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General Thoracic 3.0 Flashcards

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1
Q

2017 Lung Cancer Staging

T0 –

A

T0 – no primary tumor

T1a (mi) – Minimally invasive adenoma

T1a ss –superfical spreading in central airways (any size but confined to the tracheal or bronchial wall)

T1a Tumor =< 1cm

T1b tumor > 1 but =< 2 cm

T1c Tumor > 2 but =< 3cm

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2
Q

Lung Cancer 2017 Staging

T1a (mi) –

A

Lung Cancer 2017 Staging

T1a (mi) – Minimally invasive adenoma

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3
Q

Lung Cancer 2017 Staging

T1a ss

A

Lung Cancer 2017 Staging

T1a ss:

superfical spreading in central airways

(any size but confined to the tracheal or bronchial wall)

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4
Q

Lung Cancer 2017 Staging

T1a

A

Lung Cancer 2017 Staging

T1a Tumor =< 2cm

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5
Q

Lung Cancer 2017 Staging

T1b

A

tumor > 2, but =< 3cm

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6
Q

Lung Cancer 2017 Staging

T1c?

A

Tumor > 2 but =< 3cm

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7
Q

ACOSOG Z0050 trial

Trial purpose

Trial Conclusion

A

ACOSOG Z0050 trial (2011)

  • Examined the utility of PET for staging patents with potentially operable NSCLC
  • The authors concluded that their study validated that mediastinoscopy (prior to the widespread use of EBUS) is the gold standard for mediastinal staging when compared to the CT and/or PET interpretations.
  • Therefore: N2 disease should be confirmed pathologically.
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8
Q

Specificty of PET for N2/N3 disease ?

A

ACOSOG Z0050 trial (2011)

PET for N2/N3

Specificity: 84%

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9
Q

PPV of PET for mediastinal lymph nodes

A

ACOSOG Z0050 trial (2011)

The PPV (positive predictive value) of PET in that study was only 56%.

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10
Q

Comparison of VATS vs. Thoracotomy
Mortality

A

No differences in mortality

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11
Q

Comparison of VATS vs. Thoracotomy

Respiratory issues:

A

Perioperative respiratory complications (12.2% vs. 7.6%, p=0.0001)

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12
Q

Comparison of VATS vs Thoracotomy

Atrial arrhythmia:

A

Comparison of VATS vs Thoracotomy

Atrial arrhythmia:

atrial arrhythmias (11.5% vs. 7.3%, p=0.0004) were higher in the thoracotomy group.

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13
Q

Comparison of VATS vs Thoracotomy

Lymph Node Status and Up Staging

Mediastinal and hilar lymph node staging

A

Mediastinal Lymph nodes

no difference in the number of mediastinal stations sampled or of upstaging of mediastinal nodes (5.0% with thoracotomy vs. 4.9% with VATS; p = 0.52).

Peribronchial lymph nodes

There was, however, a difference in the rates of hilar and peribronchial upstaging for N1 disease favoring thoracotomy (9.3% vs. 6.7%, p<0.001).

This was assumed to indicate variability in the completeness of hilar and peribronchial lymph node dissection during the VATS cases.

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14
Q

Cameron’s Ulcers

A
  1. Patients with a type III hernia may have an associated unexplained anemia.
  2. Aetiology
    • The blood loss is from the stomach moving up and down through the hernia ring leading to irritation of the gastric mucosa and subsequent bleeding. This may or may not be seen on endoscopy. These erosions are referred to as Cameron’s erosions or Cameron’s ulcers.
  3. Epidemiology
    • It occurs in 20%-30% of patients with large type III hernias.
  4. Work up
    • A full investigation of other sources of gastrointestinal blood loss is warranted. This usually involves a colonoscopy and CT scan to rule out other causes of bleeding.
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15
Q

Incidence of Cameron’s ulcer

A
  1. Epidemiology
    1. It occurs in 20%-30% of patients with large type III hernias.
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16
Q

Quantification of AFB and B-HCG in young patient with anterior mediastinal mass

? how much is too high?

A

Any elevation of alpha-fetoprotein (αFP) and elevation of beta human chorionic gonadotropin(βhCG) elevation > 100 mIU/mL is diagnostic for a primary mediastinal nonseminomatous germ cell cancer.

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17
Q

IHC staining for germ cell tumors

ALK

A
  1. Eighty percent of seminomatous germ cell cancers stain positive for placental alkaline phosphatase, which is also diagnostic.
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18
Q

what is more comminon

Seminoma or non-seminoma

A

Seminoma

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19
Q

what has a better prognosis ? seminoma or non-seminoma

A

Seminoma - 5 year survival 80%

Non seminoma 50-60%

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20
Q

Most common malignant germ cell tumor in the mediastinum

A

Seminoma

###

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21
Q

A.Seminoma

1.Epidemiology

  • Frequency of mediastinum
  • Gender prevlance
  • Age?

###

A
  • Most common malignant germ cell tumor in the mediastinum
  • Occurs almost exclusively in Males
  • 30’s – 40s

###

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22
Q

Seminoma

Diagnosis

Lab and Imaging ?

###

A

a) Serum Tumor markers are slightly elevated.
b) CT: reveal characteristically large, homogenous math with smooth boaders
c) Eighty percent of seminomatous germ cell cancers stain positive for placental alkaline phosphatase, which is also diagnostic.

###

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23
Q

Seminoma

Treatment

A
  • Radiation therapy: traditionally the primary treatment.
  • Cisplatin-based chemotherapy is used for metastatic disease
  • Surgical resection is reserved for any residual disease that is manifested as the local growth of a residual mass.
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24
Q

Non-seminomatous germ cell tumors

Epidemiology

Age and gender

###

A

A.Non-seminomatous germ cell tumors

Epidemiology

a)most often in young men 20 to 30 years old

###

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25
Non-seminomatous germ cell tumors pathologic subtypes ###
(1) yolk sac carcinoma (2) embryonal carcinoma (3) choriocarcinoma ###
26
Most common side effects to Cisplatin
The most common side effects of cisplatin are: nausea and vomiting arthralgias nephrotoxicity sensory polyneuropathy electrolyte abnormalities (hypomagnesemia, hypocalcemia, hypokalemia), ototoxicity, anemia and leukopenia (usual onset after 10 days, with nadir between 14-23 days, and recovery after 21-39 days).
27
**_Bronchopleural Fistula_** Epidemiology * incidence of bronchopleural fistula (BPF)following pneumonectomy: 0.8% to 15%?
**_Bronchopleural Fistula_** Epidemiology * incidence of bronchopleural fistula (BPF)following pneumonectomy: 0.8% to 15% *
28
**_Bronchopleural Fistula_** Risk factors?
**Pneumonectomy** **Neoplastic disease** **Right \>\> Left** neoadjuvant chemotherapy or radiation hypoalbuminemia long residual bronchial stump more severe chronic obstructive lung disease the need for postoperative mechanical ventilation. B
29
CTA findings consistent with chronic pulmonary HTN
* A CT-determined main pulmonary artery diameter greater than 29 mm predicts PHTN with a sensitivity of 87% and specificity of 89%. * The specificity reaches 100% if additionally an artery-to-bronchial ratio greater than 1:1 is found at the segmental level in at least three lobes.
30
Stages of BOS
1 - 3
31
Grade 1 BOS
10% reduction in FEV1
32
Lung biopsy results consistent with BOS
intraluminal fibromyxoid granulation tissue and submucosal eosinophilic infiltrates
33
You have sent a specimen after a lung biopsy. The fresh sample shows hyphae branching at right angles. The most likely diagnosis is
1. mucormycosis
34
In Blunt chest trauma with fractured ribs what factors are predictive of morality ?
A. The adverse outcome for flail chest patients correlates with: a) Injury Severity Score b) Associated injuries. ​
35
In blunt chest trauma with fractured ribs: what impacts the length of stay (but not mortality)?
Length of Hospitalization (But not Mortality) is dependent on: a) Age, b) hemopneumothorax c) mechanical support ​
36
In blunt chest trauma with fractured ribs, what does Injury Severity Score correlate with? ​
Mortality
37
Recommendations for medical therapy for Mycobacterium Tb
1. 2010 WHO recommendations: a) 2HZRE/4HR (1) 2 months of isoniazid (H) Pyrazinamide (Z), Rifmapin, Ethambutol (E) (2) 4 months of Isoniazid and rifampin (3) ethambutol is maintained in areas of high resistance ​
38
Ranking of disease on LAS
1. **Rank of Favoring Diseases on LAS** 1. *Highest* 1. End-stage fibrotic lung disease 2. (e.g., idiopathic pulmonary fibrosis-IPF, usual interstitial pneumonitis-UIP) 2. *Middle*: 1. supportive lung disease (eg, CF, bronchiectasis) 3. *Least favored:* obstructive lung disease emphysema, alpha1 antitrypsin deficiency
39
highest ranked primary lung diseases in LAS
1. Rank of Favoring Diseases on LAS 1. **Highest** 1. End-stage fibrotic lung disease 2. (e.g., idiopathic pulmonary fibrosis-IPF, usual interstitial pneumonitis-UIP) 2.
40
Middle ranked diseases on LAS
_Middle_: supportive lung disease (eg, CF, bronchiectasis)
41
Least favored lung diseases in LAS
​ Least favored: obstructive lung disease emphysema, alpha1 antitrypsin deficiency
42
Double vs single lung transplant for primary pulmonary htn
in older patients (\>65 yrs) double lung transplantation has proven to be high risk, single lung transplantation for patients with moderate pulmonary hypertension (mean 35 mmHg) has equivalent outcomes.
43
Proximal Acinar Emphysema - typical anatomic location
Proximal acinar emphysema (centrilobular) typically located in the upper airways
44
Proximal acinar emphysema - with what is it associated (etiology)
Smoking Inflammatory lung conditions
45
Pan acinar emphysema typical anatomic location ?
typically located in the lower lung zones
46
Pan-acinar emphysema with what disease states is it associated?
associated with alpha-1-at deficiency PI deficiency
47
Distal acinar emphysema
Sub pleural fibrosis Nearly everyone will get
48
Study design of the NETT 2003 study
randomized patients into either * OMM + Pulmonary rehab * or* * LVRS
49
Inclusion criteria in the NETT trial
* _Inclusion criteria_: 1. FEV1 \< 45% * *Pt with FEV1\<20% with either (a) homogeneous lung disease distribution or (b) DLCO \< 20% were excluded* 2. pCO2 \< 60 and PO2\> 45 3. 4 months of smoking cessation
50
Exclusion criteria for the NETT trial
* _Exclusion criteria_ – * Pt with FEV1\<20% with either (a) homogeneous lung disease distribution or (b) DLCO \< 20% were excluded * PAH (mean \> 35) * O2 requirement \> 6L * Pulmonary nodule requiring surgery
51
NETT Trial results for Upper lobe predominant High Exercise capacity
No improvement in Survival Improved QOL
52
NETT Trial Results Upper Lobe predominant Low exercise Capacity
50% decrease in 2 year mortality
53
NETT Trial Results Lower Lobe predominant High exercise capacity
2x increase in mortality
54
NETT Trial Results for Lower Lobe predominant Low exercise capacity
No improvement in survival No improvement in QOL (although still better than OMM)
55
Nett trial criteria for low exercise capacity
Women \< 25 Watts Men \< 40 Watts
56
How long should one be off of PPI's and h2 blockers before having PH monitoring?
7 days off of PPI 48 hours off of H2 blocker
57
Thymoma Masaoka Stage I
Macroscopically encapsulated with no microscopically detectable capsular invasion
58
Thymoma Masaoka Stage II
Macroscopic invasion of the fatty tissue or Mediastinal pleura or Microscopic invasion into the capsule
59
Thymoma Masaoka Stage III
Macroscopic invasion of structures | (pericardium, great vessels, lung)
60
Thymoma Masaoka Stage IVA
Pleural or pericardial dissemination
61
Thymoma Masaoka Stage IVb
Lymphogenous or hematogenous spread
62
Epidemiology association between * Lymphangiomyomatosis and * Tuberous sclerosis
* 1% of patients with LAM have tuberous sclerosis complex; * 30-40% of adult women with tuberous sclerosis have LAM
63
**Esophageal cancer**- *N- Stage* N0:
**Esophageal cancer**- *N- Stage* **N0: no lymph nodes**
64
**Esophageal cancer-**_N- Stage_ N1:
**Esophageal cancer-**_N- Stage_ **N1: 1 or 2 lymph nodes**
65
Esophageal cancer- N- Stage N2:
Esophageal cancer- N- Stage **N2: 3 to 6 lymph nodes**
66
Esophageal cancer- N- Stage N3:
Esophageal cancer- N- Stage N3: 7 or more regional lymph nodes are involved
67
_ZOO60 TRIAL_
_ZOO60 TRIAL_ To clarify the role of FDG-PET in staging potentially resectable esophageal cancer, Z0060 to determine if FDG-PET could detect metastatic lesions that would preclude esophageal resection in patients believed to be surgical candidates after standard imaging procedures. * PET scan identified M1 disease in 4.8% of cases and N1 nodal disease in 31% of the patients. * named packets of nodal material by the surgeon resulted in 16 ± 9 nodes per case, as opposed to 10 ± 8 nodes for routine processing by the pathology team (P \<0.001).
68
Predictive values of lymph nodes
_Recent analysis demonstrated that number of regional lymph nodes containing metastases (positive nodes)_ * _is the most important prognostic factor in resectable esophageal cancers._ * _also predictive of distant metastases,_ * _survival of patients with 9 or more positive nodes is equivalent to that of patients with the distant metastatic disease_.
69
iHC markers for squamous cell cencer
1. IHC P40 (p63, CK 5/6)
70
71
IHC to ddx meso and andeno ca of the lung
* _Calretinin, cytokeratin 6/5 (or WT-1):_ both + for mesothelioma and negative for adeno) * _CEA and MOC-31 (or BEP-EP4, BG-8_): + for adeno and negative for meso
72
EGFR Lung tumor associated phenotype
Adenocarcinoma typically in non-smoking asians
73
What is Ludwigs Angina ?
Necrotizing crevical myofascitis
74
thoracic surgical treatment of Ludwig Angina
Radical debridment .\ May require a sternotomy

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