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1

Which pulmonary nodes are not assessed by mediastinascopy

Aorto-pulmonary (AP) window nodes (left lung drainage)

 

[UpToDate: SCM can easily access pretracheal (1, 3), paratracheal (2R, 2L, 4R, 4L), anterior subcarinal (7) and occasionally hilar (10) nodes. It is not able to sample subaortic (5) or para-aortic (6), inferior (8, 9), posterior subcarinal (7), or lobar/interlobar (11 to 14) stations. Use of the video mediastinoscope can extend access to the posterior subcarinal nodes (station 7). SCM is best used to sample lymph nodes in these selected stations, particularly when other staging modalities have failed or are not available.]

 

2

What is the difference between the granulomas seen in tuberculosis and sarcoidosis?

  • TB = Caseating granulomas
  • Sarcoidosis = Non-caseating granulomas

 

[Wikipedia: "caseation" (literally: turning to cheese) refers to a form of necrosis that, to the unaided eye (i.e., without a microscope), appears cheese-like ("caseous"), and is typically (but not uniquely) a feature of the granulomas of tuberculosis. The identification of necrosis in granulomas is important because granulomas with necrosis tend to have infectious causes.]

 

[UpToDate: Microscopy of tissue biopsy specimens in the setting of tuberculosis typically demonstrates granulomatous inflammation. Granulomas of tuberculosis characteristically contain epithelioid macrophages, Langhans giant cells, and lymphocytes. The centers of tuberculous granulomas often have characteristic caseation ("cheese-like") necrosis; organisms may or may not be seen with acid-fast staining. The demonstration of characteristic caseating granulomas on a tissue section in the appropriate clinical and epidemiologic circumstances strongly supports a diagnosis of active tuberculosis, but it is not pathognomonic; culture is required to establish a laboratory diagnosis

The sarcoid granuloma is a focal, chronic inflammatory reaction formed by the accumulation of epithelial cells, monocytes, lymphocytes, macrophages, and fibroblasts. Multinucleated giant cells are frequently found among the epithelioid cells within the granuloma follicle and often have cytoplasmic inclusions, such as asteroid bodies, Schaumann bodies, and birefringent crystalline particles (calcium oxalate and other calcium salts). Most sarcoid granulomas gradually resolve and leave few or no residual manifestations of previous inflammation. Small amounts of central fibrinoid necrosis may be seen, but large amounts of necrosis suggest an alternate diagnosis or necrotizing sarcoid granulomatosis.]

3

What are the accessory breathing muscles?

  1. Sternocleidomastoid
  2. Pectoralis major and minor
  3. Serratus posterior
  4. Scalenes (anterior, medius, and posterior)

 

[Also the Inferior fibers of serratus anterior and latissimus dorsi]

4

What is the most common type of lung cancer?

Adenocarcinoma

 

[UpToDate: Adenocarcinoma is the most common type of lung cancer in contemporary series, accounting for approximately one-half of lung cancer cases. The increased incidence of adenocarcinoma is thought to be due to the introduction of low-tar filter cigarettes in the 1960s, although such causality is unproven. The World Health Organization (WHO) classification emphasizes that tissue specimens should be managed not only for pathologic diagnosis, but also to preserve tissue for molecular studies, which may have important treatment implications such as use of targeted therapies for certain subsets of patients. Patients with advanced lung adenocarcinoma and other non-small carcinomas not otherwise specified should have their tumors tested for the presence of a driver mutation (eg, mutated epidermal growth factor receptor, ALK translocation, and increasingly, other mutations).]

5

What percent of lung carcinoid tumors have metastases at the time of diagnosis?

5%

 

[Lung carcinoid tumors are uncommon and tend to grow slower than other types of lung cancers. They are made up of special kinds of cells called neuroendocrine cells.]

 

[UpToDate: Bronchial neuroendocrine (carcinoid) tumors (NETs) are an uncommon group of pulmonary neoplasms that are characterized by neuroendocrine differentiation and relatively indolent clinical behavior.

Like neuroendocrine tumors at other body sites, bronchial NETs are thought to derive from peptide- and amine-producing neuroendocrine cells. NETs can arise at a number of sites throughout the body, including the thymus, lung, gastrointestinal (GI) tract, and ovary. The GI tract is the most frequently involved site, while lung is the second most common.]

6

This is a neuroendocrine lung tumor that usually occurs centrally

Carcinoid tumor

 

[UpToDate: Bronchial neuroendocrine (carcinoid) tumors are a rare group of pulmonary neoplasms that are often characterized by indolent clinical behavior. Like other carcinoid tumors, bronchial carcinoids are thought to derive from peptide- and amine-producing neuroendocrine cells. Bronchial neuroendocrine tumors (NETs) can arise at a number of sites throughout the body, including the thymus, lung, gastrointestinal (GI) tract, and ovary. The GI tract is the most frequently involved site for NETs, while lung is the second most common.

Bronchial NETs are characterized by strikingly heterogeneous pathological features and clinical behavior. At one end of the spectrum are typical carcinoid tumors, which are well differentiated, low-grade slowly-growing neoplasms that seldom metastasize to extrathoracic structures. At the other end of the spectrum are the poorly-differentiated and high-grade neuroendocrine carcinomas, as typified by small-cell lung cancer (SCLC), which behaves aggressively, with rapid tumor growth and early distant dissemination. The biologic behavior of atypical carcinoid tumors, which are of intermediate grade and differentiation, is intermediate between typical carcinoid tumors and SCLC. The terms "typical" and "atypical" carcinoid of the lung correspond roughly to the terms "low-grade" and "intermediate-grade," which are used more commonly in extrathoracic NETs.

Multifocal disease is not uncommon in patients with low-grade bronchial NETs. An extreme example is diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH), a benign condition characterized by diffuse hyperplasia of pulmonary neuroendocrine cells and formation of multiple carcinoid tumorlets.]

 

7

What kind of pleural fluid collection has:

  • >1,000 WBCs (>50,000 is highly specific)
  • pH <7.30
  • Pleural fluid protein to serum ratio >0.5
  • Pleural fluid LDH to serum ration >0.6?

Empyema

 

[UpToDate: Pleural fluid LDH levels above 1000 IU/L (with upper limit of normal for serum of 200 IU/L) are characteristically found in empyema, rheumatoid pleurisy, and pleural paragonimiasis, and are sometimes observed with malignancy.

Increased acid production by pleural fluid cells and bacteria (empyema) cause pleural fluid acidosis (pH <7.30).

The total pleural fluid nucleated cell count is virtually never diagnostic. There are, however, some settings in which the count may be helpful. Counts above 50,000/microL are usually found only in complicated parapneumonic effusions, including empyema.]

8

What tumor invades the apex of the chest wall and results in patients having Horner's syndrome?

Pancoast tumor

 

[Horner syndrome results from invasion of the sympathetic chain and is characterized by ptosis, miosis, and anhidrosis, and/or ulnar nerve symptoms.]

9

How is a diagnosis of a lung hamartoma made?

CT with a repeat CT in 6 months to confirm the diagnosis

 

[UpToDate: Hamartomas cause approximately 10% of benign nodules found in the lung. They typically present in middle age, grow slowly over years, and are histologically heterogeneous. Cartilage (with scattered calcification), fat, muscle, myxomatous tissue, and fibroblastic tissue may all exist. The characteristic appearance of a hamartoma on a chest radiograph is a SPN with "popcorn" calcification, although this pattern is observed in less than 10% of cases. High-resolution CT scanning of the lesion is particularly useful because it may demonstrate focal areas of fat, or calcification alternating with fat, which are virtually diagnostic of a hamartoma. Less common benign neoplasms such as fibromas, leiomyomas, hemangiomas, amyloidoma, and pneumocytoma do not have characteristic features on imaging.]

10

What is the treatment for a mediastinal teratoma?

  • Resection
  • Possible chemotherapy

 

[UpToDate: Treatment of mature mediastinal teratomas is surgical excision, and this is almost always curative. Resection generally is through a median sternotomy or posterolateral thoracotomy, depending upon the location of the tumor, although thoracoscopic resection is occasionally possible.

Subtotal resection with relief of compressive symptoms is performed if benign teratomas cannot be excised completely without endangering surrounding vital structures. If only subtotal resection is possible, it is not clear that additional treatment with chemotherapy or radiotherapy offers any benefit. Mature teratomas are relatively insensitive to both chemotherapy and radiation therapy (RT).]

11

Whiteout on chest xray with a midline shift away from the whiteout is most likely due to what?

Effusion (Place chest tube)

12

What is the most common anterior mediastinal mass in adults?

Thymoma

 

[UpToDate: The thymus arises from the third pharyngeal pouch at the sixth week of gestation. After the first year of life, the thymus decreases in size and mass until middle age. The relationship of the thymus to other mediastinal structures is shown in the figure. Thymic lesions account for approximately one-half of all anterior mediastinal masses, and can include a range of benign and malignant histologies.

Thymomas account for about 20% of mediastinal neoplasms. Most thymoma patients are between 40 and 60 years of age, and there is a similar incidence in men and women. There are no known risk factors, although there is a strong association with myasthenia gravis and other paraneoplastic syndromes.

Thymomas are associated with a variety of paraneoplastic syndromes. The most common is myasthenia gravis, which occurs in approximately 30% of patients with thymoma. Furthermore, some patients who are diagnosed with myasthenia gravis will be found to have a thymic mass on imaging. Evaluating patients with thymoma for the presence of myasthenia prior to pursuing treatment can be very important, because of the potential impact on a patient’s response to general anesthesia.

Patients with a thymic mass who have not been evaluated for myasthenia gravis should be tested for anti-acetylcholine receptor antibodies. Patients who test positive for these antibodies should be evaluated prior to undergoing anesthesia to determine if they have myasthenia gravis.]

13

What are the two preferred chemotherapy agents for stage II or higher non-small cell lung cancer?

Carboplatin and Taxol

 

[UpToDate: Patients with advanced NSCLC should have tumor assessed for the presence of a somatic driver mutation (eg, EGFR, ALK fusion oncogene). The choice of initial therapy (chemotherapy versus molecularly targeted agents) is guided by this information. This information is also useful in guiding subsequent therapy.

For patients whose tumor does not contain a driver mutation, we recommend combination therapy that incorporates a platinum (cisplatin, carboplatin) based doublet (Grade 1A). For patients with nonsquamous NSCLC, we suggest that initial treatment also include bevacizumab (Grade 2B). For patients in whom the increased toxicity or cost of bevacizumab is a significant issue, chemotherapy alone is a reasonable alternative.

  • Combinations using cisplatin have a slightly higher response rate but inconsistent survival benefits compared with carboplatin-based regimens. For the majority of patients who will receive a chemotherapy doublet, we suggest using a carboplatin-based regimen (Grade 2B). However, a cisplatin-based regimen is a reasonable alternative in appropriate patients.
  • We recommend that the duration of treatment with the initial doublet chemotherapy regimen be limited to four to six cycles (Grade 1A).

For patients with an objective response following the initial cycles of platinum based chemotherapy, we suggest that patients continue on maintenance therapy (Grade 2B). Options included single agent chemotherapy, bevacizumab, or targeted therapy with an epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor. An alternative approach might be close observation with initiation of second-line therapy at the earliest sign of progression for selected patients who are well informed about the risks and benefits of such approach.

For patients whose initial regimen included bevacizumab in addition to a chemotherapy doublet, the bevacizumab is generally continued in the absence of toxicity until there is evidence of progressive disease, without the addition of cytotoxic chemotherapy.

  • For patients whose initial regimen did not include bevacizumab, and whose tumors do not contain a driver mutation, we suggest maintenance chemotherapy with single agent chemotherapy rather than an EGFR tyrosine kinase inhibitor (Grade 2C). For patients with non-squamous NSCLC who are treated with maintenance chemotherapy, we suggest pemetrexed (Grade 2C). Docetaxel and gemcitabine are appropriate alternatives, and the EGFR tyrosine kinase inhibitor erlotinib may also be an alternative in selected patients.
  • For patients with squamous cell NSCLC who are treated with maintenance chemotherapy, we suggest either docetaxel or gemcitabine, rather than pemetrexed (Grade 2C).]

14

Arterio-venous malformations (AVMs) are connections between the pulmonary arteries and pulmonary veins and can be seen in association with which condition?

Osler-Weber-Rendu disease

 

[UpToDate: Hereditary hemorrhagic telangiectasia (HHT, Osler-Weber-Rendu syndrome), an autosomal dominant vascular disorder, has a variety of clinical manifestations. Among the most common are epistaxis, gastrointestinal bleeding, and iron deficiency anemia, along with characteristic mucocutaneous telangiectasia. In addition, arteriovenous malformations (AVMs) commonly occur in the pulmonary, hepatic, and cerebral circulations, demanding knowledge of the risks and benefits of screening and treatment of patients with these complications.]

15

When is surgery indicated for treatment of spontaneous pneumothorax?

  • Recurrence
  • If air leak lasts greater than 7 days
  • Non-reexpansion of the lung
  • High-risk profession (pilot, diver, mountain climber)
  • Patient lives in a remote area

 

[UpToDate: We suggest a preventive intervention for patients experiencing their first PSP if they are undergoing VATS or tube thoracostomy as part of their initial management, or have a vocation in which recurrence of the pneumothorax is dangerous to the patient or others (eg, airplane pilot or deep sea diver). Otherwise, we prefer to forego preventive interventions until a patient experiences recurrent PSP.

Once it has been determined that a preventive procedure is required, we recommend VATS with pleurodesis, rather than tube thoracostomy with chemical pleurodesis (Grade 1B). This procedure reduces the recurrence rate to less than 5%.

For patients who are not operative candidates or who refuse VATS, we recommend tube thoracostomy with chemical pleurodesis, rather than tube thoracostomy drainage alone, once it has been determined that a preventive intervention is indicated (Grade 1A). This procedure reduces the recurrence rate to less than 25%.]

16

Which type(s) of bronchial adenoma is slow growing, can have 10-year survival with incomplete resection, and is treated with resection (XRT can provide good palliation if unresectable)?

Adenoid cystic adenoma

 

[UpToDate: Adenoid cystic carcinoma (ACC) was previously considered to be the most common form of malignant minor salivary gland tumor. Many of these cases subsequently have been reclassified as polymorphous low-grade adenocarcinoma (PLGA). ACC arises in both major and minor salivary glands. The tumor is locally aggressive, with recurrences often arising after many years.

Three basic growth patterns are commonly seen: tubular, cribriform, and solid. These patterns are often mixed. The biologic aggressiveness of ACC correlates with the amount of the solid component within the tumor. The solid areas generally contain cells with larger, more pleomorphic nuclei, increased mitotic activity, and often, foci of necrosis. A grading scheme attempts to integrate the varied histologic components: grade 1 tumors are composed entirely of tubules or cribriform areas, while the presence of a solid component defines higher-grade tumors. A 30% solid component serves as the breakpoint between grade 2 and 3 tumors.

In a study of 129 cases, clinical stage, solid growth pattern, and p53 expression were found by multivariate analysis to be the most important prognostic features in head and neck ACC. Increased proliferative activity has also been reported as an adverse prognostic factor. ACC frequently demonstrates bone and perineural invasion. As with other tumors that commonly invade perineural spaces, neural cell adhesion molecule (NCAM), nerve growth factor (NGF) and its receptor, and TrkA are commonly expressed in adenoid cystic carcinoma, and may provide the molecular basis underlying its behavior.

Surgical resection is the treatment of choice for malignant tracheal tumors whenever possible, given retrospective data suggesting improved disease outcomes and acceptable postoperative morbidity. Because of the lack of suitable replacement material, the suggested maximum resected length of trachea is 5 cm. Decisions on resectability are based on imaging studies and the expertise of the surgical team. Studies have suggested that between 50% and 70% of patients have resectable disease at diagnosis.

The superiority of surgery, with or without radiation, to radiation alone was suggested in a Netherlands database series in which 34 patients underwent surgical resection (24 of whom also received radiation) and 156 patients were treated with RT alone. The five-year survival among patients who underwent surgical resection was 53% versus 11% among those receiving RT alone. A retrospective analysis of adenoid cystic carcinoma (ACC) of the head and neck similarly noted that radiotherapy combined with surgery resulted in better local control and survival than treatment with radiation alone. A limitation in the interpretation of these retrospective studies is that the group of patients treated nonsurgically included those with unresectable disease and therefore a worse prognosis, which biases the results toward surgical treatment.]

 

 

17

Which test is needed for centrally located lung tumors?

Bronchoscopy

 

[to check for airway invasion]

 

[UpToDate: Bronchoscopy with endobronchial ultrasound (EBUS)-directed biopsy has emerged as the most common modality used for diagnosis and staging of suspected NSCLC due to its high diagnostic accuracy for accessing central primary tumors and most mediastinal lymph nodes. Furthermore, EBUS-directed biopsy in patients with mediastinal adenopathy on computed tomography (CT) scan may be performed quickly and reduce the time to establishing of treatment decisions. If initial tissue sampling provides inconclusive results or is insufficient for essential immunohistochemical or molecular characterization, a second biopsy procedure is required. The selection of a second biopsy procedure should favor modalities with a higher diagnostic yield (eg, surgical sampling). The selection of modality and procedures used for tissue biopsy of NSCLC are discussed separately. Although genetic and molecular microarray techniques of both tissue and peripheral blood have been studied as potential diagnostic tools designed to enhance the sensitivity of bronchoscopy for the diagnosis of lung cancer, further study is required before they can be recommended for routine use.]

18

Injury at what level of the thorax results in a right-sided chylothorax?

Below T5-T6

 

[UpToDate: Generally, the thoracic duct ascends from the cisterna chyli (sac at the lower end of the thoracic duct into which the intestinal and two lumbar lymphatic trunks drain), which lies just anterior to the first or second lumbar vertebra, and passes through the aortic hiatus of the diaphragm to enter the posterior mediastinum, although wide anatomic variation exists. The thoracic duct continues cephalad in a rightward position between the aorta and azygos vein until it reaches the approximate level of the fifth thoracic vertebra, where it crosses over the vertebral column behind the esophagus and continues in the left posterior mediastinum. The thoracic duct in this region is 2 to 3 mm in diameter and passes behind the aortic arch adjacent to the left side of the esophagus and behind the left subclavian artery. It then arches over the subclavian artery in the anterolateral superior mediastinum, descending to empty into the venous circulation in the region of the left jugular and subclavian veins.

In some patients, two thoracic ducts exist within the mediastinum, and occasionally a single thoracic duct may empty into right-sided venous structures.

The anatomy of the thoracic duct determines the location of the effusion seen with duct injury or obstruction. Because the thoracic duct crosses the mediastinum at the fifth thoracic vertebral body, lymphatic injury or obstruction below this level generally results in a right–sided pleural effusion. In contrast, disease above this level usually leads to a left-sided effusion.]

19

Lung adenocarcinoma usually occurs where?

Peripherally

 

[UpToDate: Adenocarcinoma is the most common type of lung cancer in contemporary series, accounting for approximately one-half of lung cancer cases. The increased incidence of adenocarcinoma is thought to be due to the introduction of low-tar filter cigarettes in the 1960s, although such causality is unproven. The World Health Organization (WHO) classification emphasizes that tissue specimens should be managed not only for pathologic diagnosis, but also to preserve tissue for molecular studies, which may have important treatment implications such as use of targeted therapies for certain subsets of patients. Patients with advanced lung adenocarcinoma and other non-small carcinomas not otherwise specified should have their tumors tested for the presence of a driver mutation (eg, mutated epidermal growth factor receptor, ALK translocation, and increasingly, other mutations).]

20

Do lung hamartomas require resection?

No

 

[UpToDate: Hamartomas cause approximately 10% of benign nodules found in the lung. They typically present in middle age, grow slowly over years, and are histologically heterogeneous. Cartilage (with scattered calcification), fat, muscle, myxomatous tissue, and fibroblastic tissue may all exist. The characteristic appearance of a hamartoma on a chest radiograph is a SPN with "popcorn" calcification, although this pattern is observed in less than 10% of cases. High-resolution CT scanning of the lesion is particularly useful because it may demonstrate focal areas of fat, or calcification alternating with fat, which are virtually diagnostic of a hamartoma. Less common benign neoplasms such as fibromas, leiomyomas, hemangiomas, amyloidoma, and pneumocytoma do not have characteristic features on imaging.]

21

Recurrent pleural effusions can be treated with what?

Mechanical pleurodesis (Talc pleurodesis for malignant pleural effusions)

 

[UpToDate: Patients who have symptoms due to recurrent or persistent pleural effusion despite therapy directed at the underlying cause are candidates for additional therapies. Asymptomatic patients do not require additional interventions.

Prior to proceeding with more invasive therapy, the underlying cause of the NMPE should be reconfirmed (with thoracoscopic pleural biopsy) to ensure that primary treatment has been appropriate; infectious causes, hepatic hydrothorax, and trapped lung should also be excluded.

We suggest talc pleurodesis or implanted pleural catheters and intermittent drainage for patients who have symptoms due to refractory nonmalignant pleural effusions (Grade 2C).

We suggest talc pleurodesis for patients who have symptoms due to refractory nonmalignant pleural effusions and in whom repeat therapeutic thoracenteses have become burdensome (Grade 2C). The greatest pleurodesis experience is with talc; however, this choice is controversial due to concerns about immediate and long-term side effects of talc. Pleurodesis, however, should only be performed in this setting after a multi-disciplinary discussion of the risks, benefits, and alternatives.]

22

What is the treatment for lung carcinoid tumors?

Resection

 

[Treat like cancer. Outcome closely linked to histology]

 

[UpToDate: For patients with either a typical or atypical resectable bronchial NET whose medical condition and pulmonary reserve will tolerate it, we recommend surgical resection and mediastinal lymph node sampling or dissection (Grade 1B). The presence of mediastinal lymph node metastases does not preclude cure.

For most patients, endobronchial resection is a suboptimal method of definitive treatment, and we suggest not pursuing this approach over definitive surgical resection (Grade 2C). Endobronchial laser resection is best reserved for palliative treatment of patients with central airway occlusion who are poor surgical candidates (eg, elderly, debilitated).

Although some disagree, we suggest not administering postoperative adjuvant therapy for most resected bronchial NETs even in the setting of positive lymph nodes (Grade 2C). Adjuvant platinum-based chemotherapy with or without radiation therapy (RT) is a reasonable option for patients with histologically aggressive-appearing stage III atypical bronchial NETs (ie, relatively high mitotic rate, extensive necrosis, etc.), although there is only limited evidence to support this.

RT is a reasonable option for atypical bronchial NETs if gross residual disease remains after surgery, although whether this improves outcomes is unproven.]

23

What is the most common early complication after tracheal surgery?

Laryngeal edema

 

[UpToDate: Evidence suggests that laryngeal inflammation and edema are detected after extubation in more than half of patients, although not every case is associated with significant symptomatology.

Following extubation, most patients complain of mild to moderate symptoms including sore throat, dysphonia, and dysphagia thought to be due to laryngeal inflammation from the ETT.

More severe symptoms include stridor (sometimes requiring reintubation), which may be due to coexistent impairment in vocal cord mobility. As an example, one prospective study, clinically significant laryngeal edema occurred in approximately 5-13% of patients and required reintubation in approximately 1%.

Laryngeal edema may be suspected prior to extubation or following extubation failure and may be supported by the presence of a negative cuff leak test.]

24

When is surgery indicated in a clotted hemothorax?

  • Involvement of greater than 25% of lung
  • Air-fluid levels are present
  • Signs of infection

 

[surgery in 1st week to avoid peel]

 

[UpToDate: Hemothorax is treated with tube thoracostomy using a large (minimum 36 French) chest tube. Immediate bloody drainage of ≥20 mL/kg (approximately 1500 mL) is generally considered an indication for surgical thoracotomy. Shock and persistent, substantial bleeding (generally >3 mL/kg/hour) are additional indications. Vital signs, fluid resuscitation requirements, and concomitant injuries are considered when determining the need for thoracotomy.

In general, a pneumohemothorax is treated with drainage by tube thoracostomy. Small, clinically insignificant collections may be treated with needle aspiration or drainage, at the discretion of the trauma surgeon.]

25

Which pulmonary nodes are assessed by mediastinoscopy?

  • Ipsilateral (N2)
  • Contralateral (N3)
  • Mediastinal nodes

 

[if mediastinal nodes are positive, the tumor is unresectable.]

 

[UpToDate: SCM can easily access pretracheal (1, 3), paratracheal (2R, 2L, 4R, 4L), anterior subcarinal (7) and occasionally hilar (10) nodes. It is not able to sample subaortic (5) or para-aortic (6), inferior (8, 9), posterior subcarinal (7), or lobar/interlobar (11 to 14) stations. Use of the video mediastinoscope can extend access to the posterior subcarinal nodes (station 7). SCM is best used to sample lymph nodes in these selected stations, particularly when other staging modalities have failed or are not available.]

 

 

26

What are the different TNM stages of lung cancer?

  • Stage I: T1-2, N0, M0
  • Stage IIa: T1, N1, M0
  • Stage IIb: T2, N1, M0 or T3, N0, M0
  • Stage IIIa: T1-3, N2, M0 or T3, N1, M0
  • Stage IIIb: any T4 or N3 Stage IV: M1

27

Which stages of lung cancer are resectable?

Stage I, stage II, and possibly stage IIIa (T3,N1,M0)

 

[UpToDate: A patient with lung cancer may be “resectable” by virtue of having a surgically removable NSCLC, but may not be "operable" due to poor pulmonary function or comorbidities. Advances in surgical technique, the role of limited resection, and postoperative care may provide the opportunity for surgical resection in patients who previously might not have been considered candidates for aggressive treatment.

Patients with stage I or II NSCLC should be treated with complete surgical resection whenever possible. Postoperative adjuvant chemotherapy improves survival in patients with pathologic stage II disease and may have a role for patients with stage IB disease.

Patients with stage I or II disease who are not candidates for surgical resection or who refuse surgery may be candidates for nonsurgical local therapy. Radiation may be applied by stereotactic techniques or conventional methods. Radiofrequency ablation (RFA) and cryoablation are alternatives to radiation. Photodynamic therapy may also be useful as a primary treatment modality in carefully selected patients with superficial airway lesions.

For patients with pathologically proven stage III disease prior to definitive therapy, a combined modality approach using concurrent chemoradiotherapy is generally preferred. The role of surgery following chemoradiotherapy is an area of active investigation. Surgery may also retain a role for carefully selected patients with T3 or T4 lesions and negative mediastinal lymph nodes.]

28

How can one go about assessing enlarged Aorto-pulmonary (AP) window nodes?

Chamberlain procedure (anterior thoracotomy or parasternal mediastinotomy)

 

[Go through the left 2nd rib cartilage.]

 

[UpToDate: A left anterior mediastinotomy (Chamberlain procedure) is a surgical procedure that requires general anesthesia. The incision is made over the left second or third intercostal space to access lymph nodes in station 5. Due to lymphatic drainage patterns, cancers of the left upper lobe preferentially drain to this regions. However, this region are traditionally difficult to access and cannot be reached by minimally invasive techniques or by standard cervical mediastinoscopy.

A left anterior mediastinotomy is the traditional surgical procedure used to stage left-sided cancer when suspected nodes are located in station 5. It has the added advantage of accessing left upper lobe tumors for concurrent resection, if there is no evidence of nodal or distant disease.

Because it is often the only option when suspicious lymph nodes are identified in this region, there is a paucity of data regarding its diagnostic accuracy. Nonetheless, one meta-analysis of four small studies reported a sensitivity and negative predictive value of 71% and 91% respectively. No studies have directly compared its performance to ECM, VATS), or to endoscopic ultrasound-guided fine needle aspiration which can occasionally reach this region.]

 

 

29

What kind of pneumothorax occurs in temporal relation to menstruation and is caused by endometrial implants in the visceral lung pleura?

Catamenial pneumothorax

 

[UpToDate: Thoracic endometriosis should always be suspected in young women with catamenial or non-catamenial pneumothorax or hemothorax, who have a history of prior uterine surgical procedures or pelvic endometriosis (present in 65% to 84%). In such patients, the diagnostic and therapeutic approach is often performed simultaneously (eg, thorascopic biopsy, blebectomy, and pleurodesis).]

30

What is the treatment for the second phase of empyema (fibro-proliferative phase - 2nd week)?

  • Chest tube
  • Antibiotics
  • Possible VATS deloculation

 

[UpToDate: In patients with a parapneumonic effusion or an empyema, an empiric, broad spectrum antibiotic that includes coverage for anaerobic organisms should be initiated promptly, because empyemas often harbor multiple species of bacteria, particularly anaerobes.

In patients with an uncomplicated parapneumonic effusion, one that is small to moderate in size, free flowing, and has a pH of 7.20 or greater, we recommend observation rather than placement of a chest tube for drainage (Grade 1B).

In patients with a large, loculated, or complicated parapneumonic effusion, we recommend prompt drainage of any remaining pleural fluid rather than observation (Grade 1B). For further drainage of the pleural space, we suggest tube thoracostomy rather than a more invasive procedure (eg, thoracoscopy, decortication) (Grade 2C). Computed tomography (CT) or ultrasound-guided placement of multiple tubes may be needed when pleural loculations prevent adequate drainage by a single tube. Video-assisted thoracoscopic surgery (VATS) with debridement may be preferred in patients with multiple loculations and a thick pleural peel.

When tube thoracostomy is used for initial drainage of an empyema, a chest CT scan should be obtained within 24 hours after chest tube placement to document appropriate placement of the tube and assess drainage. For patients with ongoing signs of infection (fever, leukocytosis, anorexia) or those who do not have good drainage of empyema fluid from a well-placed chest tube, we suggest intrapleural administration of a combination of tissue plasminogen activator (TPA) 10 mg and deoxyribonuclease (DNase) 5 mg, twice daily for three days rather than no intrapleural therapy or either agent alone (Grade 2B).

Continued signs of infection together with failure of adequate pleural drainage should prompt thoracoscopy or thoracotomy to lyse adhesions, fully drain the pleural space, and optimize chest tube placement. The choice between thoracoscopic debridement and decortication depends on several factors; those favoring decortication include more adhesions, greater visceral pleural thickness, and larger empyema cavity size.]