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Thoracic Flashcards

1
Q

Spontaneous PTX. when do you do surgery?

A

First time: pigtail and heimlich valve. Dc home. Pull it out in 2 weeks. Done

Second time: surgery

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2
Q

What is the indication to place a chest tube for TB effusion?

A

Never ever place a chest tube for TB. You will cause a horrible bronchopleural fistula that will never ever heal. Maybe only for empyema

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3
Q

Lung abscess with air fluid level. Treatment?

A

Just abx. This is an “open” abscess. It will clear with pulmonary toilet and abx.

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4
Q

Pt referred to you for aspergillosis and aspergilloma. Rx?

A

Medical first to clear the aspergillosis. Then surgery for the aspergilloma. Oma won’t clear with medical rx only but you need to rx the diffuse aspergillosis first otherwise they are too immunocompromised for the surgery

Voriconazole

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5
Q

What’s the difference in blood supply for intrapulmonary vs extrapulmonary sequestrations?

A

Intrapulmonary: drains with the rest of the lobe

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6
Q

Solitary pulmonary nodule sizes and follow-up guidelines

A

<4 mm: no f/u needed
4-6 mm: f/u at 1 yr
6-8 mm: f/u at 6 mo
>8 mm: needs CT, biopsy

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7
Q

Who needs mediastinoscopy?

A

Anyone with a PET (+) mediastinum

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8
Q

What differentiates a stage 2 from a stage 3A lung CA?

A

Mediastinal lymph node involvement

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9
Q

When can you skip mediastinoscopy?

A

If PET (-) and the primary tumor is <2cm

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10
Q

For pneumonectomy, what’s the minimum FEV1/FVC % do you need? Below what % will ppl definitely not tolerate pneumonectomy?

How many cc of lung volume does the pt need after pneumonectomy?

A

60%. <40% definitely not. In-between you can do a VQ scan

800cc

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11
Q

What size lung cancer is T1a?

A

< 1cm

T1b < 2cm

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12
Q

Lung cancer up to what size can be T2?

A

Up to 7cm

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13
Q

What T stage is a 1cm tumor with pneumonitis

A

T2 bc of the pneumonitis

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14
Q

What T stage is a 1cm lung cancer 1cm from the carina?

A

T3. Even though 1cm tumor is T1 by size, being <2 cm from the carina makes it T3

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15
Q

2cm tumor and another 1cm in the same lobe. What T stage?

What if the 1cm lesion was in another lobe on the same side?

A

T3

Ipsilateral different lobe: T4

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16
Q

Lung cancer extends into the pericardium. What T stage?

A

T3. When it extends into things you can take out it’s T3. Chest wall, pericardium, mediastinal pleura, diaphragm

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17
Q

Chest node levels. Double digit nodes vs single digit nodes. Which one has a higher N stage if (+)?

A

Double digits: N1

Single digits: N2

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18
Q

Other than distant mets, what makes a lung cancer stage 4?

A

Tumor in the contralateral lung
Malignant effusion
Pleural nodules

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19
Q

Which lung cancer can cause SIADH?

A

Small cell

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20
Q

Which lung cancer type can cause hypercalcemia?

A

Squamous cell. (PTH related protein)

This is the only thing squamous cell CA causes. Everything else is small cell

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21
Q

Which lung cancer type can cause cushing’s?

A

Small cell

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22
Q

Whats one lung cancer stage that gets neoadjuvant therapy?

A

Stage 3a

Any N2 disease or T3N1

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23
Q

Can you operate on T3 lung cancer? How about T4?

A

Yes T3, no T4 (maybe only if >7cm size is the only thing that’s making it T4)

remember T3: 5-7cm, attaches to things you can cut out. neoadj.
T4: >7cm, attaches to things you can’t cut out

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24
Q

What’s one scenario where you can offer surgery for small cell lung cancer?

A

T1a lesion. Peripheral, <2cm

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25
How many compartments does the mediastinum have and which compartment has the most number of tumors associated with it?
Anterior Middle Posterior Anterior has the most number of tumors associated. 4T's Teratomas Thyroid Thymus Terrible lymphomas
26
Young man comes to your office with a suspected mediastinal teratoma. - which compartment? - what is your next step? Do you need to biopsy? - what is the treatment?
- anterior compartment. Thymus, thyroid, teratoma, terrible lymphomas - tumor markers. AFP, b-hcg. If they're high, no need for biopsy - 4 cycles of chemo then re-marker and rescan
27
When do you have to operate for mediastinal teratoma? What is the operation?
If there's any signs of residual disease after 4 cycles of chemo. If it's completely gone after chemo, you're done. Median sternotomy and explore the entire mediastinum
28
Young man referred to you for possible mediastinal teratoma. Why is testicular exam important?
If (+) testicular exam then rx is chemo. Oncology
29
What is the most common mediastinal tumor found in adults?
Thymomas
30
What tumors are common in middle mediastinal compartment?
Esophageal duplication cyst | Bronchial cyst
31
What types of tumors are common in posterior mediastinal compartment?
Lymphomas in kids | Neuroendocrine tumors
32
What C level innervates the diaphragm? How many hiatuses does the diaphragm have?
C3-5 3. IVC, aorta, esophagus
33
For paraesophageal hernias, the preferred approach is through the abdomen most of the time. When do you do a thoracic approach?
When the LES is >7cm from the hiatus (likely >50% of the stomach is in the chest)
34
Paraesophageal hernia repair when do you use a mesh? Synthetic or biologic mesh? Does it make a difference?
If they're >50yo and/or the defect is huge. Small defect in <50: no mesh Biologic is preferred to prevent mesh erosion Do a nissen
35
Morgagni vs bochdalek - Left vs right? Anterior vs posterior? - presents in kids vs adults?
- Bochdalek is left. Morgagni is right. Bochdalek: back. Morgagni: anterior - kids: Bochdalek, adults: morgagni
36
SVC syndrome in ED. Satting 100%. what's the first thing you do? IV steroids? Emergent external beam radiation?
1) Elevate the head of bed -> improves venous drainage 2) supplemental O2 if sob or desat Radiation is not emergent
37
Most common presentation of a mediastinal tumor in adults?
Asymptomatic
38
Most common presenting symptom of lung cancer?
Persistent cough
39
What is the most common cause of acute mediastinitis?
Direct contamination by esophageal perforation
40
What % of pts with thymoma will have myasthenia gravis? What % of pts with myasthenia will have a thymoma? What % of myasthenia pts will improve after thymectomy?
50% of those with thymoma will have myasthenia 10% of pts with myasthenia will have a thymoma? 80% of pts will show improvement
41
After you repair the tracheoinnominate fistula, what do you need to do? How do you close the initial tracheal stoma? What if the field is contaminated?
You have to relocate the tracheostomy more proximally Closure of the initial tracheal stoma is by local strap muscle flaps. Primary closure is NOT acceptable Contaminated field -> omental flap
42
What are the three stages of empyema If you let the empyema go untreated, what is the most serious complication?
Exudative < 7 days Fibrinopurulent b/w 7-21 days Organizing > 21 days Bronchopleural fistula
43
Lung cancer. What makes it stage III without nodal involvement/mets?
T4 lesions are stage III - >7 cm - Extending into things you can't cut out such as invasion of mediastinum, heart, great vessels, trachea, esophagus, carina - Tumor in a different lobe on same side
44
Positive ipsilateral mediastinal lymph node makes cancer automatically what stage?
Stage III
45
Indication to do a collis gastroplasty?
If unable to get 2-3 cm of intra-abdominal esophagus
46
71M got EGD. Fungating mass. Presents after 2 hrs. CXR shows pneumomediastinun. Stable. - What do you do? - presents after 24hr. Fever, hypotensive. What do you do?
- UGI first. If no leak: npo, ivf, ngt. If (+) leak: operate, emergency ivor lewis - 24hr later unstable: esophagectomy. Left+right chest tubes, ng tube down to the proximal staple line. Needs a quick 1hr operation to save a life
47
Iatrogenic esophageal perforations are now managed more nonoperatively. What are the 3 criteria that need to be met to go non-op? Most common complication of non-op mngmt?
1) mild symptoms 2) perforation contained within mediastinum 3) minimal sepsis Stent migration
48
20's M, Spontaneous pneumomediastinun. Treatment/next step?
From alveolar rupture with tracking along the brknchovascular bundle to the mediastinum Observation, pain Ctrl. Usually resolved in 1-3 days If there is a history of emesis, fever or pleural effusion then esophagram
49
Can you do pleurodesis in pt who has malignant effusion?
Yes you can. You can't do it if the lung is trapped however.
50
When do lung cancers get neoadjuvant chemo/rad?
Starting stage IIIa Any N2 disease: ipsilateral mediastinal or subcarinal disease T3 (5-7cm) N1 Any T4 (>7cm)
51
Achalasia is a risk factor for what kind of cancer?
Esophageal squamous cell carcinoma
52
Treatment for diffuse esophageal spasm when CCB is not one of the answer choices?
Nitrates
53
What is the treatment for nutcracker esophagus?
Extended myotomy after balloon dilation It's a hypertensive peristaltic disease. Really high amplitudes
54
Most common location for spontaneous esophageal perforation?
Spontaneous: lower/thoracic esophagus
55
Which of the following is a risk factor for Barrett's? - NSAID use - H. Pyloric - male gender
Male > female | 2:1
56
Esophageal cancer. What layer is involved with: T1 T2 T3 What's the difference between stage IIA vs IIB?
T1: mucosa, submucosa (muscularis mucosa) T2: muscularis PROPRIA T3: adventitia T4a: invades resectable adj structures (pleura, pericardium, diaphragm) T4b: invades unresectable adj structures (aorta, vertebral body, trachea) IIA: T2 IIB: T3
57
Pt with new GERD. placed on PPI. only partially responds. Next step? Only partially responds to above therapy/intervention. Next step?
Double PPI dose. If double PPI dose doesn't do it, then do a 24hr pH test then EGD
58
What is an advantage of using right colon as opposed to left colon in esophageal reconstruction? Which colon has the advantage of having more length
Bauhin valve. Aka ileocecal valve. Prevents reflux Left colon has the length advantage.
59
What tumors are common between the pericardium and the thoracic spine?
This is middle mediastinum. Cysts (pericardial, bronchogenic, enteric cysts) Lymphoma
60
What tumors are common between the tracheal bifurcation and pulmonary vessels anteriorly and anterior surfaces of the last 8 thoracic vertebrae?
This is posterior mediastinum. NEUROGENIC TUMORS Esophageal cysts, lymphoma
61
Iatrogenic perf after a scope for achalasia. Where is the most likely site of perforation? What incision to repair? Most common site of iatrogenic perforation in a healthy esophagus?
Distal esophagus Left posterolateral thoracotomy Healthy esophagus -> Killian triangle. Cricopharyngeus
62
Which stage of lung cancer is stage III without any node involvement?
T4 lesions - >7 cm - Extending into things you can't cut out such as invasion of mediastinum, heart, great vessels, trachea, esophagus, carina - Tumor in a different lobe on same side
63
What's the margin needed for esophageal cancer?
10-12cm proximal | At least 5cm distal
64
What are the borders of the Killian triangle?
Base is the cricopharyngeus muscle On top triangularly are two inferior constrictor muscles also known as thyropharyngeus So the space is inferior to the inferior constrictors Superior to the cricopharyngeus
65
Achalasia pt perfs from vomiting. Extrav of contrast into left chest along the distal esophagus. Treatment?
Esophagectomy. In pts with a perforation proximal to untreated achalasia, undilatable stricture, cancer, esophagectomy at the time of perforation should be performed if they're stable
66
Most useful diagnostic modality to detect atrial myxoma? Is it cardiac MRI?
Echo. Not Cardiac MRI. This is not as specific as the echo
67
Off pump CABG vs on pump CABG - 30d mortality? - 1yr mortality? - graft patency - length of stay - risk of stroke
- same 30d mortality - 1yr mortality higher for off pump CABG - lower patency rate for off pump - shorter length of stay for off pump CABG - same risk of stroke
68
What's the ideal timing of VATS for empyema?
Should be performed with 7 days and within 48 hrs of initial chest tube
69
most common primary malignant soft tissue tumor of the chest wall?
chondrosarcoma
70
When is esophagectomy an acceptable operation for a perforated appendix?
Undilatable stricture, malignancy, achalasia causing sigmoid esophagus or nutritional deficiency
71
What aortic valve area denotes significant aortic stenosis and an indication for valve replacement?
< 1cm²
72
Give a brief buzzword description of belsey mark IV fundoplication. When do you do it
Thoracic approach. Anterior 240 degree fundoplication For intrathoracic stomach, short esophagus, or any other reason to be in the chest
73
What is the treatment for a friable pink/purple Endobronchial mass found on bronchoscopy? What if there's mediastinal node involvement?
This is carcinoid Regardless of the mediastinal nodes you have to resect and do mediastinal node sampling/dissection
74
what are the 4 categories for parapneumonic effusion? glucose of the pleural fluid have anything to do with anything?
I & II: minimal to moderate. FREE FLOWING effusion. pH > 7.2 III & IV: pH > 7.2. purulence is IV. more than half of a hemithorax. thickened parietal pleura glucose of the fluid doesn't have anything to do with anything
75
85yo, trapped lung and malignant effusion. treatment? can you pleurodese? what if the pt was 55?
VATS and pleural catheter. decort is too aggressie for 85. pleurodesis is contraindicated with trapped lung if younger, may try decort

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