thorax Flashcards

Question

staging workup for all lung cancer pts

Answer 1

-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

Answer 2

-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

Answer 3

-know the stage and management

Answer 4

-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

Answer 5

-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

Answer 6

-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

Answer 7

-chest tube -VERY painful -MC doxy

Answer 8

-drain the fluid

Answer 9

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

Answer 10

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

Answer 11

-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

Answer 12

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

Answer 13

-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

Answer 14

-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

Answer 15

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

Answer 16

-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

Answer 17

-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

Answer 18

-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

Answer 19

-ovarian tumor that causes pleural effusion and ascites

Answer 20

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

Answer 21

-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

Answer 22

-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

Answer 23

stop macroaspiration -pt can still have microaspiration

Answer 24

-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

Answer 25

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

Answer 26

-allows pts to speak with trach

Answer 27

-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

Answer 28

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

Answer 29

Theres a breakdown with clear air fluid levels -squamous cell carcinoma -> strip blood supply -> necrosis -cyst or abscess - not solitary coin lesion

Answer 30

nipple shadow

Answer 31

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

Answer 32

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

Answer 33

-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

Answer 34

-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**

Answer 35

-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

Answer 36

PET -anterior -left lower lobe lung cancer -left adrenal gland tumor -addisonian crisis!" need CT scan of chest and upper abdomen: dont miss this!!!!

Answer 37

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

Answer 38

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

Answer 39

" -right chest wall mass -CT -invading -leiomyosarcoma"

Answer 40

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

Answer 41

" -neuroblastoma -posterior mediastinum -dumbbell -neurogenic tumor"

Answer 42

pericardial cyst -round -delineated -not malignant

Answer 43

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

Answer 44

pleural effusion - blunted costophrenic angles

Answer 45

-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

Answer 46

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)

Answer 47

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

Answer 48

* 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.

Answer 49

Can tell this is posterior because you still see the cardiac silhouette - mediastinal posterior schwannoma

Answer 50

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

Answer 51

-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

Answer 52

* 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