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Chest Wall, Lung, Mediastinum, & Pleura May 11, 2010.

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Presentation on theme: "Chest Wall, Lung, Mediastinum, & Pleura May 11, 2010."— Presentation transcript:

1 Chest Wall, Lung, Mediastinum, & Pleura May 11, 2010

2 Trachea

3 Tracheal Injury Tracheal Stenosis Tracheal Stenosis Over-inflation of the cuff Over-inflation of the cuff Ischemia, scarring, stricture Ischemia, scarring, stricture Fistula development Fistula development Incorrect placement of the tracheostomy through the first tracheal ring or the cricothyroid membrane Incorrect placement of the tracheostomy through the first tracheal ring or the cricothyroid membrane Use of a large tracheostomy tube Use of a large tracheostomy tube Stridor and dyspnea on exertion Stridor and dyspnea on exertion Resection and primary anastomosis Resection and primary anastomosis

4 TracheoInnominate Artery Fistula Causes Causes Too low placement of the tracheostomy (below the 4 th ring) Too low placement of the tracheostomy (below the 4 th ring) Hyperinflation of the tracheal cuff Hyperinflation of the tracheal cuff Typically occur 2 weeks after tracheostomy Typically occur 2 weeks after tracheostomy Signs Signs Sentinel bleed Sentinel bleed Heavy bleed – blow up cuff Heavy bleed – blow up cuff Insert finger and press against manubrium Insert finger and press against manubrium Oral intubation and emergent resection of fistlua Oral intubation and emergent resection of fistlua

5 TracheoEsophageal Fistula Causes Causes ETT cuff compresses against NG tube ETT cuff compresses against NG tube Signs Signs Gastric contents or tube feeds suctioned from airway Gastric contents or tube feeds suctioned from airway Gastric distention from positive pressure ventilation Gastric distention from positive pressure ventilation Diagnosis Diagnosis Bronchoscopy or EGD Bronchoscopy or EGD Treatment Treatment Wean off vent Wean off vent Remove NG and place GT or JT Remove NG and place GT or JT Operative repair involves resection and primary repair of tracheal pathology, repair of esophagus, and interposition muscle flap Operative repair involves resection and primary repair of tracheal pathology, repair of esophagus, and interposition muscle flap

6 Tracheal Neoplasms Rare Rare SCC or adenoid cystic carcinoma SCC or adenoid cystic carcinoma Cough, dyspnea, hemoptysis, stridor, or symptoms of invasion of contiguous structures Cough, dyspnea, hemoptysis, stridor, or symptoms of invasion of contiguous structures 50% of patients have tracheal stenosis on Xray 50% of patients have tracheal stenosis on Xray 50% have stage IV dz at time of diagnosis 50% have stage IV dz at time of diagnosis Overall 5-year survival is 40%, but falls to 15% for those with stage IV disease Overall 5-year survival is 40%, but falls to 15% for those with stage IV disease

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8 Surgical Approaches to the Thoracic Cavity Posterior Thoracotomy – most common approach for pulmonary resections, esophageal procedures, posterior mediastinal access, and vertebral procedures Posterior Thoracotomy – most common approach for pulmonary resections, esophageal procedures, posterior mediastinal access, and vertebral procedures Patient in lateral decubitus – risk of injury to brachial plexus or axillary vascular structure Patient in lateral decubitus – risk of injury to brachial plexus or axillary vascular structure Anteriolateral Thoracotomy – trauma victims Anteriolateral Thoracotomy – trauma victims Median sternotomy – cardiac procedures Median sternotomy – cardiac procedures VATS – improved pain and functional recovery VATS – improved pain and functional recovery Improved ability to tolerate chemotherapy Improved ability to tolerate chemotherapy Quicker return of respiratory function in elderly and COPD Quicker return of respiratory function in elderly and COPD

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12 Post-operative Care Chest Tube Chest Tube Evacuation of air Evacuation of air Evacuation of blood/pleural fluid Evacuation of blood/pleural fluid Check the system regularly Check the system regularly Pain Control Pain Control Epidural at T6 with ropivicaine Epidural at T6 with ropivicaine Hypotension and urinary retention Hypotension and urinary retention Narcotics and Toradol Narcotics and Toradol Aggressive Pulmonary Toilet Aggressive Pulmonary Toilet

13 Post-operative Complications Air leak Air leak Bronchopleural fistula Bronchopleural fistula Diagnose by bronchoscopy Diagnose by bronchoscopy Continued chest tube mgmt Continued chest tube mgmt Operative closure with intercostal muscle flap Operative closure with intercostal muscle flap Bronchoscopic fibrin glue application (<4mm) Bronchoscopic fibrin glue application (<4mm) Concomitant empyema may require open drainage Concomitant empyema may require open drainage Post-pneumonectomy pulmonary edema Post-pneumonectomy pulmonary edema Decreased lympnatic drainage Decreased lympnatic drainage Mechanical ventilation & diuresis Mechanical ventilation & diuresis

14 Lung Solitary Pulmonary Nodule Solitary Pulmonary Nodule A single, well-circumscribed, spherical lesion A single, well-circumscribed, spherical lesion ≤3 cm in diameter ≤3 cm in diameter Completely surrounded by normal aerated lung parenchyma Completely surrounded by normal aerated lung parenchyma Detected incidentally on chest radiographs or CT scans Detected incidentally on chest radiographs or CT scans DDx – malignancy, hamartoma (10%), granulomatous dz (70%) DDx – malignancy, hamartoma (10%), granulomatous dz (70%) 20 to 40% likelihood of being malignant 20 to 40% likelihood of being malignant 50% or higher in smokers 50% or higher in smokers growth over time, growth over time, density of the lesion on CT density of the lesion on CT associated symptom associated symptom age, sex, cigarette smoking history, occupational history, age, sex, cigarette smoking history, occupational history, prevalence of endemic granulomatous disease prevalence of endemic granulomatous disease

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16 Lung Cancer Leading cause of cancer-related death (30%) Leading cause of cancer-related death (30%) Second most common diagnosed cancer Second most common diagnosed cancer Women – breast Women – breast Men – prostate Men – prostate

17 Lung Cancer Epidemiology Epidemiology Leading risk factor – smoking (polycyclic aromatic hydrocarbons) Leading risk factor – smoking (polycyclic aromatic hydrocarbons) Secondhand smoke also increases risk Secondhand smoke also increases risk Environmental exposures - asbestos, arsenic, and chromium compounds Environmental exposures - asbestos, arsenic, and chromium compounds COPD COPD h/o tuberculosis h/o tuberculosis

18 Lung Cancer Non-small cell carcinoma vs neuroendocrine tumors Non-small cell carcinoma vs neuroendocrine tumors NSCLC - large cell carcinoma, squamous cell carcinoma, adenocarcinoma, and BAC NSCLC - large cell carcinoma, squamous cell carcinoma, adenocarcinoma, and BAC Clinical behavior and treatment options are similar and thought of as a uniform group Clinical behavior and treatment options are similar and thought of as a uniform group Neuroendocrine - typical carcinoid, atypical carcinoid, large cell neuroendocrine carcinoma, and small cell carcinoma Neuroendocrine - typical carcinoid, atypical carcinoid, large cell neuroendocrine carcinoma, and small cell carcinoma

19 Squamous Cell Carcinoma 30 to 40% of lung cancers 30 to 40% of lung cancers Highly associated with cigarette smoking Highly associated with cigarette smoking Primarily located centrally and arises in the major bronchi Primarily located centrally and arises in the major bronchi Typical symptoms are hemoptysis, bronchial obstruction with atelectasis, dyspnea, and pneumonia Typical symptoms are hemoptysis, bronchial obstruction with atelectasis, dyspnea, and pneumonia Peripherally based SCC will develop in a tuberculosis scar or in the wall of a bronchiectatic cavity Peripherally based SCC will develop in a tuberculosis scar or in the wall of a bronchiectatic cavity Central necrosis is frequent and may lead to the radiographic findings of a cavity (air-fluid level) Central necrosis is frequent and may lead to the radiographic findings of a cavity (air-fluid level) May become infected & form an abscess May become infected & form an abscess

20 Adenocarcinoma Incidence has increased over the last several decades & now 25 to 40% of all lung cancers. Incidence has increased over the last several decades & now 25 to 40% of all lung cancers. Most frequent histologic type found in women Most frequent histologic type found in women Peripherally based tumor Peripherally based tumor Frequently discovered incidentally on routine chest radiographs Frequently discovered incidentally on routine chest radiographs Symptoms of chest wall invasion or malignant pleural effusions Symptoms of chest wall invasion or malignant pleural effusions Composed of glands with or without mucin production and destruction of contiguous lung architecture Composed of glands with or without mucin production and destruction of contiguous lung architecture

21 Bronchoalveolar Carcinoma Unusual (5% of all lung cancers) subtype of adenocarcinoma Unusual (5% of all lung cancers) subtype of adenocarcinoma Unique growth pattern Unique growth pattern Rather than invading and destroying contiguous lung parenchyma, tumor cells multiply and fill the alveolar spaces Rather than invading and destroying contiguous lung parenchyma, tumor cells multiply and fill the alveolar spaces Because of their growth within alveoli, BAC tumor cells from one site can aerogenously seed other parts of the same lobe or lung, or the contralateral lung. Because of their growth within alveoli, BAC tumor cells from one site can aerogenously seed other parts of the same lobe or lung, or the contralateral lung. Three radiographic presentations: Three radiographic presentations: a single nodule a single nodule multiple nodules (in single or multiple lobes) multiple nodules (in single or multiple lobes) diffuse form with an appearance mimicking that of a lobar pneumonia diffuse form with an appearance mimicking that of a lobar pneumonia Air bronchograms can be seen Air bronchograms can be seen

22 Large Cell Carcinoma 10 to 20% of lung cancers and may be located centrally or peripherally 10 to 20% of lung cancers and may be located centrally or peripherally Often admixed with other cell types such as squamous cells or adenocarcinoma Often admixed with other cell types such as squamous cells or adenocarcinoma May be confused with a large cell variant of neuroendocrine carcinoma, with immunohistochemical staining usually allowing diagnostic distinction between the two May be confused with a large cell variant of neuroendocrine carcinoma, with immunohistochemical staining usually allowing diagnostic distinction between the two

23 Neuroendocrine Carcinoma Grade I NEC (classic or typical carcinoid) is a low-grade NEC Grade I NEC (classic or typical carcinoid) is a low-grade NEC primarily in the central airways primarily in the central airways primarily in younger patients. primarily in younger patients. classically presents with hemoptysis, with or without airway obstruction and pneumonia classically presents with hemoptysis, with or without airway obstruction and pneumonia Regional lymph node metastases are seen in 15% of patients but rarely spread systemically or cause death Regional lymph node metastases are seen in 15% of patients but rarely spread systemically or cause death Grade II NEC (atypical carcinoid) tumors with a degree of aggressive clinical behavior Grade II NEC (atypical carcinoid) tumors with a degree of aggressive clinical behavior linked to cigarette & peripherally located linked to cigarette & peripherally located Much higher malignant potential. Much higher malignant potential. Lymph node metastases found in 30 to 50% of patients Lymph node metastases found in 30 to 50% of patients At the time of diagnosis, 25% have remote metastases At the time of diagnosis, 25% have remote metastases Grade III NEC large cell–type tumors occur primarily in heavy smokers Grade III NEC large cell–type tumors occur primarily in heavy smokers Grade III NEC small cell type [small cell lung carcinoma (SCLC)] is the most malignant NEC and accounts for 25% of all lung cancers Grade III NEC small cell type [small cell lung carcinoma (SCLC)] is the most malignant NEC and accounts for 25% of all lung cancers Immunohistochemical stains distinguish from NSCLC Immunohistochemical stains distinguish from NSCLC Leading producer of paraneoplastic syndromes Leading producer of paraneoplastic syndromes

24 Paraneoplastic Syndromes Table 19-5 Table 19-5 Hypercalcemia (ectopic parathyroid hormone) Hypercalcemia (ectopic parathyroid hormone) Cushing's syndrome Cushing's syndrome Syndrome of inappropriate secretion of antidiuretic hormone Syndrome of inappropriate secretion of antidiuretic hormone Carcinoid syndrome Carcinoid syndrome Gynecomastia Gynecomastia Hypercalcitoninemia Hypercalcitoninemia Elevated growth hormone level Elevated growth hormone level Elevated levels of prolactin, follicle-stimulating hormone, luteinizing hormone Elevated levels of prolactin, follicle-stimulating hormone, luteinizing hormone Hypoglycemia Hypoglycemia Hyperthyroidism Hyperthyroidism Neuropathy Neuropathy

25 Metastatic Symptoms Lung cancer metastases occur most commonly to the CNS, vertebral bodies, bone, liver, adrenal glands, lungs, skin, and soft tissue Lung cancer metastases occur most commonly to the CNS, vertebral bodies, bone, liver, adrenal glands, lungs, skin, and soft tissue At diagnosis, 10% of patients have CNS metastases At diagnosis, 10% of patients have CNS metastases another 10 to 15% will go on to develop CNS metastases after diagnosis. another 10 to 15% will go on to develop CNS metastases after diagnosis. Focal symptoms are most common and include headache, nausea and vomiting, seizures, hemiplegia, and speech difficulty Focal symptoms are most common and include headache, nausea and vomiting, seizures, hemiplegia, and speech difficulty Most common cause of spinal cord compression Most common cause of spinal cord compression Invasion of an intervertebral foramen from a primary tumor contiguous with the spine Invasion of an intervertebral foramen from a primary tumor contiguous with the spine Direct extension of a vertebral metastasis. Direct extension of a vertebral metastasis. Bony metastases, are identified in 25% - lytic and painful Bony metastases, are identified in 25% - lytic and painful Liver & adrenal metastases are typically asymptomatic and discovered by routine CT scan Liver & adrenal metastases are typically asymptomatic and discovered by routine CT scan Skin and soft tissue metastases occur in 8% of patients dying of lung cancer and generally present as painless subcutaneous or intramuscular masses Skin and soft tissue metastases occur in 8% of patients dying of lung cancer and generally present as painless subcutaneous or intramuscular masses

26 Assessment of Primary Lung Cancer History and directed questions regarding the presence or absence of pulmonary, nonpulmonary, thoracic, and paraneoplastic symptoms History and directed questions regarding the presence or absence of pulmonary, nonpulmonary, thoracic, and paraneoplastic symptoms Imaging Imaging Nodes and invasion Nodes and invasion Tissue diagnosis Tissue diagnosis Bronchoscopy or percutaneous biopsy Bronchoscopy or percutaneous biopsy Thoracoscopy or rarely thoracotomy Thoracoscopy or rarely thoracotomy

27 Staging Mediastinal nodes Mediastinal nodes Stations 4 & 7 Stations 4 & 7 CT scan & perc biopsy CT scan & perc biopsy PET PET Bronchoscopy Bronchoscopy Mediastinoscopy Mediastinoscopy EUS w FNA EUS w FNA Distant mets Distant mets PET-CT PET-CT

28 Staging System

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30 Chest Wall Tumors

31 Mediastinal Tumors Anterior (thymus) Anterior (thymus) Thymoma – always resect Thymoma – always resect 50% malignant 50% malignant 50% have symptoms 50% have symptoms 50% have myasthenia gravis 50% have myasthenia gravis Thyroid cancer and goiter Thyroid cancer and goiter T-cell lymphoma – treat with XRT and chemo T-cell lymphoma – treat with XRT and chemo Teratoma – resection and chemo Teratoma – resection and chemo Seminoma – resectiona and XRT Seminoma – resectiona and XRT Parathyroid adenoma Parathyroid adenoma

32 Mediastinal Tumors Middle (heart, trachea, ascending aorta) Middle (heart, trachea, ascending aorta) Bronchiogenic cyst – posterior to the carina - resect Bronchiogenic cyst – posterior to the carina - resect Pericardial cyst – at right costophrenic angle – resect Pericardial cyst – at right costophrenic angle – resect Enteric cyst - resect Enteric cyst - resect Lymphoma Lymphoma Posterior (esophagus, descending aorta) Posterior (esophagus, descending aorta) Enteric cysts Enteric cysts Neurogenic tumors – cause pain and neurologic deficit – resect – 10% have intraspinal involvement Neurogenic tumors – cause pain and neurologic deficit – resect – 10% have intraspinal involvement Lymphoma Lymphoma

33 Pleural Disease Pleural effusion - any significant collection of fluid within the pleural space Pleural effusion - any significant collection of fluid within the pleural space Transudative vs exudative Transudative vs exudative Chylothorax – injury to thoracic duct Chylothorax – injury to thoracic duct

34 Pleural Tumors Malignant mesothelioma Malignant mesothelioma 50% associated with asbestos exposure 50% associated with asbestos exposure Patients present with dyspnea and chest pain Patients present with dyspnea and chest pain Treatment options include supportive care only, surgical resection, and multimodality approaches Treatment options include supportive care only, surgical resection, and multimodality approaches Fibrous Tumors Fibrous Tumors Unrelated to asbestos exposure or malignant mesothelioma Unrelated to asbestos exposure or malignant mesothelioma Single pedunculated mass arising from the visceral pleura Single pedunculated mass arising from the visceral pleura Found incidnetally Found incidnetally Benign or malignant Benign or malignant Symptoms such as cough, chest pain, and dyspnea occur in 30 to 40% of patients Symptoms such as cough, chest pain, and dyspnea occur in 30 to 40% of patients Less common are fever, hypertrophic pulmonary osteoarthropathy, hemoptysis, and hypoglycemia Less common are fever, hypertrophic pulmonary osteoarthropathy, hemoptysis, and hypoglycemia Cured by complete surgical resection Cured by complete surgical resection


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