surgical management of lung cancer Flashcards
when is surgery the treatment of choice
early and localised lung cancer
patient can make a full recovery
what are the 2 stages in assessing a patient for surgical management of lung cancer
staging of the lung cancer
fitness of the patient
what does T status involve
site of tumour
size of tumour
involvement of mediastinum and chest wall
what does N status involve
lymph node involvement
describe the general spread of cancer in the lungs
within the lung that it originated in
ipsilateral regional lymph nodes in the mediastinum
contralateral lymph nodes
other tissues in the body
N2 status
lots of nodes found in the aortic pulmonary window
phrenic nerve palsy can indicate these lymph nodes are involved
M status
metastases look at brain look at same lung (different lobes) or other lung adrenal gland liver bones
Whole body CT to look for distant mets
what is the most common presentation for early stage lung cancer
persistent cough
how are lots of early stage lung cancers diagnosed
incidentally
red flag symptoms
weight loss
fatigue
night sweats
loss of appetite
clinical staging of lung cancer
hx: pain (bony), headaches or neurological symptoms
examination: recurrent laryngeal nerve palsy, brachial plexus palsy, SVCO, supraclavicular LNs, soft tissue nodules, chest wall masses, pleural/pericardial effusion, hepatomegaly
is surgical treatment helpful in SCLC
very aggressive and invasive cancer
lots of mets
surgical treatment isn’t helpful
staging of lung cancer on CXR
pleural effusion
chest wall invasion
phrenic nerve palsy
collapsed lobe or lung
staging of lung cancer - bloods
anaemia
abnormal LFTs - liver mets
abnormal bone profile - bone mets
staging of lung cancer on CT
size of tumour mediastinal nodes mets proximity to mediastinal structures pleural/pericardial effusion diaphragmatic involvement
lymph node appearance on CT
enlarged = >1cm
homogenous enlargement = unlikely to be lung cancer
PET scanning
highlights high metabolic rates of tumours in the body
useful for diagnosing nodal activity in the mediastinum
MRI for staging
useful for determining the degree of vascular and neurological involvement
bone scan for staging
chest wall invasion
bone mets
ECHO for staging
demonstrates presence of absence of significant pericardial effusion
L ventricle function and R ventricle strain (hypertension)
bronchoscopy surgical staging
most common
sample tumours of the airway
EBUS to sample mediastinal lymph nodes
mediastinoscopy surgical staging
sample lymph nodes
more open procedure
clinical assessment of fitness for surgery
CVS
Resp
psych
other
clinical assessment of fitness for surgery CVS
angina heart problems HT DM PVD smoking stroke/TIA carotid bruits prev CABG/angioplasty heart murmurs
independence with adlS
clinical assessment of fitness for surgery resp
barrel chested COPD smoker asthma recent URTI on oxygen exercise capacity prev thoracotomy or ICD
clinical assessment of fitness for surgery psych
lung cancer surgery can be a big operation - depression post-op isn't uncommon PH of mental illness severe anxiety social background chronic pain problems
clinical assessment of fitness for surgery other
pulmonary HT - higher risk of post-op bleed
immobility
liver cirrhosis - can have severe post-op septic shock episodes
hx of radiotherapy to the chest - inflammation
fitness for surgery respiratory function testing
spirometry - FEV1, predictive post-op FEV1
diffusion studies - amount of oxygen absorbed and used by the lung
ABG on air/SLV
fractionated V/Q scan
fitness for surgery cardiac assessment
ECG echo CT - coronary and aortic calcification ETT - exercise tolerance test coronary angiogram
what is the goal of surgical treatment of lung cancer
curative resection
remove the minium amount of lung tissue to maximise post-op function
firm diagnosis of malignant is highly desirable before resection
why is minimally invasive surgery more commonly used
quicker recovery
reduced pain than with thoracotomy
less incidents of chronic neuropathic pain in the long term
reasons for peri-operative death
Acute respiratory distress syndrome bronchopneumonia MI PTE pneumothorax intrathoracic bleeding
acute respiratory distress syndrome
acute inflammation of both lungs
usually due to the stress of the operation
reduced ventilation and severe hypoxaemia
difficult to ventilate once intubated
why can bronchopneumonia occur post-op
not able to take a deep breath due to pain to be able to cough out
why can MI occur post-op
heart needs to pump the same amount of blood to more resistance following resection
heart is under more stress
what measures can be taken to prevent PTE
compression stockings
heparin injections
non-fatal complications of surgery
post thoracotomy wound pain empyema BPF wound infection AF - common after pneumonectomy MI post-op respiratory insufficiency gastroparesis/constipation
BPF
bronchopleural fistula
increases chance of infection
gastroparesis/constipation post-op
due to morphine/analgesia
abdomen becomes distended
compresses base of lungs
prone to infection
commnest problems with staging of lung cancer
collapse of lobe or lung makes tumour size difficult to assess
presence of another pulmonary nodule changes staging
retrosternal thyroid
adrenal nodule
MORTALITY pneumonectomy lobectomy wedge resection open/close thoracotomy
pneumonectomy 5-10%
lobectomy 2%
wedge resection <1%
open/close thoracotomy 5%
5YS post-op
T1N0 70% T2N0 60% T3N0 50% T1N1/T2N1 40% N2 16% chance of 2nd 1y 5%
