CHAPTER 25- THORACIC.txt

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CHAPTER 25- THORACIC.txt
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  1. Azygos vein
    runs along the right side and dumps into the superior vena cava
  2. Thoracic duct
    runs along the right side, crosses midline, and dumps into left subclavian vein at junction with internal jugular vein.

    Crosses at T4-T5
  3. Which is longer, L or R mainstem bronchi?
    Left mainstem bronchi is longer than the right
  4. Which pulmonary artery is longer before its first branch?
    right pulmonary artery longer than left before 1st branch
  5. what nerve runs anterior to the hilum?
    phrenic nerve
  6. What nerve runs posterior to hilum?
    vagus nerve
  7. Whats the right lung volume?
    Whats the left lung volume?
    • Right lung volume 55% (3 lobes: RUL, RML, and RLL)
    • Left lung volume 45% (2 lobes LUL, LLL and lingula)
  8. What muscles are used in quiet inspiration:
    What are the greatest changes in dimension:
    • 1) diaphragm 80%
    • 2) intercostals 20%

    Greatest changes in dimension are superior/inferior
  9. Accessory muscles
    • 1) sternocleidomastoid muscle (SCM)
    • 2) levators
    • 3) serratus posterior
    • 4) scalenes
  10. Type I pneumocytes:
    gas exchange
  11. Type II pneumocytes
    surfactant production
  12. Pores of Kahn
    direct air exchange between alveoli
  13. Pleural fluid
    • 1) 1-2L/day
    • 2) parietal pleura produces pleural fluid cleared by lymphatics in the visceral pleura
  14. Pulmonary function tests:
    • 1) need predicted postop FEV1 >0.8 (or at least 40% of the predicted value).
    • - If it is close --> get qualitative V/Q scan to see contribution of that portion of the lung to overall FEV1 --> if low, may still be able to resect

    • 2) need predicted postop DLCO>11-12ml/min/mmHg CO (at least 50% of the predicted value)
    • - represents carbon monoxide diffusion capacity
    • - this value is based on:
    • 1) pulmonary capillary surface area
    • 2) hemoglobin content
    • 3) alveolar architecture

    3) need predicted postop FVC >1.5L

    4) no resection if preop pCO2 >45 or pO2 <50

    5) No resection if preop VO2 max <10ml/min/kg
  15. Decision making in patients who present with a solitary pulmonary nodule
    see pg 161
  16. Lung Ca symptoms
    patients can be asymptomatic with finding on routine CXR or present with atelectasis, PNA, pain, or weight loss
  17. What is the most common cause of cancer related death in the united states?
    lung ca
  18. What has the strongest influence on survival in lung cancer?
    nodal involvement
  19. What is the single most common site of metastasis of lung ca?
    Where else can it go?
    1) brain

    • 2) can also go to:
    • 1- supraclavicular nodes
    • 2- other lung, bone
    • 3- liver
    • 4- adrenals
  20. What is the recurrence rates of lung cancer, and how does it usually appear?
    • 1) recurrence most commonly appears as disseminated metastases (brain most common)
    • 2) 80% of recurrences are within 1st 3 years
  21. What is the overall survival rate of lung cancer-With and without resection?
    Lung cancer overall 5 year survival rate-10%

    With resection- 30%
  22. Which stages are resectable; which are partially resectable?
    How is it most commonly resected?
    Stage I and II disease resectable

    T3, N1, M0 (stage IIIa) possibly resectable

    lobectomy or pneumonectomy most common; need to sample suspicious nodes
  23. What is the most common lung Ca?
    adenocarcinoma is the most common lung Ca, not squamous
  24. Non-small cell carcinoma
    • 1) 80% of lung Ca
    • 2) squamous cell carcinoma usually more central
    • 3) adenocarcinoma usually more peripheral
    • 4) local recurrences increased with squamous cell Ca
    • 5) distant metastases increased with adenocarcinoma
    • 6)other types of non-small cell Ca- undifferentiated large cell and mixed tumors
  25. TNM staging system for lung Ca
    • T1: <3cm
    • T2>3cm but >2cm away from carina
    • T3: invasion of chest wall, pericardium, diaphragm or <2cm from carina
    • T4: mediastinum, esophagus, trachea, vertebra, heart, great vessels, malignant effusion (all indicate unresectability)

    • N1: ipsilateral hilum nodes
    • N2: ipsilateral medistinal nodes (unresectable)
    • N3: contralateral mediastinal or supraclavicular nodes (unresectable)

    M1: distant metastasis

    Stages: add this in....
  26. Small cell carinoma
    • 1) 20% of lung Ca neuroendocrine in origin
    • 2) usually unresectable at time of diagnosis (<5% candidates for surgery)
    • 3) overall 5 year survival rate; very poor prognosis
    • 4) stage T1, N0, M0- 5 year survival rate 50%
    • 5) most get just chemotherapy and XRT
  27. Paraneoplastic syndromes
    • 1) squamous cell Ca- PTH-related peptide
    • 2) Small cell Ca- ACTH, ADH
    • 3) Small cell ACTH- most common paraneoplastic syndrome
  28. Mesothelioma
    • 1) most malignant lung tumor
    • 2) aggressive local invasion, nodal invasion, and distant metastases common at time of exposure
    • 3) asbestos exposure
  29. Non-small cell & small cell chemotherapy for stage II or higher-
    Non-small cell Ca chemotherapy (stage II or higher)- (1) carboplatin (2) taxol

    Small cell lung Ca chemotherapy- (1) cisplatin (2)etoposide

    XRT can be used as well
  30. Mediastinoscopy
    1) used for centrally located tumors and patients with suspicious adenopathy (>0.8cm or subcarinal >1.0cm) on chest CT

    2) does not assess aortopulmonary window nodes (left lung drainage)

    3) assesses ipsilateral (N2) and contralateral (N3) mediastinal nodes; if positive tumor unresectable

    • 4) looking into middle mediastinum with mediastinoscopy
    • 1- Left sided structures: (1) RLN, (2) esophagus, (3) aorta, (4) main PA
    • 2- Right sided structures: azygous and SVC
    • 3- anterior structures (1) innominate vein (2) innominate artery (3) right PA
  31. Chamberlain procedure
    assesses aortopulmonary window nodes; go through left 2nd rib cartilage
  32. Bronchoscopy
    needed for centrally located tumors
  33. Pancoast tumor
    1) tumor invades apex of chest wall and patient's have Horner's syndrome or ulnar nerve symptoms
  34. 2) Horners: invasion of sympathetic chain:
    • 1- ptosis
    • 2- miosis
    • 3- anhidrosis
  35. Coin lesion
    • 1) overall 5%-10% are malignant
    • 2) age <50 - <5% malignant
    • 3) age >50- >50% malignant
    • 4) Benign disease is suggested by: no growth in 2 years, smooth contour
    • 5) core needle biopsy frequently nondiagnostic
  36. How does asbestos exposure increase lung Ca risk?
    increases lung Ca risk by 90x
  37. Bronchoalveolar Ca
    1)can look like pneumonia

    2) grows along alveolar walls

    3) multifocal
  38. Metastases to the lung
    if isolated and not associated with any other systemic disease, may be resected for:

    • 1) colon
    • 2) renal cell Ca
    • 3) sarcoma
    • 4) melanoma
    • 5) ovarian or endometrial Ca
  39. carcinoids
    • 1) neuroendocrine tumor, usually central
    • - 5% have metastases at time of diagnosis; 50% have symptoms

    2) Typical carcinoid- 90% 5-year survival rate

    3) atypical carcinoid- 60% 5 year survival rate

    4) Treatment: resection; treat like cancer

    5) Outcome closely linked to histology; recurrency increased with positive nodes or tumors >3cm
  40. Bronchial adenomas:
    • Malignant tumors:
    • 1) adenoid cystic adenoma
    • 2) mucoepidermoid adenoma
    • 3) mucous gland adenoma

    • - slow growth, no metastases
    • Tx Resection

    • Adenoid cystic adenoma
    • 1) submucosal glands; spread along perineural lymphatics, well beyond endoluminal component; XRT sensitive
    • 2) slow growing; can get 10-year survival with incomplete resection
    • 3) Tx: resection; if unresectable, XRT can provide good palliation
  41. Hamartomas
    • 1) most common benign adult lung tumor
    • 2) have calcifications and can appear as a popcorn lesion on chest CT
    • 3) diagnosis can be made with CT
    • 4) do not require resection
    • 5) repeat chest CT in 6 months to confirm diagnosis
  42. Mediastinal tumors in adults
    1) most are asymptomatic; can present with chest pain, cough, dyspnea

    2) Neurogenic tumors- most common mediastinal tumor in adults and children, usually in posterior mediastinum

    • 3) Location:
    • Anterior(thymus)- most common site for mediastinal tumor
    • T's -->
    • 1) thymoma (#1 anterior mediastinal mass in adults)
    • 2) Thyroid cancer and goiters
    • 3) T-cell lymphoma
    • 4) Teratoma (and other germ cell tumors)
    • 5) Parathyroid adenomas

    • 4) Middle (heart, trachea, ascending aorta)
    • 1) pericardial cysts
    • 2) bronchiogenic cysts
    • 3) enteric cysts
    • 4) lymphoma

    • 5) Posterior (esophagus, descending aorta)
    • 1) enteric cysts
    • 2) neurogenic cysts
    • 3) lymphoma
  43. Thymoma
    • 1) all thymomas require resection
    • 2) thymus too big or associated with refractory myasthenia gravis --> resection
    • 3)50% of thymomas are malignant
    • 4) 50% of patients have symptoms
    • 5) 50% with patients with thymomas have myasthenia gravis
    • 6) 10% of patients with myasthenia gravis have thymomas

    • 7) Myasthenia gravis- fatigue, weakness, diplopia, ptosis, antibodies to acetylcholine receptors
    • 8) Treatment: anticholinesterase medications, plasmapheresis, steroids
    • 9) 80% get improvement with thymectomy, including patients who do not have thymomas
  44. Lymphoma
    1) T-cell most common (non-hodgkins lymphoma)- lymphoblastic variant most common

    2) Hodgkin's lymphoma- nodular sclerosing most common

    3) Treatment: Chemotherapy and XRT
  45. Germ cell tumors
    1) need to biopsy (usually one with mediastinoscopy)

    • Teratoma:
    • 1- most common germ cell tumor in mediastinum
    • 2- Treatment: chemotherapy and XRT

    • Seminoma:
    • 1- most common malignant germ cell tumor in the mediastinum
    • 2- Treatment: XRT (extremely sensitive); chemotherapy for positive nodes or residual disease; surgery for residual disease after that

    • Nonseminoma
    • 1- 90% have elevated beta-HCG or alpha-fetoprotein
    • 2- treatment: cisplatin-based chemotherapy and XRT; surgery for residual disease
  46. Cysts
    • 1) Bronchogenic- posterior to carina
    • Tx: resection

    • 2) Pericardial- at right costophrenic angle.
    • Tx: resection
  47. Neurogenic tumors:
    • 1) have pain, neurologic deficit
    • Tx: resection

    • 2) Neurolemmoma- most common
    • 3) Paraganglioma- produce catecholamines

    • 4) Nerve sheath- associated with von Recklinghausen's disease
    • 5) can also get neuroblastomas and neurofibromas
  48. Sympomatic/Asymptomatic and benign/malignant in terms of mediastinal masses:
    50% of symptomatic mediastinal masses are malignant

    90% of asymptomatic mediastinal masses are benign
  49. Trachea tumors
    • Benign tumors:
    • Adults- papilloma
    • Children- hemangiomas

    • Malignant-
    • squamous cell carcinoma
  50. Whats the most common late complication after tracheal surgery
    granulation tissue formation
  51. What is the most common early complication after tracheal surgery?
    • laryngeal edema
    • Tx: reintubation, racemic epinephrine, steroids
  52. post-intubation stenosis:
    1) at stoma site with tracheostomy, at cuff site with ET tube

    2) may be able to treat with serial dilatation or with laser

    3) may need resection with end-to-end anastomosis if severe
  53. Tracheoinnominate fistula
    1) tracheostomy- needs to be between the 1st and 2nd tracheal rings not >3 rings---> risk tracheoinnominate fistula

    2) Tx: overinflate balloon to plug hole or stick your finger in hole and depress innominate artery. Resect innominate and place graft. Leave trachea alone. Use new tracheostomy site.
  54. Tracheoesophageal fistula
    • 1) use large-volume cuff below fistula
    • 2) may need decompressing gastrostomy
    • 3) treatment: tracheal resection, reanastomosis, sternohyoid flap
  55. Lung Abscess
    • 1) necrotic area, most commonly associated with aspiration
    • 2) most commonly in posterior segment of RUL and superior segment of RLL
    • 3) Treatment:
    • 1- antibiotics 95% successful; CT guided drainage if that fails
    • 2- surgery if this fails or cannot rule out cancer ( >6cm, failure to resolve after 6 weeks)
    • 4) chest CT can help differentiate empyema from lung abscess
  56. Empyema
    • 1) usually secondary to pneumonia and subsequent parapneumonic effusion (staph, strep)
    • 2) can also be due to esophageal, pulmonary, or mediastinal surgery

    • 3) Symptoms:
    • 1- pleural fluid often has WBCs>500cells/cc
    • 2- positive gram stain

    • 4) Exudative phase (1st week)- tx: (1) chest tube (2) antibiotics
    • 5) Fibrinoproliferative phase (2nd week)- tx: (1) chest tube (2) antibiotics
    • 6) Organized phase (3rd week)- tx: (1) likely need decortication (2) fibrous peel occurs around lung

    • 7) May need Eloesser flap (direct opening to external environment) for chronic unresolving empyema
    • 8) Can also place a chest tube that is gradually pulled out
  57. Chylothorax
    • 1) fluid milky white; has increased lymphocytes and TAGs (>110mL/uL); Sudan red stains for fat
    • 2) fluid resistant to infection
    • 3) 50% secondary to trauma or iatrogenic injury
    • 4) 50% secondary to tumor (lymphoma most common, due to tumor burden on lymphatics
    • 5) injury above T5-6 results in left-sided chylothorax
    • 6) injury below T5-6 results in right-sided chylothorax
    • 7) 3-4 weeks of conservative therapy (chest tube, octreotide, low-fat diet or TPN)
    • 1- if that fails, surgery with ligation of thoracic duct on right side low in mediastinum (80% successful) if chylothorax secondary to trauma or iatrogenic injury.
    • 2- For malignant causes of chylothorax, can perform mechanical or talc pleurodesis (less successful than above)
  58. Massive Hemoptysis
    • 1) >600cc/24hr; bleeding is from high-pressure bronchial arteries
    • 2) most commonly secondary to: infection, mycetoma most common; death due to asphyxation
    • 3) Treatment:
    • 1- place bleeding side down if known
    • 2- rigid bronchoscopy to identify site
    • 3- mainstem intubation to side opposite of bleeding to prevent drowning in blood
    • 4- to OR for lobectomy or pneumonectomy
    • 5- bronchial artery embolization if not suitable for surgery
  59. Spontaneous Pneumothorax
    • 1) tall, healthy, thin, young males
    • 2) Recurrence risk after 1st pneumothorax 20%, after 2nd pneumothorax 60%, after 3rd pneumothorax 80%
    • 3) results from rupture of a bleb in the apex of the upper lobe of the lung; can occur in the superior segment of the lower lobe
    • 4) more common on the right
    • 5) Tx: chest tube
    • 6) Surgery for recurrence, large blebs on CT scan, air leak >7 days, nonreexpansion
    • also need surgery for high-risk profession (airline pilot, diver, mountain climber) or patients who live in remote areas
    • 7) surgery consists of thoracoscopy, apical blebectomy, and mechanical pleurodesis
  60. Bronchiogenic cysts (see also Chapter 43)
    • 1) most common cysts of the mediastinum
    • 2) abnormal lung tissue outside lung; did not get connected to the bronchial system
    • 3) usually posterior to the carina
    • 4) Treatment: remove cyst
  61. Sequesteration (see also chapter 43)
    • 1) lung tissue in lung not connected to bronchial tree
    • 2) received blood supply from anomalous systemic arteries--> usually off thoracic aorta
    • 1- can also come from the abdominal aorta through the inferior pulmonary ligament
    • 3) venous blood supply is either the pulmonary veins or systemic veins
    • 4) Extralobar- more common in children; more likely to have systemic vein drainage
    • 5) Intralobar- more common in adults; more likely to have pulmonary vein drainage
    • 6) Treatment: lobectomy
  62. Solitary pulmonary nodule with history of previous cancer
    • 1) sarcoma/melanoma--> nodule more likely metastases
    • 2) Head/Neck/Breast --> nodules more likely primary lung Ca
    • 3) GI/GU--> metastases or primary
    • 4) In the case of a primary cancer with a resectable lung metastasis, take out primary 1st, then metastasis
  63. Tension Pneumothorax
    most likely to cause arrest after blunt trauma; impaired venous return
  64. Catamenial pneumothorax
    occurs in temporal relation to menstruation

    caused by endometrial implants in the visceral lung pleura
  65. Residual hemothorax despite 2 good chest tubes
    OR for thorascopic drainage
  66. Clotted hemothorax:
    • 1) Surgical drainage if :
    • 1- >25% of lung
    • 2- air fluid levels
    • 3- signs of infection (fever, inc WBCs)

    2) surgery in 1st week to avoid peel
  67. Broncholiths
    usually secondary to infection
  68. Mediastinitis
    usually after cardiac surgery
  69. Whiteout on chest x-ray
    • 1) midline shift toward whiteout- most likely collapse --> need bronchoscopy to remove plug
    • 2) No shift- CT scan to figure it out
    • 3) Midline shift away from whiteout- most likely effusion--> place chest tube
  70. Bronchiectasis
    1) acquired from: (1) tumor (2) infection (3) cystic fibrosis

    2) Diffuse nature prevents surgery in most patients
  71. Tuberculosis:
    1) lung apices; get calcifications, caseating granulomas

    2) Ghon complex--> parenchymal lesion + enlarged hilar nodes

    3) Treatment: (1) INH (2) rifampin (3) pyrazinamide
  72. Sarcoidosis
    non-caseating granulomas
  73. Effusion- Exudative
    • 1) protein >3
    • 2) specific gravity >1.016
    • 3) LDH ratio (pleural fluid:serum) >0.6
    • 4) decreased glucose
  74. Evaluation of Pleural Fluid
    • WBC:
    • Transudate: <1,000
    • Exudate: >1,000
    • Empyema: >1,000 (>50k most specific)

    • pH
    • Transudate: 7.45-7.55
    • Exudate: <7.45
    • Empyema: <7.3

    • Pleural fluid protein to serum ratio
    • Transudate: <0.5
    • Exudate: >0.5
    • Empyema: >0.5

    • Pleural Fluid LDH to serum ratio
    • Transudate: <0.6
    • Exudate: >0.6
    • Empyema: >0.6
  75. Recurrent pleural effusion:
    1) can be treated with mechanical pleurodesis

    2) Talc pleurodesis for malignant pleural effusions
  76. Airway fires:
    1) usually associated with the laser

    2) Treatment: stop gas flow, remove ET tube, reintubate for 24hrs; bronchoscopy
  77. AVMs
    • 1) connections between the pulmonary arteries and pulmonary veins
    • 2) usually in lower lobes
    • 3) can occur with Osler-Weber-Rendu disease
    • 4) Symptoms: hemoptysis, SOB, neurologic events
    • 5) Treatment: embolization
  78. Chest Wall tumors
    • 1) Benign- osteochondroma most common
    • 2) Malignant- chondrosarcoma most common

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