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Flashcards in CHEST Deck (45):
1

Borders of Mediastinum

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

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Anterior mediastinum components

Thymus Adipose tissue Aorta Brachiocephalic vessels LN

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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

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Posterior mediastinum components

Descending aorta Esophagus Thoracic duct Posterior mediastinal LN Paravertebral tissues

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Superior mediastinum

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

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Common tumors of anterosuperior mediastinum

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

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Common tumors of the middle mediastinum

Lymphoma Lymph node hyperplasia Bronchogenic tumor Bronchogenic cyst

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Mediastinal Tumors

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

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Mediastinal tumors in children

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

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Dx approach

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

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VATS as curative tx

Middle and posterior tumors Moderate sized (

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Median sternotomy incision as tx

Large (> 6cm) anterior tumors

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Thymoma

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

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Thymoma therapy

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

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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

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Teratoma

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)

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Seminoma

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

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Superior vena cava syndrome

Obstructive sx Facial edema Flushing

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Tx: Seminoma

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

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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)

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Pleueropericardial Cysts

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

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Neurogenic tumors

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

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Nerve sheath tumors

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

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Ganglion cell tumors

Benign: ganglioneuroma Malignant: ganglioneuroblastoma, neuroblastoma

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Paraganglionic cell tumors

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

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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

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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

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Clinical presentation of lung cancer: Pulmonary sx

Cough Dyspnea Wheezing Hemoptysis Pneumonia

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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

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Pancoast's Syndrome

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

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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

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Recurrent laryngeal nerve palsy

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

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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)

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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

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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

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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

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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%

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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

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Types of resections for lung cancer

Wedge resection Segmentectomy Lobectomy Pneumonectomy

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Post-op management

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

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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

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How much fluid should we allow to drain?

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

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Air leaks

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

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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

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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)