Surgical Recall: 71 - Thoracic Surgery

Front 1

What does VATS stand for?

Back 1

Video-Assisted Thoracic Surgery (VATS)

Front 2

What is thoracic outlet syndrome?

Back 2

Compression of the:

- Subclavian artery

- Subclavian vein OR

- Brachial plexus at the superior outlet of the thorax

Front 3

What are the causes of thoracic outlet syndrome?

Back 3

1. Various congenital anomalies, including cervical rib or abnormal fascial bands to the first rib, or abnormal anterior scalene muscle

2. Trauma: fracture of clavicle or first rib, dislocation of humeral head, or crush injuries

3. Repetitive motor injuries (baseball pitchers)

Front 4

What are the symptoms of thoracic outlet syndrome?

Back 4

- Paresthesias (neck, shoulder, arm, hand); 90% are in ulnar nerve distribution

- Weakness (neural/arterial)

- Coolness of involved extremity (arterial)

- Edema, venous distention, discoloration (venous)

Front 5

What are the most common types of symptoms with thoracic outlet syndrome?

Back 5

Neurologic

Front 6

Which nerve is most often involved in thoracic outlet syndrome?

Back 6

Ulnar nerve

Front 7

What are the signs of thoracic outlet syndrome?

Back 7

- Paget-von Schroetter syndrome (Venous thrombosis leading to edema, arm discoloration, and distention of superficial veins)

- Weak brachial and radial pulses in the involved arm

- Hypesthesia/anesthesia

- Occasionally, atrophy in the distribution of ulnar nerve

- Positive Adson maneuver / Tinel's sign

- Edema

Front 8

What is the Adson maneuver?

Back 8

Evaluates for arterial compromise (sign of thoracic outlet syndrome)

Patient:

1. Extends neck (lifts head)

2. Takes a deep breath and holds

3. Turns head toward examined side

Physician:

- Monitors radial pulse on examined side

- Test finding is positive if the radial pulse decreases or disappears during maneuver

Front 9

What is Tinel's test?

Back 9

Tapping of the supraclavicular fossa producing paresthesias

Front 10

What is the treatment of thoracic outlet syndrome?

Back 10

- Physical therapy (vast majority of cases)

- Decompression of the thoracic outlet by resecting the first rib and cervical rib (if present) if PT fails and as a last resort

Front 11

What are the most common types of benign chest wall tumors?

Back 11

1. Fibrous rib dysplasia (posterolateral rib)

2. Chondroma (at costochondral junction)

3. Osteochondroma (any portion of rib)

Front 12

What is the treatment of benign chest wall tumors?

Back 12

Wide excision and reconstruction with autologous or prosthetic grafts

Front 13

What are the most common malignant chest wall tumors?

Back 13

1. Fibrosarcoma

2. Chondrosarcoma

3. Osteogenic sarcoma

4. Rhabdomyosarcoma

5. Myeloma

6. Ewing's sarcoma

Front 14

What is the treatment of malignant chest wall tumors?

Back 14

Excision with or without radiation

Front 15

What is Tietze's syndrome?

Back 15

Non-infectious costochondral cartilage inflammation

Front 16

What is a pleural effusion?

Back 16

Fluid in the pleural space

Front 17

What are the causes of pleural effusions?

Back 17

1. Pulmonary infections (pneumonia)

2. Congestive heart failure (CHF)

3. SLE or rheumatoid arthritis

4. Pancreatitis (sympathetic effusion)

5. Trauma

6. Pulmonary embolism

7. Renal disease

8. Cirrhosis

9. Malignancy (mesothelioma, lymphoma, metastasis)

10. Post-pericardiotomy syndrome

Front 18

What are the symptoms of pleural effusions?

Back 18

- Dyspnea

- Pleuritic chest pain

Front 19

What are the signs of pleural effusions?

Back 19

- Decreased breath sounds

- Dullness to percussion

- Egophony at the upper limit

Front 20

What are the properties of a transudative pleural effusion?

Back 20

- Specific gravity <1.016

- Protein <3 g/dL

- Few cells

Front 21

What are the properties of an exudative pleural effusion?

Back 21

- Specific gravity >1.016

- Protein >3 g/dL

- Many cells

Front 22

What is the key diagnostic test for pleural effusions?

Back 22

Thoracentesis (needle drainage) with studies including cytology

Front 23

What is the treatment of pleural effusions?

Back 23

1. Pigtail catheter or thoracostomy (chest tube)

2. Treat underlying condition

3. Consider sclerosis

Front 24

What is an empyema?

Back 24

- Infected pleural effusion; must be drained, usually with chest tube(s)

- Decortication may be necessary if the empyema is solid

Front 25

What is decortication?

Back 25

Thoracotomy and removal of an infected fibrous rind from around the lung (think of it as taking off a fibrous "cortex" from the lung)

Front 26

What are the signs/symptoms of a lung abscess?

Back 26

- Fever

- Sputum

- Sepsis

- Fatigue

Front 27

What are the associated diagnostic studies for a lung abscess?

Back 27

- CXR: air-fluid level

- CT scan to define position and to differentiate from an empyema

- Bronchoscopy (looking for cancer / culture)

Front 28

What is the treatment for a lung abscess?

Back 28

- Antibiotics

- Bronchoscopy for culture and toilet

- With or without surgery

Front 29

What are the indications for surgery in a patient with a lung abscess?

Back 29

- Underlying cancer / tumor

- Refractory to antibiotics

Front 30

What are the surgical options for a lung abscess?

Back 30

- Lobectomy of lobe with abscess

- Tube drainage

Front 31

What is middle lobe syndrome?

Back 31

Recurrent right middle lobe pneumonia caused most commonly by extrinsic bronchial obstruction

Front 32

What is hemoptysis?

Back 32

Bleeding into the bronchial tree

Front 33

What are the causes of hemoptysis?

Back 33

1. Bronchitis (50%)

2. Tumor mass (20%)

3. TB (8%)

Other: bronchiectasis, pulmonary catheters, trauma

Front 34

Define MASSIVE hemoptysis?

Back 34

>600 cc / 24 hours

Front 35

What comprises the workup for hemoptysis?

Back 35

- CXR

- Bronchoscopy

- Bronchial A-gram

Front 36

What is the treatment for massive hemoptysis?

Back 36

- Bronchoscopy

- Intubation of unaffected side

- Fogarty catheter occlusion of bleeding bronchus

- Bronchial A-gram with or without embolization

- Surgical resection of involved lung

Front 37

What is the treatment of mild to moderate hemoptysis?

Back 37

- Laser coagulation

- +/- Epinephrine injection

Front 38

What is a spontaneous pneumothorax?

Back 38

Atraumatic spontaneous development of a pneumothorax

Front 39

What are the causes of spontaneous pneumothorax?

Back 39

- Idiopathic (primary)

- Bleb disease

- Emphysema

Front 40

What body habitus is associated with spontaneous pneumothorax?

Back 40

Thin and tall

Front 41

How do you diagnose spontaneous pneumothorax?

Back 41

CXR

Front 42

How do you treat a spontaneous pneumothorax?

Back 42

Chest tube

Front 43

What are the options if refractory, recurrent, or bilateral spontaneous pneumothoraces?

Back 43

Pleurodesis: scar the lung to the parietal pleura with a sclerosant (talc) via chest tube / thoracoscopy, or by thoracotomy and mechanical abrasion

Front 44

Who might also need a pleurodesis after the first episode of spontaneous pneumothorax?

Back 44

Those whose lifestyle places them at increased risk for pneumothorax (eg, pilots, scuba divers)

Front 45

What is a catamenial pneumothorax?

Back 45

Pneumothorax due to intrathoracic endometriosis

Front 46

What is malignant mesothelioma?

Back 46

Primary pleural neoplasm

Front 47

What are the types of malignant mesothelioma?

Back 47

1. Localized

2. Diffuse (highly malignant)

Front 48

What are the risk factors for malignant mesothelioma?

Back 48

- Exposure to asbestos

- Smoking

Front 49

What are the symptoms of malignant mesothelioma?

Back 49

- Dyspnea and pain = 90%

- Localized: pleuritic pain, joint pain and swelling, dyspnea

- Diffuse: chest pain, malaise, weight loss, cough

Front 50

What are the signs of malignant mesothelioma?

Back 50

Pleural effusions:

- Localized (10-15%)

- Diffuse (>75%)

Front 51

What are the radiographic tests for detecting malignant mesothelioma?

Back 51

- CXR may reveal a peripheral mass, often forming an obtuse angle with the chest wall

- CT scan is also performed

Front 52

How do you diagnose malignant mesothelioma?

Back 52

Pleural biopsy, pleural fluid cytology

Front 53

What is the treatment of malignant mesothelioma if localized?

Back 53

Surgical excision

Front 54

What is the treatment of malignant mesothelioma if diffuse?

Back 54

- Early stages may be resected, followed by radiation

- For more advanced stages, radiation, chemotherapy, or both are done

Front 55

What is the prognosis for malignant mesothelioma?

Back 55

- Localized: poor

- Diffuse: dismal (average life span after diagnosis is about 1 year)

Front 56

What is benign mesothelioma?

Back 56

Benign pleural mesothelioma

Front 57

What pleura is usually involved in a benign mesothelioma?

Back 57

Visceral pleura

Front 58

What is the gross appearance of benign mesothelioma?

Back 58

Pedunculated "broccoli or cauliflower" tumor on a stalk coming off of the lung

Front 59

What is the treatment for benign mesothelioma?

Back 59

Surgical resection with at least 1 cm clear margin

Front 60

What is the prognosis for benign mesothelioma?

Back 60

In contrast to malignant mesothelioma, the benign mesothelioma has an excellent prognosis with cure in the vast majority of cases

Front 61

What is the annual incidence of lung cancer in the US?

Back 61

170,000 new cases / year

Front 62

What is the number of annual deaths from lung cancer?

Back 62

150,000 - most common cancer death in the US in men AND women

Front 63

What is the #1 risk factor for bronchogenic carcinoma?

Back 63

Smoking (85%)

Front 64

Does asbestos exposure increase the risk of bronchogenic carcinoma in patients who smoke?

Back 64

Yes

Front 65

What type of lung cancer arises the most in non-smokers?

Back 65

Adenocarcinoma

Front 66

Cancer arises more often in which lobes of the lung?

Back 66

Right > Left

Upper lobes > Lower lobes

Front 67

What are the signs/symptoms of bronchogenic carcinoma?

Back 67

- Change in a chronic cough

- Hemoptysis, chest pain, dyspnea

- Pleural effusion (suggests chest wall involvement)

- Hoarseness (recurrent laryngeal nerve involvement)

- Superior vena cava syndrome

- Diaphragmatic paralysis (phrenic nerve involvement)

- Symptoms of metastasis / paraneoplastic syndrome

- Finger clubbing

Front 68

What is Pancoast's tumor?

Back 68

Tumor at the apex of the lung or superior sulcus that may involve the brachial plexus, sympathetic ganglia, and vertebral bodies, leading to pain, upper extremity weakness, and Horner's syndrome

Front 69

What is Horner's syndrome?

Back 69

Injury to the cervical sympathetic chain;

Think: "MAP"

1. Miosis (small pupil)

2. Anhydrosis of ipsilateral face

3. Ptosis

Front 70

What are the four most common sites of extrathoracic metastases of bronchogenic carcinoma?

Back 70

1. Bone

2. Liver

3. Adrenals

4. Kidney

Front 71

What are paraneoplastic syndromes?

Back 71

Syndromes that are associated with tumors but may affect distant parts of the body; they may be caused by hormones released from endocrinologically active tumors or may be of uncertain etiology

Front 72

Name five general types of paraneoplastic syndromes?

Back 72

1. Metabolic: Cushing's, SIADH, hypercalcemia

2. Neuromuscular: Eaton-Lambert, cerebellar ataxia

3. Skeletal: hypertrophic osteoarthropathy

4. Dermatologic: acanthosis nigricans

5. Vascular: thrombophlebitis

Front 73

What are the radiographic tests used to diagnose bronchogenic carcinoma?

Back 73

- CXR

- CT scan

- PET scan

Front 74

How do you diagnose bronchogenic carcinoma?

Back 74

1. Sputum cytology

2. Needle biopsy (CT or fluoro guidance)

3. Bronchoscopy w/ brushings, biopsies, or both

4. With or without mediastinoscopy, mediastinotomy, scalene node biopsy, or open lung biopsy for definitive diagnosis

Front 75

What is the usual site in the lung and the natural course of squamous cell carcinoma?

Back 75

- 66% occur centrally in lung hilus; may also be a Pancoast's tumor

- Slow growth, late metastasis

- Associated with smoking

Think: Squamous = Sentral

Front 76

What is the usual site in the lung and the natural course of adenocarcinoma?

Back 76

- Peripheral

- Rapid growth with hematogenous / nodal metastasis

- Associated with lung scarring

Front 77

What is the usual site in the lung and the natural course of small (oat) cell?

Back 77

- Central, highly malignant

- Usually not operable

Front 78

What is the usual site in the lung and the natural course of large cell?

Back 78

- Usually peripheral

- Very malignant

Front 79

What is the definition of carcinoma of the lungs AJCC stage IA?

Back 79

Tumor <3 cm, no nodes, no metastases

Front 80

What is the definition of carcinoma of the lungs AJCC stage IB?

Back 80

Tumor 3-5 cm, no nodes, no metastases

Front 81

What is the definition of carcinoma of the lungs AJCC stage IIA?

Back 81

1. Tumor <5 cm and positive nodes to lung or ipsilateral hilum; no metastases

OR

2. Tumor 5-7 cm, no nodes, no metastases

Front 82

What is the definition of carcinoma of the lungs AJCC stage IIB?

Back 82

1. Tumor 5-7 cm and positive nodes in lung or ipsilateral hilum

OR

2. Tumor that invades chest wall, diaphragm, mediastinal pleura, phrenic nerve, pericardial sac, or bronchus (not carina) and no nodes, no metastases

Front 83

What is the definition of carcinoma of the lungs AJCC stage IIIA?

Back 83

1. Tumor <7 cm and positive nodes in ipsilateral mediastinum or subcarina with NO metastases

OR

2. Tumor >7 cm or extends into chest wall, parietal pleura, diaphragm, phrenic nerve, or pericardium and positive lymph node metastases to ipsilateral, mediastinal, or subcarinal nodes

OR

3. Any size tumor that invades heart, great vessels, trachea, esophagus, carina, or ipsilateral lobe, or positive nodes peribronchial and/or ipsilateral hilum, or intrapulmonary nodes

Front 84

What is the definition of carcinoma of the lungs AJCC stage IIIB?

Back 84

- Any tumor, positive lymph node metastases to contralateral hilum or mediastinum

- Supraclavicular / scalene nodes, NO distant metastases

Front 85

What is the definition of carcinoma of the lungs AJCC stage IV?

Back 85

Distant metastases

Front 86

What are the surgical contraindications for NON-small cell carcinoma?

Back 86

- Stage IV

- Stage IIIB

- Poor lung function (FEV1 <0.8 L)

Front 87

What is the treatment for NON-small cell lung carcinoma stage I?

Back 87

Surgical resection

Front 88

What is the treatment for NON-small cell lung carcinoma stage II?

Back 88

Surgical resection

Front 89

What is the treatment for NON-small cell lung carcinoma stage IIIA?

Back 89

Chemotherapy and XRT +/- surgical resection

Front 90

What is the treatment for NON-small cell lung carcinoma stage IIIB?

Back 90

Chemotherapy and XRT

Front 91

What is the treatment for NON-small cell lung carcinoma stage IV?

Back 91

Chemotherapy +/- XRT

Front 92

What is the treatment for isolated brain metastasis from lung cancer?

Back 92

Surgical resection

Front 93

What is the approximate prognosis (5-year survival) after treatment of NON-small cell lung carcinoma stage I?

Back 93

50%

Front 94

What is the approximate prognosis (5-year survival) after treatment of NON-small cell lung carcinoma stage II?

Back 94

30%

Front 95

What is the approximate prognosis (5-year survival) after treatment of NON-small cell lung carcinoma stage III?

Back 95

<10%

Front 96

What is the approximate prognosis (5-year survival) after treatment of NON-small cell lung carcinoma stage IV?

Back 96

1%

Front 97

How is small cell carcinoma treated?

Back 97

Chemotherapy +/- XRT (very small isolated lesions can be surgically resected)

Front 98

What are the contraindications to surgery for lung cancer?

Back 98

Think: "STOP IT"

- Superior vena cava syndrome

- Supraclavicular node metastasis

- Scalene node metastasis

- Tracheal carina involvement

- Oat cell carcinoma (treat with chemo +/- radiation)

- Pulmonary function tests show FEV1 <0.8L

- Infarction (myocardial); aka cardiac cripple

- Tumor elsewhere (metastatic disease)

Front 99

What post-op FEV1 must you have to have surgery for lung cancer?

Back 99

- FEV1 >800 cc; thus, a pre-op FEV1 >2L is usually needed for a pneumonectomy

- If FEV1 is <2L, a ventilation perfusion scan should be performed

Front 100

What is hypertrophic pulmonary osteoarthropathy?

Back 100

Periosteal proliferation and new bone formation at the end of long bones and in the bones of the hand (seen in 10% of patients with lung cancer)

Front 101

What are solitary pulmonary nodules (coin lesions)?

Back 101

Peripheral circumscribed pulmonary lesions

Front 102

What is the differential diagnosis for solitary pulmonary nodules (coin lesions)?

Back 102

- Granulomatous disease

- Benign neoplasms

- Malignancy

Front 103

What percentage of solitary pulmonary nodules (coin lesions) are malignant?

Back 103

Overall, 5-10% (but >50% are malignant in smokers >50 years old)

Front 104

Is there a gender risk for solitary pulmonary nodules (coin lesions)?

Back 104

Yes; the incidence of coin lesions is 3-9x higher and malignancy is nearly twice as common in men as in women

Front 105

What are the symptoms of solitary pulmonary nodules (coin lesions)?

Back 105

Usually asymptomatic with solitary nodules, but may include coughing, weight loss, chest pain, and hemoptysis

Front 106

What are the signs of solitary pulmonary nodules (coin lesions)?

Back 106

- Physical findings are uncommon

- Clubbing is rare

- Hypertrophic osteoarthropathy implies >80% chance of malignancy

Front 107

How is the diagnosis of solitary pulmonary nodules (coin lesions) made?

Back 107

- CXR

- Chest CT

Front 108

What is the significance of "popcorn" calcification?

Back 108

Most likely benign (ie, hamartoma)

Front 109

What are the risk factors for malignancy with solitary pulmonary nodules (coin lesions)?

Back 109

1. Size: lesions >1 cm have a significant chance of malignancy, and those >4 cm are very likely to be malignant

2. Indistinct margins (corona radiata)

3. Documented growth on follow-up x-ray (if no change in 2 years, most likely benign)

4. Increasing age

Front 110

What are the lab tests that should be used to evaluate patients with solitary pulmonary nodules (coin lesions)?

Back 110

1. TB skin tests, etc

2. Sputum cultures

3. Sputum cytology (diagnostic in 5-20% of cases)

Front 111

Which method of tissue diagnosis is used for solitary pulmonary nodules (coin lesions)?

Back 111

- Chest CT scan with needle biopsy

- Bronchoscopy (+/- transtracheal biopsy)

- Excisional biopsy (open or thoracoscopic)

Front 112

What is the treatment of solitary pulmonary nodules (coin lesions)?

Back 112

- Surgical excision is the mainstay of treatment

- Excisional biopsy is therapeutic for benign lesions, solitary metastasis, and for primary cancer in patients who are poor risks for more extensive surgery

- Lobectomy for centrally placed lesions

- Lobectomy with node dissection for primary cancer (if resectable by pre-op evaluations)

Front 113

Which solitary nodule can be followed without a tissue diagnosis?

Back 113

- Popcorn calcifications

- Mass unchanged for 2 years on previous CXR

Front 114

What is the prognosis of solitary pulmonary nodules (coin lesions)?

Back 114

For malignant coin lesions <2 cm, 5-year survival is ~70%

Front 115

What if the patient has a solitary pulmonary nodule and pulmonary hypertrophic osteoarthropathy?

Back 115

>75% chance of carcinoma

Front 116

What is hypertrophic pulmonary osteoarthropathy?

Back 116

Periosteal proliferation and new bone formation at the end of long bones and in bones of the hand

Front 117

What is the incidence of hypertrophic pulmonary osteoarthropathy?

Back 117

~7% of patients with lung cancer (2-12%)

Front 118

What are the signs of hypertrophic pulmonary osteoarthropathy?

Back 118

- Associated with clubbing of fingers

- Diagnosed by x-ray of long bones, revealing periosteal bone hypertrophy

Front 119

What is a carcinoid tumor?

Back 119

APUD (Amine-Precursor Uptake and Decarboxylation) cell tumor of the bronchus

Front 120

What is the natural course of carcinoid tumor in the lung?

Back 120

Slow growing (but may be malignant)

Front 121

What are the primary local findings of carcinoid tumor?

Back 121

Wheezing and atelectasis caused by bronchial obstruction / stenosis

Front 122

What condition can carcinoid tumors be confused with?

Back 122

Asthma

Front 123

How do you diagnose carcinoid tumor of the lung?

Back 123

Bronchoscopy reveals round red-yellow-purple mass covered by epithelium that protrudes into bronchial lumen

Front 124

What is the treatment of carcinoid tumor?

Back 124

- Surgical resection (lobectomy with lymph node dissection)

- Sleeve resection is also an option for proximal bronchial lesions)

Front 125

What is a sleeve resection?

Back 125

Resection of a ring segment of bronchus (with carcinoid tumor inside) and then end-to-end anastomosis of the remaining ends, allowing salvage of lower lobe

Front 126

What is the prognosis (5-year survival) after complete surgical resection of carcinoid tumor with negative nodes?

Back 126

>90% alive at 5 years

Front 127

What is the prognosis (5-year survival) after complete surgical resection of carcinoid tumor with positive nodes?

Back 127

66% alive at 5 years

Front 128

What is the most common benign lung tumor?

Back 128

Hamartoma (normal cells in a weird configuration)

Front 129

What is pulmonary sequestration?

Back 129

Abnormal benign lung tissue with separate blood supply that DOES NOT communicate with the normal tracheobronchial airway

Front 130

What is an "interlobar" pulmonary sequestration?

Back 130

Sequestration in normal lung tissue covered by normal visceral pleura

Front 131

What is an "extralobar" pulmonary sequestration?

Back 131

Sequestration not in normal lung covered by its own pleura

Front 132

What are the signs/symptoms of pulmonary sequestration?

Back 132

Asymptomatic, recurrent pneumonia

Front 133

How do you diagnose pulmonary sequestration?

Back 133

- CXR

- Chest CT

- Angiogram

- U/S with Doppler flow to ascertain blood supply

Front 134

What is the treatment of extralobar pulmonary sequestration?

Back 134

Surgical resection

Front 135

What is the treatment of intralobar pulmonary sequestration?

Back 135

Lobectomy

Front 136

What is the major danger during surgery for pulmonary sequestration?

Back 136

- Anolamous blood supply from below the diaphragm (these can be cut and retract into the abdomen resulting in exsanguination!)

- Always document blood supply by A-gram or U/S with Doppler flow

Front 137

What structures lie in the superior mediastinum?

Back 137

- Aortic arch

- Great vessels

- Upper trachea

- Esophagus

Front 138

What structures lie in the anterior mediastinum?

Back 138

- Thymus

- Ascending aorta

- Lymph nodes

Front 139

What structures lie in the middle mediastinum?

Back 139

- Heart

- Lower trachea and bifurcation

- Lung hila

- Phrenic nerves

- Lymph nodes

Front 140

What structures lie in the posterior mediastinum?

Back 140

- Esophagus

- Descending aorta

- Thoracic duct

- Vagus and intercostal nerves

- Sympathetic trunks

- Azygous and hemizygous veins

- Lymph nodes

Front 141

What is the major differential diagnosis for tumors of the anterior mediastinum?

Back 141

Classic "four T's":

- Thyroid tumor

- Thymoma

- Terrible lymphoma

- Teratoma

Also parathyroid tumor, lipoma, vascular aneurysms

Front 142

What is the major differential diagnosis for tumors of the middle mediastinum?

Back 142

- Lymphadenopathy (eg, lymphoma, sarcoid)

- Teratoma

- Fat pad

- Cysts

- Hernias

- Extension of esophageal mass

- Bronchogenic cancer

Front 143

What is the major differential diagnosis for tumors of the posterior mediastinum?

Back 143

- Neurogenic tumors

- Lymphoma

- Aortic aneurysm

- Vertebral lesions

- Hernias

Front 144

What is the most common type of tumor arising in the mediastinum?

Back 144

Neurogenic (most commonly in posterior mediastinum)

Front 145

What is the most common type of tumor arising in the mediastinum?

Back 145

Neurogenic (most commonly in posterior mediastinum)

Front 146

What is the differential diagnosis for a neurogenic tumor?

Back 146

- Schwannoma (aka neurolemmoma)

- Neurofibroma

- Neuroblastoma

- Ganglioneuroma

- Ganglioneuroblastoma

- Pheochromocytoma

Front 147

Where are thymomas found in the mediastinum?

Back 147

Anterior

Front 148

How do you diagnose a thymoma?

Back 148

CT scan

Front 149

What is the treatment for thymoma?

Back 149

All thymomas should be surgically resected via midline sternotomy

Front 150

What are the indications for POST-op radiation therapy in treatment of thymomas?

Back 150

Invasive malignant tumors

Front 151

What are the indications for PRE-op chemo therapy for thymoma?

Back 151

Tumor >6 cm and CT scan with invasion

Front 152

What percentage of thymomas are malignant?

Back 152

~25%

Front 153

How is a malignant thymoma diagnosed?

Back 153

At surgery with invasion into surrounding structures (not by histology!)

Front 154

What is myasthenia gravis?

Back 154

Auto-immune disease with antibodies against the muscle acetylcholine receptors

Front 155

What percentage of patients with myasthenia gravis patients have a thymoma?

Back 155

~15%

Front 156

What percentage of patients with thymoma have or will have myasthenia gravis?

Back 156

~75%

Front 157

What are teratomas?

Back 157

Tumors of branchial cleft cells; the tumors contain ectoderm, endoderm, and mesoderm

Front 158

What is a dermoid cyst?

Back 158

Teratoma made up of ectoderm derivatives (eg, teeth, skin, hair)

Front 159

Which age group is affected by teratomas?

Back 159

Usually adolescents but can occur at any age

Front 160

Where in the mediastinum do teratomas occur?

Back 160

Anterior mediastinum

Front 161

What are the characteristic x-ray findings of teratomas?

Back 161

Calcifications or teeth; tumors may be cystic

Front 162

What percentage of teratomas are malignant?

Back 162

~15%

Front 163

What is the treatment of benign dermoid cysts?

Back 163

Surgical excision

Front 164

What is the treatment of malignant teratomas?

Back 164

Pre-op chemo until tumor markers are normal, then surgical resection

Front 165

Which tumor markers are associated with malignant teratomas?

Back 165

- AFP

- CEA

Front 166

What is the incidence of neurogenic tumors?

Back 166

Most common mediastinal tumors in all age groups

Front 167

Where in the mediastinum do neurogenic tumors occur

Back 167

Posterior, int he paravertebral gutters

Front 168

What percentage of neurogenic tumors are malignant?

Back 168

50% in children

10% in adults

Front 169

What are the histologic types of neurogenic tumors? (note cells of origin and whether benign or malignant)

Back 169

1. Neurilemmoma or schwannoma (benign) - arise from Schwann cell sheaths of intercostal nerves

2. Neurofibroma (benign) - arise from intercostal nerves; may degenerate into:

3. Neurosarcoma (malignant)

4. Ganglioneuroma (benign) - from sympathetic chain

5. Neuroblastoma (malignant) - also from sympathetic chain

Front 170

Where in the mediastinum does a lymphoma occur?

Back 170

Anywhere, but most often in the anterosuperior mediastinum or hilum in the middle mediastinum

Front 171

What percentage of lymphomas involve mediastinal nodes?

Back 171

~50%

Front 172

What are the symptoms of lymphoma?

Back 172

- Cough

- Fever

- Chest pain

- Weight loss

- SVC syndrome

- Chylothorax

Front 173

How do you diagnose lymphoma?

Back 173

1. CXR, CT scan

2. Mediastinoscopy or mediastinotomy with node biopsy

Front 174

What is the treatment of lymphoma?

Back 174

Non-surgical (chemo, radiation, or both)

Front 175

What is acute mediastinitis?

Back 175

Acute suppurative mediastinal infection

Front 176

What are the six etiologies of acute mediastinitis?

Back 176

1. Esophageal perforation (Boerhaave's syndrome)

2. Post-op wound infection

3. Head and neck infections

4. Lung or pleural infections

5. Rib or vertebral osteomyelitis

6. Distant infections

Front 177

What are the clinical features of acute mediastinitis?

Back 177

- Fever

- Chest pain

- Dysphagia (especially with esophageal perforation)

- Respiratory distress

- Leukocytosis

Front 178

What is the treatment for acute mediastinitis?

Back 178

1. Wide drainage

2. Treatment of primary cause

3. Antibiotics

Front 179

What is chronic mediastinitis?

Back 179

Mediastinal fibrosis secondary to chronic granulomatous infection

Front 180

What is the most common etiology of chronic mediastinitis?

Back 180

Histoplasma capsulatum

Front 181

What are the clinical features of chronic mediastinitis?

Back 181

- 50% are asymptomatic

- Symptoms are related to compression of adjacent structures: SVC syndrome, bronchial and esophageal strictures, constrictive pericarditis

Front 182

How do you diagnose chronic mediastinitis?

Back 182

CXR or CT scan may be helpful, but surgery / biopsy often makes the diagnosis

Front 183

What is the treatment for chronic mediastinitis?

Back 183

- Antibiotics

- Surgical removal of the granulomas is rarely helpful

Front 184

What is superior vena cava syndrome?

Back 184

Obstruction of the superior vena cava, usually by extrinsic compression

Front 185

What is the #1 cause of superior vena cava syndrome?

Back 185

- Malignant tumors cause ~90% of cases; lung cancer is by far the most common

- Other tumors include thymoma, lymphoma, and Hodgkin's disease

Front 186

What are the clinical manifestations of superior vena cava syndrome?

Back 186

1. Blue discoloration and puffiness of the face, arms, and shoulders

2. CNS manifestations may include headache, nausea, vomiting, visual distortion, stupor, and convulsions

3. Cough, hoarseness, and dyspnea

Front 187

What is the treatment for superior vena cava syndrome?

Back 187

1. Diuretics and fluid restriction

2. Prompt radiation therapy +/- chemotherapy for any causative cancer

Front 188

What is the prognosis for superior vena cava syndrome?

Back 188

SVC obstruction itself is fatal in <5% of cases; mean survival time in patients with malignant obstruction is ~7 months

Front 189

What are the primary functions of the upper and lower esophageal sphincters?

Back 189

- UES: swallowing

- LES: prevention of reflux

Front 190

The esophageal venous plexus drains inferiorly into the gastric veins. Why is this important?

Back 190

Gastric veins are part of the portal venous system; portal HTN can thus be referred to the esophageal veins, leading to varices

Front 191

What type of muscle is in the proximal 1/3 of the esophagus?

Back 191

Skeletal muscle

Front 192

What type of muscle is in the middle 1/3 of the esophagus?

Back 192

Smooth muscle > skeletal muscle

Front 193

What type of muscle is in the distal 1/3 of the esophagus?

Back 193

Smooth muscle

Front 194

What is the blood supply to the proximal 1/3 of the esophagus?

Back 194

Inferior thyroid, anterior intercostals

Front 195

What is the blood supply to the middle 1/3 of the esophagus?

Back 195

Esophageal arteries, bronchial arteries

Front 196

What is the blood supply to the distal 1/3 of the esophagus?

Back 196

Left gastric artery, left inferior phrenic artery

Front 197

What is the length of the esophagus?

Back 197

~25 cm in the adult (40 cm from teeth to LES)

Front 198

Why is the esophagus notorious for anastomotic leaks?

Back 198

Esophagus has no serosa (same as distal rectum)

Front 199

What nerve runs with the esophagus?

Back 199

Vagus nerve

Front 200

What is a Zenker's diverticulum?

Back 200

Pharyngoesophageal diverticulum; a false diverticulum containing mucosa and submucosa at the UES at the pharyngoesophageal junction through Killian's triangle

Front 201

What is Zenker's diverticulum's claim to fame?

Back 201

Most common esophageal diverticulum

Front 202

What are the signs/symptoms of Zenker's diverticulum?

Back 202

- Dysphagia

- Neck mass

- Halitosis

- Food regurgitation

- Heartburn

Front 203

How do you diagnose Zenker's diverticulum?

Back 203

Barium swallow

Front 204

What is the treatment for Zenker's diverticulum?

Back 204

1. Diverticulectomy

2. Cricopharyngeus myotomy, if >2 cm

Front 205

What is achalasia?

Back 205

1. Failure of LES to relax during swallowing

2. Loss of esophageal peristalsis

Front 206

What are the proposed etiologies of achalasia?

Back 206

1. Neurologic (ganglionic degeneration of Auerbach's plexus, vagus nerve, or both); possibly infectious in nature

2. Chagas' disease in South America

Front 207

What are the associated long-term conditions with achalasia?

Back 207

Esophageal carcinoma secondary to Barrett's esophagus from food stasis

Front 208

What are the symptoms of achalasia?

Back 208

- Dysphagia for both solids and liquids, followed by regurgitation

- Dysphagia for liquids is worse

Front 209

What are the diagnostic findings for achalasia?

Back 209

- Radiographic contrast studies reveal dilated esophageal body with narrowing inferiorly

- Manometry: motility studies reveal increased pressure in the LES and failure of the LES to relax during swallowing

Front 210

What are the treatment options for achalasia?

Back 210

1. Balloon dilation of the LES

2. Medical treatment of reflux vs. Belsey Mark IV 270 degree fundoplication (do not perform 360 degree Nissen)

3. Myotomy of lower esophagus and LES

Front 211

What is a diffuse esophageal spasm?

Back 211

Strong, non-peristaltic contractions of the esophageal body; sphincter function is usually normal

Front 212

What condition is associated with diffuse esophageal spasm?

Back 212

GERD

Front 213

What are the symptoms of diffuse esophageal spasm?

Back 213

Spontaneous chest pain that radiates to the back, ears, neck, jaw, or arms

Front 214

What is the differential diagnosis of diffuse esophageal spasm?

Back 214

- Angina pectoris

- Psychoneurosis

- Nutcracker esophagus

Front 215

What are the diagnostic tests associated with diffuse esophageal spasm?

Back 215

- Esophageal manometry: motility studies reveal repetitive, high-amplitude contractions with normal sphincter response

- Upper GI may be normal, but 50% show segmented spasms or corkscrew esophagus

- Endoscopy

Front 216

What is the classic finding of diffuse esophageal spasm on esophageal contrast study (UGI)?

Back 216

"Corkscrew esophagus"

Front 217

What is the treatment for diffuse esophageal spasm?

Back 217

- Medical (anti-reflux measures, calcium channel blockers, nitrates)

- Long esophagomyotomy in refractory cases

Front 218

What is Nutcracker esophagus also known as?

Back 218

Hypertensive peristalsis

Front 219

What is Nutcracker esophagus?

Back 219

Very strong peristaltic waves, aka hypertensive peristalsis

Front 220

What are the symptoms of Nutcracker esophagus?

Back 220

Spontaneous chest pain that radiates to the back, ears, neck, jaw, or arms

Front 221

What is the differential diagnosis of Nutcracker esophagus?

Back 221

- Angina pectoris

- Psychoneurosis

- Diffuse esophageal spasm

Front 222

What are the associated diagnostic tests?

Back 222

1. Esophageal manometry: motility studies reveal repetitive, high-amplitude contractions with normal sphincter response

2. Results of UGI may be normal (rule out mass)

3. Endoscopy

Front 223

What is the treatment of Nutcracker esophagus?

Back 223

- Medical (anti-reflux measures, calcium channel blockers, nitrates)

- Long esophagomyotomy in refractory cases

Front 224

What is esophageal reflux?

Back 224

Reflux of gastric contents into the lower esophagus resulting from the decreased function of the LES

Front 225

What are the causes of esophageal reflux?

Back 225

1. Decreased LES tone

2. Decreased esophageal motility

3. Hiatal hernia

4. Gastric outlet obstruction

5. NGT

Front 226

What are four conditions / factors associated with esophageal reflux?

Back 226

1. Sliding hiatal hernia

2. Tobacco and alcohol

3. Scleroderma

4. Decreased endogenous gastrin production

Front 227

What are the symptoms of esophageal reflux?

Back 227

- Substernal pain

- Heartburn

- Regurgitation

- Symptoms are worse when patient is supine and after meals

Front 228

How is the diagnosis of esophageal reflux made?

Back 228

1. pH probe in the lower esophagus reveals acid reflux

2. EGD shows esophagitis

3. Manometry reveals decreased LES pressure

4. Barium swallow

Front 229

What is the initial treatment for esophageal reflux?

Back 229

- Medical: H2-blockers, antacids, metoclopramide, omeprazole

- Elevation fo the head of the bed, small / multiple meals

Front 230

Which four complications of esophageal reflux require surgery?

Back 230

1. Failure of medical therapy

2. Esophageal strictures

3. Progressive pulmonary insufficiency secondary to documented nocturnal aspiration

4. Barrett's esophagus

Front 231

What is a "Nissen" surgery?

Back 231

360 degree fundoplication: wrap fundus of stomach all the way around the esophagus

Front 232

What is a "Belsey Mark IV" surgery?

Back 232

270 degree fundoplication: wrap fundus of stomach, but not all the way around

Front 233

What is a "Hill" surgery?

Back 233

Tighten arcuate ligament around esophagus and tack stomach to diaphragm

Front 234

What is a "Lap Nissen" surgery?

Back 234

Nissen (360 degree fundoplication: wrap fundus of stomach all the way around the esophagus) via laparoscope

Front 235

What is a "Lap Toupet" surgery?

Back 235

Lap fundoplication posteriorly with less than 220-250 degree wrap used with decreased esophageal motility; disadvantage is more post-op reflux

Front 236

What is Barrett's esophagus?

Back 236

Replacement of the lower esophageal squamous epithelium with columnar epithelium secondary to reflux

Front 237

Why is Barrett's esophagus significant?

Back 237

This lesion is pre-malignant

Front 238

What is the treatment of Barrett's esophagus?

Back 238

People with significant reflux should be followed with regular EGDs with biopsies, H2-blockers, and anti-reflux precautions

Many experts believe that patients with severe dysplasia should undergo esophagectomy

Front 239

Which agents may cause esophageal strictures if ingested?

Back 239

- Lye

- Oven cleaners

- Drain cleaners

- Batteries

- Sodium hydroxide tablets (Clinitest)

Front 240

How do you diagnose caustic esophageal strictures?

Back 240

- History

- EGD is clearly indicated early on to assess the extent of damage (<24 hours)

- Scope to level of severe injury (deep ulcer) only, water soluble contrast study for deep ulcers to rule out perforation

Front 241

What is the initial treatment for caustic esophageal strictures?

Back 241

1. NPO / IVF / H2-blockers

2. Do NOT induce emesis

3. Corticosteroids (controversial - probably best for shallow/moderate ulcers), antibiotics (penicillin / gentamicin) for moderate ulcers

4. Antibiotic for deep ulcers

5. Upper GI at 10-14 days

Front 242

What is the treatment of caustic esophageal strictures when stricture develops?

Back 242

- Dilation with Maloney dilator / balloon catheter

- In severe refractory cases, esophagectomy with colon interposition or gastric pull-up

Front 243

What is the long-term follow-up for caustic esophageal strictures?

Back 243

Because of increased risk of esophageal squamous cancer (especially with ulceration), patients endoscopies every other year

Front 244

What is a Maloney dilator?

Back 244

Mercury-filled rubber dilator

Front 245

What are the two main types of esophageal carcinoma?

Back 245

1. Adenocarcinoma at GE junction

2. Squamous cell carcinoma in most of the esophagus

Front 246

What is the most common histology associated with esophageal carcinoma?

Back 246

- Worldwide: squamous cell carcinoma (95%)

- USA: adenocarcinoma

Front 247

What is the age and gender distribution of esophageal carcinoma?

Back 247

Most common in the 6th decade of life; men predominate, especially black men

Front 248

What are the etiologic factors that contribute to esophageal carcinoma?

Back 248

1. Tobacco

2. Alcohol

3. GE reflux

4. Barrett's esophagus

5. Radiation

Front 249

What are the symptoms of esophageal carcinoma?

Back 249

- Dysphagia, weight loss

- Other symptoms include chest pain, back pain, hoarseness

- Symptoms of metastasis

Front 250

What comprises the workup for esophageal carcinoma?

Back 250

1. UGI

2. EGD

3. Transesophageal ultrasound (TEU)

4. CT scan of chest / abdomen

Front 251

What is the differential diagnosis of esophageal carcinoma?

Back 251

- Leiomyoma

- Metastatic tumor

- Lymphoma

- Benign stricture

- Achalasia

- Diffuse esophageal spasm

- GERD

Front 252

How do you diagnose esophageal carcinoma?

Back 252

1. Upper GI localizes tumor

2. EGD obtains biopsy and assesses resectability

3. Full metastatic workup (CXR, bone scan, CT scan, LFTs)

Front 253

What are the characteristics of adenocarcinoma esophageal cancer stage I?

Back 253

- Tumor: invades lamina propria, muscularis mucosa, or submucosa

- Nodes: negative

Front 254

What are the characteristics of adenocarcinoma esophageal cancer stage IIA?

Back 254

- Tumor: invades muscularis propria (grade 3)

- Nodes: negative

Front 255

What are the characteristics of adenocarcinoma esophageal cancer stage IIB?

Back 255

- Tumor invades up to muscularis propria with positive regional nodes

OR

- Tumor invades adventitia with negative nodes

Front 256

What are the characteristics of adenocarcinoma esophageal cancer stage III?

Back 256

- Tumor invades adventitia with positive regional nodes

OR

- Tumor invades adjacent structures

Front 257

What are the characteristics of adenocarcinoma esophageal cancer stage IV?

Back 257

Distant metastasis

Front 258

What is the treatment for esophageal carcinoma?

Back 258

Esophagectomy with gastric pull-up or colon interposition

Front 259

What is an Ivor-Lewis procedure?

Back 259

Laparotomy and right thoracotomy with gastro-esophageal anastomosis in the chest after esophagectomy

Front 260

What are the treatment options for esophageal carcinoma with metastatic disease?

Back 260

- Chemotherapy and XRT

- +/- Dilation

- +/- Stent

- +/- Laser

- +/- Electrocoagulation

- +/- Photodynamic laser therapy

Front 261

What is a "blunt esophagectomy"?

Back 261

Esophagectomy with "blunt" transhiatal dissection of esophagus from abdomen and gastroesophageal anastomosis in the neck

Front 262

What is the operative mortality rate for esophageal carcinoma?

Back 262

~5%

Front 263

Has radiation therapy and/or chemotherapy been shown to decrease mortality for esophageal carcinoma?

Back 263

No

Front 264

What is the post-op complication rate of esophageal carcinoma?

Back 264

~33%

Front 265

What is the prognosis (5-year survival) for esophageal carcinoma stage I?

Back 265

66%

Front 266

What is the prognosis (5-year survival) for esophageal carcinoma stage II?

Back 266

25%

Front 267

What is the prognosis (5-year survival) for esophageal carcinoma stage III?

Back 267

10%

Front 268

What is the prognosis (5-year survival) for esophageal carcinoma stage IV?

Back 268

Basically 0%