Thoracic Flashcards
Initial tx for chylothorax?
How long can obs continue?
Treatment if obs fails for good surg cand
Poor Cand
CT
5-7d
Ligation
Embolization
3 Lights Criteria? what does this tell us
pleural:serum protein >0.5
Plearual : serum LDH>0.6
pleural LDH>2/3 normal
Exudative effusion
Causes of pleural effusion
1 inc pleural membrane perm
2 inc hydrostatic p
3 hypoalb
sepsis, malign, pe, panc
CHF, renal, iatrogenif fluid overload
cirrhosis, nephrotic, malnut
how big is a visible effusion on cxray at minimum
300
MC extra pelvic location for endometriosis?
What complication can this cause
thoracic
ectopic implants cause ptx – catamenial
secondary ptx definition
underlying cause
indications for surgical pleurodesis for ptx
Persistent air leak (≥ 4 days)
Failure of the lung to fully expand with adequate chest tube placement
Prevention of recurrent pneumothorax
After a first (or second) spontaneous pneumothorax in patients with no underlying pulmonary disease
In an individual in a high-risk profession (ie, scuba diver, pilot) after a first spontaneous pneumothorax
After a first pneumothorax in a patient with limited access to hospital care for geographic or social reasons
pleurodesis for poor surgical candidates?
talc or doxy
chance of ptx recurrence after first?
risk after pleurectomy?
vats with bleb?
60
1
2 to 5%
what muscle is spared during a muscle sparing thoracotomy
lat
3 non small cell ca in lung
adeno, large cell, squamous
leading cause of cancer related death in us?
lung
lung cancer 5y survival per stage
Five-year survival is 45% to 50% at stage I, 30% at stage II, 5% to 14% at stage III, and less than 5% at stage IV.
single nodule mets to lung (2)
sarcoma and melanoma
multifocal mets for lung
head and neck, breast, colon, renal, lung
current lung ca screening guidelines
55 to 80 years who have a 30-pack year smoking history and currently smoke or have quit within the past 15 years.
what bearing does a malignant effusion have on surgical indication
usually precludes with poor prognosis
lung mets work up
markers - cca 19-9, cea, afp, bhcg
CT CAP, PET
colonoscopy
biopsy
t staging for lung
T1 tumors: ≤ 3 cm in diameter
T2 tumors: > 3 but ≤ 5 cm in diameter
T3 tumors: > 5 but ≤ 7 cm in diameter (or invading the parietal pleural/chest wall, phrenic nerve, or pericardium, or two tumors in the same lobe)
T4 tumors: > 7 cm in diameter (or invading the mediastinum, diaphragm, heart, great vessels, trachea/carina, esophagus, recurrent laryngeal nerve, or spine, or separate nodules within the same lung but separate lobes)
supraclavicular or cervical lymphadenopathy concerning lung cancer?
what needs to be performed?
poor prognosis, N3
needs FNA
% of lung cancer with adrenal mets
7
high met area for small cell lung and pancoast
brain
what lung cancer stage gets neoadjuvant
stage 3
what are the FEv1 and dlco values assoc with good surgical candidates
what needs to be performed if too low? values?
80%
predicted post op 40%
cervical nerve roots in arm
what needs to be performed prior to pancoast tumor resection
chemo rads
only rad onc emergency
pancoast
main chemo reg for lung ca
mab tx? mech?
paclitaxel or plat based
bevacizumab; VEGF inhib
pulm nodule work up per size
MC ant mediastinal tumor
followed by…
thymoma
T cell lymphoma
posterior mediastinal tumors
neurogenic
thymoma paraneoplastic percent and specific diseases
Associated with paraneoplastic syndromes in 30% to 50% of cases
The most common is myasthenia gravis, followed by hypogammaglobulinemia and pure red cell aplasia.
who is hodgkin medistinal lymphoma found in
germ cell tumors: MC ____ site is mediastinum
bimodal peds and young women
extragonadal
MC malignant germ cell tumor of mediastinum
seminoma
MC middle medistinal mass
Cysts
bronchogenics are the issue not cardiac
4 neurogenic mediastinal tumors? what compartment?
whish is malignant
neuroblastoma - mal
neurofibroma
schwannoma
paraganglioma
posterior
mc posterior mediastinal tumor specifically
schwannoma
MC mediastinal peds tumors per compartment
ant - lymphoma
mid - cysts
post - neurogenic
MG thymoma patient presentation?
medical management?
Affected patients often present with ocular symptoms (eg, ptosis, diplopia), fatigue, and weakness.
Medical management may include anticholinesterases (pyridostigmine, neostigmine), glucocorticoids, and plasmapheresis.
thymoma staging and resectability, next steps
Stage I: encapsulated tumor
Resectable
Stage II: capsular invasion into adjacent mediastinal fat or pleural tissue
Resectable
Stage III: invasion into neighboring structure (pericardium, great vessel, lung)
Possible thymectomy based on preoperative evaluation; otherwise induction chemotherapy
Stage IV
Stage IVa (pleural or pericardial dissemination): generally unresectable; possibly surgical debulking and chemoradiation
Stage IVb (lymphatic-hematogenous metastases): generally unresectable; possibly surgical debulking and chemoradiation
biopsy for thymoma?
only if considering chemo
Describe borders for thymectomy and blood supply
chamberlain procedure
surgical concept regarding pericardial fat v thymus during thymectomy
take all fat anterior to pericardium as it all looks the same
2 complications to worry about for thymectomy and their treatments
Myasthenic crisis: respiratory failure and bulbar weakness
Provide urgent therapy with plasmapheresis or intravenous immunoglobulin.
Cholinergic crisis: increased secretions, urination, defecation, and emesis
Counteract muscarinic activation with atropine or glycopyrrolate.
3 sources of mediastinitis
tooth, trach, esoph
operative sternal mediastinitis bugs
posterior mediastinal bugs
Sternal mediastinitis after sternotomy is most commonly associated with Staphylococcus, followed by Pseudomonas and Acinetobacter.
strep and staph
3 causes of chronic medistinitis
histoplasma, autoimmun or malignancy
what arteries feed sternum
internal mamm
