Thoracic Surgery, C71 P621-648 Flashcards
What does VATS stand for?
P621
Video-Assisted Thoracic Surgery
THORACIC OUTLET SYNDROME (TOS)
What is it?
P621
Compression of the: Subclavian artery Subclavian vein or Brachial plexus at the superior outlet of the thorax
THORACIC OUTLET SYNDROME (TOS)
What are the causes (3)?
P621
1. Various congenital anomalies, including cervical rib or abnormal fascial bands to the first rib, or abnormal anterior scalene muscle 2. Trauma: Fracture of clavicle or first rib Dislocation of humeral head Crush injuries 3. Repetitive motor injuries (baseball pitchers)
THORACIC OUTLET SYNDROME (TOS)
What are the symptoms?
P621
Paresthesias (neck, shoulder, arm, hand);
90% in ulnar nerve distribution
Weakness (neural/arterial)
Coolness of involved extremity (arterial)
Edema, venous distension, discoloration
(venous)
THORACIC OUTLET SYNDROME (TOS)
What are the most common
symptoms with TOS?
P621
Neurologic
THORACIC OUTLET SYNDROME (TOS)
Which nerve is most often
involved?
P621
Ulnar nerve
THORACIC OUTLET SYNDROME (TOS)
What are the signs?
P622
Paget-von Schroetter syndrome—venous thrombosis leading to edema, arm discoloration, and distension of the superficial veins Weak brachial and radial pulses in the involved arm Hypesthesia/anesthesia Occasionally, atrophy in the distribution of the ulnar nerve Positive Adson maneuver/Tinel’s sign Edema
THORACIC OUTLET SYNDROME (TOS)
What is the Adson
maneuver?
P622
Evaluates for arterial compromise Patient: 1. Extends neck (lifts head) 2. Takes a deep breath and holds 3. Turns head toward examined side Physician: Monitors radial pulse on examined side Test finding is positive if the radial pulse decreases or disappears during maneuver
THORACIC OUTLET SYNDROME (TOS)
What is Tinel’s test?
P622
Tapping of the supraclavicular fossa
producing paresthesias
THORACIC OUTLET SYNDROME (TOS)
What is the treatment?
P622
Physical therapy (vast majority of cases)
Decompression of the thoracic outlet by
resecting the first rib and cervical rib
(if present) if physical therapy fails
and as a last resort
CHESTWALL TUMORS BENIGN TUMORS What are the most common types? P622
- Fibrous rib dysplasia (posterolateral rib)
- Chondroma (at costochondral
junction) - Osteochondroma (any portion of rib)
CHESTWALL TUMORS
BENIGN TUMORS
What is the treatment?
P622
Wide excision and reconstruction with
autologous or prosthetic grafts
CHESTWALL TUMORS MALIGNANT TUMORS What are the most common types? P623
- Fibrosarcoma
- Chondrosarcoma
- Osteogenic sarcoma
- Rhabdomyosarcoma
- Myeloma
- Ewing’s sarcoma
CHESTWALL TUMORS
MALIGNANT TUMORS
What is the treatment?
P623
Excision with or without radiation
CHESTWALL TUMORS
MALIGNANT TUMORS
What is Tietze’s syndrome?
P623
Noninfectious costochondral cartilage
inflammation
DISEASES OF THE PLEURA
PLEURAL EFFUSION
What is it?
P623
Fluid in the pleural space
DISEASES OF THE PLEURA
PLEURAL EFFUSION
What are the causes?
P623
- Pulmonary infections (pneumonia)
- Congestive heart failure (CHF)
- SLE or rheumatoid arthritis
- Pancreatitis (sympathetic effusion)
- Trauma
- Pulmonary embolism
- Renal disease
- Cirrhosis
- Malignancy (mesothelioma,
lymphoma, metastasis) - Postpericardiotomy syndrome
DISEASES OF THE PLEURA
PLEURAL EFFUSION
What are the symptoms?
P623
Dyspnea, pleuritic chest pain
DISEASES OF THE PLEURA
PLEURAL EFFUSION
What are the signs?
P623
Decreased breath sounds, dullness to
percussion, egophony at the upper limit
DISEASES OF THE PLEURA PLEURAL EFFUSION What are the properties of a transudate? P623
Specific gravity <3 g/dL
Few cells
DISEASES OF THE PLEURA PLEURAL EFFUSION What are the properties of an exudate? P623
Specific gravity >1.016
Protein >3 g/dL
Many cells
DISEASES OF THE PLEURA PLEURAL EFFUSION What is the key diagnostic test? P624
Thoracentesis (needle drainage) with
studies including cytology
DISEASES OF THE PLEURA
PLEURAL EFFUSION
What is the treatment?
P624
- Pigtail catheter or thoracostomy (chest
tube) - Treat underlying condition
- Consider sclerosis
DISEASES OF THE PLEURA
PLEURAL EFFUSION
What is an empyema?
P624
Infected pleural effusion; must be
drained, usually with chest tube(s)
Decortication may be necessary if the
empyema is solid
DISEASES OF THE PLEURA
PLEURAL EFFUSION
What is a decortication?
P624
Thoracotomy and removal of an infected
fibrous rind from around the lung (think
of it as taking off a fibrous “cortex” from
the lung)
DISEASES OF THE PLEURA LUNG ABSCESS What are the signs/ symptoms? P624
Fever, sputum, sepsis, fatigue
DISEASES OF THE PLEURA LUNG ABSCESS What are the associated diagnostic studies? P624
CXR: air-fluid level CT scan to define position and to differentiate from an empyema Bronchoscopy (looking for cancer/culture)
DISEASES OF THE PLEURA
LUNG ABSCESS
What is the treatment?
P624
Antibiotics and bronchoscopy for culture
and toilet, with or without surgery
DISEASES OF THE PLEURA LUNG ABSCESS What are the indications for surgery? P624
Underlying cancer/tumor
Refractory to antibiotics
DISEASES OF THE PLEURA LUNG ABSCESS What are the surgical options? P624
Lobectomy of lobe with abscess
Tube drainage
DISEASES OF THE PLEURA LUNG ABSCESS What is middle lobe syndrome? P624
Recurrent right middle lobe pneumonia
caused most commonly by intermittent
extrinsic bronchial obstruction
DISEASES OF THE PLEURA
HEMOPTYSIS
What is it?
P624
Bleeding into the bronchial tree
DISEASES OF THE PLEURA
HEMOPTYSIS
What are the causes?
P625
- Bronchitis (50%)
- Tumor mass (20%)
- TB (8%)
Other causes: bronchiectasis, pulmonary
catheters, trauma
DISEASES OF THE PLEURA
HEMOPTYSIS
Define MASSIVE hemoptysis
P625
>600 cc/24 hours
DISEASES OF THE PLEURA
HEMOPTYSIS
What comprises the workup?
P625
CXR
Bronchoscopy
Bronchial A-gram
DISEASES OF THE PLEURA HEMOPTYSIS What is the treatment if massive? P625
Bronchoscopy, intubation of unaffected side, Fogarty catheter occlusion of bleeding bronchus, bronchial A-gram with or without embolization, surgical resection of involved lung
DISEASES OF THE PLEURA HEMOPTYSIS What is the treatment of moderate to mild bleeding? P625
Laser coagulation, +/– epinephrine
injection
DISEASES OF THE PLEURA
SPONTANEOUS PNEUMOTHORAX
What is it?
P625
Atraumatic spontaneous development of
a pneumothorax
DISEASES OF THE PLEURA
SPONTANEOUS PNEUMOTHORAX
What are the causes?
P625
Idiopathic (primary), bleb disease,
emphysema, etc. (secondary)
DISEASES OF THE PLEURA SPONTANEOUS PNEUMOTHORAX What body habitus is associated with spontaneous pneumothorax? P625
Thin and tall
DISEASES OF THE PLEURA
SPONTANEOUS PNEUMOTHORAX
How is the diagnosis made?
P625
CXR
DISEASES OF THE PLEURA
SPONTANEOUS PNEUMOTHORAX
What is the treatment?
P625
Chest tube
DISEASES OF THE PLEURA SPONTANEOUS PNEUMOTHORAX What are the options if refractory, recurrent, or bilateral? P625
Pleurodesis: scar the lung to the parietal
pleura with a sclerosant (talc) via chest
tube/thoracoscopy, or by thoracotomy
and mechanical abrasion
DISEASES OF THE PLEURA SPONTANEOUS PNEUMOTHORAX Who might also need a pleurodesis after the first episode? P625
Those whose lifestyles place them at
increased risk for pneumothorax (e.g.,
pilots, scuba divers)
DISEASES OF THE PLEURA SPONTANEOUS PNEUMOTHORAX What is a catamenial pneumothorax? P626
Pneumothorax due to intrathoracic
endometriosis
DISEASES OF THE PLEURA MESOTHELIOMA Malignant Mesothelioma What is it? P626
Primary pleural neoplasm
DISEASES OF THE PLEURA MESOTHELIOMA Malignant Mesothelioma What are the two types? P626
- Localized
2. Diffuse (highly malignant)
DISEASES OF THE PLEURA MESOTHELIOMA Malignant Mesothelioma What are the risk factors? P626
Exposure to asbestos
Smoking
DISEASES OF THE PLEURA MESOTHELIOMA Malignant Mesothelioma What are the symptoms? P626
Dyspnea and pain = 90%
Localized: pleuritic pain, joint pain and
swelling, dyspnea
Diffuse: chest pain, malaise, weight loss,
cough
DISEASES OF THE PLEURA MESOTHELIOMA Malignant Mesothelioma What are the signs? P626
Pleural effusion:
Localized (10%–15%)
Diffuse ( >75%)
DISEASES OF THE PLEURA MESOTHELIOMA Malignant Mesothelioma What are the associated radiographic tests? P626
X-ray may reveal a peripheral mass, often
forming an obtuse angle with the chest
wall; CT scan is also performed
DISEASES OF THE PLEURA MESOTHELIOMA Malignant Mesothelioma How is the diagnosis made? P626
Pleural biopsy, pleural fluid cytology
DISEASES OF THE PLEURA MESOTHELIOMA Malignant Mesothelioma What is the treatment if localized? P626
Surgical excision
DISEASES OF THE PLEURA MESOTHELIOMA Malignant Mesothelioma What is the treatment if diffuse? P626
Early stages may be resected, followed
by radiation; for more advanced stages,
radiation, chemotherapy, or both are done
DISEASES OF THE PLEURA MESOTHELIOMA Malignant Mesothelioma What is the prognosis? P626
Localized: poor
Diffuse: dismal (average life span after
diagnosis is about 1 year)
DISEASES OF THE PLEURA MESOTHELIOMA Benign Mesothelioma What is it? P626
Benign pleural mesothelioma
DISEASES OF THE PLEURA MESOTHELIOMA Benign Mesothelioma What pleura is usually involved? P626
Visceral pleura
DISEASES OF THE PLEURA MESOTHELIOMA Benign Mesothelioma What is the gross appearance? P627
Pedunculated “broccoli or cauliflower”
tumor on a stalk coming off of the lung
DISEASES OF THE PLEURA MESOTHELIOMA Benign Mesothelioma What is the treatment? P627
Surgical resection with at least 1 cm clear
margin
DISEASES OF THE PLEURA MESOTHELIOMA Benign Mesothelioma What is the prognosis? P627
In contrast to malignant mesothelioma, the
benign mesothelioma has an excellent prognosis
with cure in the vast majority of cases
DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What is the annual incidence of lung cancer in the United States? P627
170,000 new cases/year
DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What is the number of annual deaths from lung cancer? P627
150,000; most common cancer death in
the United States in men and women
DISEASES OF THE LUNGS
BRONCHOGENIC CARCINOMA
What is the #1 risk factor?
P627
Smoking (85%!)
DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA Does asbestos exposure increase the risk in patients who smoke? P627
Yes
DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What type of lung cancer arises in nonsmoking?Adenocarcinoma P627
Adenocarcinoma
DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA Cancer arises more often in which lung? P627
Right > left; upper lobes > lower lobes
DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What are the signs/ symptoms? P627
Change in a chronic cough Hemoptysis, chest pain, dyspnea Pleural effusion (suggests chest wall involvement) Hoarseness (recurrent laryngeal nerve involvement) Superior vena cava syndrome Diaphragmatic paralysis (phrenic nerve involvement) Symptoms of metastasis/paraneoplastic syndrome Finger clubbing
DISEASES OF THE LUNGS
BRONCHOGENIC CARCINOMA
What is Pancoast’s tumor?
P628
Tumor at the apex of the lung or superior
sulcus that may involve the brachial
plexus, sympathetic ganglia, and vertebral
bodies, leading to pain, upper extremity
weakness, and Horner’s syndrome
DISEASES OF THE LUNGS
BRONCHOGENIC CARCINOMA
What is Horner’s syndrome?
P628
Injury to the cervical sympathetic chain; Think: “MAP” 1. Miosis (small pupil) 2. Anhydrosis of ipsilateral face 3. Ptosis
DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What are the four most common sites of extrathoracic metastases? P628
- Bone
- Liver
- Adrenals
- Kidney
DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What are paraneoplastic syndromes? P628
Syndromes that are associated with tumors but may affect distant parts of the body; they may be caused by hormones released from endocrinologically active tumors or may be of uncertain etiology
DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA Name five general types of paraneoplastic syndromes. P628
1. Metabolic: Cushing’s, SIADH, hypercalcemia 2. Neuromuscular: Eaton-Lambert, cerebellar ataxia 3. Skeletal: hypertrophic osteoarthropathy 4. Dermatologic: acanthosis nigricans 5. Vascular: thrombophlebitis
DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What are the associated radiographic tests? P628
CXR, CT scan, PET scan
DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA How is the tumor diagnosed? P628
- Sputum cytology
- Needle biopsy (CT or fluoro guidance)
- Bronchoscopy with brushings, biopsies,
or both - With or without mediastinoscopy,
mediastinotomy, scalene node biopsy,
or open lung biopsy for definitive
diagnosis
DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA For each tumor listed, recall its usual site in the lung and its natural course: Squamous cell? P629
66% occur centrally in lung hilus; may
also be a Pancoast’s tumor; slow growth,
late metastasis; associated with smoking
(Think: Squamous = Sentral)
DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA For each tumor listed, recall its usual site in the lung and its natural course: Adenocarcinoma? P629
Peripheral, rapid growth with
hematogenous/nodal metastasis,
associated with lung scarring
DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA For each tumor listed, recall its usual site in the lung and its natural course: Small (oat) cell? P629
Central, highly malignant, usually not
operable
DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA For each tumor listed, recall its usual site in the lung and its natural course: Large cell? P629
Usually peripheral, very malignant
DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What are the AJCC stages of carcinoma of the lungs: Stage Ia? P629
Tumor <3 cm, no nodes, no metastases
DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What are the AJCC stages of carcinoma of the lungs: Stage Ib? P629
Tumor 3–5 cm, no nodes, no
metastases
DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What are the AJCC stages of carcinoma of the lungs: Stage IIa? P629
1. Tumor <5 cm and positive nodes to lung or ipsilateral hilum; no metastases, or 2. Tumor 5–7 cm, no nodes, no metastases
DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What are the AJCC stages of carcinoma of the lungs: Stage IIb? P629
1. Tumor 5–7 cm and positive nodes in lung or ipsilateral hilum, or 2. Tumor that invades chest wall, diaphragm, mediastinal pleura, phrenic nerve, pericardial sac, or bronchus (not carina) and no nodes, no metastases
DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What are the AJCC stages of carcinoma of the lungs: Stage IIIa? P630
- Tumor 7 cm or extends into chest
wall, parietal pleura, diaphragm,
phrenic nerve, or pericardium and
+ lymph node metastases to ipsilateral,
mediastinal, or subcarinal nodes - Any size tumor that invades heart,
great vessels, trachea, esophagus,
carina, or ipsalateral lobe, or + nodes
peribronchial and/or ipsilateral hilum,
or intrapulmonary nodes
DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What are the AJCC stages of carcinoma of the lungs: Stage IIIb? P630
Any tumor, + lymph node metastases to
contralateral hilum or mediastinum
Supraclavicular/scalene nodes, NO
distant metastases
DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What are the AJCC stages of carcinoma of the lungs: Stage IV? P630
Distant metastases
DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What are the surgical contraindications for NON-small cell carcinoma? P630
Stage IV, Stage IIIb, poor lung function
FEV1 <0.8L
DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What is the treatment by stage for NON-small cell lung carcinoma: Stage I? P630
Surgical resection
DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What is the treatment by stage for NON-small cell lung carcinoma: Stage II? P630
Surgical resection
DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What is the treatment by stage for NON-small cell lung carcinoma: Stage IIIa? P630
Chemotherapy and XRT +/- surgical
resection
DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What is the treatment by stage for NON-small cell lung carcinoma: Stage IIIb? P630
Chemotherapy and XRT
DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What is the treatment by stage for NON-small cell lung carcinoma: Stage IV? P630
Chemotherapy +/- XRT
DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What is the treatment for isolated brain metastasis? P630
Surgical resection
DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What is the approximate prognosis (5-year survival) after treatment of NON-small cell lung carcinoma by stage: Stage I? P631
50%
DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What is the approximate prognosis (5-year survival) after treatment of NON-small cell lung carcinoma by stage: Stage II? P631
30%
DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What is the approximate prognosis (5-year survival) after treatment of NON-small cell lung carcinoma by stage: Stage III? P631
<10%
DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What is the approximate prognosis (5-year survival) after treatment of NON-small cell lung carcinoma by stage: Stage IV? P631
1%
DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA How is small cell carcinoma treated? P631
Chemotherapy +/- XRT (very small
isolated lesions can be surgically resected)
DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What are the contraindications to surgery for lung cancer? P631
Think: “STOP IT” Superior vena cava syndrome, Supraclavicular node metastasis, Scalene node metastasis Tracheal carina involvement Oat cell carcinoma (treat with chemotherapy +/- radiation) Pulmonary function tests show FEV1 <0.8L Infarction (myocardial); a.k.a. cardiac cripple Tumor elsewhere (metastatic disease)
DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What postoperative FEV1 must you have? P631
FEV1 >800 cc; thus, a preoperative FEV1 >2L is usually needed for a pneumonectomy If FEV1 is <2L, a ventilation perfusion scan should be performed
DISEASES OF THE LUNGS BRONCHOGENIC CARCINOMA What is hypertrophic pulmonary osteoarthropathy? P631
Periosteal proliferation and new bone
formation at the end of long bones and
in the bones of the hand (seen in 10%
of patients with lung cancer)
DISEASES OF THE LUNGS
SOLITARY PULMONARY NODULES (COIN LESIONS)
What are they?
P631
Peripheral circumscribed pulmonary
lesions
DISEASES OF THE LUNGS SOLITARY PULMONARY NODULES (COIN LESIONS) What is the differential diagnosis? P632
Granulomatous disease, benign
neoplasms, malignancy
DISEASES OF THE LUNGS SOLITARY PULMONARY NODULES (COIN LESIONS) What percentage are malignant? P632
Overall, 5% to 10% (but >50% are
malignant in smokers >50 years)
DISEASES OF THE LUNGS
SOLITARY PULMONARY NODULES (COIN LESIONS)
Is there a gender risk?
P632
Yes; the incidence of coin lesions is 3
to 9x higher and malignancy is nearly
twice as common in men as in women
DISEASES OF THE LUNGS
SOLITARY PULMONARY NODULES (COIN LESIONS)
What are the symptoms?
P632
Usually asymptomatic with solitary
nodules, but may include coughing,
weight loss, chest pain, and hemoptysis
DISEASES OF THE LUNGS
SOLITARY PULMONARY NODULES (COIN LESIONS)
What are the signs?
P632
Physical findings are uncommon; clubbing
is rare; hypertrophic osteoarthropathy
implies 80% chance of malignancy