TSRA Clinical Scenarios - General Thoracic Surgery Flashcards

1
Q

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

A

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

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2
Q

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

A

Larger - core (resection plane), incisional bx if not dx.
Small - excisional bx.

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3
Q

Toddler with hemangioma on chest wall. Management?

A

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

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4
Q

Child with chest wall mass shows lymphangioma. Management?

A

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

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5
Q

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

A

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.

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6
Q

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?

A

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

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7
Q

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?

A

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

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8
Q

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

A

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

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9
Q

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

A

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.

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10
Q

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

A

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

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11
Q

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

A

Neoadj multi drug chemo and WLE.
75% survival (only 25 if no chemo).

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12
Q

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

A

WLE.

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13
Q

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. Dx and tx?

A

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

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14
Q

For chest wall mass resections involving the sternum, what are some surgical principles?

A

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

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15
Q

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

A

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

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16
Q

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

A

Scapula entrapment. Must reconstruct this defect.

17
Q

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?

A

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

Poor prognosis. Lung is primary met site.

18
Q

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

A

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

19
Q

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?

A

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.

20
Q

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

A

Yes.

21
Q

Which NSCLC patients need PET CT staging?

A

All of them.

22
Q

When do NSCLC need brain MRI?

A

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

23
Q

When do NSCLC need invasive mediastinal staging?

A

at 3cm (T2) or suspicious nodes

24
Q

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

A

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

25
Q

What nodes can mediastinoscopy access?
EBUS?
EUS?

A

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

26
Q

What T stage is invasion of diaphragm?

A

T4 (used to be T3 in 7th edition)

27
Q

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?

A

Stage IIIA. N2 is ipsilateral mediastinum.
Multidisciplinary discussion.
Definitive concurrent chemoradiation and possible Darvalumab.
OR
Induction chemo +/- RT. Restage, and ig no progression can consider SURGERY vs RT.
- surgery more likely to be offered for single, nonbulky mediastinal node site

28
Q

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?

A

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

29
Q

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

A

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

30
Q

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

A

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.

31
Q

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

A

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

32
Q

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

A

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

33
Q

Describe fibrous dysplasia on imaging.

A

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