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Flashcards in CHEST Deck (45):

Borders of Mediastinum

Superior: thoracic outlet Inferior: diaphragm Anterior: Sternum Posterior: anterior surface of vertebral bodies *Intrathoracic compartment (extrapleural) located between pleural cavities*


Anterior mediastinum components

Thymus Adipose tissue Aorta Brachiocephalic vessels LN


Middle mediastinum components

Heart Pericardium All major vessels entering and leaving the heart Trachea Main bronchi Paratracheal and tracheobronchial LN Phrenic and upper vagus nerves


Posterior mediastinum components

Descending aorta Esophagus Thoracic duct Posterior mediastinal LN Paravertebral tissues


Superior mediastinum

Lies above aortic arch Subdivided into anterior, middle, and posterior zones


Common tumors of anterosuperior mediastinum

Goiter Aneurysm Parathyroid tumor Esophageal tumor Angiomatious tumor Teratoma Thymoma Pericardial cyst Lymphoma Morgagni hernia Lipoma


Common tumors of the middle mediastinum

Lymphoma Lymph node hyperplasia Bronchogenic tumor Bronchogenic cyst


Mediastinal Tumors

> 75% in adults are benign 50% malignant in children Three common: neurogenic tumor, thymoma, benign cyst


Mediastinal tumors in children

Neurogenic tumors (most common) Lymphomas Cysts Germ cell tumors Mesenchymal tumors Thymomas (rare)


Dx approach

Imaging: CT scan is best option Biopsy: FNA, mediastinoscopy, thoracoscopy, open Barium studies of GI tract Radioactive iodine uptake scan


VATS as curative tx

Middle and posterior tumors Moderate sized (


Median sternotomy incision as tx

Large (> 6cm) anterior tumors



Most common neoplasm of the anterior mediastinum Associated with myasthenia gravis 40-60 yo


Thymoma therapy

Aggressive surgical approach-- VATS Remove entire tumor with capsule in one piece Open mediastinal procedure if not


Germ cell tumors

Teratomas, seminomas, choriocarcinoma, embryonal cell carcinoma, endodermal sinus tumors Anterior mediastinum 20-40 yo Benign more common in women, malignant more common in men Majority in mediastinum are teratomas



Majority are benign Unicystic or multicystic Two or three embryonic layers-- teeth, skin, hair, cartilage, bone, bronchial, intestinal, or pancreatic tissue Usually found via compressive sx Dx established from CXR (although CT is ideal)



Most common malignant germ cell tumor Men in 30s-40s Primary in the mediastinum and not metastatic from testes CT scan +/- compressive sx


Superior vena cava syndrome

Obstructive sx Facial edema Flushing


Tx: Seminoma

Radiation Chemo -Poor prognosis: > 35 yo, fever, SVC syndrome


Bronchogenic and Enterogenous Cysts

Middle mediastinum near large airways Subcarinal area Commonly discovered early in life on screening CXR CT Needle biopsy (sometimes that's the tx)


Pleueropericardial Cysts

Cardiophrenic angle, right side Single layer of mesothelial cells Usually asx CT diagnostic Needle aspiration


Neurogenic tumors

Posterior mediastinal masses Arise from nerve sheath or nerve itself Higher malignancy in children Benign in adults Common in those


Nerve sheath tumors

Benign: neurilemoma, neurofibroma, melanotic schwannoma, granular cell tumor Malignant: neurofibrosarcoma


Ganglion cell tumors

Benign: ganglioneuroma Malignant: ganglioneuroblastoma, neuroblastoma


Paraganglionic cell tumors

Benign: chemodectoma, pheochromocytoma Malignant: malignant chemodectoma, malignant pheochromocytoma


Lung Cancer: Stats

Leading cancer killer, second most frequently diagnosed cancer in US 28% of all cancer deaths 1 in 13 men, 1 in 16 women RF: cigarette smoking, secondhand smoke, radon gas


Lung Cancer-- Diagnostic evaluation

-Hx of primary tumor location -Hx of signs/sx of metastatic disease -Exam-- pulmonary, nodes, skin, neuro, voice -Radiology for primary tumor: CT chest w/contrast, +/- PET scan -Radiology for metastatic disease: + bone scan, head MRI, abdominal CT -Tissue analysis to subtype primary tumor -Tissue analysis for metastatic disease


Clinical presentation of lung cancer: Pulmonary sx

Cough Dyspnea Wheezing Hemoptysis Pneumonia


Clinical presentation of lung cancer: nonpulmonary thoracic sx

Pleuritic pain Local chest wall pain Radicular chest pain Pancoast's syndrome Hoarseness Swelling of head and arms


Pancoast's Syndrome

Tumors originating in superior sulcus Apical chest wall and/or shoulder pain Horner's syndrome Radicular arm pain


Phrenic nerve palsy

Tumors at the medial lung surface or anterior hilum can directly invade the nerve shoulder pain (referred), hiccups, and dyspnea with exertion because of diaphragm paralysis


Recurrent laryngeal nerve palsy

commonly occurs on the left side, (hilar location of left RLN as it passes under aortic arch)


Broad classification of lung cancer

Non-small cell lung carcinoma-- large cell, squamous cell, adenocarcinoma Neuroendocrine tumors-- neuroendocrine hyperplasia, neuroendocrine carcinoma (NEC, grade I-IV)


Non-small cell lung carcinoma: Large cell

10-20% of Lung CA's (central or peripheral), cell diameter of 30-50micrometers, can be confused with large-cell variant of neuroendocrine CA, differentiate with stains


Non-small cell lung carcinoma: squamous cell

30-40% of Lung CA's (Central: main/lobar/first segmental Bronchi), smokers, cough/hemoptysis/wheezing-obstruction/dyspnea/pneumonia


Non-small cell lung carcinoma: adenocarcinoma

-Most common Lung CA (peripheral), asymptomatic until invasion into pleura or chest wall -30% male smokers, 40% female smokers, 80/60% in non-smoker M/F -Classified as: pre-invasive (in situ), minimally invasive, invasive, or variant


Neuroendocrine tumors: Neuroendocrine carcinoma (NEC) Grades I and II

I: classic carcinoid; 80% central; young, hemoptysis/hemorrhage II: atypical carcinoid; peripheral; smokers, lymph mets 50%


Neuroendocrine tumors: Neuroendocrine carcinoma (NEC) Grades III and IV

III: Large cell type; mid-peripheral; heavy smokers IV: small cell/oat cell; central, widespread mets; 25% of all lung CAs


Types of resections for lung cancer

Wedge resection Segmentectomy Lobectomy Pneumonectomy


Post-op management

Chest tube: continuous suction (-20 cm H2O), off suction (water seal), monitor output, monitor for resolution of air leak


When to remove chest tube?

-Normal healthy person: less than 500 mL over 24 h -After VATS: drainage less than 400mL over 24 h -Malignant pleural effusion, pleural space infection, or inflammation or pleurodesis: less than 100-150 mL over 24 h


How much fluid should we allow to drain?

Limit to 1500 mL initially (rapid drainage can cause SOB, clinical instability, and postexpansion pulmonary edema)


Air leaks

common after pulmonary resection, fibrosis and destroyed blood supply impairs healing of surface injuries


Prolonged Air Leak (Lasting > 5 days)

-treated by diminishing or discontinuing suction, by continuing chest drainage, or by instilling a pleurodesis agent (doxycycline or talcum powder) -Pleurodesis of the lung within the chest cavity - minimize the possible collapse of the lung due to persistent air leak


Bronchopleural fistula

-if the leak is moderate to large -flexible bronchoscopy is performed to evaluate the bronchial stump -Management includes prolonged chest tube drainage, reoperation, and reclosure (with stump reinforcement with an intercostal muscle flap or a pedicled serratus muscle flap)