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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

EDGR and ALK

A

EDGR: peripheral; adenocarcinoma
ALK gene: central

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8
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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9
Q

x ray

A

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

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10
Q

x ray

A

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

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11
Q

x ray

A

-nipples

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12
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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13
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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14
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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15
Q

types of lung cancer

A

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

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16
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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17
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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18
Q

tumor location

A

-central- sclc -> metastasize
-peripheral- nsclc

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19
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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20
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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21
Q

clubbing

A

-not exclusive to lung cancer

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22
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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23
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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24
Q

flow chart for lung cancer

A

-important for staging

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25
staging workup for all lung cancer pts
-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
26
molecular testing
-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
27
tx recommendation of non small cell lung cancer
-know the stage and management
28
mediastinoscopy
-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
29
malignant pleural effusion
-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
30
Assessment of Pulmonary Function Preoperatively
-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
31
characteristics of chemical pleurodesis agents
-chest tube -VERY painful -MC doxy
32
pleurX catheter
-drain the fluid
33
SCLS surgical options
-pneumonectomy -lobectomy- preferred surgical intervention!!! -segmentectomy or wedge resection -sleeve resection -VAT- video assisted thoracotomy
34
pancoast tumor
Pancoast tumor: adenocarcinoma and squamous (MC) ○ Tumor at the apices of the lung associated with adenoma and SCC ○ Apices: near the 1st rib and the neurovascular bundle ○ Tumor growth -> compress blood vessels and NERVES; ex R pancoast tumor - Recurrent laryngeal nerve: hoarseness - Phrenic : R hemidiaphragm paralysis; unilateral chest expansion and elevated hemidiaphragm Sympathetic plexus: horner's syndrome - ptosis, miosis, anhidrosis - Brachial plexus: UE weakness/paresthesia - SCV: UE edema; JVD increased
35
adjuvant therapy for lung cancer: pembrolizumab
-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 pembrolizumab: "releases the brakes" on T cells: allows T cells to recognize and kill cancer cells
36
major (but rare) complication of pembrolizamab (keytruda)
-immunotherapy induced colitis with perforation -acute abdomen, stool peritonitis -severe pancreatitis -will kill you
37
benign chest wall lesions
-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
38
malignant chest wall lesions
-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
39
mediastinum
-anteriorsuperior- thyoma, teratoma, terrible lymphoma, thyroid tumors -thyoma assoc with myasthenia gravis -middle -posterior- neuroblastoma (kids), schwannomas (adults) -3 parts
40
pleura
-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
41
causes of pleural effusions
-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
42
pleural effusion tx
-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
43
meigs syndrome
-ovarian tumor that causes pleural effusion and ascites
44
pulmonary embolism
-usually exudative pleural effusion -westermark sign- diminished vascular marking -hamptons hump- infarction sign- wedge shaped
45
trachea
-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
46
tracheal innominate artery fistula
-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
47
low pressure endotracheal tube balloons
stop macroaspiration -pt can still have microaspiration
48
endotracheal tube
-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
49
tracheal neoplasm
-investigate through bronchoscopy -mediastinoscopy -> collar incision at suprasternal notch -> scope nodes -PET scan
50
passy-muir valve
-allows pts to speak with trach
51
adenocarcinoma
-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
52
solitary pulmonary nodule vs nipple shadow
solitary pulmonary lesion!!! nipple shadow: * bilateral and symmetric * "fuzzy" margins or radiolucent "halo" * sharp lateral border and poorly defined medial border (may be present only on PA projections 3) * nodules are in a characteristic position: * male: between the 5th and 6th ribs anteriorly * female: at the inferior aspect of the breast shadow were not present on a very recent film
53
what is this
Theres a breakdown with clear air fluid levels -squamous cell carcinoma -> strip blood supply -> necrosis -cyst or abscess - not solitary coin lesion
54
nipple shadow
55
-non small cell cancer -large central lesion -bronchoscopy -transbronchial bx"
56
-non small cell lung cancer -left pleural effusion -nodule hidden in the fluid -tap the pleural effusion -> malignant cells -non operable - metastatic"
57
-non small cell cancer -left upper lobe collapse -bronchogenic -> causes lung to collapse -Diaphragm is pulled up: bad atelectasis Usually BRONCHIAL LESION PULLING UP DIAPHRAGM
58
-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**
59
-CT, contrast enhanced -large left lung lesion -huge complex lesion -> different densities -hilar mass - INVADING: the L pulm artery -> hylar mass, most like SMALL CELL cancer
60
PET -anterior -left lower lobe lung cancer -left adrenal gland tumor -addisonian crisis!" need CT scan of chest and upper abdomen: dont miss this!!!!
61
" -bone scan -metastatic -non curable -spine, pelvis, scapula -poor prognosis"
62
sclc operative decision
1: localized: surgery 2: larger, localized and local LNs: surgery + adjuvant chemo 3: mediastinal LN or large tumor: trimodal approach - chemo, radiation, surgery 4: distant metastasis: not curable/no surgery
63
chest wall mass work-up flow chart
64
chest wall mass work-up flow chart if dx is not clear
65
" -right chest wall mass -CT -invading -leiomyosarcoma"
66
" -middle mediastinum -mediastinal lymph node metastases to aortopulmonary window area -ex. pericardial cyst"
67
" -neuroblastoma -posterior mediastinum -dumbbell -neurogenic tumor"
68
pericardial cyst -round -delineated -not malignant
69
Mediastinitis: deadly * Perforated esophagus * Have blood supply - need to treat underlying cause * Tx: irrigated -> operated -> chest tube placed -> abx -> drainage -> still has high mortality and morbidity
70
pleural effusion - blunted costophrenic angles
71
-large pleural effusion -chest tube or thoracentesis -> needle at most inferior portion - When doing a tube thoracostomy , if you take more than 1 liter at a time you can cause.. unilateral pulmonary expansion edema
72
tx flow chart for malignant pleural effusion
how to tell if pleural effusion is loculated? - take cxr in l lateral decubitus view to see if effusion flows freely (non-loculated) or stays put (loculated)
73
suspicious of malignant pleural effusion flow chart
74
"pleural fluid analysis/lights criteria
75
Chylothorax
Central line and can hit thoracic duct -> milky white fluid -> chyle Dx: MRI, lymphograms and see it leaking out through thoracic duct Tx: ligate the thoracic duct or you can try to repair thoracic duct * Best to avoid injury * Identify key areas you want to avoid
76
Anterior mediastinum: 4 Ts
* Thymoma: MC ○ associated with paraneoplastic syndrome, myasthenia gravis ○ Near thymus gland: smooth, lobulated * Teratoma: germ cell tumor ○ contain tissue from all three germ layers (e.g., hair, teeth, fat) ○ Young adults ○ mixed densities on CT due to the presence of fat, fluid, and calcifications * Thyroid mass: ○ Ectopic thyroid tissue ○ Goiter ○ Continuity with the thyroid gland on CT ○ Compressive sx: dyphagia, hoarseness * "Terrible" Lymphoma: ○ Hodgkin lymphoma and primary mediastinal large B-cell lymphoma systemic symptoms (B symptoms) like fever, night sweats, and weight loss, as well as compressive symptoms from a large mass.
77
Can tell this is posterior because you still see the cardiac silhouette - mediastinal posterior schwannoma
78
Paraneoplastic syndromes: SCC Adenocarcinoma Carcinoid tumor SCLC
SCC: PTHrP - acts like PTH - Increases calcium in blood from kidney, bones Adenocarcinoma: -increases fibroblasts -> increases periosteal thickness -> hypertrophic osteoarthropathy* - Increase in procoagulation -> increase coagulable state -> increase DVT/PE; MI, Trosseau syndrome - dermatomyositis carcinoid tumor: - Carcinoid syndrome: elevated serotonin and vasoactive substances - histamines, prostaglandins - wheezing, diarrhea, bronchospasms. flushing SCLC: - SIADH - Cushing syndrome - Lambert eaton: myasthenia gravis
79
peripheral lung cancer sx
-Pleural effusion: increase inflammation near the pleura -> fluid leaks; exudative - Pneumothorax: cancer near visceral and parietal pleura -> starts eating at the visceral pleura -> air enters the pleural cavity
80
central lung cancer sx
* Cough: cough reflex due to localized inflammation * Hemoptysis: erosion in vascular wall into the lumen * Dyspnea * Wheezing * Post-obstructive PNA: normally mucus is coughed up -> mucus is stuck and bacteria thrives -> PNA * Nearby compression of mediastinum: ○ Hoarseness ○ Dysphagia ○ SVC syndrome: common in SCLC * Acevedo: atelectasis Mucus plugging + tumor obstruction can block central airway -> lack of air in alveolar spaces/decrease surfactant -> atelectasis

surgery (6 decks)

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