Transcript Chest Wall, Lung, Mediastinum, & Pleura May 11, 2010 Trachea Tracheal Injury • Tracheal Stenosis • Over-inflation of the cuff • Ischemia, scarring, stricture • Fistula development • Incorrect.

Chest Wall, Lung,
Mediastinum, & Pleura
May 11, 2010
Trachea
Tracheal Injury
• Tracheal Stenosis
• Over-inflation of the cuff
• Ischemia, scarring, stricture
• Fistula development
• Incorrect placement of the
tracheostomy through the first
tracheal ring or the cricothyroid
membrane
• Use of a large tracheostomy
tube
• Stridor and dyspnea on exertion
• Resection and primary
anastomosis
TracheoInnominate Artery
Fistula
• Causes
• Too low placement of the
tracheostomy (below the 4th ring)
• Hyperinflation of the tracheal cuff
• Typically occur 2 weeks after
tracheostomy
• Signs
• Sentinel bleed
• Heavy bleed – blow up cuff
• Insert finger and press against
manubrium
• Oral intubation and emergent
resection of fistlua
TracheoEsophageal
Fistula
• Causes
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ETT cuff compresses against NG
tube
• Signs
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Gastric contents or tube feeds
suctioned from airway
Gastric distention from positive
pressure ventilation
• Diagnosis
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Bronchoscopy or EGD
• Treatment
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Wean off vent
Remove NG and place GT or JT
Operative repair involves resection
and primary repair of tracheal
pathology, repair of esophagus,
and interposition muscle flap
Tracheal Neoplasms
• Rare
• SCC or adenoid cystic carcinoma
• Cough, dyspnea, hemoptysis, stridor, or symptoms
of invasion of contiguous structures
• 50% of patients have tracheal stenosis on Xray
• 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
Surgical Approaches to the
Thoracic Cavity
• 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
• Anteriolateral Thoracotomy – trauma victims
• Median sternotomy – cardiac procedures
• VATS – improved pain and functional recovery
• Improved ability to tolerate chemotherapy
• Quicker return of respiratory function in elderly and COPD
Post-operative Care
• Chest Tube
• Evacuation of air
• Evacuation of blood/pleural fluid
• Check the system regularly
• Pain Control
• Epidural at T6 with ropivicaine
• Hypotension and urinary retention
• Narcotics and Toradol
• Aggressive Pulmonary Toilet
Post-operative
Complications
• Air leak
• Bronchopleural fistula
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Diagnose by bronchoscopy
Continued chest tube mgmt
Operative closure with intercostal muscle flap
Bronchoscopic fibrin glue application (<4mm)
Concomitant empyema may require open drainage
• Post-pneumonectomy pulmonary edema
• Decreased lympnatic drainage
• Mechanical ventilation & diuresis
Lung
• Solitary Pulmonary Nodule
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A single, well-circumscribed, spherical lesion
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≤3 cm in diameter
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Completely surrounded by normal aerated lung
parenchyma
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Detected incidentally on chest radiographs or CT
scans
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DDx – malignancy, hamartoma (10%),
granulomatous dz (70%)
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20 to 40% likelihood of being malignant
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50% or higher in smokers
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growth over time,
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density of the lesion on CT
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associated symptom
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age, sex, cigarette smoking history,
occupational history,
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prevalence of endemic granulomatous disease
Lung Cancer
• Leading cause of
cancer-related death
(30%)
• Second most
common diagnosed
cancer
• Women – breast
• Men – prostate
Lung Cancer
• Epidemiology
• Leading risk factor – smoking (polycyclic aromatic
hydrocarbons)
• Secondhand smoke also increases risk
• Environmental exposures - asbestos, arsenic, and
chromium compounds
• COPD
• h/o tuberculosis
Lung Cancer
• Non-small cell carcinoma vs neuroendocrine tumors
• NSCLC - large cell carcinoma, squamous cell
carcinoma, adenocarcinoma, and BAC
• 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
Squamous Cell Carcinoma
• 30 to 40% of lung cancers
• Highly associated with cigarette smoking
• Primarily located centrally and arises in the major bronchi
• 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
• Central necrosis is frequent and may lead to the
radiographic findings of a cavity (air-fluid level)
• May become infected & form an abscess
Adenocarcinoma
• Incidence has increased over the last several decades &
now 25 to 40% of all lung cancers.
• Most frequent histologic type found in women
• Peripherally based tumor
• Frequently discovered incidentally on routine chest
radiographs
• Symptoms of chest wall invasion or malignant pleural
effusions
• Composed of glands with or without mucin production
and destruction of contiguous lung architecture
Bronchoalveolar
Carcinoma
• Unusual (5% of all lung cancers) subtype of
adenocarcinoma
• Unique growth pattern
• 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.
• Three radiographic presentations:
• a single nodule
• multiple nodules (in single or multiple lobes)
• diffuse form with an appearance mimicking that of a lobar
pneumonia
• Air bronchograms can be seen
Large Cell Carcinoma
• 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
• May be confused with a large cell variant of
neuroendocrine carcinoma, with
immunohistochemical staining usually allowing
diagnostic distinction between the two
Neuroendocrine
Carcinoma
• Grade I NEC (classic or typical carcinoid) is a low-grade NEC
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primarily in the central airways
primarily in younger patients.
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
• Grade II NEC (atypical carcinoid) tumors with a degree of aggressive clinical
behavior
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linked to cigarette & peripherally located
Much higher malignant potential.
Lymph node metastases found in 30 to 50% of patients
At the time of diagnosis, 25% have remote metastases
• 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
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Immunohistochemical stains distinguish from NSCLC
Leading producer of paraneoplastic syndromes
Paraneoplastic Syndromes
• Table 19-5
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Hypercalcemia (ectopic parathyroid hormone)
Cushing's syndrome
Syndrome of inappropriate secretion of antidiuretic hormone
Carcinoid syndrome
Gynecomastia
Hypercalcitoninemia
Elevated growth hormone level
Elevated levels of prolactin, follicle-stimulating hormone,
luteinizing hormone
• Hypoglycemia
• Hyperthyroidism
• Neuropathy
Metastatic Symptoms
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Lung cancer metastases occur most commonly to the CNS, vertebral bodies, bone, liver,
adrenal glands, lungs, skin, and soft tissue
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At diagnosis, 10% of patients have CNS metastases
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another 10 to 15% will go on to develop CNS metastases after diagnosis.
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Focal symptoms are most common and include headache, nausea and vomiting, seizures,
hemiplegia, and speech difficulty
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Most common cause of spinal cord compression
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Invasion of an intervertebral foramen from a primary tumor contiguous with the spine
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Direct extension of a vertebral metastasis.
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Bony metastases, are identified in 25% - lytic and painful
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Liver & adrenal metastases are typically asymptomatic and discovered by routine CT scan
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Skin and soft tissue metastases occur in 8% of patients dying of lung cancer and generally
present as painless subcutaneous or intramuscular masses
Assessment of Primary
Lung Cancer
• History and directed questions regarding the
presence or absence of pulmonary, nonpulmonary,
thoracic, and paraneoplastic symptoms
• Imaging
• Nodes and invasion
• Tissue diagnosis
• Bronchoscopy or percutaneous biopsy
• Thoracoscopy or rarely thoracotomy
Staging
• Mediastinal nodes
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Stations 4 & 7
CT scan & perc biopsy
PET
Bronchoscopy
Mediastinoscopy
EUS w FNA
• Distant mets
• PET-CT
Staging System
Chest Wall Tumors
Mediastinal Tumors
• Anterior (thymus)
• Thymoma – always resect
• 50% malignant
• 50% have symptoms
• 50% have myasthenia gravis
• Thyroid cancer and goiter
• T-cell lymphoma – treat with XRT and chemo
• Teratoma – resection and chemo
• Seminoma – resectiona and XRT
• Parathyroid adenoma
Mediastinal Tumors
• Middle (heart, trachea, ascending aorta)
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Bronchiogenic cyst – posterior to the carina - resect
Pericardial cyst – at right costophrenic angle – resect
Enteric cyst - resect
Lymphoma
• Posterior (esophagus, descending aorta)
• Enteric cysts
• Neurogenic tumors – cause pain and neurologic deficit –
resect – 10% have intraspinal involvement
• Lymphoma
Pleural Disease
• Pleural effusion - any
significant collection
of fluid within the
pleural space
• Transudative vs
exudative
• Chylothorax – injury
to thoracic duct
Pleural Tumors
• Malignant mesothelioma
• 50% associated with asbestos exposure
• Patients present with dyspnea and chest pain
• Treatment options include supportive care only, surgical resection, and
multimodality approaches
• Fibrous Tumors
• Unrelated to asbestos exposure or malignant mesothelioma
• Single pedunculated mass arising from the visceral pleura
• Found incidnetally
• Benign or malignant
• 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
• Cured by complete surgical resection