Thoracic

Question 1

Pancoast Tumor

Answer 1

Superior sulcus tumor
apical small cell lung cancer
Cause Pancoast syndrome: Horner syndrome (miosis, ptosis, hypohydrosis/anhydrosis), shoulder pain, arm pain along C8-T1 dermatomes, muscle atrophy in hand (distribution along ulnar nerve)
2/2 invasion or compression of paravertebral sympathetic chain & brachial plexus
Commonly invade chest wall, 1st-3rd ribs, vertebrae

Tx: chemo, rads, surgery (if fit)

Question 2

Lung abscess

Answer 2

~80-90% managed without surgery
Start w/ Abx. Then catheter drainage (perc/peripheral vs bronchoscopic/central) then surgery.

Indications for surgery:

• bronchopleural fistula
• empyema
• bleeding
• failed med tx
• suspicion of malignancy

sxs: hemoptysis 2/2 erosion of infection into blood vessel and airway.

Question 3

Tx of persistent hemothorax

Answer 3

CT if < 24 hours since injury

>24 hours, VATS for evacuation

Question 4

Absolute CIs to surgery for Pancoast Tumors

Answer 4

Distant mets
N2 (mediastinal) or N3 (C/L supraclavicular) disease
>50% vertebral body involvement
Brachial plexus involvement above T1 nerve
Invasion of esophagus or trachea

Question 5

Relative CIs to surgery for Pancoast tumor

Answer 5

N1 or N3 (ipsilateral supraclavicular) disease
Invasion of subclavian artery
<50% vertebral body involvement
Intraforaminal extension
Invasion of CCA or Vertebral artery

Question 6

Pulmonary mets

Answer 6

Sarcomas, melanoma: mets to lung as solitary nodules
Head/neck, breast, colon, renal cell: mets as multifocal lesions
Spread hematogenously; deposit in distal small vessels

Renal cell carcinoma: highest survival benefit after metastasectomy

Best survival benefit seen with:
Single lesion
DFS > 1 year
Normal preop CEA (<5)
No nodal mets
U/L disease

Question 7

Type of pleural effusion

Answer 7

Exudative (PNA, malignancy, infection, chylothorax)

• pleural fluid to serum protein ratio > 0.5
• pleural fluid to serum LDH ratio > 0.6
• pleural fluid LDH [] > 2/3 upper limits of serum reference range

Transudative (CHF - MCC)

Question 8

Muscles involved in forced exhalation (active expiration)

Answer 8

abdominal wall, internal intercostal muscles, diaphragm

Most important are abdominal wall muscles (rectus, obliques, etc) which drive intra-and pressure up

Question 9

Posterior mediastinal tumors

Answer 9

Neurogenic (MC) - Schwannoma, neurofibroma
Malignant tumors (rare) - neuroblastoma, ganglioneuroblastoma

w/u: CT chest –> MRI (assess spinal cord involvement)

Tx: complete resection. If unable to completely resect –> chemo/rads

Question 10

Anterior mediastinal tumors

Answer 10

4Ts

Thymoma
Teratoma
Terrible lymphoma
Thyroid goiter/substernal

Question 11

Middle mediastinal tumors

Answer 11

Pericardiac cyst

Bronchogenic cysts

Question 12

Paraneoplastic syndrome of SCLC

Answer 12

SIADH - hyponatremia, hypoosmolarity

Question 13

Histo of SCLC

Answer 13

High nucleus to cytoplasm ratio, absent nucleoli

Question 14

LNs accessed with cervical mediastinoscopy

Answer 14

2L, 2R, 4L, 4R, 7 (historical gold standard)

Question 15

LNs accessed with VATS

Answer 15

2, 4R, 5, 6, 8, 9

Can also see lung parenchyma and pleura

Question 16

LNs accessed with Esophageal US

Answer 16

Eval stations 7, 8, 9

Question 17

LNs accessed with navigational bronch

Answer 17

Evals stations 1-4, 7, 10-12

Question 18

LNs accessed with EBUS

Answer 18

Visualize superior and inferior mediastinal LNs

Stations 1-4, 7, 10-12