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

2. Trachea

3. Tracheal Injury Tracheal Stenosis Resection and primary anastomosis
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

4. 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

5. TracheoEsophageal Fistula
Causes
ETT cuff compresses against NG tube
Signs
Gastric contents or tube feeds suctioned from airway
Gastric distention from positive pressure ventilation
Diagnosis
Bronchoscopy or EGD
Treatment
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

6. 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

8. 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

12. Post-operative Care Chest Tube Pain Control
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

13. Post-operative Complications
Air leak
Bronchopleural fistula
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

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

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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. Neuroendocrine Carcinoma
Grade I NEC (classic or typical carcinoid) is a low-grade NEC
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
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
Immunohistochemical stains distinguish from NSCLC
Leading producer of paraneoplastic syndromes

24. Paraneoplastic Syndromes
Table 19-5
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

25. Metastatic Symptoms
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
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
Most common cause of spinal cord compression
Invasion of an intervertebral foramen from a primary tumor contiguous with the spine
Direct extension of a vertebral metastasis.
Bony metastases, are identified in 25% - lytic and painful
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

26. 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

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

28. Staging System

30. Chest Wall Tumors

31. 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

32. Mediastinal Tumors Middle (heart, trachea, ascending aorta)
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

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

34. Pleural Tumors Malignant mesothelioma Fibrous Tumors
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