THORACIC

Question 1

What type of non-small cell carcinoma of the lung has the greatest risk for local recurence

Answer 1

squamous cell lesions than for other lesions; the risk averages 20% to 30% overall.

The greatest risk, however, is of distant metastasis, which occurs among 70% to 80% of patients, regardless of stage of the tumor.

Almost all recurrences take place within 5 years.

After 2 years, the risk of NEW lung cancer is higher rather than recurrence!

Question 2

most common site of distant metastasis for squamous lung cancer

Answer 2

The brain

Question 3

Adjuant for squamous lung

Answer 3

STAGE II and III

Modern studies of adjuvant chemotherapy following R0 pulmonary resection show a survival benefit for platinum-based adjuvant chemotherapy for patients with pathologic stage II and III non-small cell lung cancer.

Question 4

Survival after resection for non-small cell lung cancer is related to the stage of the disease with a strong adverse effect of

Answer 4

nodal involvement.

cure.

Question 5

management of non-small cell lung cancer large peripheral tumors that extend into the chest wall

Answer 5

EN BLOC for CURE!
40% to 50% survival rate would be expected in the absence of nodes (T3N0, stage IIB),

but only a 15% survival with hilar (N1) or ipsilateral mediastinal (N2) nodal involvement (stage IIIA). Radiation therapy would be a postoperative consideration to reduce the incidence of local recurrence.

Question 6

A 42-year-old woman with hemoptysis has a 2-cm mulberry-appearing polypoid lesion in the left main stem bronchus that may be a bronchial adenoma. The differential diagnosis includes which of the following

Answer 6

The term bronchial adenoma includes a spectrum of tumors arising from epithelial stem cells:

benign mucous gland adenoma
malignant adenoid cystic
mucoepidermoid carcinoma,

carcinoid tumor

mong these variants, carcinoids are most common, representing 80% to 90% of all bronchial adenomas.

Question 7

Malignant pleural mesothelioma

Answer 7

Malignant pleural mesothelioma is a fatal cancer for which operation continues to be the primary therapy. Radiation therapy and chemotherapy alone are relatively ineffective. Pneumonectomy does not address the pleural component of the tumor, and pleurectomy and decortication, although they address the parietal pleural component, do not address the visceral pleural component and its extensions into the lung. In a lung cancer study group trial reported in 1990, extrapleural pneumonectomy was evaluated in the treatment of malignant mesothelioma. Recurrence-free survival was significantly longer for patients undergoing extrapleural pneumonectomy versus patients who had a limited operation with and without adjuvant therapy and those who received nonsurgical treatment. There was no difference in overall survival among the groups, but local control was best obtained by extrapleural pneumonectomy. Chemotherapy and radiation therapy are not yet first choice treatments for this disease process.

Question 8

A new pulmonary lesion in a patient who has undergone therapy for sarcoma, melanoma, head, neck, or breast, gastrointestinal or genitourinary tract

Answer 8

The lesion is most likely to be metastatic
sarcoma
or
melanoma

most likely to be a NEW primary lung cancer if the previous malignant lesion originated in the
head,
neck,
breast.

50/50 metastatic/ NEW primary if:
When the original lesion was in the gastrointestinal or genitourinary tract, there is an equal chance that it is metastatic or a new primary lesion.

Question 9

A new pulmonary lesion in a patient who has undergone therapy for previous cancer what is utility of FNA

Answer 9

fine-needle aspiration do NOT usually alter the plan for excision.

ONLY FNA if:
patient is not an operative candidate (to guide adjuvant) or patient wants to know the diagnosis.

Question 10

Primary squamous cell carcinoma and adenoid cystic carcinoma of the trachea are best treated by

Answer 10

resection when primary reconstruction may be safely accomplished. Resection should be followed by full-dose mediastinal irradiation in most cases. Malignant primary tracheal tumors of other types should also be resected if resection will permit a safe primary reconstruction. These patients should probably be given postoperative radiation therapy. Laser resection is palliative only, and radiation therapy is palliative as well. Chemotherapy is not effective for tracheal tumors.

Question 11

Elevation of both urinary vanillylmandelic acid and vasoactive intestinal polypeptide can be caused by what medialstinal tumor

Answer 11

ganglioneuroma,

NOT be characteristic of paraganglioma.

Question 12

The destroyed areas of the lung are typically located where in smokers vs alpha 1 antitrypsin

Answer 12

SMOCKERs UPPER smoke rises

alpha1 antitrypsin deficiency - LOWERlobes

Question 13

Contraindications to lung volume reduction surgery include

Answer 13

severe kyphoscoliosis; 
pulmonary hypertension 
(mean pulmonary artery pressure > 35 mm Hg 
or
 systolic pressure > 45 mm Hg); 

significant coronary artery disease;
previous thoracotomy or pleurodesis

long-standing history of asthma, bronchiectasis, or chronic bronchitis with production of purulent sputum.

Question 14

In the absence of atypia, carcinoids of the bronchus are can be managed by means of

Answer 14

limited resection of the lung, bronchus, or both.

Sleeve resection of the bronchus that preserves distal lung would be appropriate.

Lymph node sampling at resection, however, is advisable to ensure that complete resection has been performed.

Question 15

carcinoid syndrome affects what valves

Answer 15

left-sided cardiac valves

Question 16

sternum land marks,

Answer 16

The xiphoid marks the anterior border of the thoracic outlet. The junction of the manubrium and body is the sternal angle or angle of Louis, which corresponds to the level of T4 posteriorly and attaches to the second costal cartilage anteriorly.

Question 17

the most common benign tumor of the lung

Answer 17

hamartoma,

Question 18

lung hamartoma xray characteristics

Answer 18

has a variable pattern of slow growth and typically shows popcorn calcification.

Question 19

Concentric calcification on lung xray suggests

Answer 19

benign granuloma.

Question 20

Pleural fluid level of glucose lower than the serum level is characteristic of

Answer 20

empyema
rheumatoid arthritis,
neoplasia,
tuberculosis.

Question 21

Every patient with spontaneous empyema should undergo

Answer 21

bronchoscopy to rule out endobronchial obstruction by a foreign body or tumor.

Question 22

superior vena cava syndrome, the most common cause

Answer 22

Although mediastinal granulomatous disease is one cause of superior vena cava syndrome, the most common cause (75%) is malignant disease. A venogram adds little information to the typical findings and increases risk of subcutaneous extravasation of contrast medium from the venous hypertension. Mediastinoscopy can be used for tissue diagnosis to recognize increased risk of bleeding and airway problems caused by the edema associated with the endotracheal intubation needed for the procedure. If a malignant tumor is found, operative resection usually is precluded by the extent of mediastinal invasion. In the case of benign disease, the symptoms tend to improve as chest wall and mediastinal collaterals enlarge.