CHAPTER 25- THORACIC.txt

runs along the right side and dumps into the superior vena cava

runs along the right side, crosses midline, and dumps into left subclavian vein at junction with internal jugular vein.

Crosses at T4-T5

Left mainstem bronchi is longer than the right

right pulmonary artery longer than left before 1st branch

phrenic nerve

vagus nerve

• Right lung volume 55% (3 lobes: RUL, RML, and RLL)
• Left lung volume 45% (2 lobes LUL, LLL and lingula)

• 1) diaphragm 80%
• 2) intercostals 20%

Greatest changes in dimension are superior/inferior

• 1) sternocleidomastoid muscle (SCM)
• 2) levators
• 3) serratus posterior
• 4) scalenes

gas exchange

surfactant production

direct air exchange between alveoli

• 1) 1-2L/day
• 2) parietal pleura produces pleural fluid cleared by lymphatics in the visceral pleura

• 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

see pg 161

patients can be asymptomatic with finding on routine CXR or present with atelectasis, PNA, pain, or weight loss

lung ca

nodal involvement

1) brain

• 2) can also go to:
• 1- supraclavicular nodes
• 2- other lung, bone
• 3- liver
• 4- adrenals

• 1) recurrence most commonly appears as disseminated metastases (brain most common)
• 2) 80% of recurrences are within 1st 3 years

Lung cancer overall 5 year survival rate-10%

With resection- 30%

Stage I and II disease resectable

T3, N1, M0 (stage IIIa) possibly resectable

lobectomy or pneumonectomy most common; need to sample suspicious nodes

adenocarcinoma is the most common lung Ca, not squamous

• 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

• 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....

• 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

• 1) squamous cell Ca- PTH-related peptide
• 2) Small cell Ca- ACTH, ADH
• 3) Small cell ACTH- most common paraneoplastic syndrome

• 1) most malignant lung tumor
• 2) aggressive local invasion, nodal invasion, and distant metastases common at time of exposure
• 3) asbestos exposure

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

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

assesses aortopulmonary window nodes; go through left 2nd rib cartilage

needed for centrally located tumors

1) tumor invades apex of chest wall and patient's have Horner's syndrome or ulnar nerve symptoms

• 2) Horners: invasion of sympathetic chain:
• 1- ptosis
• 2- miosis
• 3- anhidrosis

• 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

increases lung Ca risk by 90x

1)can look like pneumonia

2) grows along alveolar walls

3) multifocal

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

• 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

• 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

• 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

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

• 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

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

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

• 1) Bronchogenic- posterior to carina
• Tx: resection

• 2) Pericardial- at right costophrenic angle.
• Tx: resection

• 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

50% of symptomatic mediastinal masses are malignant

90% of asymptomatic mediastinal masses are benign

• Benign tumors:
• Adults- papilloma
• Children- hemangiomas

• Malignant-
• squamous cell carcinoma

granulation tissue formation

• laryngeal edema
• Tx: reintubation, racemic epinephrine, steroids

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

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.

• 1) use large-volume cuff below fistula
• 2) may need decompressing gastrostomy
• 3) treatment: tracheal resection, reanastomosis, sternohyoid flap

• 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

• 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

• 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)

• 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

• 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

• 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

• 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

• 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

most likely to cause arrest after blunt trauma; impaired venous return

occurs in temporal relation to menstruation

caused by endometrial implants in the visceral lung pleura

OR for thorascopic drainage

• 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

usually secondary to infection

usually after cardiac surgery

• 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

1) acquired from: (1) tumor (2) infection (3) cystic fibrosis

2) Diffuse nature prevents surgery in most patients

1) lung apices; get calcifications, caseating granulomas

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

3) Treatment: (1) INH (2) rifampin (3) pyrazinamide

non-caseating granulomas

• 1) protein >3
• 2) specific gravity >1.016
• 3) LDH ratio (pleural fluid:serum) >0.6
• 4) decreased glucose

• 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

1) can be treated with mechanical pleurodesis

2) Talc pleurodesis for malignant pleural effusions

1) usually associated with the laser

2) Treatment: stop gas flow, remove ET tube, reintubate for 24hrs; bronchoscopy

• 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

• 1) Benign- osteochondroma most common
• 2) Malignant- chondrosarcoma most common