TSRA Clinical Scenarios - General Thoracic Surgery Flashcards
Chest wall mass workup.
In what situations would you get specific studies?
CXR. CT (highest yield). MRI (vasc/neuro relationships to surrounding structures). PET (malignancy, tumor grade). Biopsy (plane of resection).
For a chest wall mass on CT with benign features, what is a reasonable biopsy plan?
Larger - core (resection plane), incisional bx if not dx.
Small - excisional bx.
Toddler with hemangioma on chest wall. Management?
Nonop unless need cosmesis or stop bleeding or ulcerated.
T2 MRI - high signal intensity.
If surgery, just need grossly negative margins.
Child with chest wall mass shows lymphangioma. Management?
Resect to prevent recurrence.
OK-432 and ascetic acid sclerotherapy may be used.
Young adult with chest wall mass and hx of trauma and Gardner’s syndrome.
Management?
Adjuvant?
Recurrence rate?
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.
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?
Fibrous dysplasia.
Mgmt depends on sx: Local excision if painful. Leave if asx.
Albright (skin lesions and precocious puberty in women).
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?
Osteochondroma.
Sx, enlarging, need more dx info: WLE w/ 2-4 cm margin.
Young adult pt with asymptomatic slow growing chest wall mass. Imaging shows periostial lytic lesion w/ thinning cortex and sclerotic borders. Differential? Mgmt?
Chondroma vs chondrosarcoma.
WLE w/ 2cm margins for all.
If malignant, re-resect w/ 4 cm margins.
Older male w/ chest wall PAIN WITHOUT MASS. Ca is elevated. Urine w/ Bence Jones proteins.
Diagnosis?
Association?
Mgmt?
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.
Older male pt w/ painless slow growing chest wall mass. Imaging shows mass originates from muscle and grows along fascial plane.
Dx and tx?
Malignant fibrous histiocytoma.
Most common chest wall sarcoma.
WLE.
If bad margins or high grade - adj radx.
If low grade - can perform re-resection.
Adolescent w/ chest wall lesion found to be rhabdomyosarcoma.
What is tx?
Prognosis?
Neoadj multi drug chemo and WLE.
75% survival (only 25 if no chemo).
Older male with chest wall mass. Large encapsulated tumor. Biopsy shows liposarcoma. Mgmt?
WLE.
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?
Chondrosarcoma.
WLE w/ 2-4 cm margins. One uninvolved rib above and below.
If margin +: adj radx (rad resistant).
Prognosis dep on grade.
For chest wall mass resections involving the sternum, what are some surgical principles?
Excise adherent tissue en bloc.
If lower sternum involved, spare manubrium.
If upper sternum involved, spare lower sternum.
Rigid reconstruction of sternum required.
What rib resection pts (chest wall mass) usually DON’T require reconstruction?
High posterior defect, ABOVE 5th rib, <10 cm (scapula covers).
Anterior defect <5cm.
2 rib resection if no baseline pulm compromise.