Thoracic Surgery - Diseases of the Lungs

Question 1

What is the number of annual deaths from lung cancer?

Answer 1

160,000 (most common cancer death in the US in men and women)

Question 2

1 risk factor for lung cancer?

Answer 2

Smoking

Question 3

True or false - asbestos exposure increases the risk of lung cancer in patients who smoke.

Answer 3

True

Question 4

What type of lung cancer arises in non-smokers?

Answer 4

Adenocarcinoma

Question 5

Cancer arises more often in which lung?

Answer 5

R>L

Upper>lower

Question 6

Signs and symptoms of lung cancer?

Answer 6

Change in a chronic cough
Hemoptysis, chest pain, dypsnea
Pleural effusion (suggests chest wall involvement)
Hoarseness (recurrent laryngeal nerve involvement)
SVC syndrome
Diaphragmatic paralysis (phrenic nerve involvement)
Symptoms of mets/paraneoplastic syndrome
Finger clubbing

Question 7

What is a pancoast (superior sulcus) tumor?

Answer 7

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

Question 8

What is Horner’s syndrome?

Answer 8

Injury to the cervical sympathetic chain; think “MAP”

1. Miosis (small pupil)
2. Anhidrosis of ipsilateral face
3. Ptosis

Question 9

What are the 5 most common sites of extrathoracic metastases?

Answer 9

1. Brain
2. Bone
3. Adrenals
4. Liver
5. Kidney

Question 10

What are paraneoplastic syndromes?

Answer 10

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

Question 11

Name 5 general types of paraneoplastic syndromes.

Answer 11

1. Metabolic - Cushing’s, SIADH, hypercalcemia
2. Neuromuscular: Eaton-Lambert, cerebellar ataxia
3. Skeletal: hypertrophic osteoarthropathy
4. Dermatologic: acanthosis nigricans
5. Vascular: thrombophlebitis

Question 12

What are the associated radiographic tests for lung cancer?

Answer 12

CXR, CT, PET

Question 13

How is a tumor diagnosed?

Answer 13

1. Needle biopsy (CT or fluoro guidance)
2. Bronch with brushings, biopsies, or both
3. +/- mediastinoscopy, mediastinotomy, scalene node biopsy, or thoracoscopic/open lung biopsy for definitive diagnosis

Question 14

How is small cell carcinoma treated?

Answer 14

Chemo +/- XRT and prophylactic whole brain irradiation (very small isolated lesions can be surgically resected)

Question 15

Contraindications to surgery for lung cancer

Answer 15

SSSSTOP IT

SVC syndrome
Supraclavicular node mets
Scalene node mets
Tracheal carina involvement
Oat cell carcinoma (rx with chemo +/- radiation)
PFTs FEV1 <0.8 L
Infarction (myocardial)
Tumor elsewhere (mets)

Question 16

What post-op FEV1 must you have?

Answer 16

FEV1 >/= 800 CC; preoperative FEV1 >/= 2L usually needed for pneumoectomy

If FEV1 is <2L, V/Q scan should be performed

Question 17

What is hypertrophic pulmonary osteoarthropathy?

Answer 17

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)

Question 18

What is a solitary pulmonary nodule (SPN)?

Answer 18

Intraparenchymal pulmonary lesion <3 cm (considered at mass at 3cm); causes can be benign (60%) or malignant (40%)

Question 19

Risk of malignancy based on size of SPN?

Answer 19

<3 mm: 0.2%
4-7 mm: 0.9%
8-20 mm: 18%
>20 mm: 50%

Question 20

Dx solitary pulmonar nodule?

Answer 20

CXR, chest CT

Question 21

Characteristic appearance of hamartoma on CXR?

Answer 21

Popcorn calficiation

Question 22

Common benign etiologies of SPN?

Answer 22

Infectious granuloma (80% of benign SPN)
Hamartoma (10% of benign SPN)

Question 23

What percentage of SPNs are malignant?

Answer 23

Overall 5-10%, but >50% in smokers >50 y/o

Question 24

Is there a gender risk?

Answer 24

Yes; the incidence of coin lesions is 3-9x higher and malignancy is nearly 2x as common in men as in women

Question 25

Risk factors for malignancy?

Answer 25

Size: lesions >1 cm hae a significant chance of malignancy and those >4 cm are very likely to be malignant
Indistinct margins (corona radiata)
Documented growth on follow-up XR (if no change in 2 years, most likely benign)
Increasing age

Question 26

Dx modalities available for tissue diagnosis?

Answer 26

CT-guided perc biopsy (excellent accuracy if 1+ cm)
Navigational bronch (employs CT and electromagnetic guidance to target the bronchus associated with the pulmonary nodule for biopsy; also can place markers to aid in thorascopic ID for wedge resection

Thorascopic (better tolerated) or open thoracotomy with wedge resection

Question 27

What is the risk of cancer in a patient with SPN and pulmonary hypertrophic osteoarthropathy?

Answer 27

> 75% of carcinoma

Question 28

Incidence of pulmonary hyeprtrophic osteoarthropathy?

Answer 28

~7% of patients with lung cancer (2-12%)

Question 29

Signs of pulmonary hpyertrophy osteoarthropathy?

Answer 29

Associated with finger clubbing

Dx by x-ray of long bones revealing perisosteal bone hypertrophy