Flail Chest: What is the Determinant of the underlying pathophysiology:

Determinant of the underlying pathophysiology: underlying pulmonary contusion

General Thoracic Flashcards by Louis Stein

How long post Esophagectomy does it take for resoution of QOL

9 Months

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time course of post esophagectomy strictures

Within the first 9 months

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Major causes of reflux following esophagectomy:

Anastomosis
1. Location:
  - The severity of reflux after esophagectomy is, in part, related to the location of the anastomosis.
    - Severe reflux is associated with the low intrathoracic anastomosis created with a left thoracoabdominal approach;
    - less common with a cervical anastomosis.
Vagotomy/Pyloroplasty:
- Vagotomy is required for esophageal cancer resections, and inadequate pyloroplasty, incomplete pyloromyotomy, or denervation of the pylorus may cause functional gastric outlet obstruction.
- Pyloric Drainage:
  - A meta-analysis of three randomized trials reported:
  - a significant benefit in favor of pyloric drainage versus no drainage in terms of early gastric outlet obstruction, which may contribute to early satiety.
  - In this review, delayed emptying was a difficulty for approximately one third of the patients who had no pyloric operation.
Ivor-Lewis = Redundant Sigmoid Gastric conduit
1. sigmoid gastric tube that may fall into the right costophrenic gutter with resulting delayed emptying.
This problem is known to follow colon interposition as well, but it is rarely seen after transhiatal esophagectomy. However, obstruction of any of the conduit choices at the level of the hiatus is possible

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Flail Chest:

What is the Determinant of the underlying pathophysiology:

Determinant of the underlying pathophysiology:
- underlying pulmonary contusion
  *

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Flail chest - what is the optimal treatment in the current era …

optimal treatment principles include:

avoidance of fluid overload
vigorous pulmonary toilet
effective analgesia.

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Small cell lung cancer linked to smoking?

Yes

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Small cell lung cancer

what % of all lung cancers?

15-25%

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90 year old patients with lymphoma presents with chest mass and biopsy below… appropriate step?

Likely extrapulmonary TB

PPD skin test next to see if active infection

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Presentation of extrapulmonary TB

Painless “cold” abscesses

Should be suspicisous in patietns with immunocompramised or endemic areas

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Chest wall osteocarcoma
typical associaiton ?

typically associated with:

prior radiation
chemotherapy
Paget disease

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Chest wall osteocarcoma
characteristic Radiology findings :

Radiology findings :
“Sunburst periosteal reaction”

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Chest wall osteosarcoma

Characteristic Histology:

Malignant spindle cells
Mitoses
Excess ostoid

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Chest wall osteocarcoma
% of primaiary chest wall tumors ?

overall osteosarcoma 10% of malignant primary chest wall tumors

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Chest wall osteocarcoma
fraction that have metastais ?

1/3 have metastisis

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Chest wall osteocarcoma
Rib and sternal lesions account for what percent of osteogenic sarcoma ?

Rib and sternal lesions account for only 5% of osteogenic sarcomas,

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Chest wall osteocarcoma

Treatment?

Neoadjuvant protocols are typically recommended

efficacy of chemotherapy is frequently limited.
Aggressive 3-month regimens and their attendant toxicities are recommended for large and high-grade tumors.

complete resection with wide margins offers the best chance of cure

Radiation therapy is not routinely recommended, but it may help with pain management in palliative circumstances.

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Prognosis of chest wall osteosarcoma

how does this compare with extremity osteosarcoma ?

Despite a multimodality approach osteosarcomas of ribs, sternum and thoracic spine have an overall 5-year survival less than 30%.
This compares to 65%-80% for extremity sarcomas, where neoadjuvant protocols and limb-sparing resection are goals

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Chest wall tumors

what % are malignant ?

90% are malignant

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Chest wall tumors

what are the most common malignant tumors?

Chest wall tumors

Most common malignant tumors are:

chondrosarcoma
Ewing sarcoma
Osteosarcoma

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Chest wall tumors

The most common benign tumors are:

chondroma
fibrous dysplasia
osteochondroma

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Chondroma

what is it ?

Epidemiology ?

Path?

Histo?

Management: ?

Chondroma: Benign chest wall lesion

Epidemiology :

15% of benign rib tumors
occurs in the 2nd and 3rd decade of life

Path:

Gross: found at the costochondral junction
Histo:
- difficult to differentiate from chroncdrosarcoma
- lobules of hyaline cartilage

Management:

as a malignant lesion

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CT of the chest

Rib lesion

expansile lesion with cortical thickening

Ground glass center

Fiberous dysplaisia

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Osteochondroma:

occurs at the metaphysical area of the rib, bony stalk and cartilaginous cap

Occurs mainly in children and can undergo malignant transformation

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Chondrosarcoma

what proportion of primairy malignant bone tumors

1/3

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what is the most common *primairy* _malignant bone tumor_ ?

Chondrosarcoma

Chondrosarcoma Epidemiology

Most common malignant bone tumor most common betwen 30-40 years old M\> F may be assoaciated with history of trauma

Chondrosarcoma treatment 5 year surival predictors of survival

treatment is complete resection 65% five year survival Predictors of survival : R0 ressection and the grade of the tumor

Ewing sarcoma % of primairy malignant tumors of the chest

15%

Ewing sarcoma Gross Pathology

1. flat bones 2. midshart of the long bone

Ewing sarcoma Natural history

25% have Mets 70% will develop Mets during up-front chemotherapy

Ewings sarcoma treatment

chemotherapy followed by EBRT surgery if residual tumor

Ewings sarcoma 5-year survial

65%

% of patients who devellop sarcoma forllowing radiation therapy ?

\< 1%

The mean latency after irridation for osteosarcoma

15 years, but may be as soon as 4 years

Haller Index

Haller index: It is the ratio of inner transverse diameter of the chest to the shortest distance between the vertebrae and the sternum (A/B in the figure = 4.4 in this example). A normal index is 2.5, and a ratio greater than 3.25 is considered a severe pectus excavatum deformity.

Pulmonary AVM associated lesions

Up to 90% of patients with pulmonary AVM have: Hereditary hemorrhagic telangectasia (Osler-Webber-Rendu) syndrome - Conversely, only 50% of patients

Blood supply to a pulmonary AVM

85% have a single feeding artery

Sequale of pulmonary AVM

_The natural history in untreated individuals entails substantial morbidity and mortality._ 33% stroke 18% of a transient ischemic attack (TIA) 23% of a cerebral abscess 3% of hemothorax.

Predictors of stroke in pulmonary AVM

* Shovlin and colleagues found no correlation between any index of PAVM severity and the risk of brain complications. * the risk of ischemic stroke was associated with low mean pulmonary artery (PA) pressures.

Treatment of pulmonary AVM

Embolization

Comparison of presentation of ILS and ELS

Comparison of presentation: **Extralobar sequestration** typically present in infancy secondary to respiratory distress a sizeable, nonfunctional "accessory lung." **ILS:** ,a young adult patient with an intralobar BPS (the most common type) presents with recurrent infections.

Concern with surgery for ILS

the abarent arterial supply must be addressed

Vascular supply 1. CCAM 2. ILS 3. ELS

1. CCAM : Pulmonary 2. ILS : Systemic 3. ELS Systemic

venous drainage ## Footnote CCAM ILS ELS

CCAM : pulmonary ILS : pulmonary ELS Systemic

laterality CCAM ILS ELS

CCAM : 90% are unilateral , either side ILS : 60% left ELS : 90% left

Gender predominance CCAM ILS ELS

CCAM Male \> Female ILS Equal ELS Male\> Female

laterality of Morgagni and Bochdaleck hernia

Morgagni hernias right-sided (\>90%), Bochdalek hernias are commonly left-sided (\>90%).

Bochdaleck hernia frequency

1/5000

Etiology of Bochdaleck hernia

Due to in uetro failure ofthe pleuro-peritoneal folds to join --- \> Results in a **left** sided defect

Presentation of Bochdaleck hernia

Adults -- More common, and p/w poorly described pain In utero -- may result in pulmonary hypoplasia

when should diaphragmatic hernia be ressected ?

_repair should be considered beause of the potetial for intestinal obstruction or strangulation_ **Symptoms** are *not necessary* to justify surgery.

Bochdalek hernia salient features of repair

Bochdalek: abdominal or transthoracic approach, hernia sack must be ressected:

Space of Larrey:

* space through wich a _Morgagni hernia_ is created. * between the xiphoid proscess and the distal body of the strum and the costochondral attachments of the diaphragm * trhough which the _IMA passes_

Indicaiton for repair of a type III paraesophageal hernia

Type III paraesophageal hernia: . Due to the risk of incarceration of the non-sliding component, repair is advised in any patient with acceptable anesthetic risk.

Lung Cancer Staging Intrapulmonary Mets of the Same Lobe

Lung Cancer Staging Intrapulmonary Mets - different lobe on the same side

Lung cancer staging Mets to a contralatteral lung

M1a Stage IV disese

5 year survival for patient with mets within the same lobe

48%

Radiation Therapy Oncology Group (R9309)

Stage III Lung Cancer: after neoadjuvant therapy, patients operated for stage III lung cancer did poorly _if they were not downstaged, had persistent multi-station disease, or if they required a pneumonectom_

Most common complication from Nissen fundoplication what is the frequency

slippage of the wrap a reported incidence of 0.7-20%.

Lower esophageal Sphincter Normal resting pressure and length

Normal resting pressure: 12-20mmHg Normal Length of LES: 3-5 cm

Dysfunctional LES Resting pressure and length

LES dysfunctional if the resting pressure \< 6 dusfucntional if the length is \< 2cm

Treatment of patient with positive (PET and Biopsy) mediastinal lymphnodes (for lung cancer) and no parenchymal disease

by definition the patient is T3; therefore, the patient should be started on radiation chemotherapy

8th Ed lung cancer Staging T1c

Tumor \> 2 cm but =\< 3 cm

8th Ed lung cancer Staging Tumor involving the visceral pleurae

Gene mutations responsible for Critzotinib

ALK ROS1

Treatment of antenatal diagnosis of CCAM ?

most experts recommend: resection of all cystic lesions in the first 10 months of life because of the risks of infection and malignant transformation.

should be considered when unexplained dyspnea, pneumothorax, pleural effusion or infiltrative radiographic changes occurs in a woman of childbearing age.

I. Lymphangiomyomatosis (LAM)