Thoracic Flashcards
What is a good way to remember the thoracic lymph node stations?
single digits are mediastinal, double digits are hilar
Describe the course of the thoracic duct.
the cisterna chili at L2 crosses at T5 from right to left and then empties into the L IJ and subclavian veins
The azygos vein drains into what structure?
the superior vena cava
The thoracic duct is between what two other structure?
the azygos vein and the esphagus
What are the two types of pneumocytes and their function?
- type 1: gas exchange
- type 2: make surfactant
What is the primary component of surfactant?
phosphatidylcholine
What are the pores of Kahn?
pores in alveoli that enable direct air exchange
What PFTs should a patient have prior to undergoing lobectomy?
- DLCO2 and FEV1 > 80%
- post-op predicted values > 40%
If post-operative predicted DLCO2 or FEV1 is lower than 40%, what is the best next test?
a V/Q scan to show the contribution of the diseased lung
What are lights criteria?
any one criteria suggests an exudative effusion
- pleural/serum protein > 0.5
- pleural/serum LDH > 0.6
- pleural LDH > ⅔ normal serum
How should you manage a retained hemothorax?
early VATS for washout
What test confirms a chylothorax?
a pleural fluid triglyceride level > 110
- will also have a lymphocyte predominance
- suda red stains fat and will be positive
What is the most common cause of a chylothorax?
1) lymphoma
2) trauma/iatrogenic
Medical management of a lymphatic leak includes what interventions?
- low fat, medium-chain fatty acid diet (avoid long chain)
- can also consider bowel rest with TPN
- or octreotide
What surgical intervention can be offered to those with a lymphatic leak?
- ligation of the thoracic duct in the low right mediastinum
- talc pleurodesis and possible chemoradiation for malignancy
What is the difference between a primary and secondary pneumothorax?
- primary is usually seen in tall, thin individuals
- secondary is due to an underlying medical condition (most commonly COPD)
What pneumothoraces can you manage expectantly?
those < 3cm in asymptomatic, stable patients
When should you operate on those with pneumothorax?
- persistent air leak > 5 days
- reucrrent spontaneous pneumothorax
- high risk profession (scuba diver) after first spontaneous pneumothorax
You take a patient with recurrent spontaneous pneumothorax to the OR and don’t see any blebs. What operation should you perform?
an apical wedge resection and pleurodesis
What are the most common etiologies for lung abscesses?
aspiration and poor dental hygiene
When should you resect pulmonary abscesses?
- if they persist for > 2 months
- if they are > 4cm in size
- if they are thick walled
What is the best next step when evaluating for Boerhave’s syndrome?
gastrografin esophagram
What is Ludwig angina?
a descending mediastinitis from an oropharyngeal infection
What is the most common cause of mediastinal adenopathy?
lymphoma
What is the most common overall type of mediastinal tumor in adults and children?
neurogenic (found in the posterior mediastinum)
What is the most common site of a mediastinal tumor?
anterior (think terrible Ts)
What are the possible etiologies of a posterior and anterior mediastinal mass?
- posterior: lymphoma (MC overall)
- anterior: thymoma (MC anterior), teratoma, ectopic thyroid, lymphoma
What else do you need to check on physical exam in a male with a mediastinal mass?
scrotum for possible testicular germ cell tumor
Describe the relationship between thymoma and myasthenia gravis.
- 50% are malignant
- 50% are symptomatic
- 50% have myasthenia gravis
- 10% of MG patients have a thymoma
- 80% of MG patients improve with thymectomy
What is the treatment of post-thymectomy myasthenia crisis?
plasmapheresis or IVIG
What is the most common etiologies of superior vena cava syndrome?
malignancy
1) small cell lung cancer
2) lymphoma
What is Horner syndrome?
a collection of ptosis, mitosis, and anhidrosis seen in those with a pan coast tumor which disrupts sympathetics
Describe the diagnostic workup and treatment of SVC syndrome.
- get a CXR, CT with contrast, +/- venogram
- treat with positioning, steroids, +/- anticoagulation
- can consider emergent radiation if very symptomatic
What are the screening recommendations for lung cancer?
annual low-dose CT for those 50 to 80 years old with > 20 pack year history of smoking that are active users or quit in the last 15 years
What is the number one cause of cancer-related death in the US?
lung cancer
What is the strongest prognostic factor in lung cancer?
nodal involvement
What is the most common site of metastasis from lung cancer?
the brain
Describe the workup of a solitary pulmonary nodule.
- nothing further if benign calcification or stable for two years
- if not a surgical candidate, consider biopsy and radiation
- if a surgical candidate, consider serial imaging, PET, perc/bronchoscopic biopsy, or VATS excisional biopsy depending on assessed risk
Which lung cancers are more central? More peripheral?
- central: squamous and small cell
- peripheral: adenocarcinoma
Squamous cell carcinoma of the lung is associated with what paraneoplastic syndrome?
PTHrP causing hypercalcemia
Small cell carcinoma of the lung is associated with which paraneoplastic syndrome?
ACTH and ADH secretion
Which mediastinal lymph nodes are assessed with mediastinoscopy?
aortopulmonary notes (stations 5 and 6)
When should you perform mediastinoscopy in those with a lung mass?
when there is suspicious lymphadenopathy at stations 5/6 because positive nodes would make the tumor unresectable
How is a chamberlain procedure/mediastinoscopy performed?
anterior thoracotomy or parasternal mediastinotomy through L 2nd rib cartilage
Describe the staging for lung cancer.
T1: < 3cm
T2: 3-5cm
T3: 5-7cm, invading chest wall/pericardium/phrenic nerve, ipsilateral satellite nodules
T4: > 7 cm or invading mediastinum
N1: ipsilateral hilar nodes
N2: ipsilateral mediastinal nodes
N3: supraclavicular, cervical, contralateral nodes
What is the recommended treatment for lung cancer by stage?
- stage I: resection or definitive radiation
- stage II: resection or definitive radiation
- stage III: neoadjuvant chemoradiation (N2)
- stage IIIb: chemoradiation (T4 tumor or N3 nodes)
- stage IV: palliative resection or radiation
When can you resect lung cancer in VATS fashion?
- less than 5cm
- without regional lyphadenopathy or local invasion
- peripheral lesions
Describe post-operative lung cancer surveillance guidelines.
- stage I/II: CT every 6 months for three years followed by annually
- stage III/IV: CT every 3-6 months for three years followed by every 6 months then annually
What is a pancoast tumor?
one that invades the thoracic inlet, potentially leading to SVC syndrome or Horner syndrome
What is the treatment for pancoast tumors
neoadjuvant chemoradiation
What are the indications for trauma thoracotomy?
- penetrating thoracic injury with < 15min CPR
- blunt trauma with < 10min CPR
- extra-thoracic penetrating trauma < 5min CPR
When should you resect pericardial cysts? Where are they found?
- only if symptomatic
- at the right costobronchial angle
DO bronchogenic cysts have to be resected? Where are they found?
- yes
- find them posterior to the carina
What are the most common benign and malignant lung masses in adults?
- benign: hamartomas
- malignant: squamous cell carcinoma
What are the most common benign and malignant lung masses in children?
- benign: hemangiomas
- malignant: carcinoid
What type of lung cancer mimics pneumonia?
bronchoalveolar, it grows along the alveolar walls and is usually multifocal
What is the treatment for post-pneumonectomy syndrome?
tissue expander placed in the pneumonectomy site
What is the best conduit for CABG?
IMA
