Thoracic Flashcards

Question

Pancoast tumor

Answer 1

Lung cancer that invades the thoracic inlet (first rib, brachial plexus, subclavian) They CAN present with Horner’s or SVC syndrome Pancoast tumors need neoadjuvant chemo-rad then surgery

Answer 2

MC is small cell lung CA. Also caused by central lines Surgery to resect CA is contraindicated with SVC syndrome Tx: Endovascular stent for all!! Radiation is no longer supported as treatment

Answer 3

Screening CT chest, need all 3: - 55-80 y/o - 30 pack year history - Currently smoking or quit < 15 years ago

Answer 4

Pulmonary nodule - Must be < 3 cm to be called nodule - MC lesion is granuloma (laminated calcification): No further work up - MC tumor is hamartoma (popcorn calcification) (cartilage and fat): Diagnoses made with repeat CT in 3 months - If > 3 cm go straight to resection - < 8 mm less likely to be malignant  follow with CT - > 8 mm: low risk = CT, moderate risk = CT/PET, high risk = biopsy * High risk  smoker, age > 50

Answer 5

Children – 90% benign. MC benign hemangioma. MC malignant Carcinoid Adults – 90% malignant. MC benign papilloma, MC malignant squamous cell CA For all 3 below Bronchial gland tumors  resection with 1 cm margin and post op XRT 1. Carcinoid – 90% of all bronchial gland tumors in adults - Typical 90% - 5% mets. Pink, purple, friable mucosa. 5YS 95% - Atypical 10% - 50% mets, necrosis, 5YS 50% 2. Adenoid cystic - Mucosa intact, predilection for perineural invasion - Very responsive to XRT, avoid taking vital structures - Post op XRT after resection. 3. Mucoepidermoid

Answer 6

Malignant pleural effusion  TALC pleurodesis. Contraindication to this is non-re-expansion of the lung - If you can’t get lung up  indwelling pleural catheter

Answer 7

2/2 PNA & paraneumonic effusion (staph, strep); also 2/2 surgery Pleuritic chest pain, fever, SOB, cough All empyemas are infected by definition and is a form of complicated parapneumonic effusion and need drainage by CT or surgery - > 500 WBC, pH <7.2, glucose <40, bacteria = Need chest tube

Answer 8

- Uncomplicated = no infection, no loculations. Normal pH, normal glucose. Abx only, no drainage -Complicated – pH < 7.2, glucose < 40 (key), + gram stain = ALL need drainage -Exudative – Day 1-5 - 2/2 to lung infection. Sterile, NOT INFECTED pleural fluid: Tx: Just abx unless infected then Chest tube -Fibrinopurulent - After day 5 – ALL INFECTED: Drainage of fluid is mandatory. Tx: chest tubes + tPA and DNase, If does not resolve after 72 hours VATS deloculation -Organized – after 3 - 4 weeks – Lung trapped, thick fibrinous peel; lung won't expand; VATS decortication/deloculation - If lung won’t expand : VATS Decortication/deloculation. -If elderly or frail: Eloesser flap (open thoracic window)

Answer 9

High frequency ventilation can assist with closure ## Footnote Symptoms include tracheal secretions resembling saliva or gastric distension if intubated.

Answer 10

Bronchoscopy

Answer 11

Chylothorax >110 Triglycerides. MCC is iatrogenic. MC non-iatrogenic = lymphoma. Treatment: - FIRST thing to do is: Conservative X 2 weeks. 1st: high protein, low fat with medium chain fatty acids: FOR BOTH LYMPHOMA AND IATROGENIC -if this fails next step is: NPO, TPN without lipids, and octreotide - if above fails do lymphoscintigrophy to find leak if iatrogenic - If traumatic or iatrogenic, >1 L/day X5 days predicts failure -VATS ligation of thoracic duct on right side low in mediastinum OR can embolize thoracic duct if patient is too sick to operate - Malignant chylothorax  Difference here is you must do thoracentesis, and conservative measures as above, treat the cancer, NEVER OPERATE FOR THESE. if this fails will need talc pleurodesis - pleuroperitoneal shunting usually not recommended Chylous ascites MCC is lymphoma. Can be caused by trauma, surgery (especially in the retroperitoneum in the para-aortic area, especially after AAA repair), cirrhosis or TB Triglycerides > 110 - Steps are the same as above - Peritoneovenous shunting are usually NOT recommended - If conservative management fails then ligate cysterna chyli, right side of aorta just below right renal artery ## Footnote No surgical repair while intubated; try to extubate first.

Answer 12

Massive hemoptysis = > 600 cc/24 hours. MC from bronchial arteries. MCC TB. Treatment  bleeding side down, double lumen ETT  1st step is to do a rigid bronchoscopy with cautery (do this to locate the bleed too). Tx: bronchial artery embolization has best chance to stop the bleed

Answer 13

MC lower lobes. Hemoptysis. Associated with osler weber rendu. Tx: embolization

Answer 14

- MC after tracheostomy. -Patients have a sentinel bleed followed by massive hemoptysis. -Best thing to do first is place an ETT distal to bleeding site (Secure airway). Also can try to hyperinflate the trach cuff, can try Utley Manuever, finger in distal trachea with anterior pressure Go to OR immediately for bronchoscopy but prep for median sternotomy first. - After airway control and control of bleed  median sternotomy and resect innominate artery. NO GRAFT. Repair trachea

Answer 15

Tracheoesophageal fistula – MC from hyperinflated ETT. Sx: tracheal secretions that look like saliva or gastric distension if intubated Dx: bronchoscopy Tx: remove tracheostomy (if present) place ETT with cuff below fistula. - No surgical repair while intubated. Try to extubate 1st. If unable then below - If intubated  Start PPI, place ETT balloon distal to fistula, Remove NGT, and place decompressive PEG. Wait until extubated for repair - If unable to extubate or poor surgical candidate  esophageal stent as bridge to surgery or definitive tx - If malignant TEF  esophageal stent and +/- tracheal stent Surgery  only when extubated. Only for BENIGN causes. No cancer. - Primary surgical treatment is tracheal resection with primary anastomosis. Closure of esophagus. Use muscle flaps. - If small < 5 mm , can argue no need for resection and primarily close all.

Answer 16

MCC is prolonged intubation, also tracheostomy too high 1-2 ring or cricothyroidotomy. - Symptoms present about 5 weeks after extubation - Dx: Bronchoscopy. - Treatment  tracheal resection and anastomosis - Bronchoscopic laser ablation and dilation does not work for tracheal stenosis caused by intubation.

Answer 17

Phrenic nerve (runs over anterior scalene), Anterior to posterior anatomical location of structures: clavicle, subclavian vein, Phrenic nerve, Anterior Scalene, Subclavian artery, brachial plexus, middle scalene, spinal accessory Surgery for thoracic outlet syndrome (all 3 below): 1st rib resection, divide anterior/middle scalene. Cervical rib resection (if present), Neurogenic TOS – MC TYPE. medial forearm and 4-5th fingers (MC ulnar affected). Dx: CXR look for cervical rib. Nerve conduction velocity < 60. Tx: Physiotherapy X 3 months. If that fails and NCV < 60 then OR above Paget von schrotter – Dx Duplex US. -Effor induced thrombosis of subclavian vein (e.g. baseball pitchers): acutely painful, swollen, blue limb - If acute and symptomatic 1st give full dose heparin, then only if acute (<2 weeks) Catheter thrombolytic. (If > 2 weeks don’t do thrombolytic). Then surgical repair (above) during same hospitalization or DC with AC and elective surgery Arterial TOS – Dx: angiogram. Tx: surgery above AND usually interposition bypass graft (artery usually too damaged for repair OR an aneurysm is present) - compression 2/2 anterior scalene hypertrophy (weight lifters); absent radial pulse with head turned to ipsilateral side= adson's test - If there is acute thrombosis: * Threatened limb: open balloon thrombectomy via brachial artery * Non-threatened limb: catheter directed thrombolytics * Both will need 1st rib resection and bypass during same admission

Answer 18

To Diagnose these: Core needle biopsy (avoid FNA) 1st, if unsuccessful and in anterior, the best method is  Chamberlain procedure. Can also use VATS to bx Incision and removal of anterior mediastinal masses  median sternotomy MC site for mediastinal tumors in adults and children – Anterior Anterior (The T’s) – MC here is thymoma, thyroid CA and goiter, Terrible Hodgkin’s and B-cell lymphoma, germ cell tumor (teratoma, seminoma, non-seminoma) Middle - (Heart, trachea, and ascending aorta) MC here is lymphadenopathy (lymphoma, infection, mets), bronchogenic pericardia and enteric cysts - Bronchogenic and enteric cysts should be resected to confirm dx. Leave pericardial cysts alone Posterior - (esophagus, descending aorta) MC here is neurogenic tumor (Neurofibroma, neuroganglioma, neuroblastoma), lymphoma, benign cyst MCC of mediastinal adenopathy  lymphoma. NHL MC. Teratoma – Benign if markers negative. Malignant if high AFP and BHCG. Tx: Resection and chemo if malignant. Bronchogenic and enteric cysts can get infected  resection Pericardial cyst  Leave alone, no CA risk Neurogenic tumors MC in paravertebral sulcus. Tx: resection. Neurolemma is MC (Shwannoma benign nerve sheathe tumor). Mediastinal masses in children Anterior - Thyroid CA, lymphoma = #1 anterior mass in children, teratoma Middle – T cell lymphoma, teratoma, cardiogenic or bronchogenic cyst Posterior – T cell lymphoma, neuroblastoma, neurogenic tumor

Answer 19

- All thymomas need resection (median sternotomy) - MC neoplasm in anterior mediastinum in adults - Thymus too big or any associated with myasthenia gravis  resection - Children never get thymomas - 50% are malignant. 50% symptomatic. - 50% of patients with thymoma have myasthenia. 10% of myasthenia have thymoma. - Thymectomy improves/resolves symptoms in 90% of myasthenia gravis WITHOUT a thymoma and only 25% WITH a thymoma

Answer 20

Dx: EMG, shows Jitter Tx: Pyridostigmine Indication for thymectomy: thymoma or severe disease Need to give post op steroids to avoid Addisonian crisis

Answer 21

2 umbilical arteries – from fetus to the placenta. Carries deoxygenated blood 1 umbilical vein – from placenta to fetus. Carries oxygenated blood High O2 content causes ductus arteriosus to close after birth (connection between descending aorta and left pulmonary artery= blood shunted away from lungs in utero) Lowered pulmonary vascular resistance causes foramen ovale to close after birth (shunts blood away from lungs)

Answer 22

VSD, ASD, PDA: L -> R shunt. Causes CHF Increasing heart rate, tachypnea, hepatomegaly, pulmonary edema

Answer 23

Left main coronary artery branches into LAD and circumflex. Right coronary artery MC has posterior descending artery. Less commonly PDA comes off of left circumflex. Left internal mammary artery (LIMA) to left anterior descending is best conduit for CABG 90% 20-year patency

Answer 24

Indications for CABG: 1. Left main (>50%) 2. 3 vessel disease 3. LAD (>70%) + circumflex disease

Answer 25

Valve area < 1 cm squared = severe. This is when symptoms start - Worst prognostic indicator is CHF, not syncope Indications for surgery: Severe with any symptoms or asymptomatic with < 0.6 cm valve area

Answer 26

MC cardiac tumor and MC benign tumor – myxoma, MC located in the left atrium (mobile lesions can cause obstruction of the AV valve; dx best= echo; also histological exam of distal embolus) MC primary malignancy – angiosarcoma MC mets to heart – lung CA MC pediatric cardiac tumor – rhabdomyoma (obstructive sx most common presentation, may exhibit spontaneous regression, carry association with tuberous sclerosis)

Answer 27

90% non-functional PET DOTATE to localize, or octreotide scan Tx: resection with 1 cm margin and post op XRT 90% of all bronchial gland tumors in adults - Typical 90% - 5% mets. Pink, purple, friable mucosa. 5YS 95% - Atypical 10% - 50% mets, necrosis, 5YS 50% Treatment: lobectomy

Thoracic Flashcards

(51 cards)