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General Surgery > Thoracic > Flashcards

Thoracic Flashcards

1
Q

Azygous vein - located on the ______ and drains into the _________.

A

Located on the right and drains into the SVC

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2
Q

Thoracic duct is located on the _______, crosses midline at _______ and drains into the __________.

A
  • Right
  • T4-5
  • Left subclavian vein at the junction with internal jugular vein
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3
Q

Phrenic nerve runs ________ to the hilum.

Vagus nerve runs ________ to the hilum.

A

Phrenic - anterior

Vagus - posterior

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4
Q

Right lung volume: ___%

Left lung volume: ___%

A

Right: 55%
Left: 45%

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5
Q

Type I pneumatocyte function

A

Gas exchange

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6
Q

Type II pneumatocyte function

A

Surfactant production - mostly phosphatidylcholine

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7
Q

Pores of Kahn function

A

Direct air exchange between alveoli

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8
Q

Need predicted postop FEV1 _____

A

> 0.8

Or > 40% of the predicted postop value

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9
Q

______ is the best predictor of pulmonary complications and being able to wean off the ventilator.

A

FEV1

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10
Q

If preop FEV1 is close/borderline, what test can you order to see if resection is feasible?

A

Qualitative V/Q scan

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11
Q

Need predicted postop DLCO ______

A

> 10 mL/min/mm Hg CO

Or > 40% of the predicted postop value

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12
Q

DLCO measures ______ and represents _______.

A
  • Carbon monoxide diffusion
  • Oxygen exchange capacity

*Value depends on pulmonary capillary surface area, hemoglobin content and alveolar architecture.

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13
Q

No resection if preop
pCO2 is > ____
pO2 is < _____
VO2 Max is < ______

A

pCO2 is > 50
pO2 is < 60
VO2 Max is < 10-12 mL/min/kg (maximum oxygen consumption)

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14
Q

Persistent airleak is most common after ______

A

Segmentectomy/wedge

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15
Q

Most common complication after lobectomy?

Treatment?

A
  • Atelectasis

- Incentive spirometer

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16
Q

Common complication after pneumonectomy

A

Arrhythmia

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17
Q

Strongest influence of survival in lung cancer?

A

Nodal involvement

  • Hilar nodal involvement does not preclude resection
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18
Q

Single most common site of metastasis for lung cancer

A

Brain

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19
Q

___% of recurrences of lung cancer occur within the first 3 years

A

80%

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20
Q

Overall 5-year survival for lung cancer

A

10%

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21
Q

Non-small cell carcinoma makes up ___% of lung cancers

A

80%

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22
Q

Most common lung cancer

A

Adenocarcinoma

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23
Q

_______ lung cancer is usually more central.

_______ lung cancer is usually more peripheral.

A

Squamous cell carcinoma is usually more central

Adenocarcinoma is usually more peripheral

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24
Q 
Lung Cancer Staging
T1: 
T2:
T3:
T4:
A

T1: < 3 cm

T2: > 3 cm but > 2 cm from the carina

T3: invasion of chest wall, pericardium, diaphragm, or < 2 cm from carina

T4: mediastinum, esophagus, trachea, vertebra, heart, great vessels, malignant effusion. *Usually indicate unresectability

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25
Q

Lung Cancer Staging
N1:
N2:
N3:

A

N1: ipsilateral hilum nodes

N2: ipsilateral mediastinal, subcarinal, or aortopulmonary window nodes (unresectable)

N3: contralateral mediastinal or supraclavicular nodes (unresectable)

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26
Q

Small cell lung cancer is ______ in origin

A

Neuroendocrine

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27
Q

Overall 5-year survival rate of small cell lung cancer

A

< 5%

  • <5% of patients are candidates for resection at time of diagnosis. Most just get chemo-XRT
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28
Q

Most common paraneoplastic syndrome

A

Small Cell - ATCH

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29
Q

Squamous cell paraneoplastic syndrome

A

PTH-related peptide

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30
Q

Small cell lung cancer paraneoplastic syndromes (2)

A

ACTH and ADH

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31
Q

Most malignant lung tumor

A

Mesothelioma

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32
Q

Non-small cell lung cancer chemotherapy

A

Carboplatin

Taxol

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33
Q

Small cell lung cancer chemotherapy

A

Cisplatin

Etoposide

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34
Q

Single best test for clinical assessment of T and N status in lung cancer

A

CT chest, abdomen and pelvis

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35
Q

Single best test for M status in lung cancer

A

PET scan

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36
Q

Chamberlain procedure description and purpose

A
  • Anterior thoracotomy or parasternal mediastinotomy (go through left 2nd rib cartilage)
  • Assesses enlarged AP window nodes
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37
Q

Mediastinoscopy - used for tumors located ______ and in patients with suspicious lymphadenopathy defined as _____.

A
  • Tumors located centrally
  • LAD > 0.8 cm or subcarinal > 1.0 cm

*Assesses ipsilateral (N2) and contralateral (N3) mediastinal nodes. Does not assess AP window nodes (Left lung drainage)

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38
Q

During mediastinoscopy

  • Left-side structures (4)
  • Right-side structures (2)
  • Anterior structures (3)
A
  • Left-side structures: RLN, esophagus, aorta, main PA
  • Right-side structures: Azygous and SVC
  • Anterior structures: Innominate vein, innominate artery, right PA
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39
Q

Pancoast tumor definition and symptoms

A

Lung cancer that invades apex of chest wall

  • Horner’s syndrome: invasion of sympathetic chain; miosis, ptosis and anhydrosis
  • Ulnar nerve symptoms
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40
Q

Most common cause of SVC syndrome

A

Lung cancer

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41
Q

SVC syndrome symptoms and treatment

A
  • Swelling of the head, neck and upper extremities

- Emergent XRT

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42
Q

Overall, ___% of coin lesions are malignant

  • If age < 50, ___% are malignant
  • If age > 50, ___% are malignant
A
  • 10%
  • < 5%
  • > 50%
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43
Q

Coin lesion

  • most common lesion:
  • most common tumor:
  • most common malignancy:
A
  • most common lesion: granuloma
  • most common tumor: hamartoma
  • most common malignancy: lung adenocarcinoma
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44
Q

Non-calcified coin lesions are more likely to be (benign/malignant)

A

Malignant

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45
Q

Work-up of suspicious coin lesion

A
  • Bronch-guided biopsy for centrally located lesions
  • CT guided biopsy for peripheral lesions

or VATS wedge resection

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46
Q

Lung cancer that can look like pneumonia on imaging

A

Bronchoalveolar cancer; grows along alveolar walls, multifocal

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47
Q

Isolated metastases to the lung without any other systemic disease can be resected for what cancers? (6)

A
  • Colon
  • Renal cell carcinoma
  • Sarcoma
  • Melanoma
  • Ovarian
  • Endometrial carcinoma

*COMERS

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48
Q

Lung carcinoids are usually located (centrally/peripherally).

A

Centrally

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49
Q

Lung Carcinoid

  • __% have metastases at time of diagnoses
  • __% have symptoms
A
  • 5%

- 50%

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50
Q

Typical lung carcinoid __% 5-year survival

Atypical lung carcinoid __% 5-year survival

A

Typical - 90%

Atypical - 60%

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51
Q

Lung carcinoid tumor recurrence increased with tumors > __ cm and ____.

A

> 3 cm and nodal involvement

52
Q

Most common type of bronchial adenoma

A

Carcinoid

53
Q

Bronchial adenomas are usually located in the (upper/lower) airway

A

Upper airway

54
Q

Bronchial adenomas - Mucoepidermoid adenoma and Mucous gland adenoma characteristics and treatment

A
  • Malignant
  • Slow growing
  • No metastasis
  • Tx: resection with 1 cm margin
55
Q

Bronchial adenomas - Adenoid cystic adenoma characteristics and treatment

A
  • Malignant
  • From submucosal glands
  • Spreads along perineural lymphatics
  • Very XRT sensitive
  • Slow-growing; Can get 10-year survival with incomplete resection
  • Tx: resection. If unresectable, XRT
56
Q

Most common benign adult lung tumor

A

Hamartomas

57
Q

Hamartoma composition and CT appearance

A
  • Fat, cartilage, and connective tissue

- Popcorn lesion, calcifications

58
Q

Hamartoma diagnosis and treatment

A
  • Can be diagnosed on CT
  • No resection needed
  • Get follow-up chest CT in 6 months to confirm diagnosis
59
Q

Most common cause of mediastinal adenopathy in adults

A

Lymphoma

60
Q

Most common mediastinal tumor in adults and children

A

Neurogenic tumors

* usually located in posterior mediastinum

61
Q

__% of symptomatic mediastinal tumors are malignant

__% of asymptomatic mediastinal tumors are benign

A
  • 50%

- 90%

62
Q

Most common site for mediastinal tumor

A

Anterior mediastinum (thymus)

63
Q

Anterior mediastinal tumors (5)

A
  • Thymoma
  • Thyroid cancer and goiters
  • T-cell lymphoma
  • Teratoma (and other germ cell tumors)
  • ParaThyroid adenoma
64
Q

Most common anterior mediastinal mass in adults

A

Thymoma

65
Q

Middle mediastinal tumors (4)

A
  • Bronchogenic cysts
  • Pericardial cysts
  • Enteric cysts
  • Lymphoma
66
Q

Middle mediastinal structures (3)

A
  • Heart
  • Trachea
  • Ascending aorta
67
Q

Posterior mediastinal structures (2)

A
  • Esophagus

- Descending aorta

68
Q

Posterior mediastinal tumors (3)

A
  • Enteric cysts
  • Neurogenic tumors
  • Lymphoma
69
Q

__% of thymomas are malignant
__% of patients with thymomas have myasthenia gravis
__% of patients with myasthenia gravis have thymomas

A
  • 50%
  • 50%
  • 10%
70
Q

Thymoma treatment

A

Resection

71
Q

Myasthenia gravis symptoms, pathology and treatment

A
  • Fatigue, weakness, diplopia, and ptosis (ocular symptoms most common)
  • Antibodies to acetylcholine receptors
  • Tx: Anticholinesterase inhibitors (Neostigmine), steroids, plasmapheresis, Thymectomy

*80% of patients with myasthenia gravis have improvement after thymectomy including those who do not have a thymoma

72
Q

Procedure to perform for open biopsy of mediastinal germ cell tumor

A

Chamberlain procedure (anterior thoracotomy, parasternal mediastinotomy)

*Mediastinoscopy will not reach tumor if it is in the anterior or posterior mediastinum

73
Q

Most common mediastinal germ cell tumor

A

Teratoma

*can be benign or malignant

74
Q

Teratoma treatment

A

Tx: Resection, possibly chemotherapy

75
Q

Most common malignant mediastinal germ cell tumor

A

Seminoma

76
Q

Seminoma lab tests and treatment

A
  • 10% are beta-HCG positive
  • AFP negative
  • Tx: XRT (very sensitive); chemotherapy for bulky nodal disease or metastasis and surgery for residual disease
77
Q

Non-seminoma lab tests and treatment

A
  • 90% have elevated beta-HGC and AFP

- Tx: Chemotherapy (cisplatin, bleomycin, etoposide) and surgery for residual disease

78
Q

Bronchogenic cyst location and treatment

A
  • Usually posterior to carina

- Tx: Resection

79
Q

Pericardial cysts location and treatment

A
  • Usually at right costophrenic angle

- tx: Can leave alone (benign)

80
Q

Mediastinal neurogenic tumor symptoms and treatment

A
  • Pain, neurological defects

- Tx: Resection

81
Q

Most common mediastinal neurogenic tumor

A

Neurolemmoma (Schwannoma)

82
Q

Type of neurogenic tumor that creates catecholamines and is associated with von Recklinghausen’s disease

A

Paraganglioma

83
Q

Most common benign tracheal tumor in adults

A

Papilloma

84
Q

Most common benign tracheal tumor in children

A

Hemangioma

85
Q

Most common malignant tracheal tumor in adults

A

Squamous cell carcinoma

86
Q

Most common malignant tracheal tumor in children

A

Carcinoid

87
Q

Most common early complication after tracheal surgery

A

Laryngeal edema

Tx: intubation, racemic epi, steroids

88
Q

Most common late complication after tracheal surgery

A

Granulation tissues formation

89
Q

Location of post-intubation stenosis after

  • tracheostomy
  • ET tube
A
  • Tracheostomy = stoma site

- ET tube = cuff site

90
Q

Treatment for tracheal stenosis

A

Serial dilation, bronchoscopic resection or laser ablation if minor

Tracheal resection with end-to-end anastomosis if severe or keeps recurring

91
Q

Tracheo-innominate artery fistula treatment and prevention

A

Treatment: place finger in tracheostomy hold and hold pressure then median sternotomy with ligation and reseciton of innominate artery (no graft)

Prevention: place tracheostomy between 2nd and 3rd tracheal rings

92
Q

Most common cause of tracheo-esophageal fistula

A

Prolonged intubation

93
Q

Treatment for tracheo-esophageal fistula

A
  • Place a large-volume cuff ET tube below fistula
  • Patient may need decompressive G tube
  • Repair after weaned from vent
  • Tracheal resection, reanastomosis, close hole in esophagus, sternohyoid flap between esophagus and trachea
94
Q

Most common cause of lung abscess

A

Aspiration

95
Q

Most common location for lung abscess

A

Superior segment of RLL

96
Q

Most common organism in lung abscess

A

Staph aureus

97
Q

Treatment for lung abscess

- Indications for surgery

A
  • Antibiotics alone (95% successful)
  • CT-guided drainage if fails
  • Surgery if above fails or can’t rule out cancer ( > 6 cm, failure to resolve after 6 week)
98
Q

Empyema phases and treatments

A
  • Exudative phase (1st week): Chest tube, antibiotics
  • Fibro-proliferative phase (2nd week): Chest tube, antibiotics, possible VATS deloculation if lung doesn’t re-expand
  • Organized phase (3rd-4th weeks): likely need decortication, intra-pleural tPA, or Eloesser flap if frail/elderly
99
Q

What is an Eloesser flap?

A

Open thoracic window - direct opening to external environment used to treat empyemas in frail/elderly patients

100
Q

Leukocyte and TAG levels in chylothorax fluid

A

Increased leukocytes and TAGS ( > 100)

*Fluid is resistant to infection

101
Q

Common causes of chylothorax

A
  • 50% due to trauma or iatrogenic injury

- 50% due to tumor (lymphoma most commonly)

102
Q

Injury above T5-6 results in a ____-sided chylothorax

A

Left-sided chylothorax

103
Q

Injury below ____ results in a right-sided chylothorax

A

Below T5-6

104
Q

Chylothorax treatment

A
  • 2-3 weeks of conservative management (chest tube, octreotide, TPN/low fat diet)

If fails and due to

  • Trauma/iatrogenic = ligation of thoracic duct on right side low in mediastinum (80% successful)
  • Malignancy = talc pleurodesis or chemo/XRT
105
Q

Define massive hemoptysis

A

> 600 cc/24 hours

106
Q

Most common cause of massive hemoptysis

Bleeding from massive hemoptysis usually comes from ________.

A
  • Infection
  • High-pressure bronchial arteries
  • Death usually from asphyxiation
107
Q

Treatment for massive hemoptysis

A
  • Place bleeding side down
  • Mainstem intubation of side not bleeding
  • Rigid bronch to identify site and possibly control bleeding
  • May need lobectomy or pneumonectomy to control
  • Bronchial artery embolization if not able to have surgery
108
Q

Recurrence risk of spontaneous pneumothorax after
1st -
2nd -
3rd -

A

1st - 20%
2nd - 60%
3rd - 80%

*More common on right side

109
Q

Treatment of spontaneous pneumothorax

Indications for surgery and procedure of choice

A
  • Chest tube placement
  • Recurrence, air leak after 7 days, non-reexpansion (despite 2 chest tubes), high risk profession, lives in remote area, tension PTX, hemothorax, bilateral PTX, previous pneumonectomy, large bleb on CT
  • VATS, apical blebectomy, mechanical pleurodesis
110
Q

Most common cause of malignant pericardial effusions

- Treatment

A
  • Lung cancer

- Pericardial window

111
Q

Most common cause of malignant pleural effusions

- Treatment

A
  • Lung cancer

- Drainage and talc pleurodesis

112
Q

Most likely cause of arrest after blunt trauma

A
  • Tension pneumothorax causing decreased venous return
113
Q

Catamenial pneumothorax definition and cause

A
  • Occurs in temporal relation to menstruation

- Caused by endometrial implants in the visceral lung pleura

114
Q

Indications for surgical drainage of a clotted hemothorax

A
  • > 25 % of lung involved, air-fluid levels, signs of infection
  • Surgery in first week to avoid peel. Empyema risk
115
Q

Causes of whiteout on CXR and treatments

  • Shift towards whiteout
  • Shift away from whiteout
A
  • Shift towards = Collapse. Needs bronch to remove plug

- Shift away = Effusion. Needs chest tube

116
Q

Tuberculosis lung findings and treatment

A
  • Calcifications, caseating granulomas
  • Usually in lung apices
  • INH, Rifampin, Pyrazinamide
117
Q

Ghon complex

A

Parenchymal lesion + enlarged hilar lymph nodes

Seen in TB

118
Q

Sarcoidosis has ______ granulomas

A

Non-caseating

119
Q

Most common benign chest wall tumor

A

Osteochondroma

120
Q

Most common malignant chest wall tumor

A

Chondrosarcoma

121
Q

Pulmonary AVMs are usually found in ___ lobes.

  • Symptoms
  • Treatment
A
  • Lower lobes
  • Symptoms: hemopytsis, SOB, neurologic events
  • Tx: embolization
122
Q

Treatment for recurrent pleural effusions

  • Benign
  • Malignant
A
  • Benign: Mechanical pleurodesis

- Malignant: Talc pleurodesis

123
Q

Treatment for airway fires

A
  • Stop gas flow, remove ET tube, re-intubate for 24 hours, bronchoscopy
124
Q

Evaluation of Pleural Fluid - Transudate

  • WBC:
  • pH:
  • Pleural fluid protein to serum ratio:
  • Pleural fluid LDH to serum ratio:
A
  • WBC: < 1000
  • pH: 7.45 - 7.55
  • Pleural fluid protein to serum ratio: < 0.5
  • Pleural fluid LDH to serum ratio: < 0.6
125
Q

Evaluation of Pleural Fluid - Exudate

  • WBC:
  • pH:
  • Pleural fluid protein to serum ratio:
  • Pleural fluid LDH to serum ratio:
A
  • WBC: > 1000
  • pH: < 7.45
  • Pleural fluid protein to serum ratio: > 0.5
  • Pleural fluid LDH to serum ratio: > 0.6
126
Q

Evaluation of Pleural Fluid - Empyema

  • WBC:
  • pH:
  • Pleural fluid protein to serum ratio:
  • Pleural fluid LDH to serum ratio:
A
  • WBC: > 1000 ( > 50,000 most specific)
  • pH: < 7.30
  • Pleural fluid protein to serum ratio: > 0.5
  • Pleural fluid LDH to serum ratio: > 0.6

General Surgery (14 decks)

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