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ABTS > Thoracic > Flashcards

Thoracic Flashcards

1
Q

EGFR mutation (lung ca)

A

More common in non smokers, adenoCA
Erlotinib or other TK inhibitor has benefit in advanced stage NSCLC and is first line if EGFR mutation present
Adjuvant therapy after surgery is still platinum based chemo for resectable disease

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2
Q

Approach for distal trachea/carina/prox main branches

A

Right posterolateral thoracotomy

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3
Q

Approach to Distal left main stem

A

Left posterolateral thoracotomy

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4
Q

Barrett’s esophagus

A

Result of long standing GERD
Salmon colored on EGD
Screening indicated for men with GERD and another risk factor.
Need to make dx histologically with Seattle protocol - sampling 4 quadrants every cm. Looking for low or high grade dysplasia or early cancer
Treat HGD with endoscopic mucosal resection but avoid circumferential which causes stricture
If mucosal involvement of CA needs esophagectomy unless very superficial
Followup screening 1,3,6 months and yearly for HGD. Follow up annually for LGD

Radiofreq ablation is indicated for remaining Barrett’s after resection of HGD lesion

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5
Q

Best marker for esophagogastric junction

A

Important to make sure wrap is in the right place
Ruggal folds of stomach demarcate transition
Gastric fat pad is very variable and can’t be used

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6
Q

Infected in dwelling pleural drainage in setting of malignant pleural effusion

A

90% resolve with antibiotics
Open drainage and packing is most definitive source control but most can just treat w abx

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7
Q

Hamartoma

A

Lobulated nodule with fat and popcorn calcification
Benign
Just observation and resect if any growth
Usually peripheral, lower lung fields

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8
Q

Carcinoid tumor features

A

Round or lobulated. Smooth. Non calcified, no fat.

Usually central/assocaited with bronchus (airway compromise often initial Presentation)

Bimodal presentation (older more likely atypical)

Typical <2 mitotic figures
Atypical 2-10 mitotic figures with necrosis

If no nodal disease on clinical staging, no need to do LN sampling (proceed to resection) but if positive nodes on clinical staging, should get tissue.

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9
Q

Lung cancer on imaging

A

Often spiculated
Solid, non solid or ground glass features possible
Usually non calcified but if it is then it’s eccentric calcium. (Calcified granuloma often has central calcification and associated calcified LN)

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10
Q

Leiomyoma of esophagus

A

Rare but this is most common submucosal benign lesion
Occur in Distal esophagus
Benign but should rule out GiST with FNA
Smooth bulging see on endo
Observation for small asymptomatic or vats/lap enucleation if large/symptoms (dysphagia)
Endoscopic mucosal resection can lead to full thickness defect if lesion is more than 2cm
Avoid messing up sphincter in which case an anti reflux procedure is indicated

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11
Q

Sarcoidosis

A

More common in AA
Non caseating granulomas
Diffuse interstitial process in upper lobes
Hilar/mediastinal Adenopathy common and sampling these nodes provides dx
Endoscopic ultrasound guided needle biopsy best approach
Mediastinoscopy could sample nodes but higher risk
Many improve without treatment but 20% progress.
Steroids first line

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12
Q

Tracheal release maneuvers

A

Neck flex room/guardian stitch gives 4cm

Suprahyoid release (horiz incision in neck crease) has supplanted laryngeal release for upper tracheal lengthening (buys 1-2cm). Laryngeal release risks nerve/artery damage

Hilar and pericardial release for Lower trachea (usually right thoracotomy). Incise pericardium with U shaped incision around pulmonary vein (ant/post/inferior U). Phrenic nerve injury is key risk. Divide pulmonary ligament to help exposure

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13
Q

Adenoid cystic carcinoma (ACC)

A

Second most common tracheal tumor (first is SCC)
Try for Ro resection but often spreads along lymphatics and submucosa. If residual margin, should get radiation.

Chemo for metastatic disease/recurrence

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14
Q

PTLD

A

Post transplant lymphoprolif disease
3-8% post lung txp
Associated w EBV in donor
B cell expansion
Early lesion treated with reducing immunosuppression (as tolerated w rejection) and rituximab if cd20 positive

Good response if early lesion

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15
Q

Toupet fundoplication

A

Partial wrap - (270) better if there is ineffective peristalsis

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16
Q

Nissen

A

Full wrap

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17
Q

Esophageal duplication cyst

A

Usually doesn’t communicate with esophagus
Surgical resection if symptoms (not drainage or marsupialization)

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18
Q

Locally advanced esophageal cancer (T3) treatment (2b-3c)

A

Definitive chemoradiation vs chemorad followed by esophagectomy are equivalent outcomes. So no surgery generally

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19
Q

Mediastinal nonseminomatous germ cell tumor treatment

A

Tx - systemic chemo (bleo/etoposide/cisplatin)
Tumors are chemo sensitive but there will be residual mass that needs resection

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20
Q

Esophageal adeno demographics

A

M>F 6 fold
Advanced age biggest risk factor
Smoking NC increases risk (2 fold) but not as much as for SCC
Obesity (BMI>30 has 2 fold risk compared to less than 25)

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21
Q

Treatment for metastatic esophageal ca

A

5FU-Cisplatin (add 3d agent if medically fit)

HER2 testing indicated for metastatic. Trastuzamab indicated if HER2 is over expressed

Keynote 590 - adding pembromizulab (PD1) has survival advantage in sCC and adeno

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22
Q

Lung abscess in alcoholic

A

Actinomyces- facultative anaerobe

4-6 weeks IV penicillin then oral 6-12 weeks

Dx: flex bronch +/- transthoracic needle biopsy

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23
Q

Thymic Ca TNM

A

T1 - does not invade neighboring structures
T2 - Pericardial invasion
T3 - adjacent structures (lung/SVC,phrenic)
T4 - Aorta/heart invasion (non resectable)

N1 0 anterior perithymic nodes
N2 - outside perithymic area (cervical or supraclavicular)

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24
Q

Fibrosing Mediastinitis

A

Unclear pathophysiology.

Histoplasma capaulatum may be underlying cause setting off a hyper immune response

Leads to inflammation and calcified lesions throughout mediastinum. Causes airway and vascular (PA) compression. No good treatment but stenting palliative

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25
Q

Stereotactic ablative radiotherapy

A

Used for both SCC and adeno tumors that are medically inoperable

High risk if preexisting fibrosis exists

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26
Q

Minimally invasive adeno carcinoma

A

Rare type of NSCLC

Lepidic growth (grows in air spaces). Less than 5mm of an invasive component

Surgery alone, no additional treatment necessary

100% cure

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27
Q

Chicago classification

A

Type 1 achalasia - Absent peristalsis and negligible pressurization in the esophagus (mostly blue)

Type 2 - absent peristalis and pan-esophageal pressurization (mostly green). Best treatment response

Type 3 - spastic type - rapidly propagating or spastic simulatneous contractions, involve at least 20%. Worst treatment response

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28
Q

Integrated relaxing pressure

A

LES

Should be below 15 if normal. High in achalasia

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29
Q

Achalasia tx

A

Heller myotomy most effective

Baloon dilation, less long term effective but option of non op

Botox injection if above not possible.

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30
Q

Malignant TE fistula

A

erosion by mass and radiation can cause communication

Esophageal stent is favored method of paliation. Placing tracheal stent as well can cause necrosis.

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31
Q

Gastric outlet obstruction following esophagectomy

A

Endoscopy to inspect pylorius and baloon dilitation if it’s tight. Dont use botox

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32
Q

Cervical mediastinoscopy nodes

A

2,4,7 (defines N2 or N3).
Subcarinal (N2)
Ipsilateral 2/4 (N2)
Contra lateral 2/4 (N3)

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33
Q

prediceted postop FEV1 and DLCO cutoffs

A

<40% high risk
<20% inoperable

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34
Q

Factors that are high/projbitive surgery risk

A

VO2<10ml/kg/min are prohibitive risk and most important determinant

predicted FEV1<0.8L or <40% predicted
FVC<1.5L or <30% predicted
FEV1/FVC<50%
Resting pO2<45
Resting pCO2>50

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35
Q

Genetic mutation cancer associations (kras, EGFR,cMyc)

A

K ras - worse prognosis in NSCLC
EGFR - adenocarcinoma in smoker and nmon smokers. Respond to TK inhibitors
c-Myc - linked to SCLC

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36
Q

Carcinoid tumor treatment

A

Ro resection (margin doesn’t matter)

Mediastinal node sampling should be done for clinical staging showing nodes or atypical disease.

May be role for adjuvant chemo in N2 disease but data lacks.

Metastatic carcinoid treated with chemotherapy.

37
Q

Malignant pleural effuson

A

Rarely do thoracotomy/decort

Goal is to drain and pleurodese if lung is expanded and in apposition to chest wall

If trapped lung, do indwelling catheter

38
Q

Esophageal stricture

A

GERD accounts for 70-80% of benign strictures

PPI and balloon dilation

39
Q

Diaphragmatic rupture (blunt abdominal injury)

A

Very difficult to detect by CXR/CT unless organs are visibly herniating (not always the case)

Surgical exploration usually needed to daignoe. Can look from belly or chest, belly better to inspect other injuries.

40
Q

Solitary pulmonary nodule

A

Defined as nodule <3cm surrounded by normal aerated lung

<4mm very unlikely to be malignant (just follow)

Risk of malignancy increases with size

If stable for 2 years most likely benign

Very rapidly growing nodule is unlikely cancer (more likely infectious)

41
Q

Superior sulcus (pan coast)

A

Classic triad of shoulder pain/horners(ptosis/myosis/anhydrosis) and atrophy of hand

Neoadjuvant chemo radiation followed by surgical resection

Darteville (anterior approach for plexus involvement) or Shawn-Paulson (posterior approach for vertebral incolvement)

Ok to sacrifice t1 nerve but not c8 (klumkes)

Must get Ro

42
Q

Relative contraindications to vats lung resection

A

Tumors greater than 4-5 cm
Chest wall involvement
Inability to tolerate single lung vent
Highly calcified LN adherent to pulmonary vessels

43
Q

EA-TEF

A

Associated with congenital abnormalities (CHARGE, VACTERL, Down, Digeorge)

EA with distal TEF is most common (85% type C)

Right thoracotomy with primary anastomosis. If long gap, do G tube and decompress proximal pouch.

Long term complications include tracheomalacia, reflux, reactive airway disease

44
Q

Sequestration

A

Mass of lung tissue that does not connect too tracheobronch tree.

Intralobar (shares same visceral pleura, usually LLL) or extralobar (different visceral pleura, associated with other anmoalies)

Resection is treatment if symptomatic.

Has own arterial blood supply off aorta (control for resection)

45
Q

CCAM

A

Most common lung cystic abnormality. Communicates with tracheobronch tree but does not participate in gas exchange

Type I (60-70%) macrocystic (singlr or multiple large cysts (>2cm), best prognosis

Large CCAM can compress esophagus in development leading to polyhydramnious - can do fetal lobectomy

Urgent resection for symptomatic. resedction at 3-12 months if asymptomatic.

Long term risk of malignant transformation

46
Q

Bronchogenic cyst

A

does not communicate with airway. thin walled, mucus-filled cysts in paratracheal/carinal/hilar area.

Remove as prone to infection or airway compromisee

47
Q

Congenital lobar emphysema

A

Expansion of normal lung alveoli due to lobar bronchial obstruction. Extrinsic compression vs. unknown reason. upper lobes more frequently involved

All symptomatic lesions should get removed - usually lobectomy.

Can spontaneously regress

Associated with CHD (15% oof time) so should get echo

48
Q

Congenital tracheal stenosis

A

Wheezing/stridor after birth.

Endoscopy to dx.

Segmental resection and primary anastamosis for stenosis up to 50% of tracha. If longer segment, may need trachoplasty with pericardium, cadaveric trachea etc.

Non surgical candidates - palliation with baloon dilation, stenting, steroids, cryotherapy

49
Q

Absolute contraindications to lung txp

A

Malignancy in last 2 years
Active smoking
Active viral hepatitis
Organ dysfunction

Age>65 (relative contraindication)

50
Q

Indication for lung txp in copd

A

BODE score 7-10 with one of following:
History of Acute exacerbation
Pulm htn
Fev1<20 and dlco <20

51
Q

Indication for lung transplant in sarcoidosis

A

Hypoxemia at rest
Phtn
Rap>15

52
Q

Lung txp outcomes

A

82 % 1 year
55% 5 year
30% 10 year

Cf has best survival

53
Q

Indications for surgery in TB

A

Massive hemoptysis
Bpf
Bronchial stenosis
Trapped lung
Destroyed lung
Persistent cavities disease
Medical failure

54
Q

First line tx for TB

A

6 months isoniazid and rifampin (+pyrazinamide in first 2 months)

55
Q

TB - airway compromise

A

Endobronchial scarring/stricture possible but more likely airway is compressed by infected LN
Inhaled steroids and I/D of lymph nodes (not excision)

56
Q

Pulmonary AVM

A

Treat with embolisation regardless of size/symptoms. Risk of stroke

57
Q

Pectus

A

Haller index over 3.25 indication for repair
Nuss or ravitch similar outcomes in terms of pain and result
Remove nuss bar at 3 years

58
Q

Malignant chest wall tumors

A

Chondrosarcoma (35%)
Plasmacytomas (25%)
Ewing’s (15%)

59
Q

Chondrosarcoma

A

Most common malignant chest wall.
May be assocaited with prior trauma.
Males 20-50
Lobulated mass arising from medullary portion of rib.
CT scan to dx
Wide local excision. No role for adjuvant chemo or RT
Prognosis depends on tumor grade, size, location

60
Q

Plasmacytoma

A

Second most common primary chest wall malignancy

Older men

Ribs>clavicle>sternum

Progression to multiple myeloma

Treat with definitive RT and surgery only for refractory cases. Chemo only if disease progression occurs.

61
Q

Ewing’s treatment

A

Wide excision (remove entire rib and above/below. Follow by adjuvant RT

Chemo for systemic disease

62
Q

Bochdalek hernia

A

Most common CDH

Back and to the left

If abdomen contents herniate up during development it causes underdevelopment of lungs and respiratory distress at birth.

Surgery through belly to reduce hernia and close defect either primarily or with patch.

63
Q

Morgangni’s hernia

A

4% of CDH. Between xyphoid and costochondral attachments. Usually on right side.

Usually asympomatic but should repair of found to avoid herniation/incarceration

64
Q

4 layers of esophagus

A

mucosa

submucosa (strength layer - contains vascular, nerve, lymphatics)
muscularis propria
lamina propria

NO Serosa unlike other parts of digestive tract. So sutures have to get the submucosa layer.

65
Q

First line test for suspected esophageal CA

A

Endoscopy with biopsy

Barium swallow for complex cases with TE fistula or esophageal perforation.

Strictures should be biopsied and ballooned

66
Q

Esophageal duplication cyst

A

Does not communicate w esophagus
Vats resection (don’t drain or marsupialize due to recurrence/infection risk)

67
Q

Diffuse esophageal spasm

A

Substantial chest pain w dysphasia
Manometry shows simultaneous contractions in >20% of swallows
Sometimes corkscrew
Normal endoscopy
Difficult to treat - ccb, nitrates, pde inhibitor have limited value S does Botox

Long myotomy/poem

68
Q

Benign esophageal strictures

A

Most common due to reflux
Egd to diagnose
Balloon dilation to treat (multiple needed)

69
Q

Malignant esophageal strictures

A

Esophageal steering for palliation
Plus chemo/radiation for palliation

70
Q

Diaphragm paralysis

A

If symptoms not debilitating, allow 1-2 years for recovery
Else do plication

Pacing for narrow indications. Requires intact phrenic nerves. Central apnea, spinal cord, degenerative diseases, mechanically ventilated patients

71
Q

Approach to cervical esophagus (injury)

A

Left cervical incision

72
Q

approach to thoracic esophagus

A

Right thoracotomy

73
Q

Distal esophageal injuries

A

Left thoracotomy or belly approach.
If a proximal/distal landing zone is feasible than covered stent could be used (but GE junction tear poses challenge here)

74
Q

Screening for lung cA

A

Annal low dose CT for age 55-74, >30 py smoking history with less than 15 years quitting

75
Q

Caustic esophageal injury

A

If no perforation or severe injury, thx conservatively w Npo/ppi/abx and maybe steroids. Serial cxrs to rule out late perf

Consider g tube for kids w small esophagus.
Monitor for strictures which usually req serial dilations

Esophageal resection for perforation or transmural necrosis. Respect all necrotic tissue

76
Q

Esophageal perforation

A

Cervical perf often contained. Scm incision. Repair primarily of defect easily seen, otherwise irrigate and drain

Upper and middle Thiracic esophagus, do right thoracotomy, do longitudinal myotomy and close primarily with 2 layers of interrupted absorbable sutures over bouvier.

If primary repair not possible or unstable, T tube diversion, esophageal exclusion or resection with delayed reconstruction

77
Q

Approach to distal esophagus

A

Left posterolat thoraco

78
Q

LAM

A

Proliferation of smooth muscle cells throughout lung. Leads to air trapping and cysts. Can also cause bleeding and chylothorax

Anatomical resection indicated but disease often is diffuse and leads to lung transplant

Women in 20-30

Estrogen and progesterone sensitive but limited efficacy

79
Q

Zenkers

A

do crycooharyngeal myotomy
If larger than 3cm can use oral approach and divide w stapler

80
Q

Thymoma

A

Stage I - not invading capsule
II - invades capsule
IIB - invade beyond capsule into neighboring fatty tissue
III- growth into pericardium/lungs/great vessels
iVA - pleural/pericardial spread
IVb- distant organs

Good survival even for stage IV

Respect 1/2.
3/4 get definitive chemo rad or neoadj with reevaluation for surgery

81
Q

Risk for tracheal dehiscence

A

Length removed more than 4cm
Diabetes
Redo surgery
Young patients
Laryngotracheal anast

82
Q

Solitary fibrous tumor

A

50/60yo presentation

Arise from pleura or chest wall

May produce insulin like growth factor leading to HYPOglycemia

Resection is treatment.

Not responsive to chemo/rad

Confused for mesothelioma

83
Q

LVRS exclusion

A

Fev1 or dlco below 20%

Homogenous disease

84
Q

Malignant pleural mesothelioma

A

Surgery for I-IIIA disease (if N2-> not resectable. Contra lateral mediastinal nodes or supraclavicular nodes, if T4 -> not resectable. Complete involvement of all pleural surfaces and invasion of nigh print organs/spine/peritoneum/contra lateral pleura)

No difference between extrapleural pneumonectomy and radical pleurectomy

All should get additional chemo/and or rads

85
Q

Non seminoma germ cell

A

Elevated afp usually.
Nwoadjuvant platinum chemo then resect residual tissue
Salvage chemo if tumor markers don’t normalize.

86
Q

Teraratoma

A

At least two tissue types
Usually benign but resect because they can become malignant

87
Q

Seminoma

A

No AFP elevation
Large homogeneous smooth mass on imaging
Chemotherapy +/- radiation and resectiioj for residual mass

88
Q

Lymphoma

A

Diagnose with core needle or excisional biopsy. fNA doesn’t get enough tissue.

Treat with chemo and radiation

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