surgical management of lung cancer

Question 1

when my surgery to remove a lung cancer be turned down?

Answer 1

• if lung function is too low for the patient to survive with a lung or lobe removed
• metastases present or other reasons that mean all cancer cannot be removed

Question 2

what is phrenic nerve palsy?

Answer 2

a cancer invades a phrenic nerve, meaning that one side of the diaphragm is not innervated so sits much higher than normal

Question 3

are tumours invading the trachea operable?

Answer 3

no

Question 4

what are some metastatic sites for lung cancer?

Answer 4

brain
liver
bone eg. vertebrae
adrenal glands
lung

Question 5

what are the signs in the history that can help stage lung cnacer?

Answer 5

pain, especially bony pain
headaches or neurological symptoms including personality change
haematuria (blood in urine)

Question 6

what features on examination help to stage lung cancer?

Answer 6

• recurrent laryngeal nerve palsy
• brachial plexus palsy
• SVCO (superior vena cava obstruction)
• supraclaviclar lymph nodes
• soft tissue nodules
• chest wall masses
• pleural/pericardial effusion
• hepatomegaly

Question 7

what can be looked for in a CXR to stage lung cancer?

Answer 7

pleural effusion
chest wall invasion
phrenic nerve palsy
collapsed lobe or lung
size

Question 8

what blood tests can be used to stage cancer and what do they show?

Answer 8

-anaemia cancer causing severe blood loss
abnormal LFTs (liver function tests) (?liver metastases)
abnormal bone profile (?bone metastases)

Question 9

what can CT scanning be useful to find out about a lung cancer to stage it?

Answer 9

• size of tumour
• mediastinal nodes
• metastatic disease
• proximity to mediastinal structures
• pleural/pericardial effusion
• diaphragmatic involvement

Question 10

what is MRI useful for when staging lung cancer?

Answer 10

determining the degree of vascular and neurological involvement in pancoast tumour

Question 11

what is a bone scan useful for when staging lung cancer?

Answer 11

good test for chest wall invasion and bony metastases

Question 12

what is an echocardiogram useful for when staging lung cancer?

Answer 12

will demonstrate the presence or absence of pericardial effusion

Question 13

what surgical methods are used to stage lung cancer?

Answer 13

bronchoscopy

mediastinoscopy

Question 14

what cvs conditions may affect a patients fitness for surgery?

Answer 14

• angina
• heart problems
• HBP
• diabetes mellitus
• peripheral vascular disease
• smoking
• stroke or transient ischaemic attack
• carotid bruits (cystolic noises heard in catotid artery)
• previous coronary artery bypass graft
• angioplasty (widening or coronary artery)
• heart murmurs

Question 15

what respiratory conditions may affect a patient’s fitness for surgery?

Answer 15

barrell-chested
COPD
smoking
asthmatic
recent URTI
on oxygen
exercise capacity
previous thoracotomy or ICD (implantable cardioverter-defibrillator)

Question 16

what psychological conditions may affect a patient’s fitness for surgery?

Answer 16

• PH of mental illness
• severe anxiety
• social background
• chronic pain problems

Question 17

what are some ‘other’ conditions that will affect a patient’s fitness for surgery?

Answer 17

-Pulmonary hypertension
-permanent
tracheostomy
-rheumatoid arthritis
-immobile patient Cirrhosis
h/o radiotherapy to chest

Question 18

what are some respiratory function tests used to assess fitness for surgery?

Answer 18

• spirometry
• diffusion studies eg. CO study
• fractionated V/Q scan
• arterial blood gas

Question 19

which tests can be done to test fitness for surgery (in terms cvs)?

Answer 19

ECG
ECHO
CT scan
ETT (exercise tolerance test)
Coronary angiogram

Question 20

what is the ultimate goal of surgical treatment of lung cancer?

Answer 20

curative resection by removing the minimum amount of lung

Question 21

is resection of the parietal structures faesible?

Answer 21

yes

Question 22

what is highly desirable before resection?

Answer 22

firm diagnosis of malignancy

Question 23

what are the reasons for post operative death?

Answer 23

• adult respiratory distress syndrome (fluid collects in the lungs)
• Bronchopneumonia
• Myocardial Infarction
• PTE (pulmonary thromboembolism)
• Pneumothorax
• Intrathoracic bleeding

Question 24

what are some non-fatal complications of lung cancer?

Answer 24

• Post thoracotomy wound pain
• Empyema
• BPF (broncho-pleural fissula, stitches/ staples loosen and air leaks into interpleural space
• Wound infection
• AF-atrial fibrilation
• MI
• Post-op respiratory insufficiency
• Gastroparesis/constipation

Question 25

what are some conditions that can be mistaken for lung cancer?

Answer 25

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

Question 26

what are some problems with staging lung cancer?

Answer 26

• Collapse of a lobe or lung makes tumour size difficult to assess
• Presence of another (usually small) pulmonary nodule
• Retrosternal thyroid
• Adrenal nodule
• CT head is not routinely performed pre-op