Chapter 25: Thoracic Flashcards by Margo Carlin

Runs along the right side and dumps into the SVC

Azygous vein

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Runs along the right side, crosses midline at T4-T5, and dumps into left subclavian vein at junction with internal jugular vein

Thoracic duct

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Nerve runs anterior to hilum

Phrenic nerve

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Nerve runs posterior to hilum

Vagus nerve

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Right lung volume

55% (3 lobes: RUL, RML, RLL)

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Left lung volume

45% (2 lobes: LUL and LLL and lingula)

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Muscles involved in quite inspiration

Diaphragm 80%

Intercostals 20%

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Greatest change in dimension when breathing

Anterior and posterior

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Accessory muscles of inspiration

SCM, levators, serratus posterior, scalenes

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Function: type 1 pneumocytes

Gas exchange

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Function: type 2 pneumocytes

Surfactant production

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Function: pores of Kahn

direct air exchange between alveoli

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Predicted postop requirements:
FEV1
DLCO

FEV1 > 0.8 (or >40% of the predicted post value)

- DLCO > 10mL/min/mmHg CO (or > 40% of the predicted post value)

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What if predicted postop FEV1 is not > 0.8 but is close?

If it is close -> get qualitative V/Q scan to see contribution of that portion of the lung to overall FEV1 -> if low, may still be able to resect

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Measures carbon monoxide diffusion and represents oxygen exchange capacity
This value depends on pulmonary capillary surface area, hemoglobin content, and alveolar architecture.

DLCO

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pre op pCO2, pO2, VO2 max that say no resection

pCO2 > 50 at rest

pO2

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MC after segmentectomy / wedge

Persistent air leak

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MC after lobectomy

Atelectasis

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MC after pneumonectomy

Arrhythmias

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Symptoms: can be asymptomatic with finding on routine CXR; cough, hemoptysis, atelectasis, PNA, pain, weight loss

Lung cancer

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MCC cancer-related death in the United States

Lung cancer

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Strongest influence on survival in lung cancer

Nodal involvement

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Lung cancer: single most common site of metastasis

Brain

- Can also go to supraclavicular nodes, other lung, bone, liver, and adrenals

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Usually appears as disseminated metastasis

Recurrence

- 80% of recurrences are within the 1st three years

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Overall 5-year survival rate lung cancer

10% 5-year survival rate | - 30% with resection for cure

What lung cancer is resectable?

Stage 1 and 2 disease resectable; T3,N1,M0 (stage3a) possibly resectable

MC procedure for lung cancer

Lobectomy or pneumonectomy; sample suspicious nodes

80% of lung cancer

Non-small cell carcinoma

Lung cancer: usually more central

Squamous cell carcinoma

Lung cancer: usually more peripheral

Adenocarcinoma

MC lung cancer

Adenocarcinoma (not squamous)

TNM staging system for lung cancer

T: 1 (3cm but >2cm away from carina) 3(invasion of chest wall, pericardium, diaphragm or

- 20% of lung cancer; neuroendocrine in origin | - usually unresectable at time of diagnosis (

Small cell carcinoma

Overall 5 year survival rate of small cell carcinoma

Small cell carcinoma: 5 year survival rate T1, N0, M0

50%

Most treatment for small cell carcinoma

Just get chemo-XRT

Paraneoplastic syndrome: squamous cell CA

PTH-related peptide

Paraneoplastic syndrome: small cell CA

ACTH and ADH

Most common paraneoplastic syndrome

Small cell ACTH

- Most malignant lung tumor | - Aggressive local invasion, nodal invasion, and distant metastases common at the time of diagnosis.

Mesothelioma

What is mesothelioma related to?

Asbestos exposure

Non-small cell CA chemotherapy (stage 2 or higher)

Carboplatin, Taxol

Small cell lung CA chemotherapy

Cisplatin, etoposide

Can XRT be used for lung CA?

Yes

Single best test for clinical assessment of T and N status for lung cancer

Chest and abdominal CT scan

Best test for M status in lung cancer?

PET scan

Use for centrally located tumors and patients with suspicious adenopathy (> 0.8 cm or subcarinal > 1.0 cm) on chest CT

Mediastinoscopy

What does mediastinoscopy assess?

- Does not assess aorto-pulmonary (AP) window nodes (left lung drainage) - Assesses ipsilateral (N2) and contralateral (N3) mediastinal nodes

Treatment if mediastinal nodes are positive

Tumor is unresectable

Looking into middle mediastinum with mediastinoscopy: - Left-side structures - Right side structures - Anterior

Left-side: RLN, esophagus, aorta, main pulmonary artery (PA) Right-side: azygous and SVC Anterior: innominate vein, innominate artery, right PA

assesses enlarged AP window nodes; go thru left 2nd rib cage

Chamberlain procedure (anterior thoracotomy or parasternal mediastinotomy)

Needed for centrally located tumors to check for airway invasion

Bronchoscopy

For lung CA, patients need to be...

1) operable (FEV1/DLCO) | 2) resectable (can't have T4, N2, N3, or M disease)

Tumor invades apex of chest wall and patients have Horner's syndrome (invasion of sympathetic chain - ptosis miosis, anhidrosis) or ulnar nerve symptoms

Pancoast tumor

- Overall, 10% are malignant. - Age 50 -> >50% malignant - No growth in 2 years, and smooth contour suggests benign disease

coin lesion

Management of suspicious coin lesion

if suspicious, will need either guided biopsy or wedge resection

Increased lung CA risk 90x

Asbestos exposure

Can look like pneumonia; grows along alveolar walls; multifocal

Bronchoalveolar cancer

Management: metastases to the lung -> if isolated and not associated with any other systemic disease

May be resected for colon, renal cell CA, sarcoma, melanoma, ovarian, and endometrial CA

Neuroendocrine tumor, usually central | - 5% have metastases at time of diagnosis; 50% have symptoms (cough, hemoptysis)

Carcinoids

5-year Survival rate: typical carcinoid

90%

5-year Survival rate: atypical carcinoid

60%

Tx: carcinoid

Resection, treat like cancer, outcome closely linked to histology

Malignant bronchial adenomas

Mucoepidermoid adenoma, mucous gland adenoma, and adenoid cystic adenoma

Type - bronchial adenomas - Slow growth, no metastases - Tx: resection

Mucoepidermoid adenoma, and mucous gland adenoma

- From submucosal glands; spreads along perineural lymphatics, well beyond endoluminal component; very XRT sensitive - Slow growing; can get 10-year survival with incomplete resection - Tx: resection; if unresectable, XRT can provide good palliation

Adenoid cystic adenoma

- Most common benign adult lung tumor - Have calcifications and can appear as a popcorn lesion on chest CT - diagnosis can be made with CT

Hamartomas

Tx: hamartomas

- Do not require resection. | - Repeat chest CT in 6 months to confirm diagnosis

Most are asymptomatic, can present with chest pain, cough, dyspnea

Mediastinal tumors in adults

Most common mediastinal tumor in adults and children, usually in posterior mediastinum

Neurogenic tumors

% of symptomatic mediastinal masses that are malignant

50%

% of asymptomatic mediastinal masses are benign

90%

Most common site for mediastinal tumors

Anterior (thymus)

Tumors in the anterior mediastinum

- Thymoma - Thyroid CA and goiters - T-cell lymphoma - Teratoma (and other germ cell tumors) - Parathyroid adenomas

Structures in the middle mediastinum

Heart Trachea Ascending aorta

Pathology in the middle mediastinum

Bronchogenic cysts Pericardial cysts Enteric cysts Lymphoma

Structures in the posterior mediastinum

Esophagus | Descending aorta

Pathology in the posterior mediastinum

Enteric cysts Neurogenic tumors Lymphoma

Structures in mediastinum

- Anterior: thymus - Middle: heart, trachea, ascending aorta - Posterior: esophagus, descending aorta

Treatment: thymoma

All thymomas require resection

Thymus too big or associated with refractory myasthenia gravis

Resection

__% of thymomas are malignant

50%

__% of patients with thymomas have symptoms

50%

__% of patients with thymomas have myasthenia gravis

50%

__% of patients myasthenia gravis have thymomas

10%

Fatigue, weakness, diplopia, ptosis, antibodies to acetylcholine receptors

Myasthenia gravis

Tx: myasthenia gravis

Anticholinesterase inhibitors (neostigmine); steroids, plasmapheresis

Myasthenia gravis: __% of patients get improvement with thymectomy, including patients who do not have thymomas

80%

Need to biopsy (often done with mediastinoscopy)

Germ cell tumors

Most common germ cell tumor in mediastinum - Can be benign or malignant - Tx: resection, possible chemotherapy

Teratoma

Most common malignant germ cell tumor in mediastinum

Seminoma

- 10% are beta-hcg positive, should not have AFP - Tx: XRT (extremely sensitive); chemotherapy reserved only for metastases or bulky nodal disease; surgery for residual disease after that

Seminoma

90% have elevated beta-hcg and AFP | -TX: chemo (cisplatin, bleomycin, VP-16); surgery for residual disease

Non-seminoma

Cysts: usually posterior to carina. | - Tx: resection

Bronchiogenic cyst

Cysts: usually at right costophrenic angle. | - Tx: can leave alone (benign)

Pericardial cyst

Have pain, neurologic deficit. - Tx: resection - 10% have intra-spinal involvement that requires simultaneous spinal surgery

Neurogenic tumors

Most common neurogenic tumor

Neurolemmoma (schwannoma)

Neurogenic tumors: can produce catecholamines, associated with von Recklinghausen's disease

Paraganglioma

What is associated with neurogenic tumors?

Neuroblastomas and neurofibromas

Trachea: benign tumors Adult? Children?

Adults - papilloma | Children - hemangioma

Trachea malignancy

Squamous cell carcionma

Most common late complication after tracheal surgery

Granulation tissue formation

Most common early complication after tracheal surgery

Laryngeal edema

Tx: laryngeal edema after tracheal surgery

Reintubation, racemic epinephrine, steroids

Where does post-intubation stenosis occur: - with tracheostomy - with ET tube

- Tracheostomy: at stoma site | - ETT: cuff site

Tx: post-intubation stenosis

- Serial dilatation, bronchoscopic resection, or laser ablation if minor - Tracheal resection with end-to-end anastomosis if severe or if it keeps recurring

Occurs after tracheostomy, can have rapid exsanguination

Tracheo-innominate artery fistula

Tx: tracheo-innominate artery fistula

Place finger in tracheostomy hole and hold pressure -> median sternotomy with ligation and resection of innominate artery

How do you avoid trachea-innominate artery fistula?

This complication is avoided by keeping tracheostomy above the 3rd tracheal ring.

- Usually occurs with prolonged intubation - Place large-volume cuff ETT below - May need decompressing gastrostomy - Attempt repair after the patient is weaned from ventilator

Tracheo-esophageal fisutla

Tx: tracheal resection, reanastomosis, close hole in esophagus, sternohyoid flap between esophagus and trachea

Tracheo-esophageal fistula

Necrotic area; most commonly associated with aspiration | - MC'ly in the superior segment of the RLL

Lung abscess

Tx: lung abscess

``` Antibiotics alonge (95% successful); CT-guided drainage if that fails. - Surgery if above fails or cannot rule out cancer (>6cm, failure to resolve after 6 weeks) ```

What can help you differentiate empyema from lung abscess?

Chest CT

What are the causes of empyema?

Usually secondary to pneumonia and subsequent parapneumonic effusion (Staph, strep) - Can also be due to esophageal, pulmonary or mediastinal surgery

Symptoms: pleuritic chest pain, fever, cough, SOB | - Pleural fluid often has WBCs > 500 cells/cc, bacteria, and a positive gram stain

Empyema

What are the three phases of empyema?

1st week: exudative phase 2nd week: fibroproliferative phase 3rd week: organized week

Tx: exudative phase of empyema

1st week: chest tube, antiobiotics

Tx: fibro-proliferative phase of empyema

2nd week: chest tube, antibiotics; possible VATS (video-assisted thoracoscopic surgery) deloculation

Tx: organized phase

3rd week: likely need decortication; fibrous peel occurs around lung. - Some are using intra-pleural tPA to try and dissolve the peel - May need Eloesser flap (open thoracic window - direct opening to external environment) in frail / elderly

Open thoracic window - direct opening to external environment

Eloesser flap

Milky white fluid; has increased lymphocytes and TAGs (>110 mL/uL) - fluid is resistant to infection

Chylothorax

What stain would you used for chylothorax?

Sudan red stains fat

Chylothorax: % secondary to trauma or iatrogenic injury

50%

Chylothorax: % secondary to tumor (lymphoma most common, due to tumor burden in the lymphatics)

50%

Results in left-sided chylothorax

Injury above T5-T6

Results in right-sided chylothorax

Injury below T5-T6

Tx: chylothorax

2-3 weeks of conservative therapy (chest tube, octreotide, low-fat diet or TPN)

If conservative therapy fails and chylothorax secondary to trauma or iatrogenic injury?

Need ligation of thoracic duct on right side low in mediastinum (80% successful)

Treatment for malignant causes of chylothorax

Need talc pleurodesis and possible chemo and/or XRT (less successful than above)

Define massive hemoptysis

> 600 cc/hr

What usually causes bleeding from massive hemoptysis?

Bleeding usually from high-pressure bronchial arteries

What is massive hemoptysis most commonly secondary to?

Infection

What causes death in massive hemoptysis?

Asphyxiation

Tx: massive hemoptysis

Place bleeding side down; mainstem intubation to side opposite of bleeding to prevent drowning in blood; rigid bronchoscopy to identify site and possibly control bleeding; may need lobectomy or pneumonectomy to control; bronchial artery embolization if not suitable for surgery

Tall, healthy, thin, young males; more common on the right

Spontaneous pneumothorax

Recurrence risk after 1st pneumothorax, 2nd pneumothorax, 3rd pneumothorax

1st: 20% 2nd: 60% 3rd: 80%

What causes spontaneous pneumothorax?

Results from rupture of a bleb usually in the apex of the upper lobe of the lung

Tx: spontaneous pneumothorax

chest tube

Indications for surgery in spontaneous pneumothorax

Recurrence, air leak > 7 days, non-reexpansion, high-risk profession (airline pilot, diver, mountain climber), or patients who live in remote areas

Surgery options for spontaneous pneumothorax

Thorascoscopy, apical blebectomy, and mechanical pleurodesis

Most likely to cause arrest after blunt trauma; impaired venous return

Tension pneumothorax

Pneumothorax: occurs in temporal relation to menstruation

Catamenial pneumothorax

What causes catamenial pneumothorax?

Caused by endometrial implants in the visceral lung pleura

Residual hemothorax despite 2 good chest tubes

OR for thoracoscopic drainage

Indications for surgery for clotted hemothorax

Surgical drainage if > 25% of lung, air-fluid levels, or signs of infection (fever, leukocytosis); surgery in 1st week to avoid peel

Causes of broncholiths

Usually secondary to infection

Cause of mediastinitis

Usually occurs after cardiac surgery

Whiteout on CXR: midline shift toward whiteout

Most likely collapse: need bronchoscopy to remove plug

Whiteout on CXR: no shift

CT scan to figure it out

Whiteout on CXR: midline shift away from whiteout

Most likely effusion -> place chest tube

What causes bronchiectasis?

Acquired from infection, tumor, cystic fibrosis | - Diffuse nature prevents surgery in most patients

Lung apices, get calcifications, caseating granulomas | - Tx: INH, rifampin, pyrazinamide

Tuberculosis

What makes up a Ghon complex?

Parenchymal lesion + enlarged hilar nodes

Has non-caveating granulomas

Sarcoidosis

``` Transudate: WBC pH Pleural fluid protein to serum Pleural fluid LDH to serum ```

WBC:

``` Exudate: WBC pH Pleural fluid protein to serum Pleural fluid LDH to serum ```

WBC: > 1,000 pH: 7.45 Protein: > 0.5 LDH: > 0.6

``` Empyema: WBC pH Pleural fluid protein to serum Pleural fluid LDH to serum ```

WBC: > 1,000, > 50,000 most specific pH: 0.5 LDH: > 0.6

Can be treated with mechanical pleurodesis

Recurrent pleural effusions

What is talc pleurodesis used for?

Malignant pleural effusions

What are airway fires associated with?

Usually associated with the laser

Tx: airway fires

Stop gas flow, remove ETT, re-intubate for 24 hours, bronchoscopy

Connections between the pulmonary arteries and pulmonary veins; usually in lower lobes; can occur with Osler-Weber-Rendu disease

AVMs

Symptoms: hemoptysis, SOB, neurologic events Tx: embolization

AVMs

Chest wall tumors: MC benign

Osteochondroma

Chest wall tumors: MC malignant

Chondrosarcoma