UpToDate Surgery Research

Question 1

Most common congenital chest wall deformities

Answer 1

Pectus excavatum

Question 2

In general, what is the cause of pectus deformities

Answer 2

abnormal costal cartilage growth

Question 3

Pectus excavatum usually spares which two ribs

Answer 3

First and second

Question 4

During pectus surgery, what is meant to be left intact/preserved when resecting the abnormal cartilage?

Answer 4

perichondrial sheath

Question 5

What is the definitive/preventative management for pneumothorax?

Answer 5

pleurodesis

Question 6

A patient presents with a pneumothorax caused by an underlying disorder that was non-traumatic. What is the classification, and what are the treatment options? What is risk of recurrence?

Answer 6

Secondary spontaneous pneumothorax - risk of recurrence 30-50% in the first year.
Is the patient a surgical candidate (medically)?
- no -> chemical pleurodesis w/ talc or tetracycline
- yes -> VATS w/ mechanical abrasion +/- chemical insufflation/pleurectomy/blebectomy

Question 7

For a patient with a primary spontaneous pneumothorax, what are some indications for definitive procedures?

Answer 7

Recurrence
Size or severity enough to warrant tube/catheter thoracostomy
High risk profession or hobby (diver, pilot; pressure changes)
High cyst burden
PAL (>4 days)
Other reason for VATS (biopsy)

Patient preference

Question 8

What is the most likely location of blebs in the lung?
Does this affect operative decision making in definitive management of spontaneous pneumothorax?

Answer 8

Apex.
Some surgeons will always do apical blebectomy/bullectomy along with pleurodesis (mechanical +/- chemical) based on retrospective data showing recurrence <5% with the combined approach.

Question 9

How do thymomas and thymic carcinomas present? (3 general presentations)

Answer 9

Incidental on imaging in asx pt.
Local thoracic symptoms (CP, SoB, cough, phrenic nerve palsy).
Paraneoplastic syndromes (MG, pure red cell aplasia, immunodeficiency, multiorgan autoimmunity).

Question 10

Describe myasthenia gravis.
Pathophys? Presentation?

Answer 10

Autoimmune disorder - auto-antibodies with AChR of voluntary muscle at NM junction.
Causes diplopia, ptosis, dysphagia, weakness, fatigue.
1/2 of patients w/ thymoma have MG.
MG is rare in thymic carcinoma.
Sx pts tend to cause earlier detection of thymoma.
Surgery usually cures sx, but not always.

Question 11

What percentage of thymoma patients get pure red cell aplasia?

Answer 11

5-15%. More common in older adult females.
Red cell aplasia will not likely improve after thymectomy for thymoma, but it is still pursued.

Question 12

Can thymectomy improve immunoglobulin levels in patients with hypogammaglobulinemia immunodeficiency associated with thymoma?
How common is this paraneoplastic syndrome?
What population does it usually affect?

Answer 12

Not reliably.
Hypogammaglobulinemia and pure white blood cell aplasia are present in fewer than 5% of patients with thymoma.
Most common in older adult females?

Question 13

Several case reports have described a syndrome of thymoma-associated multiorgan autoimmunity (TAMA). How does this present?

Answer 13

Similar to graft-versus-host disease. Morbilliform skin eruption, chronic diarrhea, and liver enzyme abnormalities.
Histopathology of the skin or bowel mucosa is similar to that seen with graft-versus-host disease.

Question 14

What is the imaging workup for an anterior mediastinal mass suspicious of thymoma?
What are you trying to determine?

Answer 14

CT or MRI.
Need to determine whether the thymoma is well circumscribed or if it infiltrates other structures. Need to determine resectability.

*Pic of thymic mass not well circumscribed.

Question 15

What imaging findings are more concerning for thymic carcinoma as opposed to thymoma?

Answer 15

Necrotic, cystic, or calcified areas.

Question 16

T staging for thymic tumors.
AJCC UICC 8th edition

Answer 16

TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
T1 Tumor encapsulated or extending into the mediastinal fat; may involve the mediastinal pleura
T1a Tumor with no mediastinal pleura involvement
T1b Tumor with direct invasion of mediastinal pleura
T2 Tumor with direct invasion of the pericardium (either partial or full thickness)
T3 Tumor with direct invasion into any of the following: Lung, brachiocephalic vein, superior vena cava, phrenic nerve, chest wall, or extrapericardial pulmonary artery or veins
T4 Tumor with invasion into any of the following: Aorta (ascending, arch, or descending), arch vessels, intrapericardial pulmonary artery, myocardium, trachea, esophagus

Question 17

N staging for thymic tumors.
AJCC UICC 8th edition

Answer 17

NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Metastasis in anterior (perithymic) lymph nodes
N2 Metastasis in deep intrathoracic or cervical lymph nodes

Question 18

M staging for thymic tumors.
AJCC UICC 8th edition

Answer 18

M0 No pleural, pericardial, or distant metastasis
M1 Pleural, pericardial, or distant metastasis
M1a Separate pleural or pericardial nodule(s)
M1b Pulmonary intraparenchymal nodule or distant organ metastasis

Question 19

Other than thymoma and thymic carcinoma, what else is on the differential for anterior mediastinal mass?
What other preop tests should be done in light of this?

Answer 19

Retrosternal thyroid, lymphoma, and mediastinal germ cell tumor.
Preoperative evaluation may include germ cell tumor markers (beta-human chorionic gonadotropin [hCG] and alpha fetoprotein), LDH, as well as pulmonary function tests.

Question 20

How do you obtain definitive diagnosis of a thymoma or thymic carcinoma?

Answer 20

Tissue:
For patients thought to have a thymoma that will be amenable to complete resection, the initial step in management is surgical resection, which can definitively establish the diagnosis.
For patients with a tumor that is not considered amenable to complete resection or in whom surgery is contraindicated because of age or comorbidity, a tissue diagnosis with a core needle biopsy or an open biopsy is required prior to therapy.

Question 21

Can preop imaging predict stage in thymomas and thymic carcinomas?

Answer 21

In approximately two-thirds of thymomas and thymic carcinomas, preoperative chest CT can accurately predict the pathologic TNM stage.

Question 22

What pathological consideration must be taken when a thymoma or thymic carcinoma is adherent to a nearby structure?

Answer 22

surgeon should designate the site of adhesion on the specimen so that the pathologist can take sections from that area; specimen should be oriented by the surgeon to identify the exact margins of resection, which should then be inked

Question 23

What are the recommendations for TAVI postop anticoag vs antiplatelet specifics?

Answer 23

If no indications for DAPT or anticoagulation, then SAPT is used. Otherwise follow concomitant indications for other medications.

Question 24

What factors generally favor SAVR over TAVR?

Answer 24

• Presence of another indication for cardiac surgery (root enlargement)
• Lack of femoral access
• Younger age (<65, longer life expectancy, particularly if patient is a candidate for surgical mechanical valve replacement)
• Anatomic feature that would make TAVI high risk: adverse aortic root, low coronary ostia height, heavily calcified bicuspid aortic valve, and severe left ventricular outflow tract calcification.

Question 25

Preprocedural TAVI/TAVR needs:
Abx ppx?
Monitoring/lines?
Pacing?
Anticoag - ACT, when?

Answer 25

• ancef
• at least 1 large bore; art line; warming
• temporary pacing
• wt adjusted, ACT 250-300 before placement of large sheath

Question 26

If severe/sx AS pt is not SAVR candidate, but cannot get transfemoral access, what are other options for TAVR?

Answer 26

subclavian/axillary approach, two transthoracic approaches (transaortic and transapical), the transcaval approach, and the transcarotid approach

Question 27

General steps of TAVI/TAVR?

Answer 27

obtaining vascular access, establishing a clear coplanar view of the aortic annulus, balloon aortic valvuloplasty (in selected cases), delivery of the transcatheter heart valve (THV), repositioning (if indicated and feasible), and post-deployment valvuloplasty (if indicated to improve frame expansion)

Question 28

What is a solitary fibrous tumor histologically? In broad anatomic terms, where can they show up?

Answer 28

histologic spectrum of rarely metastasizing fibroblastic mesenchymal neoplasms that includes tumors formerly classified as hemangiopericytoma; commonly thought of as intrathoracic tumors, 50 to 70 percent of SFTs arise outside the thorax, including the central nervous system (CNS)

Question 29

Mmainstay of therapy for all localized pleural SFTs

Answer 29

Complete en bloc surgical resection

Question 30

Pedunculated SFTs can generally be resected how?
What about larger or sessile tumors?

Answer 30

wedge resection for R0 margins

large sessile tumors and those with ipsilateral intrapleural metastases may occasionally require a lobectomy, pneumonectomy, or a chest wall or diaphragm resection to achieve negative (R0) margins

Question 31

A patient asks you what the outcomes are like for the resection of pleural SFTs. How would you respond?

Answer 31

In a retrospective series, 157 patients with a pleural SFT underwent complete en bloc resection, which required wedge resection in 122, lobectomy of one or more lobes in 19, pneumonectomy in four, chest wall resection in 8, diaphragm resection in 3, and multilevel hemivertebrectomy in 1. Despite R0 resection, 15 (10 percent) recurred at a median of 29 months. Ten recurred locally, while five recurred at distant sites. In 9 of the 10 cases with a local recurrence, disease control was achieved with reresection. Recurrences were more common in patients with malignant histology (19 versus 1.3 percent). At a median follow-up of 14 years, the overall 5- and 10-year survival rates for the entire cohort were 86 and 77 percent; long-term survival was significantly better in those with a histologically benign SFT as compared with those with malignant features (at five years, 96 versus 68 percent, respectively).

Question 32

What is the role for radiation therapy for SFTs?

Answer 32

Radiation therapy — The aim of radiation therapy (RT) is local control of disease at high risk for recurrence. In general, our approach for most patients is to proceed with surgery directly, with evaluation of adjuvant (ie, postoperative) RT on a case-by-case basis. However, some clinicians may offer neoadjuvant (ie, preoperative) RT when adjuvant RT would be challenging to deliver. The use of RT is best decided in the context of a multidisciplinary discussion.

Adjuvant radiation therapy — Our approach to adjuvant RT is as follows:

For patients with complete (ie, R0) resection and no high-risk histologic features, we offer observation rather than adjuvant RT or chemotherapy.

For patients with resected intermediate- to high-risk SFT and positive margins who are eligible for resection with minimal morbidity, we offer re-resection rather than adjuvant RT.

For patients with resected intermediate- to high-risk SFT and positive margins who are ineligible for further resection, we suggest adjuvant RT rather than observation or chemotherapy. As an example, candidates for adjuvant RT include those with positive surgical margins (ie, R1/R2 resection) and an inability to achieve R0 resection with repeat surgery due to anatomic constraints (eg, in the pleura or mediastinum). However, as there are limited prospective data for this approach, some experts may reasonably omit adjuvant RT for these patients. Optimal management is best determined in a multidisciplinary setting, and risk stratification models may be helpful in the decision to offer adjuvant RT.

For patients with locally recurrent SFT, we offer re-resection followed by adjuvant RT, as such patients likely had disease not initially controlled with surgery alone.

For patients with resected SFT and certain higher risk features (eg, positive surgical margins, high mitotic count), the use of adjuvant RT may prevent local recurrences, although an overall survival benefit has not been established in observational studies.

The use of neoadjuvant RT is decided on a case-by-case basis in patients with SFTs. Neoadjuvant RT may be offered to patients with tumors in anatomic regions that may be difficult to initially resect (eg, pelvis and retroperitoneum) and where adjuvant RT would be challenging to deliver due to the presence of bowel or other radiosensitive structures in the RT field.