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BTK Review 2024 > Thoracic > Flashcards

Thoracic Flashcards

1
Q

What is a good way to remember the thoracic lymph node stations?

A

single digits are mediastinal, double digits are hilar

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2
Q

Describe the course of the thoracic duct.

A

the cisterna chili at L2 crosses at T5 from right to left and then empties into the L IJ and subclavian veins

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3
Q

The azygos vein drains into what structure?

A

the superior vena cava

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4
Q

The thoracic duct is between what two other structure?

A

the azygos vein and the esphagus

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5
Q

What are the two types of pneumocytes and their function?

A
  • type 1: gas exchange
  • type 2: make surfactant
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6
Q

What is the primary component of surfactant?

A

phosphatidylcholine

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7
Q

What are the pores of Kahn?

A

pores in alveoli that enable direct air exchange

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8
Q

What PFTs should a patient have prior to undergoing lobectomy?

A
  • DLCO2 and FEV1 > 80%
  • post-op predicted values > 40%
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9
Q

If post-operative predicted DLCO2 or FEV1 is lower than 40%, what is the best next test?

A

a V/Q scan to show the contribution of the diseased lung

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10
Q

What are lights criteria?

A

any one criteria suggests an exudative effusion
- pleural/serum protein > 0.5
- pleural/serum LDH > 0.6
- pleural LDH > ⅔ normal serum

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11
Q

How should you manage a retained hemothorax?

A

early VATS for washout

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12
Q

What test confirms a chylothorax?

A

a pleural fluid triglyceride level > 110
- will also have a lymphocyte predominance
- suda red stains fat and will be positive

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13
Q

What is the most common cause of a chylothorax?

A

1) lymphoma
2) trauma/iatrogenic

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14
Q

Medical management of a lymphatic leak includes what interventions?

A
  • low fat, medium-chain fatty acid diet (avoid long chain)
  • can also consider bowel rest with TPN
  • or octreotide
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15
Q

What surgical intervention can be offered to those with a lymphatic leak?

A
  • ligation of the thoracic duct in the low right mediastinum
  • talc pleurodesis and possible chemoradiation for malignancy
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16
Q

What is the difference between a primary and secondary pneumothorax?

A
  • primary is usually seen in tall, thin individuals
  • secondary is due to an underlying medical condition (most commonly COPD)
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17
Q

What pneumothoraces can you manage expectantly?

A

those < 3cm in asymptomatic, stable patients

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18
Q

When should you operate on those with pneumothorax?

A
  • persistent air leak > 5 days
  • reucrrent spontaneous pneumothorax
  • high risk profession (scuba diver) after first spontaneous pneumothorax
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19
Q

You take a patient with recurrent spontaneous pneumothorax to the OR and don’t see any blebs. What operation should you perform?

A

an apical wedge resection and pleurodesis

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20
Q

What are the most common etiologies for lung abscesses?

A

aspiration and poor dental hygiene

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21
Q

When should you resect pulmonary abscesses?

A
  • if they persist for > 2 months
  • if they are > 4cm in size
  • if they are thick walled
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22
Q

What is the best next step when evaluating for Boerhave’s syndrome?

A

gastrografin esophagram

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23
Q

What is Ludwig angina?

A

a descending mediastinitis from an oropharyngeal infection

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24
Q

What is the most common cause of mediastinal adenopathy?

A

lymphoma

25
Q

What is the most common overall type of mediastinal tumor in adults and children?

A

neurogenic (found in the posterior mediastinum)

26
Q

What is the most common site of a mediastinal tumor?

A

anterior (think terrible Ts)

27
Q

What are the possible etiologies of a posterior and anterior mediastinal mass?

A
  • posterior: lymphoma (MC overall)
  • anterior: thymoma (MC anterior), teratoma, ectopic thyroid, lymphoma
28
Q

What else do you need to check on physical exam in a male with a mediastinal mass?

A

scrotum for possible testicular germ cell tumor

29
Q

Describe the relationship between thymoma and myasthenia gravis.

A
  • 50% are malignant
  • 50% are symptomatic
  • 50% have myasthenia gravis
  • 10% of MG patients have a thymoma
  • 80% of MG patients improve with thymectomy
30
Q

What is the treatment of post-thymectomy myasthenia crisis?

A

plasmapheresis or IVIG

31
Q

What is the most common etiologies of superior vena cava syndrome?

A

malignancy
1) small cell lung cancer
2) lymphoma

32
Q

What is Horner syndrome?

A

a collection of ptosis, mitosis, and anhidrosis seen in those with a pan coast tumor which disrupts sympathetics

33
Q

Describe the diagnostic workup and treatment of SVC syndrome.

A
  • get a CXR, CT with contrast, +/- venogram
  • treat with positioning, steroids, +/- anticoagulation
  • can consider emergent radiation if very symptomatic
34
Q

What are the screening recommendations for lung cancer?

A

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

35
Q

What is the number one cause of cancer-related death in the US?

A

lung cancer

36
Q

What is the strongest prognostic factor in lung cancer?

A

nodal involvement

37
Q

What is the most common site of metastasis from lung cancer?

A

the brain

38
Q

Describe the workup of a solitary pulmonary nodule.

A
  • 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
39
Q

Which lung cancers are more central? More peripheral?

A
  • central: squamous and small cell
  • peripheral: adenocarcinoma
40
Q

Squamous cell carcinoma of the lung is associated with what paraneoplastic syndrome?

A

PTHrP causing hypercalcemia

41
Q

Small cell carcinoma of the lung is associated with which paraneoplastic syndrome?

A

ACTH and ADH secretion

42
Q

Which mediastinal lymph nodes are assessed with mediastinoscopy?

A

aortopulmonary notes (stations 5 and 6)

43
Q

When should you perform mediastinoscopy in those with a lung mass?

A

when there is suspicious lymphadenopathy at stations 5/6 because positive nodes would make the tumor unresectable

44
Q

How is a chamberlain procedure/mediastinoscopy performed?

A

anterior thoracotomy or parasternal mediastinotomy through L 2nd rib cartilage

45
Q

Describe the staging for lung cancer.

A

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

46
Q

What is the recommended treatment for lung cancer by stage?

A
  • 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
47
Q

When can you resect lung cancer in VATS fashion?

A
  • less than 5cm
  • without regional lyphadenopathy or local invasion
  • peripheral lesions
48
Q

Describe post-operative lung cancer surveillance guidelines.

A
  • 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
49
Q

What is a pancoast tumor?

A

one that invades the thoracic inlet, potentially leading to SVC syndrome or Horner syndrome

50
Q

What is the treatment for pancoast tumors

A

neoadjuvant chemoradiation

51
Q

What are the indications for trauma thoracotomy?

A
  • penetrating thoracic injury with < 15min CPR
  • blunt trauma with < 10min CPR
  • extra-thoracic penetrating trauma < 5min CPR
52
Q

When should you resect pericardial cysts? Where are they found?

A
  • only if symptomatic
  • at the right costobronchial angle
53
Q

DO bronchogenic cysts have to be resected? Where are they found?

A
  • yes
  • find them posterior to the carina
54
Q

What are the most common benign and malignant lung masses in adults?

A
  • benign: hamartomas
  • malignant: squamous cell carcinoma
55
Q

What are the most common benign and malignant lung masses in children?

A
  • benign: hemangiomas
  • malignant: carcinoid
56
Q

What type of lung cancer mimics pneumonia?

A

bronchoalveolar, it grows along the alveolar walls and is usually multifocal

57
Q

What is the treatment for post-pneumonectomy syndrome?

A

tissue expander placed in the pneumonectomy site

58
Q

What is the best conduit for CABG?

A

IMA

59
Q
A

BTK Review 2024 (19 decks)

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