%
Lobectomy 3-5%
Wedge resection 2-3%
Open/close thoracotomy 5%
What are some differential diagnosis’s of lung cancer?
Infection
○ Lung abscess
○ TB
Benign tumour
○ Hamartoma
Granuloma
○ Sarcoid
○ Wegener’s
○ Rheumatoid nodule
○ Inflammatory pseudotumor
Fibrosis
○ PMF
○ Organising pulmonary infarct
Paraffinoma
