Thoracic—Lung Cancer
Concept
Surgical treatment is the only potential cure. Key is to determine if patient is resectable or not. May present as a solitary pulmonary nodule where only 1 in 20 turns out to be actually malignant.
Way Question May be Asked?
“64 y/o female found to have a new lesion, ~ 2 cm in diam- eter in the LUL found on a pre-op chest x-ray prior to a hysterectomy for fibroids. What do you want to do?”
How to Answer?
History
Tobacco use Asbestos exposure Chemical exposure Travel hx
History of prior cancer (mets?)
Symptoms
New voice changes/ neuro symptoms Weight loss
Chest/bone pain Shortness of breath Hemoptysis
Physical Exam
Auscultation of chest Examine for any adenopathy Palpate liver
How to Answer?
Need prior CXR to compare (if > 3 cm and present on prior CXR, unchanged, can follow)
Need CT scan (chest including liver/adrenals) Evaluate mass size and location
Evaluate for metastases Evaluate lymph nodes
Need three morning sputum cytologies and cultures Need flexible bronchoscopy
Need biopsy of lesion Brush biopsy Trans-bronchial Percutaneous by CT Thoracotomy
Need pre-op pulmonary tests:
ABG PFTs
V/Q scan (to predict post-op FEV1)
Staging of Lung CA:
T1 = < 3 cm T2 = > 3 cm
T3 = < 2 cm from carina or
tumor invading chest wall, diaphragm, or mediastinal pleura
T4 = tumor invades any mediastinal structure (esophagus, heart, great vessels, trachea) or satellite tumor nodules within ipsilateral lobe, or malignant pleural/pericardial effusion
N1 = hilar LN involved
N2 = ipsilateral mediastinal/subcarinal nodes involved
N3 = contralateral mediastinal nodes, ipsilateral scalene/supraclavicular nodes involved
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Contraindications to Surgical Resection
T3 or T4 lesions N3 lesions
Predicted post-op FEV1 < 0.8
Surgical Treatment
Mediastinoscopy for left sided nodules
Chamberlain procedure for right sided nodules and enlarged left para-tracheal nodes
Lobectomy
Pneumonectomy (if hilar lesion, lesion encompasses all lobes on a given side (crosses fissures)
Common Curveballs
No lesion will be benign (even if on prior CXR) Lesion will turn out to be metastatic disease (scenario
switch—will you perform pulmonary metastatec- tomy? For what tumors?)
Tumor will have characteristic of unresectability:
Horner’s syndrome
Positive cytology from pleural effusion Positive cervical lymph nodes
Tracheoesophageal fistula
Recurrent laryngeal nerve or phrenic nerve paralysis
Will present as hemoptysis Will present as pleural effusion Will present as lung abscess Tumor will be hormonally active:
ACTH PTH-like ADH
Pt will have post-pneumonectomy:
Bronchopleural fistula Atrial fibrillation Hemoptysis
Mediastinal shift in recovery room
Strikeouts
Forgetting PFTs prior to thoracotomy
Describing VATS or segmentectomy or wedge resection as an option if you don’t do (know how to do) this procedure
Not performing bronch Not checking prior CXR
Operating on small cell carcinoma
Not performing mediastinoscopy pre-op when indi- cated
Offering palliative resections
Not knowing staging system (important to understand- ing Contraindications to surgical resection)
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