SESATS General Thoracic Flashcards
What is a pulmonary arteriovenous malformation (PAVM)?
anomalous communication between PA and PV causing R-to-L shunt of blood through the lung -> dyspnea, clubbing, cyanosis, hemoptysis, hemothorax, stroke, cerebral abscess, TIAs
What is the treatment for PAVMs?
embolization is preferred; all of them
What is the most common cause of PAVMs?
hereditary hemorrhagic telangiectasia
Manage healthy clinic pt here for redo fundoplication. She has weight loss and dysphagia. Endoscopy shows tight wrap and mesh erosion into the stomach esophagus. What is the management?
Erosion is extensive.
Resect the GE jct and mesh. Reconstruct in roux-en-y fashion to control reflux (though expect more weight loss).
When should chest wall stabilization for traumatic chest wall injuries be considered?
3 or more displaced rib fxs
Flail segment
Failure of optimal med mgmt
Thoracic surgery for another reason
Early plating 24-72 hrs shows reduced inflammation, hemothorax, empyema, and early callous. If ventilated, may reduce vent days, ICU days, and hospital cost.
> 65 yo have reduced M&M from rib fx, improved mechanics, and earlier return to fct.
Most common congenital chest wall abnormality?
Pectus excavatum
How is the Haller index for pectus excavatum obtained?
What is usually the cutoff?
Distance from the inner surfaces of lateral ribs.
Distance from the posterior sternal table to anterior vertebral body at point of maximal depression.
Index = transverse measurement/AP measurement.
3.25 usually accepted cutoff for surgeons/insurance.
What is the mechanism of dyspnea in pectus excavatum?
Decreased RV filling.
Decreased stroke Volume & Cardiac Output.
PFTs don’t usually improve.
For Nuss technique for pectus excavatum, when should strut be removed?
after 3 yrs
A pt w/ penetrating lung injury has a through and through injury with active bleeding. What can provide best exposure for control of vascular/airway injuries?
tractotomy
Pleural well-marginated nodule growing gets wedge showing spindle cell neoplasm.
What is dx?
What is tx?
Predictor of metastatic potential?
Solitary fibrous tumor of the pleura - malignant potential and will continually grow.
Needs resection w/ simple negative margin.
Yearly CT surveillance.
Systemic therapy if systemic disease.
Metastatic potential: >4 mitoses/10 hpf.
Pure GGO on CT scan of chest. When should wedge resection be done?
Grow over time (usually slow), and reach at least 8-10 mm.
Almost zero risk of regional or distant mets - no urgency to resect. So monitor until those thresholds.
Lung adeno w/ invasive component <5mm (ie 5mm solid component on CT) are termed what?
What kind of risk do they have?
Minimally invasive adenocarcinoma if <5mm solid.
Low risk of nodal mets and high cure chance w/ surgery.
Many would recommend segmentectomy.
*Know solid component size in lung adeno.
*If >5mm, risk increases to those of traditional “solid” cancer.
A patient w/ effusion has high protein, low glucose, and high ADA. No organisms. What’s next to confirm dx?
What’s the role of pleural drainage?
Could be tuberculosis.
Should confirm with VATS pleural biopsy - 80% yield on histopathology.
Usually don’t require chest tube drainage.
Pleural drainage is only to relieve sx.
NSCLC involving main PA. What can be done?
Pneumonectomy can be avoided w/ lobectomy and PA resection and reconstruction.
A patient with superior sulcus NSCLC tumor has invasion of the subclavian artery. What is the management?
Induction chemoradiation, lobectomy with en bloc resection of the subclavian with reconstruction.
A patient w/ severe emphysema is undergoing BL lung volume reduction surgery. She has no cardiac problems. She is induced, and ventilation is started. Blood pressure falls. EKG shows NSR. There is no tracheal deviation. Breath sounds are faint bilaterally. What happened?
How do you manage?
Emphysema -> compliant lungs -> positive pressure causes filling to capacity -> air trapping/auto-PEEP -> restricted venous return -> hypotension -> PEA.
Allow lungs to deflate: disconnect the ventilator.
Vent strategy: reduced pressures and long expiratory time.
Criteria for lung transplant for COPD?
FEV1 <20% predicted
DLCO <20% predicted or homogenous emphysema
BODE score >7
Hospitalization for hypercapnia w/ pCO2 >50
Pulm HTN
A pt s/p pneumonectomy presents w/ cough, fever, and CT scan that shows fluid loss/dec air-fluid levels from previous. What is dx and tx?
Late BPF. The dec air-fluid levels are caused by inc air.
Protect remaining lung (ie avoid aspiration) - urgent tube drainage and elevation of functional lung.
Bronchoscopy will give dx after this.
May eventually require OR repair.
Standard first-line of care for metastatic NSCLC w/ PD-L1 expression >50% according to KEYNOTE 024 study?
systemic therapy w/ pembrolizumab
Manage a patient w/ effort thrombosis (painting then psx w/ swollen arm found to have SCV thrombus).
Initial anticoagulation and thrombolysis.
Then early first rib resection - includes debridement of the subclavius tendon at the costoclavicular joint and vigorous venolysis w/ resection of the fibrotic tissue around the vein.
In stage IV lung cancer pts w/ EGFR-mutant tumors, what is the initial recommended therapy?
TKI treatment WITHOUT chemo.
In patients who get resection, save TKI treatment in the event of later mets (as opposed to using them as adjuvant), and use standard adjuvant measures even if EGFR mutation is present.
A blunt trauma pt gets a chest tube and now has a continuous air leak w/ some compromise of ventilation. What next?
Flexible bronch identifies injury (likely bronchial tree disruption) and can place ETT to mainstem the other side. Then get scan. Then OR for repair of bronchial tree disruption.
Don’t go to CT scanner immediately.
Don’t place more chest tubes.
For NSCLC in pt w/ pre-resection FEV and DLCO of 40% and nodule size of 1-2 cm, what is the preferred resection?
Data shows segmentectomy has better survival compared to wedge.
If needing to do wedge for NSCLC, what is the resection goal?
2cm or the diameter of the tumor, whichever is greater.
How many segments are there total for both lungs?
How many segments does the RML have?
19.
2.
A pt w/ Barrett (w/o dysplasia) undergoes fundoplication. What POSTOP finding is best associated w/ regression of Barrett?
Low esophageal acid exposure.
Regression LESS likely in following: postop endoscopy w/ esophagitis suggesting ongoing reflux, recurrent hiatal hernia, long-segment Barrett (>3cm).
What is the most accurate way to identify the GEJ in pt undergoing fundoplication for hiatal hernia?
Rugal folds are a reliable landmark for the GEJ. Identify it endoscopically, and mark it laparoscopically.
Fat pad is NOT reliable.
Manage an infected pleural catheter originally placed for malignant pleural effusion in non-septic and stable pt.
Over 90% can be managed by continued drainage and culture appropriate abx. Duration 3 wks. Majority did not have recurrence.
Do NOT remove the catheter, place a big tube, or try to decorticate the cancer laden space.
Describe a pulmonary hamartoma on chest CT.
Lobulated nodule with popcorn calcification and a region of fat density.
This is benign and can be followed.
A patient with a 3 cm pulmonary mass has FNA biopsy showing neuroendocrine markers on immunohistochemistry and cytology. What is the differential?
What clues can separate the differential?
Carcinoid, atypical carcinoid, SCLC, and large cell NET.
It is particularly difficult to distinguish typical/atypical carcinoid and SCLC.
Clinical history is important - heavy smokers are more likely to have SCLC.
Risk of nodal disease of T1b esophageal cancer?
21-24%.
EMR can be offered if low risk - adenocarcinoma that is well-diffx, no lymphovascular invasion, <3cm.
If this comes back w/ positive margin, move to esophagectomy.
In an empyema pt who is a poor surgical candidate, what can be added to chest tube drainage and abx to improve success?
DNase AND t-PA reduced need for surgery from 16 to 4%.
DNase alone increased surgical referral from 16 to 39%.
Streptokinase alone did not make a difference.
Most common neurogenic tumor in mediastinum?
Schwannoma
What is the treatment for mediastinal neurogenic tumors?
Complete surgical excision. Get MRI first to check for extension into the neural foramina.
They are benign, so rarely recur.
Adjuvant therapy rarely indicated. Radx not effective.
Asymptomatic esophageal submucosal lesion differential?
How do you manage?
Usually leiomyoma, but can also be GIST.
Asymptomatic w/o concerning findings - observe*.
Symptomatic - enucleation.
Large symptomatic lesions difficult to resect - FNA.
*used to resect all of these, but review by Codipilly showed little change over long observation periods
Young African American female presents w/ hilar LAD and BL reticular pulmonary opacities. What is the suspicion, and how do you confirm?
Sarcoidosis.
EBUS and bx.
Second most common primary tracheal malignancy?
Adenoid cystic carcinoma (salivary gland type).
Insidious submucosal growth, perineural and lymphatic spread.
*SCC is first
Best way to manage R1 disease after resection of tracheal ACC?
Radiotherapy. Best treats microscopic submucosal disease.
The ideal chemotherapy has not been determined, and there aren’t standard guidelines. This is reserved for metastatic and progressive disease.
Most common cause of malignancy deaths post-transplant?
Second most?
Non-melanoma skin cancer.
PTLD.
What is PTLD associated with? What transplant pts are higher risk?
How do you ppx?
EBV.
EBV-seroNEGATIVE recipients pre-transplant who get EBV-positive donation.
Ganciclovir should be given to above pts.
How do you treat PTLD?
1) early lesions
2) cannot tolerate first line
3) CD20+ PTLD
4) refractory
5) EBV-/CD20-
6) CNS involvement or localized
Initial tx for early lesions (polyclonal B cells proliferation w/ malignant transformation) -> decrease immunosuppression and allow cytotoxic T-cell recovery. Improvement in 3-5 wks if pt can tolerate.
Pt cannot tolerate immunosuppx reduction or CD20+ PTLD -> rituximab.
Refractory pts or those w/ EBV-/CD20- -> chemo w/ cyclophosphamide, doxorubicin, vincristine, prednisone.
Involvement of central nervous system and localized -> radiation. A subset can get surgery.
In patients with septic lung disease (ie CF), do you offer a single or double lung transplant?
Double - concern that a single lung allograft will be infected d/t spillage from the contralateral.
A CF w/ low FEV is diagnosed w/ Burkholderia cepacia complex. What is the significance of this diagnosis when considering transplant?
This is a virulent organism that may preclude from transplant candidacy.
Associated w/ decreased graft fct and increased post-transplant mortality.
It is unlikely to resolve w/ treatment, and the airways are likely to never be cleared.
In reference to neurogenic tumors of the posterior mediastinum, what are dumbbell tumors?
Extension through the foramen into the spinal canal.
Surgical resection is treatment. Need neurosurgery for single-stage hemi-laminectomy and thoracotomy.
*Indolent w/ local progress w/o dissemination.
*Chemo and radx aren’t effective.
What is used as the primary treatment modality for chest wall sarcomas to achieve optimal local control and long-term oncologic survival?
What is used as a surrogate for cancer biology and is a predictor for outcomes (even worse than a positive surgical margin)?
Chemo with or without radiation.
Tumor grade is a surrogate of cancer biology and is a worse predictor for outcomes than a positive surgical margin.
If resecting, aim for 2-4 cm margin. Be at a center of excellence.
CT chest shows 10cm fluid filled mediastinal mass in R chest adjacent to esophagus. Endoscopy shows normal esophageal mucosa w/ extrinsic compression. What is dx? Tx?
Esophageal duplication cyst.
Consider for resection, especially if symptoms.
EUS drainage -> infection.
Marsupialization -> recurrence.
In a patient with a known peripheral lung cancer without PET findings of distant spread, what additional symptoms may require further workup?
Localized musculoskeletal pain.
Especially unilateral chest wall or back pain - 90% sensitive for chest wall involvement in peripheral tumors.
MRI may be required.
Which is the best method/modality to determine if the amount of trachea involved by a tumor can be resected?
Bronch vs CT vs PET vs MRI.
Explain uses of each type.
Bronchoscopy. Rigid can determine length and assess airway quality.
*CT can help determine extra-luminal extent.
*PET can determine nodal/distant spread.
*MRI can determine if vascular involvement.
A chest wall resection and reconstruction patient presents w/ delayed PTFE patch infection under a viable lat flap. Manage this.
What to do with lat flap?
Any more recon material needed?
IV abx and drainage of infected fluid. Drainage is for sx relief and micro ID. It will not resolve this on its own.
Surgically remove the patch and cover it with the previous lat flap.
Additional recon material usually isn’t required, as there is a fibrotic rind.
Additional recon may be needed if chest wall instability. Bio material may be useful in early infection requiring resection of the PTFE.
Diagnose and treat eosinophilic esophagitis.
Endoscopic biopsy - path shows >40 eosinophils per HPF. “Ringing” and “furrowing” on endoscopy are also typical.
Tx w/ PPI and topical steroids (steroid inhalers discharged into mouth then swallowed). Wash out mouth to limit oral candidiasis.
How do you manage post-thymectomy metastases localized to one area (pleural implants)?
Resect. 5 yr survival of 43%.
If can’t tolerate reop thoracic surgery, give stereotactic ablative therapy.
Manage a mycetoma.
Definitive treatment for aspergilloma is surgical resection. Active infection w/ TB must be ruled out first (sputum AFB, culture, TB PCR).
This is a complication of TB. Aspergillomas grow in the cavities TB creates.
RIPE is standard tx for TB.
Old man psx w/ confusion and glucose 53 mg/dL. He’s a smoker. CT shown.
Diagnose and manage.
Solitary fibrous tumor of the pleura w/ Doege-Potter paraneoplastic syndrome.
Resect.
Usually attached by narrow stalk despite large size.
*Arise from mesenchymal cells adjacent to the mesothelium-lined pleura.
*Can cause paraneoplastic syndrome w/ release of insulin-like GF2 -> hypoglycemia and neuro sx (Doege-Potter).
Empyema pt has CT scan shown after removal of a pigtail catheter that only drained 30cc after 7 days. Plan?
High degree of pleural thickening, loculation, and long length of symptoms.
Chest tube won’t work.
Intrapleural fibrinolytics won’t work for complicated effusions/empyemas. Can be used to temporize.
VATS decort is first-line, and there is benefit over open thoracotomy - better pain control, less blood loss, less resp compromise, shorter hospitalization, fewer postop complications, less 30-day mortality.
Pt w/ mediastinal non-seminomatous GCT has marked response to therapy and undetectable AFP and HCG. CT is below. What next?
Resect the persistent mass - could be nonseminomatous GCT or teratoma w/ potential malignant transformation.
*Elevated tumor markers don’t preclude surgery
*1st line after initial dx: systemic chemo w/ bleomycin, etoposide, cisplatin vs etoposide, ifosfamide, and cisplatin. Most will have a residual mass after tx.
*No need for repeat bx. Radiation and salvage have limited roles.
Young male presents w/ CT shown below. What should be done as workup?
AFP and HCG ordered. If positive, no biopsy needed - NSGCT.
If negative, do mediastinTOMY vs Chamberlain.
*MediastinoSCOPY is not helpful as you are in the pretracheal plane in the middle mediastinum.
Treat SCJ infection.
MRI below.
Risk factors: DM, trauma, IVDU.
Surgical resection of necrotic/infected tissue AND the underlying joint (part of manubrium and clavicle) and IV abx.
Keep wound open or w/ NPWT.
Pec muscle can be used when the wound is clean.
Pt presents w/ progressive dyspnea and fatigue with minimal risk factors. CT shown below - mixed attenuation densities throughout the mediastinum w/ associated calcification and extrinsic compression of main pulm vessels.
What is this?
How do you treat?
Fibrosing or sclerosing mediastinitis. Rare.
Progressive inflammatory process.
Assd w/ prior Histoplasma capsulatum (fungal dz in Ohio/Miss river valley) infection.
IgG4 is in biopsies.
Steroids can help, but the tx is often palliative. Stents are the treatment of choice if surgery is needed.
Lung cancer pt is medically inoperable, so SABR (stereotactic ablative radiotherapy) is chosen.
What is the strongest contraindication/predictor of adverse events?
What is the complication that you’re looking for?
Pulmonary fibrosis/interstitial lung disease (CT).
30-50% radiation pneumonitis.
6% w/ fatal complications.
*Can be used for SCC or Adeno. High SUV is a poor prognostic sign but may be independent of SABR.
*Can be used in node neg tumors up to 5cm.
Manage a T1N0M0 SMALL CELL carcinoma.
Surgical resection is treatment of choice.
Define esophageal achalasia according to the Chicago Classification of Esophageal Motility Disorders.
- Impaired relaxation of the LES (HRM bottom lines shows pressure throughout)
- Absence of effective peristalsis (3 types seen on HRM):
- [A] absent peristalsis and negligible pressurization within the esophagus (classic)
- [B] absent peristalsis and pan-esophageal pressurization
- [C] rapidly propagating or spastic simultaneous contractions within distal esophagus for 20% of swallows
An older pt presents w/ recurrent pneumonias and a barium esophagram shown below. What is this? What do you do?
Epiphrenic diverticulum.
Need to know cause of intra-esophageal pressure. Get HRM, EGD, and CT.
*Pulsion diverticulum usually within the last 10 cm of esophagus.
*Pathophys 2/2 increased intra-esophageal pressure at EGJ (eg achalasia, cancer, stenosis).
*Definitive tx = diverticulectomy, myotomy, possible fundoplication/hiatal hernia repair
A pt with confusion is seen in ED. Head CT is normal. Chest CT shows this. Ca is 14. What is next step?
What is the cause of the lab abnormality?
Treat the hypercalcemia.
IV NS at 200-300 ml/hr (adjusted clinically and for UOP 100-150 ml/hr), calcitonin 4 iu/kg IM or SQ, zoledronic acid (bisphosphonate) 4mg.
Then workup the lung mass.
If no bone mets, hypercalcemia may be a paraneoplastic syndrome from a pulmonary SCC.
*Loop diuretics are usually not recommended outside of heart or kidney failure, or fluid overload.
CT finds an enhancing middle mediastinal mass in pt w/ severe HTN on multiple meds and mild tachycardia. What is your suspicion, workup, and management?
Paraganglioma (extra-adrenal pheochromocytoma).
Plasma and urine catecholamines and metanephrines will confirm.
MIBG scan can help diagnose and locate if unclear from scans/labs.
Pre-treat w/ alpha blockade, then beta block before surgical resection.
Need anesthesia that knows endocrine - be ready with nitro while dissecting, then be ready with fluid and pressors when resected.
Old pt presents w/ dyspnea and cough. CT is obtained as shown.
What do you expect PFTs to look like?
Approach to bronch?
Critical airway obstruction.
PFTs: flattened inspiratory and expiratory limbs of flow volume loop.
Bronch: Induce w/ inhalation or total IV w/o paralysis (maintain spontaneous breathing while reducing coughing - sevoflurane is least irritating). Rigid bronch to traverse lesion, then can paralyze.
