TSRA Clinical Scenarios - General Thoracic Surgery

Question 1

Chest wall mass workup.
In what situations would you get specific studies?

Answer 1

CXR.
CT (highest yield).
MRI (vasc/neuro relationships to surrounding structures).
PET (malignancy, tumor grade).
Biopsy (in plane of resection).

Question 2

For a chest wall mass on CT with benign features, what is a reasonable biopsy plan?
What considerations affect the plan?

Answer 2

Larger - core (in resection incision), then incisional bx if core not dx (incision along resection plane).
Small (<5cm) - excisional bx (1cm margin, ie not WLE).

Question 3

Toddler with hemangioma on chest wall. Management?

Answer 3

Nonop unless need cosmesis or stop bleeding or ulcerated.
T2 MRI - high signal intensity.
If surgery, just need grossly negative margins.

Question 4

Child with chest wall mass shows lymphangioma. Management?

Answer 4

Resect to prevent recurrence.
OK-432 and ascetic acid sclerotherapy may be used.

Question 5

Young adult with chest wall mass and hx of trauma and Gardner’s syndrome.
Management?
Adjuvant?
Recurrence rate?

Answer 5

Think desmoid tumor (chest wall is most common extra-abd site).
Wide local excision w/ wide margin is ideal (4cm).
Adjuvant radiation.

Margin + => 89% recurrence.
Margin - => 18% recurrence.

Question 6

Young pt w/ chest wall mass. Slow growing, asx, incidental. CXR - ground glass central area of rib with thinning cortex and irregular Ca in medulla.
Diagnosis and management?
Associated syndrome?

Answer 6

Fibrous dysplasia.
Mgmt depends on sx: Local excision if painful. Leave if asx.
Albright (skin lesions and precocious puberty in women).

Question 7

Young adult male pt w/ chest wall mass. Imaging shows mass arising from sternal cortical bone anteriorly at costochondral jct. It has pedunculated protuberance, intact cortex, and stippled calcification. Dx and mgmt?

Answer 7

Osteochondroma.
Sx, enlarging, need more dx info: WLE w/ 2-4 cm margin.

Question 8

Young adult pt with asymptomatic slow growing chest wall mass. Imaging shows periostial lytic lesion w/ thinning cortex and sclerotic borders. Differential? Mgmt?

Answer 8

Chondroma vs chondrosarcoma.
WLE w/ 2cm margins for all.
If malignant, re-resect w/ 4 cm margins.

Question 9

Older male w/ chest wall PAIN WITHOUT MASS. Ca is elevated. Urine w/ Bence Jones proteins.
Diagnosis?
Association?
Mgmt?

Answer 9

Plasmacytoma.
Multiple myeloma.

Bone marrow bx to confirm.
Tissue diagnosis (core vs incisional).
High dose radx.
35-50% progress to MM. 25-35% alive at 5 yrs.

Question 10

Older male pt w/ painless slow growing chest wall mass. Imaging shows mass originates from muscle and grows along fascial plane.
Dx and tx?

Answer 10

Malignant fibrous histiocytoma.
Most common chest wall sarcoma.
WLE.
If bad margins or high grade - adj radx.
If low grade - can perform re-resection.

Question 11

Adolescent w/ chest wall lesion found to be rhabdomyosarcoma.
What is tx?
Prognosis?

Answer 11

Neoadj multi drug chemo and WLE w/ 4cm margins.
75% survival (only 25 if no chemo).

Question 12

Older male with chest wall mass. Large encapsulated tumor. Biopsy shows liposarcoma. Mgmt?

Answer 12

WLE.

Question 13

Middle aged pt w/ painful, hard, fixed mass at costochondral angle. CT shows mixed lytic and sclerotic pattern w/ ovulated mass originating from medulla w/ cortical lesions and areas of thickened cortex.
Diagnosis?
Surgical management?
What do you do with the positive margins?
What is the prognosis dependent on?

Answer 13

Chondrosarcoma.
WLE w/ 2-4 cm margins. One uninvolved rib above and below.
If margin +: adj radx (rad resistant).
Prognosis dep on grade.

Question 14

For chest wall mass resections involving the sternum…
- How do you manage involved adherent tissue?
- What do you want to preserve if the lower sternum is involved?
- What is the principle for sternal reconstruction?

Answer 14

Excise adherent tissue en bloc.
If lower sternum involved, spare manubrium.
If upper sternum involved, spare lower sternum.
“Rigid reconstruction” of sternum required.

Question 15

What rib resection pts (chest wall mass) usually DON’T require reconstruction?

Answer 15

• High posterior defect (ie near the spine, ABOVE 5th rib), <10 cm (scapula covers).
• Anterior defect <5cm.
• 2 rib resection if no baseline pulm compromise.

Question 16

Resection of chest wall tumor involving the posterior 5th rib can lead to what complication?

Answer 16

Scapula entrapment. Must reconstruct this defect.

Question 17

Young adult w/ hx of radx to chest now has rapidly expanding mass, elevated ALP, CT that shows sunburst pattern and tumor lifting periosteum. Dx and mgmt?
Assn?

Answer 17

Osteogenic sarcoma.
Paget disease, p53 (RB gene).
Bx of surgeon’s choice.
Tx is neoadj and WLE.

Poor prognosis. Lung is primary met site.

Question 18

Adolescent male presents with enlarging painful mass. CT shows “onion-peel” appearance.
Dx and tx?

Answer 18

Ewing sarcoma.
Core needle bx and RT-PCR.
Neoadj chemo and WLE.
If margin +, add adj radx.

Question 19

Adolescent male has large soft tissue mass on chest wall w/ pleural thickening.
Core bx: small round cells, NSE+, dense core granules in cytoplasm. Dx and tx?

Answer 19

Askin tumor - PNET in Ewing sarcoma family.
Look for NSE stain +.
Neodj and WLE.
If margin +, add radx.
Can spread along sympathetic chain.

*tx same as Ewing. More aggressive than Ewing.

Question 20

For chest wall mass, does resection of the manubrium or BL SC joints require recon?

Answer 20

Yes.

Question 21

Which NSCLC patients need PET CT staging?

Answer 21

All of them.

Question 22

When do NSCLC need brain MRI?

Answer 22

at 4cm (T2b) [optional at 3cm or T2a], or N+.

Question 23

When do NSCLC need invasive/pathologic mediastinal staging?

Answer 23

at 3cm (T2) or suspicious nodes

Question 24

If NSCLC is <3cm, what node size would be considered suspicious enough to warrant targeted biospy?

Answer 24

These pts don’t require routine invasive mediastinal staging, but will get PET CT.
If CT shows 1cm size on axial images or positive PET (SUV 2.5), then they should be biopsied.

Question 25

What nodes can mediastinoscopy access?
EBUS?
EUS?

Answer 25

Cervical med - 2, 4, 7 (3 stations should at least be sampled - usually 4L, 4R, 7).
EBUS - 2, 3 (behind trach), 4, 7, 10
EUS - 5, 7, 8, 9

Question 26

What T stage is invasion of diaphragm?

Answer 26

T4 (used to be T3 in 7th edition)

Question 27

A NSCLC T1-3 (not invasion T3) pt is found to have N2 positive nodes on pathology during staging.
What is stage?
What should be done? Options?

Answer 27

Stage IIIA. N2 is ipsilateral mediastinum.

Mgmt:
* Multidisciplinary discussion.
* Definitive concurrent chemoradiation and possible Darvalumab.

OR
* Induction chemo +/- RT; restage (PET-CT); and if no progression, consider SURGERY vs RT.
* Surgery more likely to be offered for single, nonbulky mediastinal node site.

Question 28

A NSCLC T1-3 (INCLUDES T3 with multiple nodules in same lobe) pt is found to have N1 positive nodes on pathology during staging.
What should be done?

Answer 28

N1 is ipsilateral hilar nodes.
Determine resectability. Can resect this.

Question 29

A NSCLC invasion T3 pt is found to have N2 positive nodes on pathology during staging.
What should be done? Options?

Answer 29

Definitive concurrent chemoradiation.
Cannot offer surgery unlike T3N1 or or T3(noninvasive)N2.

Question 30

During cervical mediastinoscopy at 4R position, a dark structure is seen. What could this be? What should be done?

Answer 30

Could be lymph node… or azygous or R PA.
Keep dissecting. If cannot completely determine, then use a 21 gauge spinal needle to aspirate the structure through the scope.

Question 31

During mediastinoscopy, you sample a clearly defined node in subcarinal space. Bleeding continues to fill the scope. What do you do?

Answer 31

Pack gauze strip into the area.
Can carefully use electrocautery if can directly visualize.

Question 32

During 4R mediastinoscopy biopsy, a copious amount of blood fills the scope, and the patient becomes hypotensive. What do you do?

Answer 32

You probably injured the azygous or R PA.
Pack the mediastinum.
Alert anesthesia. Bring in blood. Get access.
Prepare for sternotomy and vascular control.

Question 33

Describe fibrous dysplasia on imaging.

Answer 33

CXR - ground glass central area of rib with thinning cortex and irregular Ca in medulla.