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Utah / kirklin > Thoracic 3.0 > Flashcards

Thoracic 3.0 Flashcards

1
Q

Myasthenia Gravis

Prevalence:

A

5 to 12 per 100, 000 in the population.

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2
Q

Myasthenia Gravis

Gender prevalance and how does this effect presentation?

A

disease is twice as common in women

Males have more rapid progression, fewer remission, and less improvement

Age:

Women: the second to third decade of life.

Men, sixth to seventh decade of life.

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3
Q

Myasthenia Gravis

Grading of Symptoms

A

Grading of Symptoms

(I) focal disease—ocular muscle weakness

(II) generalized mild to moderate disease

(III) severe generalized weakness

(IV) life-threatening weakness—respiratory failure.

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4
Q

Myasthenia Gravis

Grade 1 Symptoms

A

Myasthenia Gravis

Grading of Symptoms

(I) focal disease—ocular muscle weakness

(II) generalized mild to moderate disease

(III) severe generalized weakness

(IV) life-threatening weakness—respiratory failure.

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5
Q

Myasthenia Gravis

Grade II symptoms

A

Myasthenia Gravis

Grading of Symptoms

(I) focal disease—ocular muscle weakness

(II) generalized mild to moderate disease

(III) severe generalized weakness

(IV) life-threatening weakness—respiratory failure.

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6
Q

Myasthenia Gravis

Grade III symptoms

A

Myasthenia Gravis

Grading of Symptoms

(I) focal disease—ocular muscle weakness

(II) generalized mild to moderate disease

(III) severe generalized weakness

(IV) life-threatening weakness—respiratory failure.

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7
Q

Myasthenia Gravis

Grade IV symptoms

A

Myasthenia Gravis

Grading of Symptoms

(I) focal disease—ocular muscle weakness

(II) generalized mild to moderate disease

(III) severe generalized weakness

(IV) life-threatening weakness—respiratory failure.

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8
Q

Myasthenia Gravis

Grading of Symptoms:

focal disease—ocular muscle weakness

A

Myasthenia Gravis

Grading of Symptoms

(I) focal disease—ocular muscle weakness

(II) generalized mild to moderate disease

(III) severe generalized weakness

(IV) life-threatening weakness—respiratory failure.

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9
Q

Myasthenia Gravis

How to diagnose ?

A

Diagnosis

  1. a physical examination identifying the level of weakness
  2. an edrophonium (shortacting anticholinesterase) test is confirmatory if the patient shows improvement.
  3. Assay for AChR antibody is also available.
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10
Q

Myasthenia Gravis

Grading of Symptoms

generalized mild to moderate disease

A

Myasthenia Gravis

Grading of Symptoms

(I) focal disease—ocular muscle weakness

(II) generalized mild to moderate disease

(III) severe generalized weakness

(IV) life-threatening weakness—respiratory failure.

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11
Q

Myasthenia Gravis

Treatment - medical therapy

A
  • Anticholinesterase therapy (pyridostigmine)
  • corticosteroids if needed for immunosuppression.
  • Plasmapheresis and IVIG are short-term
    • for myasthenic crises
    • preoperatively, or intermittently in patients with poor control of MG despite immunosuppression.
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12
Q

Myasthenia Gravis

Indications/contraindications for thymectomy

A

Thymectomy

indicated

  1. in patients with thymic hyperplasia or a thymoma.
  2. any MG patient with early, generalized, moderate to severe disease, especially if refractory to medical management.

Contraindications

should not be performed emergently for a myasthenic crisis/class IV disease.

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13
Q

Results of thymectomy for MG?

  1. % “some clinical improvement” ?
  2. % resolution of symptoms ?
  3. % improved symptoms ?
  4. % drug free remission ?
A
  1. 85% of patients will have some clinical improvement
  2. 25-30% will have resolution of sx
  3. 30-50% will have Improved symptoms
  4. 50-60% will have drug free remission
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14
Q

Age and symptomatology of mediastinal masses

A

Adults are more likely to be asymptomatic (60%)

Children are more likely to be symptomatic (60%)

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15
Q

Symptomatology of mediastinal masses

Anatomic location and symptoms

A
  • Anterior / superior masses (75%) -most likely to be symptomatic

compared with:

  • posterior (50%)
  • Middle (45%)
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16
Q

symptomatology of mediastinal masses

which are more likely to have sx - benign or malignant?

A

Malignant masses are more likely to have symptoms

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17
Q

Mediastinal masses - by anatomic location what is the the most likely to be malignant?

A
  • Anterior superior are most likely to be malignant (60%)
  • Middle (29%)
  • Posterior (16%)
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18
Q

Thymic carcinoid

Gender predominance

A

> 75% are male

19
Q

Thymic carcinoid

  1. prevalance of symptoms?
  2. what are they?
  3. clinical implication?
A

Thymic carcinoid

  • 2/3 are symptomatic
  • Most commonly: cushing’s syndrome (33%)
  • annother 15% may have ADH, MEN I, or PTH
  • the presence of symptoms is a poor prognostic factor.
20
Q

Pre-thoracic surgery testing & evaluation

A
  1. IS —> evaluate data… a reasonable cut-off for preoperative FEV1 and DLCO are 60% of predicted.
  2. If either value is less than 60% predicted, do predicted postoperative values
  3. If estimated postoperative FEV1 or DLCO is less than 40% predicted, do cardiopulmonary exercise .
  4. Maximal exercise oxygen consumption (VO2max) is a better patient-specific functional measure to establish a threshold for risk.
  5. VO2max < 10ml/(kg*min) correlates with high morbidity and mortality and such patients are generally considered inoperable.
21
Q

Shuttle walk and MVO2 max

A

MVO2 Max

VO2max < 10ml/(kg*min) correlates with high morbidity and mortality and such patients are generally considered inoperable.

The inability to perform 25 shuttles has been correlated with a maximal oxygen uptake of less than 10 mL/kg/min and signifies prohibitive operative risk.

A healthy adult should be able to climb five flights of stairs. A drop in oxygen saturation of 4 percent or more during activity is considered significant.

22
Q

Karnofsky and Zubrod score relationship with post operative outcomes

A

A high Karnofsky score (80–100%) or low Zubrod score (0–1) is associated with low mortality.

23
Q

Cryptococcus: major related syndromes

A

Cryptococcus will go to the CNS

If serology or sputum cx are positive - patient should have CSF examined

24
Q

Crytpcoccus

sp:

Endemic: Tropism:

Clinic:

Rx:

Histology:

A

Crytpcoccus

sp: Crytpcoccus neoformans

Endemic: World wide, Tropism - soil.

Clinic: Lungs forms a granuloma that can be confused with cancer. CNS Tropism for meninges can cause meningitis.

Need to check the CSF is serum or sputum are positive

Rx: Amphoteracin B for aggressive disease including mening itis

Histology: Budding yeast with THICK capsule

25
Q

Crytpcoccus

Endemic: ?

A

Crytpcoccus

sp: Crytpcoccus neoformans

Endemic: World wide, Tropism - soil.

26
Q

Diagnosis ?

A

Crytpcoccus

Histology: Budding yeast with THICK capsule

27
Q

Small cell lung cancer

  • Histology
A

Scant cytoplasm.

Fiberous stroma

Abundant neurosecretory granules

28
Q

Diagnosis ?

A

Small scell lung cancer

abundant neurosecretory granules

Scant cytoplasm

fiberous stroma

29
Q

NSCLCA - Adenocarcinoma

Histologic Morphologic criteria:

A

Glandular differentiation and/or Mucin

30
Q

Squamous cell lung cancer

Histology Morphologic criteria:

A

Intracellular bridges and/or keratinization

31
Q

WHO 2015 Classification of Adenocarcinoma

A

Pre-invasive lesions

  1. Atypical adenomatous hyperplasia
  2. Adenocarcinoma in situ

Adenocarcinoma

  • Minimally invasive adenocarcinoma (MIA)

Invasive adenocarcinoma defined by predominant subtype:

  • Lepidic predominant adenocarcinoma
  • Acinar predominant adenocarcinoma (5-year survival: 84%)
  • Papillary predominant adenocarcinoma (5-year survival: 83%)
  • Micropapillary predominant adenocarcinoma (30-40% 5-year survival)
  • Solid predominant adenocarcinoma (30-40% 5-year survival)
  • Invasive mucinous adenocarcinoma
  • Mixed invasive mucinous and non-mucinous adenocarcinoma
  • Colloid adenocarcinoma
  • Fetal adenocarcinoma
  • Enteric adenocarcinoma
32
Q

2015 WHO Classificaiton of Lung Tumors

Adenocarcinoma - variants with 100% 5 year DFS

A

Adenocarcinoma in situ

MIA

33
Q

Lung cancer - Adenocarcinoma in situ

A

part of the 2015 WHO Classification of lung cancer

  • Pure lipidic
  • ≤3cm
  • No areas of invasion
  • 100% DFS
34
Q

Lung cancer : Minimaly invasive adenocarcinoma

A

Minimally invasive adenocarcinoma (MIA)

  • Lepidic cells
  • ≤3cm with ≤5mm of invasion (Difference from AIS is the 5mm invasion)
    • Disease free survival = 100%
35
Q

2015 WHO Lung cancer classificaton

criteria for lepidic predominant acendocarcinoma

A

Lepidic predominant adenocarcinoma

Differentiation from AIS /MIA

If < 3 cm

  • >5mm of stromal invasion
  • Pleural or vascular invasion
  • Airspace spread
  • Necrosis

if > 3cm

  • Even if ≤ 5mm or no invasion
36
Q

WHO 2015 lung cancer classification -

what is the 5 year DFS for

Lepidic predominant

Acinar predominant

Micropapillary predominant

Solid predominant

A

Lepidic predominant : 90%

Acinar predominant : 84%

Micropapillary predominant : 30-40%

Solid predominant : 30-40%

37
Q

Diagnosis ?

A

Lepidic pattern of adenocarcinoma. Lepidic growth refers to growth of tumor cells along alveolar septa without invasion of destruction of lung architecture (arrows).

This pattern may occur as a component of virtually any lung adenocarcinoma, but when this pattern comprises 100% of a resected tumor the

term adenocarcinoma in situ is used

38
Q

Diagnosis ?

A

Papillary pattern of adenocarcinoma.

Papillary adenocarcinoma is characterized by malignant cells covering fibrovascular cores

39
Q

Diagnosis ?

A

Micropapillary pattern of adenocarcinoma. Micropapillary adenocarcinoma is characterized by tufts of tumor cells surrounding a sclerotic center but lacking a fibrovascular core (arrows).The micropapillary tufts are frequently found within glandular spaces, as in this example, or may be seen within alveolar spaces or within retraction spaces in a fibrotic stroma.

40
Q

Phenotype of NSCLCA - adenocarcinoma

A

Young, asian, female

Never smoker

41
Q

“scar carcinoma”

A

adenocarcinoma derived from a peripheral scar and fibrosis especially in COPD z

42
Q

Diagnosis ?

A

Adenocarcinoma with micropapillary pattern.

When an airspace contains a micropapillary pattern (arrowheads),

even if it is surrounded by lepidic or acinar structures,

it should be classified as a micropapillary pattern.

43
Q

what are the tracheal release maneuvers

A
  1. Pretracheal dissection (along the mediastinoscopy plane)
  2. Neck flexion up to 30° with concomitant chin-to-sternum stitch
  3. Laryngeal release to “drop” the larynx, cricoid, and trachea
  4. Release of the inferior pulmonary ligament
  5. Hilar release of the right lung by incision of the pericardium and, if necessary, mobilization
  6. of the right PA and superior pulmonary vein
44
Q

How to relieve tension during right carinal resection

A

Mobilize the anterior (same as the Med plane)

also, consider next flexion

a rigt hilar release will not be helpful

Utah / kirklin (12 decks)

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