(Iii-Surgery) Lung Chest And Esophagus

Front 1

Describe the epidemiology of lung cancer

Back 1

#1 cause of death from cancer in both men and women

Increasing in women compared to men

Smoking is by far #1 risk factor

Front 2

If an asymptommatic nodule is found on x-ray and is unchanged for ____ years, no follow up is needed

Back 2

2 years

Front 3

CT to check for lung cancer should include these 2 organs:

Back 3

Should extend to include liver and adrenals as these are frequent sites of mets.

Front 4

Two types of lung cancer that are centrally located:

Back 4

Small cell and squamous

Front 5

Is bronchoscopy better for central or peripheral nodules?

Back 5

Central

Front 6

Suppose you were working a patient up whom you are worried about lung cancer based on nodule found on x-ray. What would you do?

Back 6

Get biopsy. Bronchoscopy vs FNA-B.

If bronchoscopy is unsuccessful try FNA-B.

If both unsuccessful at showing cancer but you still suspect it, consider resection

Front 7

Ectopic hormone often seen in non-small cell lung cell cancers:

Back 7

PTH

Front 8

Describe the lung cancer syndrome:

Horner Syndrome

Back 8

Sympathetic nerve paralysis (miosis, ptosis, ipsilateral ahidrosis)

Front 9

Describe the lung cancer syndrome:

Pancoast syndrome

Back 9

Tumor in the superior sulcus which causes C8-T2 nerve damage. Pain radiating to arm

Front 10

Describe the lung cancer syndrome:

SVC syndrome

Back 10

Obstruction of SVC producing swelling, dyspnea, cough, HA, syncope.

Sx worse when bending forward or when waking up in morning

Front 11

Describe the following lung cancer syndrome:
Trousseau syndrome

Back 11

Venous thrombosis associated with metastatic cancer

Front 12

Describe the following lung cancer syndrome:

Eaton-Lambert

Back 12

Antibodies to presynaptic nerve terminals - causes an MG like picture.

Seen with small cell lung cancer

Rx = plasmapheresis and immunosuppression

Front 13

For which stages of NSCLC is surgery indicated:

Back 13

Stages I, II, III-A

Front 14

Is the myasthenia gravis that is seen with thymoma considered Eaton-Lambert?

Back 14

No!

Front 15

What is the best lab test to order if determining a patient can tolerate a lobectomy / penumectomy?

What is the value you are looking?

Back 15

FEV1 seems to correlate the best. Next best is DLCO.

As for lab values, you want FEV1 > 2L (this will leave about 1L remaining post-op). Normal FEV1 is approx 3 L. FEV1 = 2L = 40-50% predicted.

Front 16

Treatment for thymoma

Back 16

Usually found @ high grade. Do surgery + radiation

Front 17

Most common cause of spontaneous pneumothorax:

Back 17

Rupture of pulmonary bleb due to increased transpulm pressure.

Other common causes including apical bullae in COPD, Connective tissue disorders, CF, are less common

Front 18

Risks for increased transpulmonary pressure leading to rupture of a bleb

Back 18

Falls, coughing, scuba diving, fighter jet

Front 19

Standard diagnosis of pneumothorax:

Back 19

PA and lat chest x-ray

Front 20

Treatment for small asymptommatic pneumothorax

Back 20

Nothing (monitoring)

Front 21

Treatment for a clinically significant pneumothorax (>30%):

Back 21

Chest tube with suctioning via 1-way heimlich valve. If this fails to cause re-expansion, pt will require hospitalization with under-water suctioning.

Front 22

Recurrence rate for simple pneumothorax

Back 22

50% after first one, 75% after second one, and 80% after third one.

Front 23

Indications for surgery for a patient with pneumothorax

Back 23

Pts with air leaks > 7 days
High risk occupations (fighter pilots)
Pts with poor pulmonary fx
Pts who have to travel far for medical therapy

Front 24

Two types of tumors that can occur in the thymus

Back 24

Thymoma
Lymphoma

Note that these two can be tough to distinguish from each other

Front 25

Percentage of patients with thymoma who have MG

Back 25

30%

Front 26

Percentage of patients with MG who have a thymoma

Back 26

15%

Front 27

Treatment for thymoma

Back 27

TOTAL removal of thymus, with neo-adjuvent chemotherapy / radiation

Front 28

Is MG an indication for early thymectomy?

Back 28

Yes

Front 29

Describe the pleural effusion seen in cancer

Back 29

Often bloody, with positive cytology, low glucose

Front 30

Why should you be careful in treating a pleural effusion caused by malignancy?

Back 30

Because the prognosis is already so poor, you want the patient to have the highest quality of life possible for the remaining months

Front 31

Describe the effusion seen with rheumatoid arthritis:

Back 31

Very low gluocse. Green in color. Predominantly lymphocytic

Front 32

Describe the effusion seen in pulmonary embolis:

Back 32

Sanguinous

Front 33

#1 cause of chylothorax

Back 33

Surgical procedures

Front 34

Most common types of cancers that produce pleural effusions

Back 34

Lung, breast, lymphoma (10%)

10% are caused by pleural tumors

Front 35

Amount of fluid needed for an effusion to show up on xray (as blunting of costophrenic angle)

Back 35

200-300 mL

Front 36

Workup for a pleural effusion

Back 36

Chest X-ray

Thoracentesis

Front 37

Before fixing an empyema, what should you do first?

Back 37

CT scan

Front 38

Treatment for malignant pleural effusion

Back 38

Palliative surgery

Front 39

Indications for use of sclerosing agents like TALC:

Back 39

Chemical pleurodesis has been used to manage malignant pleural effusions, refractory nonmalignant pleural effusions, and pneumothorax.

Front 40

#1 cause of empyema:

Back 40

Parapneumonic (Secondary to pneumonia, or lung abscess)

#2 is surgery

Front 41

Most common organisms associated with empyema:

Back 41

Anerobes in adults,

Staph in kids <2

Front 42

Sx of empyema:

Back 42

Diminished breath sounds,
Fever, tachycardia
Clubbing
Diminished breath sounds

Front 43

This is your most important lab test when it comes to diagnosing empyema vs other causes of effusion

Back 43

pH. LOW in empyema

Front 44

Workup of empyema

Back 44

CT scan (especially if worried about loculated empyema)

Bronchoscopy to rule out obstruction

Thoracentesis

Front 45

Treatment algorithm for empyema:

First step

Back 45

Do CT / diagnostic thoracentesis.

If clear do gram stain and check pH

If pus, convert to open drainage

Front 46

Treatment algorithm for empyema:

Pus found on thoracentesis

Back 46

Do sonogram. Looking for loculations

If no loculations, can do simple chest tube

If loculations, will need to do wide surgery

Front 47

Preferred diagnostic test of choice for pt with dysphagia (according to online cases)

Back 47

Barium swallow

Front 48

Definitive diagnosis of esophageal cancer:

Back 48

EGD

Front 49

Most common type of esophageal cancer worldwide:

Back 49

Squamous cell carcinoma

Front 50

Most common type of esophageal cancer in USA:

Back 50

Adenocarcinoma

Front 51

What is the histological change seen in Barrett esophagus:

Back 51

Change from squamous cell to columnar cells (with goblet cells)

Front 52

Risk of adenocarcinoma in patient with Barrett's compared to general population

Back 52

Twice as likely

Front 53

Do all patient's with Barrett's require surgery?

Back 53

No! Only those with high grade dysplasia.

Lower grades can be treated with medical therapy and periodic monitoring

Front 54

Surveillance guidelines for a patient with Barretts without dysplasia or cancer:

Back 54

Endoscopy every three years. Only do surgery if pt is refractory to treatment

Front 55

Indications for surgery for GERD:

Back 55

Barrett's with high grade dysplasia / cancer

Regurgitation

Pts with a heavy medical regimen / burden

Pts who are refractory to medical treatment

Front 56

Would esophageal cancer present as difficulty swallowing solids, liquids, or both?

Back 56

Mostly solids (occurs at about 60% obstruction)

Front 57

Treatment for esophageal carcinoma

Back 57

Most palliative. May do radiation first to shrink tumor before operating.

Front 58

What is the surgery of choice for GERD (assuming surgery is indicated)

Back 58

Nissan Fundoplications (wrap the fundus of the stomach around the esophagus)

Front 59

Risk factors for esophageal strictures:

Back 59

GERD
Radiation
Infection
Corrosion
Sclerotherapy for bleeding varices

Front 60

Diagnostic test(s) of choice for esophageal stricture

Back 60

Barium swallow followed by EGD to rule out cancer

Front 61

What percentage of esophageal perforations / rupture are iatrogenic?

Back 61

50-75% of cases

Front 62

Differential diagnosis of esophageal rupture:

Back 62

MI
Spontaneous pneumothorax
Pancreatitis
Perforated peptic ulcer

Front 63

What are the signs and symptoms of perforation that would NOT be expected in a partial tear:

Back 63

Subcutaneous emphysema

Mediastinal emphysema (Hammon's crunch on auscultation)

Front 64

Diagnostic workup of Boerhaves

Back 64

CXR to look for mediastinal or SC emphysema

Esophagogram with water-soluble contrast

-Endoscopy plays little to no role in workup

Front 65

Treatment for rupture and/or perforation of esophagus:

Back 65

Surgery for full thickness tears

NG decompression and gastric lavage for most partial tears. (Surgery if severe)

Front 66

What is an apple core lesion?

Back 66

A circumferential narrowing of the esophagus noted on barium swallow. Often seen in cancer or stricture

Front 67

Follow-up testing if esophageal cancer is found

Back 67

CT scan of abdomen, pelvis and chest for metastases

Endoscopic ultrasound to see depth of invasion of tumor and nodal disease