thorax Flashcards
key questions to ask
-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
solitary pulmonary nodule/coin lesion
-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!!!!
physical exam
-not usually helpful
-may help if there are assoc pulmonary diseases -> TB, COPD, emphysema, chronic bronchitis
diagnostic tools
-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
tumor markers
-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
tumor markers: galectin-3-binding protein
-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
EDGR and ALK
EDGR: peripheral; adenocarcinoma
ALK gene: central
C163A
-investigation for use in risk stratification for cancer
-shows promise in eval of benign lung lesions
-not yet developed
-expieremental
x ray
-is this a nodule or a nipple shadow
-right lower
x ray
-squamous cell carcinoma -> strip blood supply -> necrosis
-cyst or abscess
-air fluid level
x ray
-nipples
approach to a small pulmonary nodule
-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
complication of SPN intervention
-Usually Attributed to Surgical Interventions:
-Bleeding
-PE
-Infections:
-Empyema
-Pneumonia
-Surgical site infections
-Pleural Effusion
-Pneumothorax
-Myocardial Infarction
-Central neurological events- stroke
lung cancer etiology
-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
types of lung cancer
-Adenocarcinoma
-Squamous Cell Carcinoma
-Adenosquamous Carcinoma
-Large Cell Carcinoma
-Small Cell Carcinoma
NSCLC
-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
SCLC
-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
tumor location
-central- sclc -> metastasize
-peripheral- nsclc
questions to ask
-Smoking History
-Work History
-Exposures
-Nothing specific exists to look for or ask on the history & physical examination
-perineoplastic signs?
hx and PE
-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
clubbing
-not exclusive to lung cancer
concerning presentations
-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)
serious complications
-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
flow chart for lung cancer
-important for staging
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
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
tx recommendation of non small cell lung cancer
-know the stage and management
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
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
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
characteristics of chemical pleurodesis agents
-chest tube
-VERY painful
-MC doxy
pleurX catheter
-drain the fluid
SCLS surgical options
-pneumonectomy
-lobectomy- preferred surgical intervention!!!
-segmentectomy or wedge resection
-sleeve resection
-VAT- video assisted thoracotomy
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
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
major (but rare) complication of pembrolizamab (keytruda)
-immunotherapy induced colitis with perforation
-acute abdomen, stool peritonitis
-severe pancreatitis
-will kill you
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
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
mediastinum
-anteriorsuperior- thyoma, teratoma, terrible lymphoma, thyroid tumors
-thyoma assoc with myasthenia gravis
-middle
-posterior- neuroblastoma (kids), schwannomas (adults)
-3 parts
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
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
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
meigs syndrome
-ovarian tumor that causes pleural effusion and ascites
pulmonary embolism
-usually exudative pleural effusion
-westermark sign- diminished vascular marking
-hamptons hump- infarction sign- wedge shaped
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
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
low pressure endotracheal tube balloons
stop macroaspiration
-pt can still have microaspiration
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
tracheal neoplasm
-investigate through bronchoscopy
-mediastinoscopy -> collar incision at suprasternal notch -> scope nodes
-PET scan
passy-muir valve
-allows pts to speak with trach
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
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
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
nipple shadow
-non small cell cancer
-large central lesion
-bronchoscopy
-transbronchial bx”
-non small cell lung cancer
-left pleural effusion
-nodule hidden in the fluid
-tap the pleural effusion -> malignant cells
-non operable - metastatic”
-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
-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**
-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
PET
-anterior
-left lower lobe lung cancer
-left adrenal gland tumor
-addisonian crisis!”
need CT scan of chest and upper abdomen: dont miss this!!!!
”
-bone scan
-metastatic
-non curable
-spine, pelvis, scapula
-poor prognosis”
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
chest wall mass work-up flow chart
chest wall mass work-up flow chart if dx is not clear
”
-right chest wall mass
-CT
-invading
-leiomyosarcoma”
”
-middle mediastinum
-mediastinal lymph node metastases to aortopulmonary window area
-ex. pericardial cyst”
”
-neuroblastoma
-posterior mediastinum
-dumbbell
-neurogenic tumor”
pericardial cyst
-round
-delineated
-not malignant
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
pleural effusion
- blunted costophrenic angles
-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
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)
suspicious of malignant pleural effusion flow chart
“pleural fluid analysis/lights criteria
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
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.
Can tell this is posterior because you still see the cardiac silhouette
- mediastinal posterior schwannoma
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
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
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
