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ENT > Thoracic Surgery, C71 P621-648 > Flashcards

Thoracic Surgery, C71 P621-648 Flashcards

1
Q

What does VATS stand for?

P621

A

Video-Assisted Thoracic Surgery

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2
Q

THORACIC OUTLET SYNDROME (TOS)
What is it?
P621

A 
Compression of the:
Subclavian artery
Subclavian vein or
Brachial plexus at the superior outlet
    of the thorax
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3
Q

THORACIC OUTLET SYNDROME (TOS)
What are the causes (3)?
P621

A 
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)
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4
Q

THORACIC OUTLET SYNDROME (TOS)
What are the symptoms?
P621

A

Paresthesias (neck, shoulder, arm, hand);
90% in ulnar nerve distribution
Weakness (neural/arterial)
Coolness of involved extremity (arterial)
Edema, venous distension, discoloration
(venous)

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5
Q

THORACIC OUTLET SYNDROME (TOS)
What are the most common
symptoms with TOS?
P621

A

Neurologic

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6
Q

THORACIC OUTLET SYNDROME (TOS)
Which nerve is most often
involved?
P621

A

Ulnar nerve

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7
Q

THORACIC OUTLET SYNDROME (TOS)
What are the signs?
P622

A 
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
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8
Q

THORACIC OUTLET SYNDROME (TOS)
What is the Adson
maneuver?
P622

A 
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
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9
Q

THORACIC OUTLET SYNDROME (TOS)
What is Tinel’s test?
P622

A

Tapping of the supraclavicular fossa

producing paresthesias

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10
Q

THORACIC OUTLET SYNDROME (TOS)
What is the treatment?
P622

A

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

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11
Q 
CHESTWALL TUMORS
BENIGN TUMORS
What are the most common
types?
P622
A
  1. Fibrous rib dysplasia (posterolateral rib)
  2. Chondroma (at costochondral
    junction)
  3. Osteochondroma (any portion of rib)
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12
Q

CHESTWALL TUMORS
BENIGN TUMORS
What is the treatment?
P622

A

Wide excision and reconstruction with

autologous or prosthetic grafts

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13
Q 
CHESTWALL TUMORS
MALIGNANT TUMORS
What are the most common
types?
P623
A
  1. Fibrosarcoma
  2. Chondrosarcoma
  3. Osteogenic sarcoma
  4. Rhabdomyosarcoma
  5. Myeloma
  6. Ewing’s sarcoma
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14
Q

CHESTWALL TUMORS
MALIGNANT TUMORS
What is the treatment?
P623

A

Excision with or without radiation

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15
Q

CHESTWALL TUMORS
MALIGNANT TUMORS
What is Tietze’s syndrome?
P623

A

Noninfectious costochondral cartilage

inflammation

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16
Q

DISEASES OF THE PLEURA
PLEURAL EFFUSION
What is it?
P623

A

Fluid in the pleural space

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17
Q

DISEASES OF THE PLEURA
PLEURAL EFFUSION
What are the causes?
P623

A
  1. Pulmonary infections (pneumonia)
  2. Congestive heart failure (CHF)
  3. SLE or rheumatoid arthritis
  4. Pancreatitis (sympathetic effusion)
  5. Trauma
  6. Pulmonary embolism
  7. Renal disease
  8. Cirrhosis
  9. Malignancy (mesothelioma,
    lymphoma, metastasis)
  10. Postpericardiotomy syndrome
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18
Q

DISEASES OF THE PLEURA
PLEURAL EFFUSION
What are the symptoms?
P623

A

Dyspnea, pleuritic chest pain

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19
Q

DISEASES OF THE PLEURA
PLEURAL EFFUSION
What are the signs?
P623

A

Decreased breath sounds, dullness to

percussion, egophony at the upper limit

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20
Q 
DISEASES OF THE PLEURA
PLEURAL EFFUSION
What are the properties of a
transudate?
P623
A

Specific gravity <3 g/dL

Few cells

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21
Q 
DISEASES OF THE PLEURA
PLEURAL EFFUSION
What are the properties of
an exudate?
P623
A

Specific gravity >1.016
Protein >3 g/dL
Many cells

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22
Q 
DISEASES OF THE PLEURA
PLEURAL EFFUSION
What is the key diagnostic
test?
P624
A

Thoracentesis (needle drainage) with

studies including cytology

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23
Q

DISEASES OF THE PLEURA
PLEURAL EFFUSION
What is the treatment?
P624

A
  1. Pigtail catheter or thoracostomy (chest
    tube)
  2. Treat underlying condition
  3. Consider sclerosis
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24
Q

DISEASES OF THE PLEURA
PLEURAL EFFUSION
What is an empyema?
P624

A

Infected pleural effusion; must be
drained, usually with chest tube(s)
Decortication may be necessary if the
empyema is solid

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25
Q

DISEASES OF THE PLEURA
PLEURAL EFFUSION
What is a decortication?
P624

A

Thoracotomy and removal of an infected
fibrous rind from around the lung (think
of it as taking off a fibrous “cortex” from
the lung)

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26
Q 
DISEASES OF THE PLEURA
LUNG ABSCESS
What are the signs/
symptoms?
P624
A

Fever, sputum, sepsis, fatigue

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27
Q 
DISEASES OF THE PLEURA
LUNG ABSCESS
What are the associated
diagnostic studies?
P624
A 
CXR: air-fluid level
CT scan to define position and to
    differentiate from an empyema
Bronchoscopy (looking for
    cancer/culture)
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28
Q

DISEASES OF THE PLEURA
LUNG ABSCESS
What is the treatment?
P624

A

Antibiotics and bronchoscopy for culture

and toilet, with or without surgery

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29
Q 
DISEASES OF THE PLEURA
LUNG ABSCESS
What are the indications for
surgery?
P624
A

Underlying cancer/tumor

Refractory to antibiotics

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30
Q 
DISEASES OF THE PLEURA
LUNG ABSCESS
What are the surgical
options?
P624
A

Lobectomy of lobe with abscess

Tube drainage

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31
Q 
DISEASES OF THE PLEURA
LUNG ABSCESS
What is middle lobe
syndrome?
P624
A

Recurrent right middle lobe pneumonia
caused most commonly by intermittent
extrinsic bronchial obstruction

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32
Q

DISEASES OF THE PLEURA
HEMOPTYSIS
What is it?
P624

A

Bleeding into the bronchial tree

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33
Q

DISEASES OF THE PLEURA
HEMOPTYSIS
What are the causes?
P625

A
  1. Bronchitis (50%)
  2. Tumor mass (20%)
  3. TB (8%)
    Other causes: bronchiectasis, pulmonary
    catheters, trauma
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34
Q

DISEASES OF THE PLEURA
HEMOPTYSIS
Define MASSIVE hemoptysis
P625

A

> 600 cc/24 hours

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35
Q

DISEASES OF THE PLEURA
HEMOPTYSIS
What comprises the workup?
P625

A

CXR
Bronchoscopy
Bronchial A-gram

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36
Q 
DISEASES OF THE PLEURA
HEMOPTYSIS
What is the treatment if
massive?
P625
A 
Bronchoscopy, intubation of unaffected
side, Fogarty catheter occlusion of
bleeding bronchus, bronchial A-gram
with or without embolization, surgical
resection of involved lung
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37
Q 
DISEASES OF THE PLEURA
HEMOPTYSIS
What is the treatment of
moderate to mild bleeding?
P625
A

Laser coagulation, +/– epinephrine

injection

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38
Q

DISEASES OF THE PLEURA
SPONTANEOUS PNEUMOTHORAX
What is it?
P625

A

Atraumatic spontaneous development of

a pneumothorax

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39
Q

DISEASES OF THE PLEURA
SPONTANEOUS PNEUMOTHORAX
What are the causes?
P625

A

Idiopathic (primary), bleb disease,

emphysema, etc. (secondary)

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40
Q 
DISEASES OF THE PLEURA
SPONTANEOUS PNEUMOTHORAX
What body habitus is
associated with spontaneous
pneumothorax?
P625
A

Thin and tall

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41
Q

DISEASES OF THE PLEURA
SPONTANEOUS PNEUMOTHORAX
How is the diagnosis made?
P625

A

CXR

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42
Q

DISEASES OF THE PLEURA
SPONTANEOUS PNEUMOTHORAX
What is the treatment?
P625

A

Chest tube

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43
Q 
DISEASES OF THE PLEURA
SPONTANEOUS PNEUMOTHORAX
What are the options if
refractory, recurrent, or
bilateral?
P625
A

Pleurodesis: scar the lung to the parietal
pleura with a sclerosant (talc) via chest
tube/thoracoscopy, or by thoracotomy
and mechanical abrasion

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44
Q 
DISEASES OF THE PLEURA
SPONTANEOUS PNEUMOTHORAX
Who might also need a
pleurodesis after the first
episode?
P625
A

Those whose lifestyles place them at
increased risk for pneumothorax (e.g.,
pilots, scuba divers)

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45
Q 
DISEASES OF THE PLEURA
SPONTANEOUS PNEUMOTHORAX
What is a catamenial
pneumothorax?
P626
A

Pneumothorax due to intrathoracic

endometriosis

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46
Q 
DISEASES OF THE PLEURA
MESOTHELIOMA
Malignant Mesothelioma
What is it?
P626
A

Primary pleural neoplasm

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47
Q 
DISEASES OF THE PLEURA
MESOTHELIOMA
Malignant Mesothelioma
What are the two types?
P626
A
  1. Localized

2. Diffuse (highly malignant)

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48
Q 
DISEASES OF THE PLEURA
MESOTHELIOMA
Malignant Mesothelioma
What are the risk factors?
P626
A

Exposure to asbestos

Smoking

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49
Q 
DISEASES OF THE PLEURA
MESOTHELIOMA
Malignant Mesothelioma
What are the symptoms?
P626
A

Dyspnea and pain = 90%
Localized: pleuritic pain, joint pain and
swelling, dyspnea
Diffuse: chest pain, malaise, weight loss,
cough

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50
Q 
DISEASES OF THE PLEURA
MESOTHELIOMA
Malignant Mesothelioma
What are the signs?
P626
A

Pleural effusion:
Localized (10%–15%)
Diffuse ( >75%)

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51
Q 
DISEASES OF THE PLEURA
MESOTHELIOMA
Malignant Mesothelioma
What are the associated
radiographic tests?
P626
A

X-ray may reveal a peripheral mass, often
forming an obtuse angle with the chest
wall; CT scan is also performed

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52
Q 
DISEASES OF THE PLEURA
MESOTHELIOMA
Malignant Mesothelioma
How is the diagnosis made?
P626
A

Pleural biopsy, pleural fluid cytology

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53
Q 
DISEASES OF THE PLEURA
MESOTHELIOMA
Malignant Mesothelioma
What is the treatment if
localized?
P626
A

Surgical excision

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54
Q 
DISEASES OF THE PLEURA
MESOTHELIOMA
Malignant Mesothelioma
What is the treatment if
diffuse?
P626
A

Early stages may be resected, followed
by radiation; for more advanced stages,
radiation, chemotherapy, or both are done

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55
Q 
DISEASES OF THE PLEURA
MESOTHELIOMA
Malignant Mesothelioma
What is the prognosis?
P626
A

Localized: poor
Diffuse: dismal (average life span after
diagnosis is about 1 year)

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56
Q 
DISEASES OF THE PLEURA
MESOTHELIOMA
Benign Mesothelioma
What is it?
P626
A

Benign pleural mesothelioma

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57
Q 
DISEASES OF THE PLEURA
MESOTHELIOMA
Benign Mesothelioma
What pleura is usually
involved?
P626
A

Visceral pleura

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58
Q 
DISEASES OF THE PLEURA
MESOTHELIOMA
Benign Mesothelioma
What is the gross appearance?
P627
A

Pedunculated “broccoli or cauliflower”

tumor on a stalk coming off of the lung

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59
Q 
DISEASES OF THE PLEURA
MESOTHELIOMA
Benign Mesothelioma
What is the treatment?
P627
A

Surgical resection with at least 1 cm clear

margin

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60
Q 
DISEASES OF THE PLEURA
MESOTHELIOMA
Benign Mesothelioma
What is the prognosis?
P627
A

In contrast to malignant mesothelioma, the
benign mesothelioma has an excellent prognosis
with cure in the vast majority of cases

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61
Q 
DISEASES OF THE LUNGS
BRONCHOGENIC CARCINOMA
What is the annual incidence
of lung cancer in the United
States?
P627
A

170,000 new cases/year

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62
Q 
DISEASES OF THE LUNGS
BRONCHOGENIC CARCINOMA
What is the number of annual
deaths from lung cancer?
P627
A

150,000; most common cancer death in

the United States in men and women

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63
Q

DISEASES OF THE LUNGS
BRONCHOGENIC CARCINOMA
What is the #1 risk factor?
P627

A

Smoking (85%!)

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64
Q 
DISEASES OF THE LUNGS
BRONCHOGENIC CARCINOMA
Does asbestos exposure
increase the risk in patients
who smoke?
P627
A

Yes

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65
Q 
DISEASES OF THE LUNGS
BRONCHOGENIC CARCINOMA
What type of lung cancer
arises in nonsmoking?Adenocarcinoma
P627
A

Adenocarcinoma

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66
Q 
DISEASES OF THE LUNGS
BRONCHOGENIC CARCINOMA
Cancer arises more often in
which lung?
P627
A

Right > left; upper lobes > lower lobes

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67
Q 
DISEASES OF THE LUNGS
BRONCHOGENIC CARCINOMA
What are the signs/
symptoms?
P627
A 
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
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68
Q

DISEASES OF THE LUNGS
BRONCHOGENIC CARCINOMA
What is Pancoast’s tumor?
P628

A

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

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69
Q

DISEASES OF THE LUNGS
BRONCHOGENIC CARCINOMA
What is Horner’s syndrome?
P628

A 
Injury to the cervical sympathetic chain;
Think: “MAP”
    1. Miosis (small pupil)
    2. Anhydrosis of ipsilateral face
    3. Ptosis
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70
Q 
DISEASES OF THE LUNGS
BRONCHOGENIC CARCINOMA
What are the four most
common sites of extrathoracic
metastases?
P628
A
  1. Bone
  2. Liver
  3. Adrenals
  4. Kidney
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71
Q 
DISEASES OF THE LUNGS
BRONCHOGENIC CARCINOMA
What are paraneoplastic
syndromes?
P628
A 
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
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72
Q 
DISEASES OF THE LUNGS
BRONCHOGENIC CARCINOMA
Name five general types of
paraneoplastic syndromes.
P628
A 
1. Metabolic: Cushing’s, SIADH,
    hypercalcemia
2. Neuromuscular: Eaton-Lambert,
    cerebellar ataxia
3. Skeletal: hypertrophic osteoarthropathy
4. Dermatologic: acanthosis nigricans
5. Vascular: thrombophlebitis
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73
Q 
DISEASES OF THE LUNGS
BRONCHOGENIC CARCINOMA
What are the associated
radiographic tests?
P628
A

CXR, CT scan, PET scan

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74
Q 
DISEASES OF THE LUNGS
BRONCHOGENIC CARCINOMA
How is the tumor
diagnosed?
P628
A
  1. Sputum cytology
  2. Needle biopsy (CT or fluoro guidance)
  3. Bronchoscopy with brushings, biopsies,
    or both
  4. With or without mediastinoscopy,
    mediastinotomy, scalene node biopsy,
    or open lung biopsy for definitive
    diagnosis
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75
Q 
DISEASES OF THE LUNGS
BRONCHOGENIC CARCINOMA
For each tumor listed, recall
its usual site in the lung and
its natural course:
Squamous cell?
P629
A

66% occur centrally in lung hilus; may
also be a Pancoast’s tumor; slow growth,
late metastasis; associated with smoking
(Think: Squamous = Sentral)

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76
Q 
DISEASES OF THE LUNGS
BRONCHOGENIC CARCINOMA
For each tumor listed, recall
its usual site in the lung and
its natural course:
Adenocarcinoma?
P629
A

Peripheral, rapid growth with
hematogenous/nodal metastasis,
associated with lung scarring

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77
Q 
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
A

Central, highly malignant, usually not

operable

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78
Q 
DISEASES OF THE LUNGS
BRONCHOGENIC CARCINOMA
For each tumor listed, recall
its usual site in the lung and
its natural course:
Large cell?
P629
A

Usually peripheral, very malignant

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79
Q 
DISEASES OF THE LUNGS
BRONCHOGENIC CARCINOMA
What are the AJCC stages of
carcinoma of the lungs:
Stage Ia?
P629
A

Tumor <3 cm, no nodes, no metastases

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80
Q 
DISEASES OF THE LUNGS
BRONCHOGENIC CARCINOMA
What are the AJCC stages of
carcinoma of the lungs:
Stage Ib?
P629
A

Tumor 3–5 cm, no nodes, no

metastases

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81
Q 
DISEASES OF THE LUNGS
BRONCHOGENIC CARCINOMA
What are the AJCC stages of
carcinoma of the lungs:
Stage IIa?
P629
A 
1. Tumor <5 cm and positive nodes
to lung or ipsilateral hilum; no
metastases, or
2. Tumor 5–7 cm, no nodes, no
metastases
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82
Q 
DISEASES OF THE LUNGS
BRONCHOGENIC CARCINOMA
What are the AJCC stages of
carcinoma of the lungs:
Stage IIb?
P629
A 
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
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83
Q 
DISEASES OF THE LUNGS
BRONCHOGENIC CARCINOMA
What are the AJCC stages of
carcinoma of the lungs:
Stage IIIa?
P630
A
  1. 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
  2. Any size tumor that invades heart,
    great vessels, trachea, esophagus,
    carina, or ipsalateral lobe, or + nodes
    peribronchial and/or ipsilateral hilum,
    or intrapulmonary nodes
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84
Q 
DISEASES OF THE LUNGS
BRONCHOGENIC CARCINOMA
What are the AJCC stages of
carcinoma of the lungs:
Stage IIIb?
P630
A

Any tumor, + lymph node metastases to
contralateral hilum or mediastinum
Supraclavicular/scalene nodes, NO
distant metastases

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85
Q 
DISEASES OF THE LUNGS
BRONCHOGENIC CARCINOMA
What are the AJCC stages of
carcinoma of the lungs:
Stage IV?
P630
A

Distant metastases

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86
Q 
DISEASES OF THE LUNGS
BRONCHOGENIC CARCINOMA
What are the surgical
contraindications for
NON-small cell carcinoma?
P630
A

Stage IV, Stage IIIb, poor lung function

FEV1 <0.8L

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87
Q 
DISEASES OF THE LUNGS
BRONCHOGENIC CARCINOMA
What is the treatment by
stage for NON-small cell
lung carcinoma:
Stage I?
P630
A

Surgical resection

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88
Q 
DISEASES OF THE LUNGS
BRONCHOGENIC CARCINOMA
What is the treatment by
stage for NON-small cell
lung carcinoma:
Stage II?
P630
A

Surgical resection

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89
Q 
DISEASES OF THE LUNGS
BRONCHOGENIC CARCINOMA
What is the treatment by
stage for NON-small cell
lung carcinoma:
Stage IIIa?
P630
A

Chemotherapy and XRT +/- surgical

resection

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90
Q 
DISEASES OF THE LUNGS
BRONCHOGENIC CARCINOMA
What is the treatment by
stage for NON-small cell
lung carcinoma:
Stage IIIb?
P630
A

Chemotherapy and XRT

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91
Q 
DISEASES OF THE LUNGS
BRONCHOGENIC CARCINOMA
What is the treatment by
stage for NON-small cell
lung carcinoma:
Stage IV?
P630
A

Chemotherapy +/- XRT

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92
Q 
DISEASES OF THE LUNGS
BRONCHOGENIC CARCINOMA
What is the treatment for
isolated brain metastasis?
P630
A

Surgical resection

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93
Q 
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
A

50%

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94
Q 
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
A

30%

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95
Q 
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
A

10%

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96
Q 
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
A

1%

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97
Q 
DISEASES OF THE LUNGS
BRONCHOGENIC CARCINOMA
How is small cell carcinoma
treated?
P631
A

Chemotherapy +/- XRT (very small

isolated lesions can be surgically resected)

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98
Q 
DISEASES OF THE LUNGS
BRONCHOGENIC CARCINOMA
What are the
contraindications to surgery
for lung cancer?
P631
A 
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)
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99
Q 
DISEASES OF THE LUNGS
BRONCHOGENIC CARCINOMA
What postoperative FEV1
must you have?
P631
A 
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
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100
Q 
DISEASES OF THE LUNGS
BRONCHOGENIC CARCINOMA
What is hypertrophic
pulmonary
osteoarthropathy?
P631
A

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)

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101
Q

DISEASES OF THE LUNGS
SOLITARY PULMONARY NODULES (COIN LESIONS)
What are they?
P631

A

Peripheral circumscribed pulmonary

lesions

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102
Q 
DISEASES OF THE LUNGS
SOLITARY PULMONARY NODULES (COIN LESIONS)
What is the differential
diagnosis?
P632
A

Granulomatous disease, benign

neoplasms, malignancy

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103
Q 
DISEASES OF THE LUNGS
SOLITARY PULMONARY NODULES (COIN LESIONS)
What percentage are
malignant?
P632
A

Overall, 5% to 10% (but >50% are

malignant in smokers >50 years)

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104
Q

DISEASES OF THE LUNGS
SOLITARY PULMONARY NODULES (COIN LESIONS)
Is there a gender risk?
P632

A

Yes; the incidence of coin lesions is 3
to 9x higher and malignancy is nearly
twice as common in men as in women

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105
Q

DISEASES OF THE LUNGS
SOLITARY PULMONARY NODULES (COIN LESIONS)
What are the symptoms?
P632

A

Usually asymptomatic with solitary
nodules, but may include coughing,
weight loss, chest pain, and hemoptysis

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106
Q

DISEASES OF THE LUNGS
SOLITARY PULMONARY NODULES (COIN LESIONS)
What are the signs?
P632

A

Physical findings are uncommon; clubbing
is rare; hypertrophic osteoarthropathy
implies 80% chance of malignancy

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107
Q

DISEASES OF THE LUNGS
SOLITARY PULMONARY NODULES (COIN LESIONS)
How is the diagnosis made?
P632

A

CXR, chest CT

108
Q 
DISEASES OF THE LUNGS
SOLITARY PULMONARY NODULES (COIN LESIONS)
What is the significance of
“popcorn” calcification?
P632
A

Most likely benign (i.e., hamartoma)

109
Q 
DISEASES OF THE LUNGS
SOLITARY PULMONARY NODULES (COIN LESIONS)
What are the risk factors for
malignancy?
P632
A 
1. Size: lesions >1 cm have a significant
    chance of malignancy, and those >4 cm
    are very likely to be malignant
2. Indistinct margins (corona radiata)
3. Documented growth on follow-up
    x-ray (if no change in 2 years, most
    likely benign)
4. Increasing age
110
Q 
DISEASES OF THE LUNGS
SOLITARY PULMONARY NODULES (COIN LESIONS)
What are the associated lab
tests?
P632
A
  1. TB skin tests, etc.
  2. Sputum cultures
  3. Sputum cytology is diagnostic in 5% to
    20% of cases
111
Q 
DISEASES OF THE LUNGS
SOLITARY PULMONARY NODULES (COIN LESIONS)
Which method of tissue
diagnosis is used?
P632
A

Chest CT scan with needle biopsy,
bronchoscopy ( +/- transtracheal biopsy),
excisional biopsy (open or thoracoscopic)

112
Q

DISEASES OF THE LUNGS
SOLITARY PULMONARY NODULES (COIN LESIONS)
What is the treatment?
P633

A

Surgical excision is the mainstay of
treatment
Excisional biopsy is therapeutic for
benign lesions, solitary metastasis, and
for primary cancer in patients who are
poor risks for more extensive surgery
Lobectomy for centrally placed lesions
Lobectomy with node dissection for
primary cancer (if resectable by
preop evaluations)

113
Q 
DISEASES OF THE LUNGS
SOLITARY PULMONARY NODULES (COIN LESIONS)
Which solitary nodule can
be followed without a tissue
diagnosis?
P633
A

Popcorn calcifications
Mass unchanged for 2 years on previous
CXR

114
Q

DISEASES OF THE LUNGS
SOLITARY PULMONARY NODULES (COIN LESIONS)
What is the prognosis?
P633

A

For malignant coin lesions 2 cm, 5-year

survival is ≈70%

115
Q 
DISEASES OF THE LUNGS
SOLITARY PULMONARY NODULES (COIN LESIONS)
What if the patient
has an SPN and
pulmonary hypertrophic
osteoarthropathy?
P633
A

> 75% chance of carcinoma

116
Q 
DISEASES OF THE LUNGS
SOLITARY PULMONARY NODULES (COIN LESIONS)
What is hypertrophic
pulmonary osteoarthropathy?
P633
A

Periosteal proliferation and new bone
formation at the end of long bones and in
bones of the hand

117
Q

DISEASES OF THE LUNGS
SOLITARY PULMONARY NODULES (COIN LESIONS)
What is its incidence?
P633

A

≈7% of patients with lung cancer

2%–12%

118
Q

DISEASES OF THE LUNGS
SOLITARY PULMONARY NODULES (COIN LESIONS)
What are the signs?
P633

A

Associated with clubbing of the fingers;
diagnosed by x-ray of long bones,
revealing periosteal bone hypertrophy

119
Q

DISEASES OF THE LUNGS
CARCINOID TUMOR
What is it?
P633

A

APUD (Amine-Precursor Uptake and

Decarboxylation) cell tumor of the bronchus

120
Q 
DISEASES OF THE LUNGS
CARCINOID TUMOR
What is its natural course in
the lung?
P633
A

Slow growing (but may be malignant)

121
Q 
DISEASES OF THE LUNGS
CARCINOID TUMOR
What are the primary local
findings?
P633
A

Wheezing and atelectasis caused by

bronchial obstruction/stenosis

122
Q 
DISEASES OF THE LUNGS
CARCINOID TUMOR
What condition can it be
confused with?
P634
A

Asthma

123
Q

DISEASES OF THE LUNGS
CARCINOID TUMOR
How is the diagnosis made?
P634

A

Bronchoscopy reveals round red-yellowpurple
mass covered by epithelium that
protrudes into bronchial lumen

124
Q

DISEASES OF THE LUNGS
CARCINOID TUMOR
What is the treatment?
P634

A

Surgical resection (lobectomy with lymph
node dissection)
Sleeve resection is also an option for
proximal bronchial lesions

125
Q

DISEASES OF THE LUNGS
CARCINOID TUMOR
What is a sleeve resection?
P634

A

Resection of a ring segment of bronchus
(with tumor inside) and then end-to-end
anastomosis of the remaining ends,
allowing salvage of lower lobe

126
Q 
DISEASES OF THE LUNGS
CARCINOID TUMOR
What is the prognosis
(5-year survival) after
complete surgical resection
of carcinoid:
Negative nodes?
P634
A

> 90% alive at 5 years

127
Q 
DISEASES OF THE LUNGS
CARCINOID TUMOR
What is the prognosis
(5-year survival) after
complete surgical resection
of carcinoid:
Positive nodes?
P634
A

66% alive at 5 years

128
Q 
DISEASES OF THE LUNGS
CARCINOID TUMOR
What is the most common
benign lung tumor?
P634
A

Hamartoma (normal cells in a weird

configuration)

129
Q

DISEASES OF THE LUNGS
PULMONARY SEQUESTRATION
What is it?
P634

A

Abnormal benign lung tissue with
separate blood supply that DOES NOT
communicate with the normal
tracheobronchial airway

130
Q 
DISEASES OF THE LUNGS
PULMONARY SEQUESTRATION
Define the following terms:
Interlobar
P634
A

Sequestration in normal lung tissue

covered by normal visceral pleura

131
Q 
DISEASES OF THE LUNGS
PULMONARY SEQUESTRATION
Define the following terms:
Extralobar
P634
A

Sequestration not in normal lung covered

by its own pleura

132
Q

DISEASES OF THE LUNGS
PULMONARY SEQUESTRATION
What are the signs/symptoms?
P634

A

Asymptomatic, recurrent pneumonia

133
Q

DISEASES OF THE LUNGS
PULMONARY SEQUESTRATION
How is the diagnosis made?
P634

A

CXR, chest CT, A-gram, U/S with

Doppler flow to ascertain blood supply

134
Q 
DISEASES OF THE LUNGS
PULMONARY SEQUESTRATION
What is the treatment in the
following cases:
Extralobar?
P635
A

Surgical resection

135
Q 
DISEASES OF THE LUNGS
PULMONARY SEQUESTRATION
What is the treatment in the
following cases:
Intralobar?
P635
A

Lobectomy

136
Q 
DISEASES OF THE LUNGS
PULMONARY SEQUESTRATION
What is the major danger
during surgery for
sequestration?
P635
A 
Anomalous blood supply from below the
    diaphragm (these can be cut and
    retract into the abdomen resulting in
    exsanguination!)
Always document blood supply by
    A-gram or U/S with Doppler flow
137
Q 
DISEASES OF THE MEDIASTINUM
MEDIASTINAL ANATOMY
What structures lie in the
following locations:
Superior mediastinum?
P635
A

Aortic arch, great vessels, upper trachea,

esophagus

138
Q 
DISEASES OF THE MEDIASTINUM
MEDIASTINAL ANATOMY
What structures lie in the
following locations:
Anterior mediastinum?
P635
A

Thymus, ascending aorta, lymph nodes

139
Q 
DISEASES OF THE MEDIASTINUM
MEDIASTINAL ANATOMY
What structures lie in the
following locations:
Middle mediastinum?
P635
A

Heart, lower trachea and bifurcation,

lung hila, phrenic nerves, lymph nodes

140
Q 
DISEASES OF THE MEDIASTINUM
MEDIASTINAL ANATOMY
What structures lie in the
following locations:
Posterior mediastinum?
P635
A

Esophagus, descending aorta, thoracic
duct, vagus and intercostal nerves,
sympathetic trunks, azygous and
hemizygous veins, lymph nodes

141
Q 
DISEASES OF THE MEDIASTINUM
MEDIASTINAL ANATOMY
What is the major differential
diagnosis for tumors of the
mediastinum:
Anterior mediastinum?
P635
A

Classic “four Ts”: Thyroid tumor,
Thymoma, Terrible lymphoma,
Teratoma; also parathyroid tumor,
lipoma, vascular aneurysms

142
Q 
DISEASES OF THE MEDIASTINUM
MEDIASTINAL ANATOMY
What is the major differential
diagnosis for tumors of the
mediastinum:
Middle mediastinum?
P635
A

Lymphadenopathy (e.g., lymphoma,
sarcoid), teratoma, fat pad, cysts,
hernias, extension of esophageal mass,
bronchogenic cancer

143
Q 
DISEASES OF THE MEDIASTINUM
MEDIASTINAL ANATOMY
What is the major differential
diagnosis for tumors of the
mediastinum:
Posterior mediastinum?
P636
A

Neurogenic tumors, lymphoma, aortic

aneurysm, vertebral lesions, hernias

144
Q 
DISEASES OF THE MEDIASTINUM
MEDIASTINAL ANATOMY
What is the most common
type of tumor arising in the
mediastinum?
P636
A

Neurogenic (most commonly in posterior

mediastinum)

145
Q 
DISEASES OF THE MEDIASTINUM
MEDIASTINAL ANATOMY
What is the differential
diagnosis for a neurogenic
tumor?
P636
A

Schwannoma (a.k.a. neurolemmoma),
neurofibroma, neuroblastoma,
ganglioneuroma, ganglioneuroblastoma,
pheochromocytoma

146
Q 
DISEASES OF THE MEDIASTINUM
PRIMARY MEDIASTINAL TUMORS
Thymoma
Where are they found in the
mediastinum?
P636
A

Anterior

147
Q 
DISEASES OF THE MEDIASTINUM
PRIMARY MEDIASTINAL TUMORS
Thymoma
How is the diagnosis made?
P636
A

CT scan

148
Q 
DISEASES OF THE MEDIASTINUM
PRIMARY MEDIASTINAL TUMORS
Thymoma
What is the treatment?
P636
A

All thymomas should be surgically resected

via midline sternotomy

149
Q 
DISEASES OF THE MEDIASTINUM
PRIMARY MEDIASTINAL TUMORS
Thymoma
What are the indications for
postop radiation therapy?
P636
A

Invasive malignant tumor

150
Q 
DISEASES OF THE MEDIASTINUM
PRIMARY MEDIASTINAL TUMORS
Thymoma
What are the indications for
preop chemotherapy?
P636
A

Tumor >6 cm and CT scan with invasion

151
Q 
DISEASES OF THE MEDIASTINUM
PRIMARY MEDIASTINAL TUMORS
Thymoma
What percentage of
thymomas are malignant?
P636
A

≈25%

152
Q 
DISEASES OF THE MEDIASTINUM
PRIMARY MEDIASTINAL TUMORS
Thymoma
How is a malignant
thymoma diagnosed?
P636
A

At surgery with invasion into surrounding

structures (not by histology!)

153
Q 
DISEASES OF THE MEDIASTINUM
PRIMARY MEDIASTINAL TUMORS
Thymoma
What is myasthenia gravis?
P636
A

Autoimmune disease with antibodies

against the muscle acetylcholine receptors

154
Q 
DISEASES OF THE MEDIASTINUM
PRIMARY MEDIASTINAL TUMORS
Thymoma
What percentage of patients
with myasthenia gravis have
a thymoma?
P636
A

≈15%

155
Q 
DISEASES OF THE MEDIASTINUM
PRIMARY MEDIASTINAL TUMORS
Thymoma
What percentage of patients
with thymoma have or will
have myasthenia gravis?
P636
A

≈75%!

156
Q 
DISEASES OF THE MEDIASTINUM
PRIMARY MEDIASTINAL TUMORS
Teratomas
What are they?
P537
A

Tumors of branchial cleft cells; the
tumors contain ectoderm, endoderm, and
mesoderm

157
Q 
DISEASES OF THE MEDIASTINUM
PRIMARY MEDIASTINAL TUMORS
Teratomas
What is a dermoid cyst?
P637
A

Teratoma made up of ectodermal

derivatives (e.g., teeth, skin, hair)

158
Q 
DISEASES OF THE MEDIASTINUM
PRIMARY MEDIASTINAL TUMORS
Teratomas
Which age group is affected?
P637
A

Usually adolescents, but can occur at

any age

159
Q 
DISEASES OF THE MEDIASTINUM
PRIMARY MEDIASTINAL TUMORS
Teratomas
Where in the mediastinum
do they occur?
P637
A

Anterior

160
Q 
DISEASES OF THE MEDIASTINUM
PRIMARY MEDIASTINAL TUMORS
Teratomas
What are the characteristic
x-ray findings?
P637
A

Calcifications or teeth; tumors may be

cystic

161
Q 
DISEASES OF THE MEDIASTINUM
PRIMARY MEDIASTINAL TUMORS
Teratomas
What percentage are
malignant?
P637
A

≈15%

162
Q 
DISEASES OF THE MEDIASTINUM
PRIMARY MEDIASTINAL TUMORS
Teratomas
What is the treatment of
benign dermoid cysts?
P637
A

Surgical excision

163
Q 
DISEASES OF THE MEDIASTINUM
PRIMARY MEDIASTINAL TUMORS
Teratomas
What is the treatment of
malignant teratoma?
P637
A

Preoperative chemotherapy until tumor
markers are normal, then surgical
resection

164
Q 
DISEASES OF THE MEDIASTINUM
PRIMARY MEDIASTINAL TUMORS
Teratomas
Which tumor markers are
associated with malignant
teratomas?
P637
A

AFP, CEA

165
Q 
DISEASES OF THE MEDIASTINUM
PRIMARY MEDIASTINAL TUMORS
Neurogenic Tumors
What is the incidence?
P637
A

Most common mediastinal tumors in all

age groups

166
Q 
DISEASES OF THE MEDIASTINUM
PRIMARY MEDIASTINAL TUMORS
Neurogenic Tumors
Where in the mediastinum
do they occur?
P637
A

Posterior, in the paravertebral gutters

167
Q 
DISEASES OF THE MEDIASTINUM
PRIMARY MEDIASTINAL TUMORS
Neurogenic Tumors
What percentage are
malignant?
P637
A

50% in children

10% in adults

168
Q 
DISEASES OF THE MEDIASTINUM
PRIMARY MEDIASTINAL TUMORS
Neurogenic Tumors
What are the histologic types
(5)? (Note cells of origin and
whether benign or malignant.)
P638
A
  1. Neurilemmoma or schwannoma
    (benign)—arise from Schwann cell
    sheaths of intercostal nerves
  2. Neurofibroma (benign)—arise from
    intercostal nerves; may degenerate into:
  3. Neurosarcoma (malignant)
  4. Ganglioneuroma (benign)—from
    sympathetic chain
  5. Neuroblastoma (malignant)—also
    from sympathetic chain
169
Q 
DISEASES OF THE MEDIASTINUM
LYMPHOMA
Where in the mediastinum
does it occur?
P638
A

Anywhere, but most often in the
anterosuperior mediastinum or hilum
in the middle mediastinum

170
Q 
DISEASES OF THE MEDIASTINUM
LYMPHOMA
What percentage of
lymphomas involve
mediastinal nodes?
P638
A

≈50%

171
Q

DISEASES OF THE MEDIASTINUM
LYMPHOMA
What are the symptoms?
P638

A

Cough, fever, chest pain, weight loss,

SVC syndrome, chylothorax

172
Q

DISEASES OF THE MEDIASTINUM
LYMPHOMA
How is the diagnosis made?
P638

A
  1. CXR, CT scan
  2. Mediastinoscopy or mediastinotomy
    with node biopsy
173
Q

DISEASES OF THE MEDIASTINUM
LYMPHOMA
What is the treatment?
P638

A

Nonsurgical (chemotherapy, radiation,

or both)

174
Q 
DISEASES OF THE MEDIASTINUM
MEDIASTINITIS
Acute Mediastinitis
What is it?
P638
A

Acute suppurative mediastinal infection

175
Q 
DISEASES OF THE MEDIASTINUM
MEDIASTINITIS
Acute Mediastinitis
Name the six etiologies.
P638
A 
1. Esophageal perforation (Boerhaave’s
    syndrome)
2. Postoperative wound infection
3. Head and neck infections
4. Lung or pleural infections
5. Rib or vertebral osteomyelitis
6. Distant infections
176
Q 
DISEASES OF THE MEDIASTINUM
MEDIASTINITIS
Acute Mediastinitis
What are the clinical
features?
P639
A

Fever, chest pain, dysphagia (especially
with esophageal perforation), respiratory
distress, leukocytosis

177
Q 
DISEASES OF THE MEDIASTINUM
MEDIASTINITIS
Acute Mediastinitis
What is the treatment?
P639
A
  1. Wide drainage
  2. Treatment of primary cause
  3. Antibiotics
178
Q 
DISEASES OF THE MEDIASTINUM
MEDIASTINITIS
Chronic Mediastinitis
What is it?
P639
A

Mediastinal fibrosis secondary to chronic

granulomatous infection

179
Q 
DISEASES OF THE MEDIASTINUM
MEDIASTINITIS
Chronic Mediastinitis
What is the most common
etiology?
P639
A

Histoplasma capsulatum

180
Q 
DISEASES OF THE MEDIASTINUM
MEDIASTINITIS
Chronic Mediastinitis
What are the clinical
features?
P639
A 
50% are asymptomatic; symptoms are
related to compression of adjacent
structures: SVC syndrome, bronchial
and esophageal strictures, constrictive
pericarditis
181
Q 
DISEASES OF THE MEDIASTINUM
MEDIASTINITIS
Chronic Mediastinitis
How is the diagnosis made?
P639
A

CXR or CT may be helpful, but surgery/

biopsy often makes the diagnosis

182
Q 
DISEASES OF THE MEDIASTINUM
MEDIASTINITIS
Chronic Mediastinitis
What is the treatment?
P639
A

Antibiotics; surgical removal of the

granulomas is rarely helpful

183
Q

DISEASES OF THE MEDIASTINUM
SUPERIOR VENA CAVA SYNDROME
What is it?
P639

A

Obstruction of the superior vena cava,

usually by extrinsic compression

184
Q

DISEASES OF THE MEDIASTINUM
SUPERIOR VENA CAVA SYNDROME
What is the #1 cause?
P639

A

Malignant tumors cause 90% of cases;
lung cancer is by far the most common;
other tumors include thymoma,
lymphoma, and Hodgkin’s disease

185
Q 
DISEASES OF THE MEDIASTINUM
SUPERIOR VENA CAVA SYNDROME
What are the clinical
manifestations?
P639
A 
1. Blue discoloration and puffiness of the
    face, arms, and shoulders
2. CNS manifestations may include
    headache, nausea, vomiting, visual
    distortion, stupor, and convulsions.
3. Cough, hoarseness, and dyspnea
186
Q

DISEASES OF THE MEDIASTINUM
SUPERIOR VENA CAVA SYNDROME
What is the treatment?
P640

A
  1. Diuretics and fluid restriction
  2. Prompt radiation therapy +/-
    chemotherapy for any causative cancer
187
Q

DISEASES OF THE MEDIASTINUM
SUPERIOR VENA CAVA SYNDROME
What is the prognosis?
P640

A

SVC obstruction itself is fatal in 5% of
cases; mean survival time in patients with
malignant obstruction is ≈7 months

188
Q 
DISEASES OF THE ESOPHAGUS
ANATOMIC CONSIDERATIONS
What are the primary
functions of the Upper
and Lower Esophageal
Sphincters?
P640
A

UES: swallowing
LES: prevention of reflux

189
Q 
DISEASES OF THE ESOPHAGUS
ANATOMIC CONSIDERATIONS
The esophageal venous
plexus drains inferiorly into
the gastric veins. Why is this
important?
P640
A

Gastric veins are part of the portal venous
system; portal hypertension can thus be
referred to the esophageal veins, leading
to varices

190
Q 
DISEASES OF THE ESOPHAGUS
ANATOMIC CONSIDERATIONS
Identify the esophageal
muscle type:
Proximal 1/3
P640
A

Skeletal muscle

191
Q 
DISEASES OF THE ESOPHAGUS
ANATOMIC CONSIDERATIONS
Identify the esophageal
muscle type:
Middle 1/3
P640
A

Smooth muscle > skeletal muscle

192
Q 
DISEASES OF THE ESOPHAGUS
ANATOMIC CONSIDERATIONS
Identify the esophageal
muscle type:
Distal 1/3
P640
A

Smooth muscle

193
Q 
DISEASES OF THE ESOPHAGUS
ANATOMIC CONSIDERATIONS
Identify the blood supply to
the esophagus:
Proximal 1/3
P640
A

Inferior thyroid, anterior intercostals

194
Q 
DISEASES OF THE ESOPHAGUS
ANATOMIC CONSIDERATIONS
Identify the blood supply to
the esophagus:
Middle 1/3
P640
A

Esophageal arteries, bronchial arteries

195
Q 
DISEASES OF THE ESOPHAGUS
ANATOMIC CONSIDERATIONS
Identify the blood supply to
the esophagus:
Distal 1/3
P640
A

Left gastric artery, left inferior phrenic artery

196
Q 
DISEASES OF THE ESOPHAGUS
ANATOMIC CONSIDERATIONS
What is the length of the
esophagus?
P640
A

≈25 cm in the adult (40 cm from teeth to

LES)

197
Q 
DISEASES OF THE ESOPHAGUS
ANATOMIC CONSIDERATIONS
Why is the esophagus
notorious for anastomotic
leaks?
P640
A

Esophagus has no serosa (same as the distal

rectum)

198
Q 
DISEASES OF THE ESOPHAGUS
ANATOMIC CONSIDERATIONS
What nerve runs with the
esophagus?
P641
A

Vagus nerve

199
Q

DISEASES OF THE ESOPHAGUS
ZENKER’S DIVERTICULUM
What is it?
P641 (picture)

A 
Pharyngoesophageal diverticulum; a
false diverticulum containing mucosa
and submucosa at the UES at the
pharyngoesophageal junction through
Killian’s triangle
200
Q 
DISEASES OF THE ESOPHAGUS
ZENKER’S DIVERTICULUM
What is the disease’s “claim
to fame”?
P641
A

Most common esophageal diverticulum

201
Q 
DISEASES OF THE ESOPHAGUS
ZENKER’S DIVERTICULUM
What are the signs/
symptoms?
P641
A

Dysphagia, neck mass, halitosis, food

regurgitation, heartburn

202
Q

DISEASES OF THE ESOPHAGUS
ZENKER’S DIVERTICULUM
How is the diagnosis made?
P641

A

Barium swallow

203
Q

DISEASES OF THE ESOPHAGUS
ZENKER’S DIVERTICULUM
What is the treatment?
P641

A
  1. Diverticulectomy

2. Cricopharyngeus myotomy, if >2 cm

204
Q

DISEASES OF THE ESOPHAGUS
ACHALASIA
What is it?
P641

A
  1. Failure of the LES to relax during
    swallowing
  2. Loss of esophageal peristalsis
205
Q

DISEASES OF THE ESOPHAGUS
ACHALASIA
What are the proposed
P641

A
  1. Neurologic (ganglionic degeneration
    of Auerbach’s plexus, vagus nerve, or
    both); possibly infectious in nature
  2. Chagas’ disease in South America
206
Q 
DISEASES OF THE ESOPHAGUS
ACHALASIA
What are the associated
long-term conditions?
P642
A

Esophageal carcinoma secondary to

Barrett’s esophagus from food stasis

207
Q

DISEASES OF THE ESOPHAGUS
ACHALASIA
What are the symptoms?
P642 (picture)

A

Dysphagia for both solids and liquids,
followed by regurgitation; dysphagia for
liquids is worse

208
Q 
DISEASES OF THE ESOPHAGUS
ACHALASIA
What are the diagnostic
findings?
P642
A 
v\Radiographic contrast studies reveal
    dilated esophageal body with
    narrowing inferiorly
Manometry: motility studies reveal
    increased pressure in the LES and
    failure of the LES to relax during
    swallowing
209
Q 
DISEASES OF THE ESOPHAGUS
ACHALASIA
What are the treatment
options?
P642
A
  1. Balloon dilation of the LES
  2. Medical treatment of reflux versus
    Belsey Mark IV 270 fundoplication
    (do not perform 360 Nissen)
  3. Myotomy of the lower esophagus and
    LES
210
Q

DISEASES OF THE ESOPHAGUS
DIFFUSE ESOPHAGEAL SPASM
What is it?
P642

A

Strong, nonperistaltic contractions of the
esophageal body; sphincter function is
usually normal

211
Q 
DISEASES OF THE ESOPHAGUS
DIFFUSE ESOPHAGEAL SPASM
What is the associated
condition?
P642
A

Gastroesophageal reflux

212
Q

DISEASES OF THE ESOPHAGUS
DIFFUSE ESOPHAGEAL SPASM
What are the symptoms?
P642

A

Spontaneous chest pain that radiates to

the back, ears, neck, jaw, or arms

213
Q 
DISEASES OF THE ESOPHAGUS
DIFFUSE ESOPHAGEAL SPASM
What is the differential
diagnosis?
P643
A

Angina pectoris
Psychoneurosis
Nutcracker esophagus

214
Q 
DISEASES OF THE ESOPHAGUS
DIFFUSE ESOPHAGEAL SPASM
What are the associated
diagnostic tests?
P643
A 
Esophageal manometry: Motility
    studies reveal repetitive, highamplitude
    contractions with normal
    sphincter response
Upper GI may be normal, but 50% show
    segmented spasms or corkscrew
    esophagus
Endoscopy
215
Q 
DISEASES OF THE ESOPHAGUS
DIFFUSE ESOPHAGEAL SPASM
What is the classic finding
on esophageal contrast study
(UGI)?
P643
A

“Corkscrew esophagus”

216
Q

DISEASES OF THE ESOPHAGUS
DIFFUSE ESOPHAGEAL SPASM
What is the treatment?
P643

A

Medical (antireflux measures, calcium
channel blockers, nitrates)
Long esophagomyotomy in refractory cases

217
Q

DISEASES OF THE ESOPHAGUS
NUTCRACKER ESOPHAGUS
What is it also known as?
P643

A

Hypertensive peristalsis

218
Q

DISEASES OF THE ESOPHAGUS
NUTCRACKER ESOPHAGUS
What is it?
P643

A

Very strong peristaltic waves

219
Q

DISEASES OF THE ESOPHAGUS
NUTCRACKER ESOPHAGUS
What are the symptoms?
P643

A

Spontaneous chest pain that radiates to

the back, ears, neck, jaw, or arms

220
Q 
DISEASES OF THE ESOPHAGUS
NUTCRACKER ESOPHAGUS
What is the differential
diagnosis?
P643
A

Angina pectoris
Psychoneurosis
Diffuse esophageal spasm

221
Q 
DISEASES OF THE ESOPHAGUS
NUTCRACKER ESOPHAGUS
What are the associated
diagnostic tests?
P643
A 
1. Esophageal manometry: motility studies
    reveal repetitive, high-amplitude
    contractions with normal sphincter
    response
2. Results of UGI may be normal (rule
    out mass)
3. Endoscopy
222
Q

DISEASES OF THE ESOPHAGUS
NUTCRACKER ESOPHAGUS
What is the treatment?
P643

A

Medical (antireflux measures, calcium
channel blockers, nitrates)
Long esophagomyotomy in refractory cases

223
Q

DISEASES OF THE ESOPHAGUS
ESOPHAGEAL REFLUX
What is it?
P644

A 
Reflux of gastric contents into the lower
esophagus resulting from the decreased
function of the LES
224
Q

DISEASES OF THE ESOPHAGUS
ESOPHAGEAL REFLUX
What are the causes?
P644

A

.1. Decreased LES tone

  1. Decreased esophageal motility
  2. Hiatal hernia
  3. Gastric outlet obstruction
  4. NGT
225
Q 
DISEASES OF THE ESOPHAGUS
ESOPHAGEAL REFLUX
Name four associated
conditions/factors
P644
A
  1. Sliding hiatal hernia
  2. Tobacco and alcohol
  3. Scleroderma
  4. Decreased endogenous gastrin
    production
226
Q

DISEASES OF THE ESOPHAGUS
ESOPHAGEAL REFLUX
What are the symptoms?
P644

A

Substernal pain, heartburn, regurgitation;
symptoms are worse when patient is
supine and after meals

227
Q

DISEASES OF THE ESOPHAGUS
ESOPHAGEAL REFLUX
How is the diagnosis made?
P644

A 
1. pH probe in the lower esophagus
    reveals acid reflux
2. EGD shows esophagitis
3. Manometry reveals decreased LES
    pressure
4. Barium swallow
228
Q

DISEASES OF THE ESOPHAGUS
ESOPHAGEAL REFLUX
What is the initial treatment?
P644

A

Medical: H(2)-blockers, antacids,
metoclopramide, omeprazole
Elevation of the head of the bed; small,
multiple meals

229
Q 
DISEASES OF THE ESOPHAGUS
ESOPHAGEAL REFLUX
Which four complications
require surgery?
P644
A
  1. Failure of medical therapy
  2. Esophageal strictures
  3. Progressive pulmonary insufficiency
    secondary to documented nocturnal
    aspiration
  4. Barrett’s esophagus
230
Q 
DISEASES OF THE ESOPHAGUS
ESOPHAGEAL REFLUX
Describe each of the
following types of surgery:
Nissen
P644
A

360 fundoplication: wrap fundus of

stomach all the way around the esophagus

231
Q 
DISEASES OF THE ESOPHAGUS
ESOPHAGEAL REFLUX
Describe each of the
following types of surgery:
Belsey Mark IV
P645
A

270 fundoplication: wrap fundus of

stomach, but not all the way around

232
Q 
DISEASES OF THE ESOPHAGUS
ESOPHAGEAL REFLUX
Describe each of the
following types of surgery:
Hill
P645
A

Tighten arcuate ligament around

esophagus and tack stomach to diaphragm

233
Q 
DISEASES OF THE ESOPHAGUS
ESOPHAGEAL REFLUX
Describe each of the
following types of surgery:
Lap Nissen
P645
A

Nissen via laparoscope

234
Q 
DISEASES OF THE ESOPHAGUS
ESOPHAGEAL REFLUX
Describe each of the
following types of surgery:
Lap Toupet
P645
A

Lap fundoplication posteriorly with less
than 220 to 250 wrap used with decreased
esophageal motility; disadvantage is more
postoperative reflux

235
Q

DISEASES OF THE ESOPHAGUS
ESOPHAGEAL REFLUX
What is Barrett’s esophagus?
P645

A

Replacement of the lower esophageal
squamous epithelium with columnar
epithelium secondary to reflux

236
Q

DISEASES OF THE ESOPHAGUS
ESOPHAGEAL REFLUX
Why is it significant?
P645

A

This lesion is premalignant

237
Q

DISEASES OF THE ESOPHAGUS
ESOPHAGEAL REFLUX
What is the treatment?
P645

A 
People with significant reflux should be
followed with regular EGDs with
biopsies, H(2)-blockers, and antireflux
precautions; many experts believe that
patients with severe dysplasia should
undergo esophagectomy
238
Q 
DISEASES OF THE ESOPHAGUS
CAUSTIC ESOPHAGEAL STRICTURES
Which agents may cause
strictures if ingested?
P645
A

Lye, oven cleaners, drain cleaners, batteries,

sodium hydroxide tablets (Clinitest)

239
Q

DISEASES OF THE ESOPHAGUS
CAUSTIC ESOPHAGEAL STRICTURES
How is the diagnosis made?
P645

A

History; EGD is clearly indicated early
on to assess the extent of damage
( <24 hrs); scope to level of severe injury
(deep ulcer) only, water soluble contrast
study for deep ulcers to rule out perforation

240
Q 
DISEASES OF THE ESOPHAGUS
CAUSTIC ESOPHAGEAL STRICTURES
What is the initial
treatment?
P645
A
  1. NPO/IVF/H2-blocker
  2. Do not induce emesis
  3. Corticosteroids (controversial—
    probably best for shallow/moderate
    ulcers), antibiotics (penicillin/
    gentamicin) for moderate ulcers
  4. Antibiotic for deep ulcers
  5. Upper GI at 10 to 14 days
241
Q 
DISEASES OF THE ESOPHAGUS
CAUSTIC ESOPHAGEAL STRICTURES
What is the treatment if a
stricture develops?
P646
A 
Dilation with Maloney dilator/balloon
    catheter
In severe refractory cases, esophagectomy
    with colon interposition or gastric
   pull-up
242
Q 
DISEASES OF THE ESOPHAGUS
CAUSTIC ESOPHAGEAL STRICTURES
What is the long-term
follow-up?
P646
A

Because of increased risk of esophageal
squamous cancer (especially with
ulceration), patients endoscopies every
other year

243
Q

DISEASES OF THE ESOPHAGUS
CAUSTIC ESOPHAGEAL STRICTURES
What is a Maloney dilator?
P646

A

Mercury-filled rubber dilator

244
Q 
DISEASES OF THE ESOPHAGUS
ESOPHAGEAL CARCINOMA
What are the two main
types?
P646
A
  1. Adenocarcinoma at the GE junction
  2. Squamous cell carcinoma in most of
    the esophagus
245
Q 
DISEASES OF THE ESOPHAGUS
ESOPHAGEAL CARCINOMA
What is the most common
histology?
P646
A

Worldwide: squamous cell carcinoma
(95%!)
USA: adenocarcinoma

246
Q 
DISEASES OF THE ESOPHAGUS
ESOPHAGEAL CARCINOMA
What is the age and gender
distribution?
P646
A

Most common in the sixth decade of life;

men predominate, especially black men

247
Q 
DISEASES OF THE ESOPHAGUS
ESOPHAGEAL CARCINOMA
What are the etiologic
factors (5)?
P646
A
  1. Tobacco
  2. Alcohol
  3. GE reflux
  4. Barrett’s esophagus
  5. Radiation
248
Q

DISEASES OF THE ESOPHAGUS
ESOPHAGEAL CARCINOMA
What are the symptoms?
P646

A

Dysphagia, weight loss
Other symptoms include chest pain,
back pain, hoarseness, symptoms of
metastasis

249
Q 
DISEASES OF THE ESOPHAGUS
ESOPHAGEAL CARCINOMA
What comprises the
workup?
P646
A
  1. UGI
  2. EGD
  3. Transesophageal ultrasound (TEU)
  4. CT scan of chest/abdomen
250
Q 
DISEASES OF THE ESOPHAGUS
ESOPHAGEAL CARCINOMA
What is the differential
diagnosis?
P646
A

Leiomyoma, metastatic tumor, lymphomas,
benign stricture, achalasia, diffuse
esophageal spasm, GERD

251
Q

DISEASES OF THE ESOPHAGUS
ESOPHAGEAL CARCINOMA
How is the diagnosis made?
P647

A
  1. Upper GI localizes tumor
  2. EGD obtains biopsy and assesses
    resectability
  3. Full metastatic workup (CXR, bone
    scan, CT scan, LFTs)
252
Q 
DISEASES OF THE ESOPHAGUS
ESOPHAGEAL CARCINOMA
Describe the stages of
adenocarcinoma esophageal
cancer:
Stage I
P647
A

Tumor: invades lamina propria,
muscularis mucosae, or submucosa
Nodes: negative

253
Q 
DISEASES OF THE ESOPHAGUS
ESOPHAGEAL CARCINOMA
Describe the stages of
adenocarcinoma esophageal
cancer:
Stage IIa
P647
A

Tumor: invades muscularis propria
(grade 3)
Nodes: negative

254
Q 
DISEASES OF THE ESOPHAGUS
ESOPHAGEAL CARCINOMA
Describe the stages of
adenocarcinoma esophageal
cancer:
Stage IIb
P647
A
  1. Tumor: invades up to muscularis
    propria
    Nodes: positive regional nodes
  2. Invades adventitia with negative nodes
255
Q 
DISEASES OF THE ESOPHAGUS
ESOPHAGEAL CARCINOMA
Describe the stages of
adenocarcinoma esophageal
cancer:
Stage III
P647
A
  1. Tumor: invades adventitia
    Nodes: positive regional nodes
  2. Tumor: invades adjacent structures
256
Q 
DISEASES OF THE ESOPHAGUS
ESOPHAGEAL CARCINOMA
Describe the stages of
adenocarcinoma esophageal
cancer:
Stage IV
P647
A

Distant metastasis

257
Q

DISEASES OF THE ESOPHAGUS
ESOPHAGEAL CARCINOMA
What is the treatment?
P647

A

Esophagectomy with gastric pull-up or

colon interposition

258
Q 
DISEASES OF THE ESOPHAGUS
ESOPHAGEAL CARCINOMA
What is an Ivor-Lewis
procedure?
P647
A

Laparotomy and right thoracotomy with
gastroesophageal anastomosis in the chest
after esophagectomy

259
Q 
DISEASES OF THE ESOPHAGUS
ESOPHAGEAL CARCINOMA
Treatment options with
metastatic disease
(unresectable)?
P647
A

Chemotherapy and XRT +/- dilation,
stent, laser, electrocoagulation,
brachytherapy, photodynamic laser therapy

260
Q 
DISEASES OF THE ESOPHAGUS
ESOPHAGEAL CARCINOMA
What is a “blunt
esophagectomy”?
P647
A

Esophagectomy with “blunt” transhiatal
dissection of esophagus from abdomen
and gastroesophageal anastomosis in the
neck

261
Q 
DISEASES OF THE ESOPHAGUS
ESOPHAGEAL CARCINOMA
What is the operative
mortality rate?
P648
A

≈5%

262
Q 
DISEASES OF THE ESOPHAGUS
ESOPHAGEAL CARCINOMA
Has radiation therapy and/or
chemotherapy been shown
to decrease mortality?
P648
A

No

263
Q 
DISEASES OF THE ESOPHAGUS
ESOPHAGEAL CARCINOMA
What is the postop
complication rate?
P648
A

≈33%!

264
Q 
DISEASES OF THE ESOPHAGUS
ESOPHAGEAL CARCINOMA
What is the prognosis (5-year
survival) by stage:
I?
P648
A

66%

265
Q 
DISEASES OF THE ESOPHAGUS
ESOPHAGEAL CARCINOMA
What is the prognosis (5-year
survival) by stage:
II?
P648
A

25%

266
Q 
DISEASES OF THE ESOPHAGUS
ESOPHAGEAL CARCINOMA
What is the prognosis (5-year
survival) by stage:
III?
P648
A

10%

267
Q 
DISEASES OF THE ESOPHAGUS
ESOPHAGEAL CARCINOMA
What is the prognosis (5-year
survival) by stage:
IV?
P648
A

Basically 0%

ENT (7 decks)

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