Surgical Management of Lung Cancer

Question 1

When is surgery not used for treatment?

Answer 1

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 blood tests can be done to stage lung cancer?

Answer 2

FBC - anaemia
Abnormal LFTs
Abnormal bone profile

Question 3

What other features of the tumour are used to stage the lung cancer?

Answer 3

Size of tumour
Mediastinal nodes
Metastatic disease - other parts of lungs, liver, adrenals, kidneys
Proximity to mediastinal structures
Pleural/pericardial effusion
Diaphragmatic involvement

Question 4

Why are MRIs useful in staging of lung cancer?

Answer 4

Determines degree of vascular and neurological involvement in pan coast tumour

Question 5

Why is a bone scan useful in staging lung cancer?

Answer 5

Shows chest wall invasion and bony metastases

Question 6

Why is an ECHO a useful investigation to stage lung cancer?

Answer 6

Presence or absence of significant pericardial effusion

Question 7

What are the signs in the history that can help stage lung cancer?

Answer 7

Pain - bony pain
Headaches
Neurological symptoms: personality change
Haematuria (blood in urine)

Question 8

What are the signs in the examination that can help stage lung cancer?

Answer 8

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

Question 9

What should be looked out for in a CXR to stage lung cancer?

Answer 9

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

Question 10

What surgical methods can be used to stage lung cancer?

Answer 10

Bronchoscopy

Mediastinoscopy

Question 11

What CVS conditions might affect a patient’s fitness for surgery?

Answer 11

Angina
Heart problems
High BP
Diabetes M
Peripheral vascular disease
Smoking 
Stroke/TIA
Carotid bruits
Previous CABG/angioplasty 
Heart murmurs

Question 12

What respiratory conditions might affect a patient’s fitness for surgery?

Answer 12

Barrell-chested
COAD
Smoking 
Asthmatic 
Recent URTI 
On O2
Previous thoracotomy or ICD (defibrillator)

Question 13

What psychological conditions may affect a patients fitness for surgery?

Answer 13

PH of mental illness
Severe anxiety
Social background
Chronic pain problems

Question 14

What other conditions can affect a patients fitness for surgery?

Answer 14

Pulmonary hypertension
Tracheostomy 
Rheumatoid arthritis 
Immobile patients 
Cirrhosis

Question 15

What test are carried out for respiratory function testing to determine fitness for surgery?

Answer 15

Spirometry
Diffusion studies (with CO)
ABG on air (PCO2 levels with room air)
Fractionated V/Q scan

Question 16

What investigations are carried to assessment the heart for fitness for surgery?

Answer 16

ECG
ECHO 
CT scan 
ETT
Coronary angiogram 
If in doubt, don't operate

Question 17

What are the aims of surgical treatment for lung cancer?

Answer 17

Curative resection
Remove the minimum amount of lung tissue
Resection of parietal structures is feasible
Firm diagnosis of malignancy before lung resection

Question 18

What are reasons for pre-operative death?

Answer 18

ARDS
Bronchopneumonia
MI
PTE
Pneumothorax 
Intrathoracic bleeding

Question 19

List non-fatal complications of surgery for lung cancer?

Answer 19

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

Question 20

What are common problems with staging of lung cancer?

Answer 20

Collapse of a lobe or lung makes tumour size difficult
Presence of another pulmonary nodule
Retrosternal thyroid
Adrenal nodule

Question 21

What can the mass that was thought to be a tumour end up to be?

Answer 21

Infection - TB, lung abscess
Benign tumour - hamartoma
Granuloma
Fibrosis 
Other - paraffinoma