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Surgery > thorax > Flashcards

thorax Flashcards

1
Q

key questions to ask

A

-Smoking History:
-Previous Cancers
-Personal and Family History of Cancer

-Current Lung Diseases:
-Chronic obstructive pulmonary disease (COPD)
-Emphysema
-Interstitial lung disease

-Travel History:
-Endemic TB Regions

-History of:
-rheumatoid arthritis -> rheumatoid lung
-Granulomatosis with polyangiitis
-Other autoimmune disorders

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2
Q

solitary pulmonary nodule/coin lesion

A

-Discrete lesion that is rounded and normal lung parenchyma surrounds it
-<3 is cm in diameter
-No associated findings such as:
-Lymphadenopathy
-Atelectasis
-Pneumonia

-When located in a patient > 50 high risk of it being lung cancer.
-General Population Screening: 2 – 24%
-High Risk Population Screening: 17 – 53%
-Vast majority are benign.
-Key to tx is making the correct diagnosis. Why?
-Fear of Malignancy!!!!

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3
Q

physical exam

A

-not usually helpful
-may help if there are assoc pulmonary diseases -> TB, COPD, emphysema, chronic bronchitis

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4
Q

diagnostic tools

A

-Computed Tomography (CT):
-Most Likely to Detect solitary pulmonary nodule!!!!
-Best Modality for Follow-up (subtle 1 – 2 mm changes in size)
-picks up small changes in size

-Chest Radiograph:
-Most Commonly! used
-Performed as an Initial Diagnostic Imaging Study
-incidental finding
-compare to previous images

-MRI:
-use if there is a Cystic of Ground-Glass Lesions

-PET Scan:
-use If SPN > 8mm
-likely cancer if larger

-Electromagnetic Navigation Bronchoscopy (ENB):
-$$$ Noninvasive Modality
-not really needed

-Tumor Markers:
-See Next Slide

-**Biopsy!!:
-Ultimately Need Tissue

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5
Q

tumor markers

A

-Carcinoembryonic Antigen (CEA):
-Colon and rectum(colorectal or bowel cancer)
-Prostate
-Ovary
-Lung
-Thyroid
-Liver
-Pancreas
-Breast

-Folate Receptor-Positive Circulating Tumor Cells:
-Ovarian
-Non-Small Cell Lung Cancer (NSCLC)

-tumor markers are not always present -> not used as screening bc of this
-useful for monitoring of reoccurrence of a tumor that was previously secreting a marker

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6
Q

tumor markers: galectin-3-binding protein

A

-Breast Cancer
-Lung Cancer
-Melanoma
-Ovarian
-HCC
-Pancreatic Cancer
-Prostate
-Oral Squamous Cell Cancer
-Neuroblastoma
-Glioblastoma Multiforme
-Gastric Cancer
-Lymphoma
-Colon Cancer
-Mesothelioma
-Ewing’s Sarcoma

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7
Q

C163A

A

-investigation for use in risk stratification for cancer
-shows promise in eval of benign lung lesions
-not yet developed
-expieremental

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8
Q

x ray

A

-is this a nodule or a nipple shadow
-right lower

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9
Q

x ray

A

-squamous cell carcinoma -> strip blood supply -> necrosis
-cyst or abscess
-air fluid level

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10
Q

x ray

A

-nipples

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11
Q

approach to a small pulmonary nodule

A

-SPN Found on CXR
-Look for prior films to collaborate finding
-If on an old film then interval surveillance is acceptable
-If it is a new lesion, go to CT scan evaluation
-High suspicion on CT Scan, move to PET scan
-PET-avid lesion in a smoker if they are a good candidate resection is suggested
-After PET still unclear or poor surgical candidate perform biopsy
-If biopsy attempt fails, then wedge resection via VATS

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12
Q

complication of SPN intervention

A

-Usually Attributed to Surgical Interventions:
-Bleeding
-PE
-Infections:
-Empyema
-Pneumonia
-Surgical site infections

-Pleural Effusion
-Pneumothorax
-Myocardial Infarction
-Central neurological events- stroke

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13
Q

lung cancer etiology

A

-Smoking***
-Passive Smoking
-Treatment of Non-Lung Cancer- Breast, Non-Hodgkins Lymphoma -> Radiation exposure
-Heavy Metal Exposure: Chromium, Nickel, Arsenic, and Polycyclic aromatic hydrocarbons
-Lung Diseases: Idiopathic Pulmonary FIbrosis
-Exposures: Asbestos, Radon

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14
Q

types of lung cancer

A

-Adenocarcinoma
-Squamous Cell Carcinoma
-Adenosquamous Carcinoma
-Large Cell Carcinoma
-Small Cell Carcinoma

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15
Q

NSCLC

A

-Adenocarcinoma
-can also be a Squamous Cell Carcinoma (women; central lesion, smokers 1st or 2nd hand)
-Surgical resection, chemotherapy, radiotherapy, and immunotherapy
-Potential Operability & Surgical Cure

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16
Q

SCLC

A

-Central Necrosis
-Sensitive to CTX but high recurrence rate
-MC with paraneoplastic syndromes
-Surgical Cure is NOT a Realistic Option but is Utilized
-Median Survival 7 Months
-toes, bones, and perio-osteo overgrowth -> hypertrophic pulmonary osteoarthropathy

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17
Q

tumor location

A

-central- sclc -> metastasize
-peripheral- nsclc

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18
Q

questions to ask

A

-Smoking History
-Work History
-Exposures
-Nothing specific exists to look for or ask on the history & physical examination
-perineoplastic signs?

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19
Q

hx and PE

A

-Local Factors
-Compression Factors- SVC syndrome- plethoric face, edema -> radiation immediately (not surgery) -> this is a emergency -> need to restore blood flow
-Paraneoplastic Factors
-Cough 50 – 70% of patients- primary and metastatic pts

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20
Q

clubbing

A

-not exclusive to lung cancer

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21
Q

concerning presentations

A

-Cough
-lesion with Pneumonia
-Hemoptysis- can be tb
-Chest Pain
-Dyspnea
-SVC Syndrome

-Metastatic Disease:
-Bone (20% in NSCLC; 30 – 40% in SCLC)
-Brain (20% in SCLC)
-Liver (uncommon until advanced)

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22
Q

serious complications

A

-SVC Syndrome: Common in SCLC

-Pancoast Syndrome:
-Superior Sulcus Tumor of Wide Mediastinum
-Shoulder Pain
-Horner Syndrome- ptosis, miosis, anhidrosis -> Neurovascular involvement is bad prognosis -> involves stellate ganglion - sympathetic chains C6-C7 (numbness/tingling of hand/arm)

-Bone Erosion- clavicle
-Atrophy of Hand Muscles- innervation abnormalities

-Paraneoplastic Syndromes
-PTH-like Hormone
-SIADH-Like Hormone
-ACTH-Lile Hormone (SCLC)
-Lambert-Eaton Myasthenia Syndrome- myasthenia gravis

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23
Q

flow chart for lung cancer

A

-important for staging

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24
Q

staging workup for all lung cancer pts

A

-CT scan of chest and upper abdomen -> metastasize to adrenal glands -> Addisonian crisis!!!
-CBC w/ diff- leukocytosis, anemia
-serum chemistry - Cr, electrolytes, Ca, alk phos - hypercalcemia
-aspartate aminotransferase (AST)
-pulmonary function testing- required only if surgical resection is considered
-mediastinoscopy- required only if surgical resection is considered

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25
Q

molecular testing

A

-Epidermal growth factor receptor (EGFR) mutation (MC; Peripheral)!!
-Anaplastic lymphoma kinase (ALK) rearrangement (MC, Central)!!!
-use these to tell if its bronchogenic or non-bronchogenic / peripheral or central)

DONT NEED TO KNOW:
-BRAFV600Emutation
-RETrearrangement
-ROS-1rearrangement
-NTRK 1/2/3gene fusion
-METexon 14 skipping
-KRASG12C mutation
-Programmed death ligand 1 (PD-L1) expression

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26
Q

tx recommendation of non small cell lung cancer

A

-know the stage and management

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27
Q

prognostic factors

A
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28
Q
A

-non small cell cancer
-large central lesion
-bronchoscopy
-transbronchial bx

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29
Q
A

-non small cell lung cancer
-left pleural effusion
-nodule hidden in the fluid
-tap the pleural effusion -> malignant cells
-non operable - metastatic

30
Q
A

-non small cell cancer
-left upper lobe collapse
-bronchogenic -> causes lung to collapse

31
Q
A

-non small cell cancer
-complete collapse
-bronchogenic carcinoma of left main stem bronchus
-trachea is not midline (to left) -> atelectasis pull towards affected side
-bronchoscopy needed to clear blockage so lung can re-expand

32
Q
A

-CT
-contrast enhanced
-large left lung lesion
-huge complex lesion -> different densities
-invading the pulmonary artery
-hilar mass
-small cell lung carcinoma

33
Q
A

PET
-anterior
-left lower lobe lung cancer
-left adrenal gland tumor
-addisonian crisis!

34
Q
A

-bone scan
-metastatic
-non curable
-spine, pelvis, scapula
-poor prognosis

35
Q

mediastinoscopy

A

-look for nodes in the sternum
-mediastinoscopy
-collar incision midline
-put finger in
-find innominate artery

-can cause damage:
-Right pneumothorax
-Left recurrent nerve palsy
-Significant bleeding- innominate artery
-Bronchomediastinal fistula
-Postoperative death

36
Q

malignant pleural effusion

A

-pleurodesis- get the pleural layers (visceral and parietal) -> fuse
-you can fuse with indwelling catheter
-not curable
-eliminates the potential space
-chemical pleurodesis agents - painful
-doxycyclin- burns

37
Q

SCLC operative decision

A
38
Q

Assessment of Pulmonary Function Preoperatively

A

-Rationale: Prevent creation of a pulmonary “cripple.
-For all pts who may undergo radical surgery, it is recommended to measure both FEV1 and (diffusing capacity for carbon monoxide) DLCO and calculate and evaluate (predictive post op) PPO-FEV1 and PPO-DLCO according to the resection sizes
-must make sure they have the pulmonary reserve to tolerate surgery (not as prevalent bc we do lobectomy now)
-For all pts who may undergo radical surgery, no further evaluation is required if the PPO-FEV1 and PPO-DLCO are >60% predicted according to the resection size, and surgical resection can be scheduled.
-For all pts who may undergo radical surgery, low-technology exercise tests [including stair climbing test (SCT) and shuttle walk test (SWT)] are recommended if either PPO-FEV1 or PPO-DLCO is < 60% predicted and both are greater than 30% predicted according to the resection size.
-For all pts who may undergo radical surgery, CPET is recommended to measure VO2max if either PPO-FEV1 or PPO-DLCO is less than 30% predicted according to the resection size

39
Q

characteristics of chemical pleurodesis agents

A

-chest tube
-VERY painful
-MC doxy

40
Q

pleurX catheter

A

-drain the fluid

41
Q

SCLS surgical options

A

-pneumonectomy
-lobectomy- preferred surgical intervention!!!
-segmentectomy or wedge resection
-sleeve resection
-VAT- video assisted thoracotomy

42
Q

adjuvant therapy for lung cancer

A

-Immunotherapy, radiation therapy, chemotherapy, targeted therapy or a combination of them

-pembrolizamab (Keytruda)
-alone for advanced NSCLC if CTX with platinum did not or no longer works
-Tumor tests positive for “PD-L1”and
-Tumor has an abnormal “EGFR” or “ALK” gene
-You have also received an “EGFR” or “ALK” inhibitor medicine that did not work or is no longer working

43
Q

major (but rare) complication of pembrolizamab (keytruda)

A

-immunotherapy induced colitis with perforation
-acute abdomen, stool peritonitis
-severe pancreatitis
-will kill you

44
Q

chest wall mass flow chart

A
45
Q

chest wall flow chart if dx is NOT clear

A
46
Q

benign chest wall lesions

A

-Chondroma: Common in children and young adults

-Fibrous Dysplasia: Young adults, posterolateral rib cage

-Osteochondroma: MC BENIGN BONE TUMOR (PANCE)- anterior rib at costocartilage junction

-Eosinophilic Chondroma: Painful and tender osteolytic tenderness

-Desmoid Tumors: Surgical incisions abdomen and thorax, adenomatosis polyposis coli

47
Q

malignant chest wall lesions

A

-Chondrosarcoma- MC- wide resection
-Osteosarcoma- neoadjuctive chemo -> will have high alk phos

-Malignant Fibrous Histiocytoma
-Liposarcoma
-Fibrosarcoma
-Rhabdomyosarcoma- neoadjuctive chemo

-sarcomas:
-metabolic needs- hypoglycemia!!!!
-retroperitoneal tumors

48
Q
A

-right chest wall mass
-CT
-invading
-leiomyosarcoma

49
Q

mediastinum

A

-anteriorsuperior- thyoma, teratoma, terrible lymphoma, thyroid tumors
-thyoma assoc with myasthenia gravis
-middle
-posterior- neuroblastoma (kids), schwannomas (adults)
-3 parts

50
Q
A

-thyoma
-superioranterior lesion

51
Q
A

-middle mediastinum
-mediastinal lymph node metastases to aortopulmonary window area
-ex. pericardial cyst

52
Q
A

-neuroblastoma
-posterior mediastinum
-dumbbell
-neurogenic tumor

53
Q
A

pericardial cyst
-round
-delineated
-not malignant

54
Q
A

infections
-mediastinitis
-deadly
-perforated esophagus
-irrigated
-operated
-antibiotics
-chest tube
-drainage

55
Q

pleura

A

-parietal - where the pain fibers are
-can cause shift in mediastinum
-pressure on heart
-kinking of inferior vena cava -> no return to right side of heart -> no return to left -> MI
-excess fluid in pleural cavity

56
Q
A

-blunting of the costophrenic angles

57
Q
A

-large pleural effusion
-chest tube or thoracentesis -> needle at most inferior portion

58
Q

tx flow chart for malignant pleural effusion

A
59
Q

pleural fluid analysis

A
60
Q

causes of pleural effusions

A

-TRANSUDATE:
-CHF
-cirrhosis
-nephrotic syndrome
-peritoneal dialysis

-EXUDATE
-infections
-malignancy
-connective tissue diseases
-inflammatory disorders
-movement of fluid from abdomen to pleural space
-coronary artery bypass surgery
-pulmonary embolism (usually)
-hitting the thoracic duct during surgery -> chyle -> chylothorax

61
Q

pleural effusion tx

A

-if fluid is not moving -> loculated
-non-loculated -> tube thoracostomy
-loculated -> refer to IR -> if they cant drain -> VATS
-dont take more than 1L at a time -> can cause unilateral pulmonary expansion edema

62
Q

meigs syndrome

A

-ovarian tumor that causes pleural effusion and ascites

63
Q

pulmonary embolism

A

-usually exudative pleural effusion
-westermark sign- diminished vascular marking
-hamptons hump- infarction sign- wedge shaped

64
Q

trachea

A

-at the level of T3-T4
-T3- carina -> same as innominate artery
-tracheostomy complication -> tracheal innominate artery fistula
-MC issue with intubation -> tracheoesophageal fistula
-ET tube must be 2.5cm above carina -> if too low will only ventilate right lung
-baby first feeding is dextrose and water in case there is a tracheoesophageal fistula -> aspirating this is better than formula

65
Q

tracheal innominate artery fistula

A

-due to prolonged intubation
-ET balloon erodes through trachea and then innominate artery
-due to continuous pulsations against trachea
-pt presents with herald bleed → sudden gush of bright red blood from trachea
-need to hyperinflate balloon and shove it down along with emergency surgery
-usually not a survivable injury → pt will exsanguinate

66
Q

low pressure endotracheal tube balloons

A

stop macroaspiration
-pt can still have microaspiration

67
Q

endotracheal tube

A

-2.5cm above carina
-need to place a feeding tube -> give protein -> otherwise catabolic and muscles waste away -> no diaphragm
-oral care - chlorhexidine and mouth emollient -> pt can aspirate bacteria-laden saliva -> anaerobic bacterial pneumonia
-head is 50 degrees or higher to prevent ventilator associated pneumonia
-1 day = 1% chance of developing pneumonia
-can cause tracheomalacia (softening) -> pts can end up with tracheal stenosis and need surgery
-check cuff pressure everyday! -> balloon over inflated causes ischemia/necrosis, stenosis
-balloon underinflated -> oral secretions go into lungs -> ventilator associated pneumonia

68
Q

tracheal neoplasm

A

-investigate through bronchoscopy
-mediastinoscopy -> collar incision at suprasternal notch -> scope nodes
-PET scan

69
Q

passy-muir valve

A

-allows pts to speak with trach

70
Q

adenocarcinoma

A

-Associated w/ pleural effusions and distant metastases
-Could present w/ back pain
-invades the lung, visceral pleura, parietal pleura, innermost intercostals to the chest wall
-pleuritic chest pain
-Premalignant lesion = atypical alveolar hyperplasia
-Smaller PERIPHERAL airways
-phrenic nerve palsy → paralyzed hemidiaphragm
-pancoast tumor and horner syndrome
-Requires En Bloc resection → removes the tumor and involved segment of chest wall and reconstructs it

Surgery (21 decks)

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