surgical management of lung cancer

Question 1

when is surgery the treatment of choice

Answer 1

early and localised lung cancer

patient can make a full recovery

Question 2

what are the 2 stages in assessing a patient for surgical management of lung cancer

Answer 2

staging of the lung cancer

fitness of the patient

Question 3

what does T status involve

Answer 3

site of tumour
size of tumour
involvement of mediastinum and chest wall

Question 4

what does N status involve

Answer 4

lymph node involvement

Question 5

describe the general spread of cancer in the lungs

Answer 5

within the lung that it originated in
ipsilateral regional lymph nodes in the mediastinum
contralateral lymph nodes
other tissues in the body

Question 6

N2 status

Answer 6

lots of nodes found in the aortic pulmonary window

phrenic nerve palsy can indicate these lymph nodes are involved

Question 7

M status

Answer 7

metastases
look at brain
look at same lung (different lobes) or other lung 
adrenal gland 
liver 
bones

Whole body CT to look for distant mets

Question 8

what is the most common presentation for early stage lung cancer

Answer 8

persistent cough

Question 9

how are lots of early stage lung cancers diagnosed

Answer 9

incidentally

Question 10

red flag symptoms

Answer 10

weight loss
fatigue
night sweats
loss of appetite

Question 11

clinical staging of lung cancer

Answer 11

hx: pain (bony), headaches or neurological symptoms
examination: recurrent laryngeal nerve palsy, brachial plexus palsy, SVCO, supraclavicular LNs, soft tissue nodules, chest wall masses, pleural/pericardial effusion, hepatomegaly

Question 12

is surgical treatment helpful in SCLC

Answer 12

very aggressive and invasive cancer
lots of mets
surgical treatment isn’t helpful

Question 13

staging of lung cancer on CXR

Answer 13

pleural effusion
chest wall invasion
phrenic nerve palsy
collapsed lobe or lung

Question 14

staging of lung cancer - bloods

Answer 14

anaemia
abnormal LFTs - liver mets
abnormal bone profile - bone mets

Question 15

staging of lung cancer on CT

Answer 15

size of tumour 
mediastinal nodes
mets 
proximity to mediastinal structures
pleural/pericardial effusion
diaphragmatic involvement

Question 16

lymph node appearance on CT

Answer 16

enlarged = >1cm

homogenous enlargement = unlikely to be lung cancer

Question 17

PET scanning

Answer 17

highlights high metabolic rates of tumours in the body

useful for diagnosing nodal activity in the mediastinum

Question 18

MRI for staging

Answer 18

useful for determining the degree of vascular and neurological involvement

Question 19

bone scan for staging

Answer 19

chest wall invasion

bone mets

Question 20

ECHO for staging

Answer 20

demonstrates presence of absence of significant pericardial effusion
L ventricle function and R ventricle strain (hypertension)

Question 21

bronchoscopy surgical staging

Answer 21

most common
sample tumours of the airway
EBUS to sample mediastinal lymph nodes

Question 22

mediastinoscopy surgical staging

Answer 22

sample lymph nodes

more open procedure

Question 23

clinical assessment of fitness for surgery

Answer 23

CVS
Resp
psych
other

Question 24

clinical assessment of fitness for surgery CVS

Answer 24

angina 
heart problems 
HT
DM
PVD
smoking 
stroke/TIA
carotid bruits
prev CABG/angioplasty 
heart murmurs

independence with adlS

Question 25

clinical assessment of fitness for surgery resp

Answer 25

``` barrel chested COPD smoker asthma recent URTI on oxygen exercise capacity prev thoracotomy or ICD ```

Question 26

clinical assessment of fitness for surgery psych

Answer 26

``` lung cancer surgery can be a big operation - depression post-op isn't uncommon PH of mental illness severe anxiety social background chronic pain problems ```

Question 27

clinical assessment of fitness for surgery other

Answer 27

pulmonary HT - higher risk of post-op bleed immobility liver cirrhosis - can have severe post-op septic shock episodes hx of radiotherapy to the chest - inflammation

Question 28

fitness for surgery respiratory function testing

Answer 28

spirometry - FEV1, predictive post-op FEV1 diffusion studies - amount of oxygen absorbed and used by the lung ABG on air/SLV fractionated V/Q scan

Question 29

fitness for surgery cardiac assessment

Answer 29

``` ECG echo CT - coronary and aortic calcification ETT - exercise tolerance test coronary angiogram ```

Question 30

what is the goal of surgical treatment of lung cancer

Answer 30

curative resection remove the minium amount of lung tissue to maximise post-op function firm diagnosis of malignant is highly desirable before resection

Question 31

why is minimally invasive surgery more commonly used

Answer 31

quicker recovery reduced pain than with thoracotomy less incidents of chronic neuropathic pain in the long term

Question 32

reasons for peri-operative death

Answer 32

``` Acute respiratory distress syndrome bronchopneumonia MI PTE pneumothorax intrathoracic bleeding ```

Question 33

acute respiratory distress syndrome

Answer 33

acute inflammation of both lungs usually due to the stress of the operation reduced ventilation and severe hypoxaemia difficult to ventilate once intubated

Question 34

why can bronchopneumonia occur post-op

Answer 34

not able to take a deep breath due to pain to be able to cough out

Question 35

why can MI occur post-op

Answer 35

heart needs to pump the same amount of blood to more resistance following resection heart is under more stress

Question 36

what measures can be taken to prevent PTE

Answer 36

compression stockings | heparin injections

Question 37

non-fatal complications of surgery

Answer 37

``` post thoracotomy wound pain empyema BPF wound infection AF - common after pneumonectomy MI post-op respiratory insufficiency gastroparesis/constipation ```

Question 38

BPF

Answer 38

bronchopleural fistula | increases chance of infection

Question 39

gastroparesis/constipation post-op

Answer 39

due to morphine/analgesia abdomen becomes distended compresses base of lungs prone to infection

Question 40

commnest problems with staging of lung cancer

Answer 40

collapse of lobe or lung makes tumour size difficult to assess presence of another pulmonary nodule changes staging retrosternal thyroid adrenal nodule

Question 41

``` MORTALITY pneumonectomy lobectomy wedge resection open/close thoracotomy ```

Answer 41

pneumonectomy 5-10% lobectomy 2% wedge resection <1% open/close thoracotomy 5%

Question 42

5YS post-op

Answer 42

``` T1N0 70% T2N0 60% T3N0 50% T1N1/T2N1 40% N2 16% chance of 2nd 1y 5% ```