Thoracic Flashcards
1
Q
Azygous vein - located on the ______ and drains into the _________.
A
Located on the right and drains into the SVC
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
3
Q
Phrenic nerve runs ________ to the hilum.
Vagus nerve runs ________ to the hilum.
A
Phrenic - anterior
Vagus - posterior
4
Q
Right lung volume: ___%
Left lung volume: ___%
A
Right: 55%
Left: 45%
5
Q
Type I pneumatocyte function
A
Gas exchange
6
Q
Type II pneumatocyte function
A
Surfactant production - mostly phosphatidylcholine
7
Q
Pores of Kahn function
A
Direct air exchange between alveoli
8
Q
Need predicted postop FEV1 _____
A
> 0.8
Or > 40% of the predicted postop value
9
Q
______ is the best predictor of pulmonary complications and being able to wean off the ventilator.
A
FEV1
10
Q
If preop FEV1 is close/borderline, what test can you order to see if resection is feasible?
A
Qualitative V/Q scan
11
Q
Need predicted postop DLCO ______
A
> 10 mL/min/mm Hg CO
Or > 40% of the predicted postop value
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.
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)
14
Q
Persistent airleak is most common after ______
A
Segmentectomy/wedge
15
Q
Most common complication after lobectomy?
Treatment?
A
- Atelectasis
- Incentive spirometer
16
Q
Common complication after pneumonectomy
A
Arrhythmia
17
Q
Strongest influence of survival in lung cancer?
A
Nodal involvement
- Hilar nodal involvement does not preclude resection
18
Q
Single most common site of metastasis for lung cancer
A
Brain
19
Q
___% of recurrences of lung cancer occur within the first 3 years
A
80%
20
Q
Overall 5-year survival for lung cancer
A
10%
21
Q
Non-small cell carcinoma makes up ___% of lung cancers
A
80%
22
Q
Most common lung cancer
A
Adenocarcinoma
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
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
25
Lung Cancer Staging
N1:
N2:
N3:
N1: ipsilateral hilum nodes
N2: ipsilateral mediastinal, subcarinal, or aortopulmonary window nodes (unresectable)
N3: contralateral mediastinal or supraclavicular nodes (unresectable)
26
Small cell lung cancer is ______ in origin
Neuroendocrine
27
Overall 5-year survival rate of small cell lung cancer
< 5%
* <5% of patients are candidates for resection at time of diagnosis. Most just get chemo-XRT
28
Most common paraneoplastic syndrome
Small Cell - ATCH
29
Squamous cell paraneoplastic syndrome
PTH-related peptide
30
Small cell lung cancer paraneoplastic syndromes (2)
ACTH and ADH
31
Most malignant lung tumor
Mesothelioma
32
Non-small cell lung cancer chemotherapy
Carboplatin
| Taxol
33
Small cell lung cancer chemotherapy
Cisplatin
| Etoposide
34
Single best test for clinical assessment of T and N status in lung cancer
CT chest, abdomen and pelvis
35
Single best test for M status in lung cancer
PET scan
36
Chamberlain procedure description and purpose
- Anterior thoracotomy or parasternal mediastinotomy (go through left 2nd rib cartilage)
- Assesses enlarged AP window nodes
37
Mediastinoscopy - used for tumors located ______ and in patients with suspicious lymphadenopathy defined as _____.
- 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)
38
During mediastinoscopy
- Left-side structures (4)
- Right-side structures (2)
- Anterior structures (3)
- Left-side structures: RLN, esophagus, aorta, main PA
- Right-side structures: Azygous and SVC
- Anterior structures: Innominate vein, innominate artery, right PA
39
Pancoast tumor definition and symptoms
Lung cancer that invades apex of chest wall
- Horner's syndrome: invasion of sympathetic chain; miosis, ptosis and anhydrosis
- Ulnar nerve symptoms
40
Most common cause of SVC syndrome
Lung cancer
41
SVC syndrome symptoms and treatment
- Swelling of the head, neck and upper extremities
| - Emergent XRT
42
Overall, ___% of coin lesions are malignant
- If age < 50, ___% are malignant
- If age > 50, ___% are malignant
- 10%
- < 5%
- > 50%
43
Coin lesion
- most common lesion:
- most common tumor:
- most common malignancy:
- most common lesion: granuloma
- most common tumor: hamartoma
- most common malignancy: lung adenocarcinoma
44
Non-calcified coin lesions are more likely to be (benign/malignant)
Malignant
45
Work-up of suspicious coin lesion
- Bronch-guided biopsy for centrally located lesions
- CT guided biopsy for peripheral lesions
or VATS wedge resection
46
Lung cancer that can look like pneumonia on imaging
Bronchoalveolar cancer; grows along alveolar walls, multifocal
47
Isolated metastases to the lung without any other systemic disease can be resected for what cancers? (6)
- Colon
- Renal cell carcinoma
- Sarcoma
- Melanoma
- Ovarian
- Endometrial carcinoma
*COMERS
48
Lung carcinoids are usually located (centrally/peripherally).
Centrally
49
Lung Carcinoid
- __% have metastases at time of diagnoses
- __% have symptoms
- 5%
| - 50%
50
Typical lung carcinoid __% 5-year survival
| Atypical lung carcinoid __% 5-year survival
Typical - 90%
| Atypical - 60%
51
Lung carcinoid tumor recurrence increased with tumors > __ cm and ____.
> 3 cm and nodal involvement
52
Most common type of bronchial adenoma
Carcinoid
53
Bronchial adenomas are usually located in the (upper/lower) airway
Upper airway
54
Bronchial adenomas - Mucoepidermoid adenoma and Mucous gland adenoma characteristics and treatment
- Malignant
- Slow growing
- No metastasis
- Tx: resection with 1 cm margin
55
Bronchial adenomas - Adenoid cystic adenoma characteristics and treatment
- 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
Most common benign adult lung tumor
Hamartomas
57
Hamartoma composition and CT appearance
- Fat, cartilage, and connective tissue
| - Popcorn lesion, calcifications
58
Hamartoma diagnosis and treatment
- Can be diagnosed on CT
- No resection needed
- Get follow-up chest CT in 6 months to confirm diagnosis
59
Most common cause of mediastinal adenopathy in adults
Lymphoma
60
Most common mediastinal tumor in adults and children
Neurogenic tumors
| * usually located in posterior mediastinum
61
__% of symptomatic mediastinal tumors are malignant
| __% of asymptomatic mediastinal tumors are benign
- 50%
| - 90%
62
Most common site for mediastinal tumor
Anterior mediastinum (thymus)
63
Anterior mediastinal tumors (5)
- Thymoma
- Thyroid cancer and goiters
- T-cell lymphoma
- Teratoma (and other germ cell tumors)
- ParaThyroid adenoma
64
Most common anterior mediastinal mass in adults
Thymoma
65
Middle mediastinal tumors (4)
- Bronchogenic cysts
- Pericardial cysts
- Enteric cysts
- Lymphoma
66
Middle mediastinal structures (3)
- Heart
- Trachea
- Ascending aorta
67
Posterior mediastinal structures (2)
- Esophagus
| - Descending aorta
68
Posterior mediastinal tumors (3)
- Enteric cysts
- Neurogenic tumors
- Lymphoma
69
__% of thymomas are malignant
__% of patients with thymomas have myasthenia gravis
__% of patients with myasthenia gravis have thymomas
- 50%
- 50%
- 10%
70
Thymoma treatment
Resection
71
Myasthenia gravis symptoms, pathology and treatment
- 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
Procedure to perform for open biopsy of mediastinal germ cell tumor
Chamberlain procedure (anterior thoracotomy, parasternal mediastinotomy)
*Mediastinoscopy will not reach tumor if it is in the anterior or posterior mediastinum
73
Most common mediastinal germ cell tumor
Teratoma
*can be benign or malignant
74
Teratoma treatment
Tx: Resection, possibly chemotherapy
75
Most common malignant mediastinal germ cell tumor
Seminoma
76
Seminoma lab tests and treatment
- 10% are beta-HCG positive
- AFP negative
- Tx: XRT (very sensitive); chemotherapy for bulky nodal disease or metastasis and surgery for residual disease
77
Non-seminoma lab tests and treatment
- 90% have elevated beta-HGC and AFP
| - Tx: Chemotherapy (cisplatin, bleomycin, etoposide) and surgery for residual disease
78
Bronchogenic cyst location and treatment
- Usually posterior to carina
| - Tx: Resection
79
Pericardial cysts location and treatment
- Usually at right costophrenic angle
| - tx: Can leave alone (benign)
80
Mediastinal neurogenic tumor symptoms and treatment
- Pain, neurological defects
| - Tx: Resection
81
Most common mediastinal neurogenic tumor
Neurolemmoma (Schwannoma)
82
Type of neurogenic tumor that creates catecholamines and is associated with von Recklinghausen's disease
Paraganglioma
83
Most common benign tracheal tumor in adults
Papilloma
84
Most common benign tracheal tumor in children
Hemangioma
85
Most common malignant tracheal tumor in adults
Squamous cell carcinoma
86
Most common malignant tracheal tumor in children
Carcinoid
87
Most common early complication after tracheal surgery
Laryngeal edema
Tx: intubation, racemic epi, steroids
88
Most common late complication after tracheal surgery
Granulation tissues formation
89
Location of post-intubation stenosis after
- tracheostomy
- ET tube
- Tracheostomy = stoma site
| - ET tube = cuff site
90
Treatment for tracheal stenosis
Serial dilation, bronchoscopic resection or laser ablation if minor
Tracheal resection with end-to-end anastomosis if severe or keeps recurring
91
Tracheo-innominate artery fistula treatment and prevention
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
Most common cause of tracheo-esophageal fistula
Prolonged intubation
93
Treatment for tracheo-esophageal fistula
- 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
Most common cause of lung abscess
Aspiration
95
Most common location for lung abscess
Superior segment of RLL
96
Most common organism in lung abscess
Staph aureus
97
Treatment for lung abscess
| - Indications for surgery
- 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
Empyema phases and treatments
- 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
What is an Eloesser flap?
Open thoracic window - direct opening to external environment used to treat empyemas in frail/elderly patients
100
Leukocyte and TAG levels in chylothorax fluid
Increased leukocytes and TAGS ( > 100)
*Fluid is resistant to infection
101
Common causes of chylothorax
- 50% due to trauma or iatrogenic injury
| - 50% due to tumor (lymphoma most commonly)
102
Injury above T5-6 results in a ____-sided chylothorax
Left-sided chylothorax
103
Injury below ____ results in a right-sided chylothorax
Below T5-6
104
Chylothorax treatment
- 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
Define massive hemoptysis
> 600 cc/24 hours
106
Most common cause of massive hemoptysis
Bleeding from massive hemoptysis usually comes from ________.
- Infection
- High-pressure bronchial arteries
* Death usually from asphyxiation
107
Treatment for massive hemoptysis
- 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
Recurrence risk of spontaneous pneumothorax after
1st -
2nd -
3rd -
1st - 20%
2nd - 60%
3rd - 80%
*More common on right side
109
Treatment of spontaneous pneumothorax
Indications for surgery and procedure of choice
- 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
Most common cause of malignant pericardial effusions
| - Treatment
- Lung cancer
| - Pericardial window
111
Most common cause of malignant pleural effusions
| - Treatment
- Lung cancer
| - Drainage and talc pleurodesis
112
Most likely cause of arrest after blunt trauma
- Tension pneumothorax causing decreased venous return
113
Catamenial pneumothorax definition and cause
- Occurs in temporal relation to menstruation
| - Caused by endometrial implants in the visceral lung pleura
114
Indications for surgical drainage of a clotted hemothorax
- > 25 % of lung involved, air-fluid levels, signs of infection
* Surgery in first week to avoid peel. Empyema risk
115
Causes of whiteout on CXR and treatments
- Shift towards whiteout
- Shift away from whiteout
- Shift towards = Collapse. Needs bronch to remove plug
| - Shift away = Effusion. Needs chest tube
116
Tuberculosis lung findings and treatment
- Calcifications, caseating granulomas
- Usually in lung apices
- INH, Rifampin, Pyrazinamide
117
Ghon complex
Parenchymal lesion + enlarged hilar lymph nodes
Seen in TB
118
Sarcoidosis has ______ granulomas
Non-caseating
119
Most common benign chest wall tumor
Osteochondroma
120
Most common malignant chest wall tumor
Chondrosarcoma
121
Pulmonary AVMs are usually found in ___ lobes.
- Symptoms
- Treatment
- Lower lobes
- Symptoms: hemopytsis, SOB, neurologic events
- Tx: embolization
122
Treatment for recurrent pleural effusions
- Benign
- Malignant
- Benign: Mechanical pleurodesis
| - Malignant: Talc pleurodesis
123
Treatment for airway fires
- Stop gas flow, remove ET tube, re-intubate for 24 hours, bronchoscopy
124
Evaluation of Pleural Fluid - Transudate
- WBC:
- pH:
- Pleural fluid protein to serum ratio:
- Pleural fluid LDH to serum ratio:
- WBC: < 1000
- pH: 7.45 - 7.55
- Pleural fluid protein to serum ratio: < 0.5
- Pleural fluid LDH to serum ratio: < 0.6
125
Evaluation of Pleural Fluid - Exudate
- WBC:
- pH:
- Pleural fluid protein to serum ratio:
- Pleural fluid LDH to serum ratio:
- WBC: > 1000
- pH: < 7.45
- Pleural fluid protein to serum ratio: > 0.5
- Pleural fluid LDH to serum ratio: > 0.6
126
Evaluation of Pleural Fluid - Empyema
- WBC:
- pH:
- Pleural fluid protein to serum ratio:
- Pleural fluid LDH to serum ratio:
- 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
