thoracic-absite_full_length sep 24,
Jason: [00:00:00] Okay, behind the knife ab site review. Today's topic is thoracic. So Kevin, let's go through, let's just get started and go
through some high yield anatomy. The anatomy of the lung left versus right. How many lobes are on the left versus the right?

Kevin: Yeah. So I'm partial as a righty to the right.

Kevin: And so that's greater. So it's three versus two. The right lung has three lobes. The left lobe has two.

Jason: Okay. How about the lymph nodes? We talk about lymph nodes. What's a good way to remember lymph node stations?

Kevin: Yeah. So the single digit. The single digit ones are the mediastinal, the double digit ones are the hilar lymph nodes.

Jason: Okay, so the single digit lymph node stations, those are going to be in the midline and the mediastinal as you get further out into
the hilum and lung. Those are your double digit lymph nodes. It's unlikely you're going to get a specific question about specific lymph
node stations, but it's worth taking a peek at those.

Jason: The, a picture of the lymph node staging and in general familiarize yourself. What about the thoracic duct?[00:01:00] Can you
chart out the full course of the thoracic duct for me?

Kevin: Okay. So the cisternocleidomastoid is at L2. It crosses at T5 from the right to the left and empties in to the junction of the left
internal jugular and the subclavian

Jason: veins.

Jason: Okay. Yep. That's right. L2 crosses T5 from right to left empties into the left internal jugular and subclavian veins. Okay. How
about the azagus vein? Where does the azagus vein drain into? So that

Patrick: drains into the superior

Jason: vena cava. Okay. What's a good just memory trick for where to find the thoracic duct between two structures?

Patrick: So you find it between, please excuse my English, but the two gooses, so the, as a goose vein and the esophagus.

Jason: Yeah, the two gooses. I love it as a goose and esophagus. Perfect. Okay. Where do so in relation to the nerves that travel along
the media signum, so the phrenic nerve and the [00:02:00] vagus nerve where did those nerves run in relation to the hilum of the lung and
how do you remember that?

Patrick: So the phrenic nerve is anterior and the vagus nerve is posterior.

Jason: Yeah. So you can think about this. If you think about it alphabetically. So A before P, anterior before posterior and P is before V,
so the phrenic is anterior before vagus, which is posterior. Is it can. Be a useful trick to help you remember those. Okay.

Patrick: Can I interrupt for one second?

Patrick: I just wanted to do two clinical correlations here. As far as when we do left carotid subclavian bypasses, are you doing say
maybe a left first rib or section? That's when you worry about that thoracic duct. It's always on the left side because that's where it
connects, not on the right side. So the right side is a little safer in that way.

Patrick: And that's why it always seems like all your cases into being left because then you're stressed out. Never seems to be on the
right side. And then as far as the Phrenic in the vagus, the phrenic runs on the [00:03:00] pericardium, on top of the heart, right? So it's
way more anterior than the vagus, which runs with the carotid.

Patrick: So just if that can help you remember that, like just if you think to your anatomy dissections and things like the phrenic runs on
top of the heart and the vagus runs deep with the

Jason: carotid. Certainly, it's way easier to remember this stuff if there's a clinical correlation for it, so thanks. Okay, what about the, so
we're talking, we're, we're talking about the mediastinum.

Jason: What are the boundaries of the mediastinum?

Patrick: Yeah, so you have the sternum anteriorly. The vertebrae posteriorly and the pleura laterally. And then you have the thoracic inlet
superiorly and the diaphragm inferiorly.

Jason: Yeah. Great. Pretty straightforward. It makes sense. If you just position yourself inside the mediastinum and pretend like you're
looking around, what structures are you gonna see?

Jason: We talk about pneumocytes of the lung sometimes this is a question, at least it used to be a question. There's a type one and the
type two. What's important to remember about those?

Patrick: Yeah. So type one, the primary function is gas exchange type two.[00:04:00] This is where it makes the surfactant.

Jason: Yeah. And that fossil title choline is that primary component of the surfactant. So that's a question I've seen asked before is which
type of pneumocyte makes surfactant and as well as what that component is. So make sure you remember that. Okay. How about with
the pores of con? What are the pores of con?

Patrick: So these are the pores in the alveoli that enable direct air
Jason: exchange. Okay. And a good analog structure, if you think about it in the right way, is that space of this in the hepatic or in the
liver. So hepatocytes interact directly with the sinusoids will in the lung. It's those pores of con that enable a direct gas exchange.

Jason: Okay. Some things that are important to know when working up patients for a potential lung resection is some different functional
definitions. We get this information from our pulmonary function test. So preoperatively, what's the workup of a patient? Who are you
considering for a lobectomy?

Jason: What numbers do you need to see for a lobectomy? [00:05:00]

Patrick: Yeah. So you want their FEV1 or their DLCO to be greater than 80%. And their postoperative predictive FEV one and DLCO to
be greater than 40%.

Jason: Okay? So yeah, so those numbers f again, FEV one, DLCO greater than 8%, and postoperative predictive FEV one and DLCO
greater than 40%.

Jason: What if it's, what if it's marginal that the postoperative predictive,

Patrick: yeah. So then you can do your VQ scan, which will show the contribution of the diseased

Jason: lungs. Okay. So you have a marginal or questionable DQ scan. Okay. Something we'll see with let's say you have a patient who
has a plural effusion and you tap it.

Jason: One thing we like to look at is figure out whether this is exudative versus transidative. And Kevin, what's that criteria called and
what are the character or what are the components of that

Patrick: criteria? Yeah, I remember studying this on my medicine rotation, believe it or not, but so you have your plural to serum protein
ratio is [00:06:00] greater than 0.

Patrick: 5 is more likely to be exudative. If the plural to serum LDH ratio is greater than 0. 6, you're leaning towards exudative or if the
plural LDH is greater than two thirds of normal serum LDH, you're thinking

Jason: exudative. Okay, great. So yeah, that's our lights criteria. It's certainly very clinically useful and also important to know for test
taking purposes.

Jason: So with regard to plural effusions and empyemo, what are some. Causes of either a pleural fusion or an empyema. What kind of
patients do we see these in?

Patrick: Yeah. So in general, you're going to see patients that have increased permeability of the pleura in the capillaries. So this is seen
in sepsis, malignancy, and pancreatitis.

Patrick: You can also see it in patients with increased hydrostatic pressure, such as CHF or CKD. And you can also see it in
hypoalbuminemia patients that have cirrhosis, nephrotic syndrome, or

Jason: malnutrition. Okay. And how, let's say you have a patient you suspect of, maybe they have some shortness of breath and clinical
[00:07:00] history is consistent with either a pleural fusion or an empyema.

Jason: What kind of imaging would you get and what are you looking for on that imaging?

Patrick: So you're going to do a chest x ray and it's going to show blunting of the costophrenic angle, and you're going to see visible
fusion on the upright film if it's greater than 300

Jason: milliliters. Yeah, that's important. So you actually need generally need a pretty significant amount to see it on that chest x ray to
see that effusion 300 mls.

Jason: And you can also see, you'll see the outline of the fissures. So you might see some fluid in the fissures. It's another thing you can
look for on the chest x ray. What about ultrasound? What would you see on ultrasound?

Patrick: So you see fluid in the plural space with loss of inspiratory

Jason: sliding.

Jason: Okay. Great. And then a lot of times we'll get a CT scan of the chest and what how is that useful? How's the CT useful?

Patrick: Yeah. So a simple effusion will be homogenous. Most are posterior and inferior, whereas an empyema would be loculated and
heterogeneous.

Jason: Okay. Treatment for let's start with the pleural effusion.

Jason: What's the treatment for pleural effusion?

Patrick: [00:08:00] Yeah. So these generally you manage them conservatively. You treat the underlying cause unless they're very
symptomatic and then you can consider a drain.

Jason: Yeah. There's some controversy there. So people are more aggressive than others as far as draining pleural effusions.

Jason: But certainly you want to figure out why, what's. You want to think about what the underlying cause is and make sure you're
reversing that and then having a fusion in a patient, puts sets them up for getting an infected infusion. And so you have to look at the
whole picture and decide whether or not you're going to drain it.
Jason: But, the key there is correct that underlying cause. Okay, how about a patient that you suspect of having an empyema? Yeah. So
for this

Patrick: patient, you're going to give antibiotics, you're going to drain, and then you're going to decorticate if it's needed.

Jason: And there's a whole evolution of empire emails as they go through their various phases and it's going to depend on the timing.

Jason: Certainly these patients can be very sick. They need resuscitation, antibiotics. You need to get drainage. They can be difficult to
drink. They're often loculated. [00:09:00] So at times that requires infusions of lytics through the chest tube versus or in combination with
a surgical decortication.

Jason: A little bit more than we likely need to get into right now. But another thing we often see, especially in the setting of trauma, are
things like retained hemothorax. What's the management for retained hemothorax?

Patrick: Yeah, so for retained hemothorax you start with a chest tube. If that fails then you can consider a VATS or a thoracotomy for

Jason: washout.

Jason: Yeah, again, a lot of these decision making processes are pretty nuanced. And, difficult to really get into and be beyond the scope
of this discussion. But it's going to depend on the patient, their presentation the timing as to how aggressive you're going to be, whether
or not you're going to treat these with range alone.

Jason: Versus vats or thoracotomy or surgical washout and decortication. But let's move on to chylothorax.[00:10:00] So how do you
diagnose a chylothorax?

Patrick: Yeah, so these are patients that are going to have, lung that's full of fluid and you're going to, you're going to tap it and it's going
to have a milky white fluid.

Patrick: There's going to be heavy triglycerides in it. So generally greater than 110 milligrams per deciliter with a lymphocyte
predominance.

Patrick: The Sudan red stain will be positive.

Jason: Okay. What are the most common etiologies of a chylothorax? So

Patrick: 50% are due to malignancy, such as lymphoma.

Patrick: And then so for the other 50% there, I actually saw a patient in real life that had a pregnancy induced one, believe it or not. So
trauma or atrogenic are some of the most common, and generally you're gonna see this once the patients start taking a diet. And then
they're going to have that, fluid collection occur

Jason: in the lung.

Jason: Okay, great. So yeah you certainly have to worry about malignancy. Malignancy is a big cause of a chylothorax. And[00:11:00]
then we do see it in iatrogenic or in a trauma, not infrequently as well. And as you say, it is heavily correlated with oral intake. So this is
something that's frequently tested is the management of a chylothorax.

Jason: What's the first line? Management for a colothorax.

Patrick: Yes, this is actually just recently on my general surgery recertifying exam a similar question And so the first line is conservative
Management with a low fat medium chain fatty acid diet or bowel rests with TPN if high volume or persistent leak on the oral diet Plus or
minus a chest tube plus or minus octreotide

Jason: Yeah.

Jason: So the thing is you want to avoid those long chain fatty acids. So medium chain fatty acid diet and see what it does. And if it's not
slowing down or still problems, then you may need to go to a NPO with TPN And then obviously you need to drain these. You can't just let
Kyle, accumulate in the chest.

Jason: So frequently we'll need some sort of drainage. And you can even add[00:12:00] octreotide if you're still having trouble getting
under control. So let's say you do all those things, and they're failing. What's the next step?

Patrick: Conservative interventions fail, you can do a ligation of the thoracic duct and the low right mediastinum, or you can consider a
top pleuridesis and possible chemo radiation for malignancy.

Jason: Yeah. So in general, ligation, if you're failing ligation, if they're failing conservative measures and you've tried everything, you can
do a surgical ligation duct again in that low right mediastinum. And then there is other options. You can try talc pleurodesis and potential
chemo radiation if the underlying cause is malignancy.

Jason: Okay. So let's move on. Kevin, let's say you have a young tall male, he's a basketball player. Yeah. He occasionally smokes some
marijuana, but he presents to you cause he, he has some shortness of breath and he suddenly felt some chest pain while [00:13:00] with
a deep inspiration. What are you thinking?

Jason: Yeah,

Patrick: so this is very classic for the primary spontaneous pneumothorax, and these are due to apical subplural

Jason: blebs. Yeah classically these are in, tall individuals, tall lengthy individuals, the spontaneous pneumothorax, as you say, from
those apical blebs. So how do you treat this?

Patrick: Yeah, so you can start with just a small gauge chest tube or pigtail.

Jason: In general there are even places that if they're, less than two centimeters, less than three centimeters different cutoffs you don't
always have to and they're stable on a chest x ray. You don't always have to drain these. You can manage them conservatively without
drainage.

Jason: There's. People that will aspirate them with I. R. But certainly, spontaneous pneumothorax are going to get a chest tube of some
sort. And there certainly is a trend for going for smaller and smaller engaged chest tubes. And even using pigtail [00:14:00] catheters are
very effective and can save that patient.

Jason: The morbidity of a large chest tube. So In general, yeah. Drainage with a small chest tube or pigtail. Although, just be aware that
there are guidelines out there, and there are even ones that you would manage without any type of drainage. I said, now you said primary
spontaneous pneumothorax, what's the difference between primary and secondary pneumothorax?

Patrick: Yeah. Secondary is due to an underlying medical condition such as COPD being the most common, also asthma, cystic fibrosis,
infection, malignancy, connective tissue disease, or congenital

Jason: Great. Yeah. So it's a good distinction between the primary and secondary, for those, again, for those primary new authorities,
once they're drained, see how they do. And then it's a conversation at that point, if it's the first occurrence, they don't have a high risk
profession. Those don't always need surgery, but certainly if they're a high risk profession or it's recurrent,

Jason: Those patients will go [00:15:00] for a vat a blood back to me in Pleurodesis. But again, that's a little bit outside the scope of the
discussion today. So Kevin, let's say the, you have the ed. Calls you. They have a pneumothorax. They saw the chest x ray. You go down
and see the patients and the patient looks very anxious.

Jason: He's got increased work of breathing. He's tachycardic tachypneic. And you glance over and you see the blood pressure is 90
over 50. What does the patient have?

Patrick: This patient has a tension pneumothorax.

Jason: Okay. And what's the first step in management?

Patrick: Yeah. You got a needle decompress this immediately. How do you do that? So you insert a needle with a large gauge angiocath.
That's readily available into the second intercostal space at a 90 degree angle to the chest, just over the

Jason: third rib.

Jason: Yeah, or you could also needle decompress in the area that you would put a chest tube in as well. That's also acceptable. In
reality, if you're a surgeon and you're there you can do a finger thoracostomy or place a chest [00:16:00] tube just as quickly as you could
do a needle decompression. But for the most.

Jason: For the most part, if you're presented on an exam with a patient with a tension pneumothorax is hemodynamically unstable, you're
going to temporize them with a needle needle decompression and then place your definitive chest tube. But let's let's get back to our non
tension pneumothorax.

Jason: So again we talked about it briefly, but but how are we going to manage, let's say we have a clinically stable patient who has a
small pneumothorax. Yeah. So

Patrick: in these patients, you can just observe it.

Jason: Okay. That's again, what I said, like what we said. So we, less, the general guidelines are less than three centimeters.

Jason: If you have a patient with a spontaneous pneumothorax and it's stable on, an interval chest x ray and they're clinically stable, you
can observe those, but let's say they're larger, over that three centimeters or the patient's symptomatic. How would you treat that? Yeah.

Patrick: In this situation, do either a pigtail catheter or

Jason: HFC.

Jason: Yeah. And like I said, the trend is[00:17:00] smaller and smaller pigtail catheters are very effective. They're very easy to place. So
pigtail catheter is what I would do in that situation. If they're unstable.

Patrick: Yeah. So if they're unstable, you're going to definitely place the chest tube.

Jason: Okay. And when, how do you make the decision to operate?

Patrick: So if they have a persistent air leak for greater than five days, then you're going to need to do your vats with pleuradesis.

Jason: Okay. And that's an arbitrary cutoff, but certainly a persistently you'll need to do something. That's with the blood back to me in
general and pleurodesis again, also, those patients with those are either recurrent or they've had a high risk professions or they're a pilot
or they're a, Navy seal or they're a scuba diver and those patients will need to be a little bit more aggressive about doing that.

Jason: That's the blood back to me and pleurodesis. Let's say let's say you do your vats. Kevin. This is an advanced level question. You
do your vats. You don't see any blobs. What do you do? [00:18:00] Yeah.

Patrick: So in that situation, you do an apical wedge resection.
Jason: Yeah. So you still need to take the apex. And do your pleurodesis.

Jason: Good.

Jason: Okay. What do you mean? You said, you Pleurodesis. What do you mean by pleurodesis?

Patrick: Yeah. So there's a couple of different types of pleurodesis. Typically the mechanical is very common. So you can use a scratch
pad or a bovie, believe it or not. And actually rough up. lung, or you can consider a chemical where you put doxycycline or bleomycin or
talk into the pleura and let that create the irritation.

Patrick: And then some people use autologous blood patches. And you can also use a pleurectomy or actually take out the pleura. And
then there's other things such as an indwelling intrapleural

Jason: catheter. What's the overall goal? And, there's also apical teps, tense when you drop down that parietal pleura so what, but what
are the, all the goals of all these different techniques?

Patrick: Yeah, so you want to abut the visceral and[00:19:00] parietal pleura by causing an inflammatory reaction that scars them
together.

Jason: Okay, great. Okay, moving on to the next topic, which are lung abscesses. So what's the most common cause of a lung abscess?

Patrick: Yes, generally this is from aspiration or poor dental hygiene.

Jason: Okay, good. And treatment?

Patrick: So you start with the IV antibiotics and then plus or minus a bronchoscopy.

Jason: Okay, and then when do you consider surgical drainage?

Patrick: If the abscess persists for greater than two months or it's greater than four centimeters in size, Or it's thick

Jason: walled.

Jason: Okay. So let's stick within the mediastinum mediastinal tumors. So high yield mediastinal tumors. So what's the most common
cause of a mediastinal adenopathy?

Jason: Lymphoma. Okay. And how about the most common overall type of medias style tumor in both mes? Style tumor in both adults
and children.

Patrick: So generally neurogenic.

Jason: Okay. And where is that [00:20:00] located? We talk, we often talk about, anterior, posterior when we talk about the mediastinum.
So for where neurogenic tumors located?

Jason: Yeah. I

Patrick: like to keep things simple. I know the spine is posterior and so that's where all the nerves are. And so neurogenics are posterior.

Jason: Okay. And again, that's the most common. Mediastinal tumor in both adults and children. Neurogenic, located in the posterior
mediastinum. Okay, how about the most common site of a mediastinal tumor?

Patrick: Yeah, so anterior, and you have to be concerned about your

Jason: terrible Ts. And what are those, your terrible Ts for your anterior mediastinal tumors?

Patrick: Thymoma. Teratoma, thyroid, such as an ectopic thyroid, or a terrible

Jason: lymphoma? Yeah, it's cheating. I would never like to have terrible lymphoma for a T just to make it fit a mnemonic, but whatever, it
is what it is.

Jason: So of all those things, thymoma, teratoma, thyroid, terrible lymphoma, what is the most common for an anterior?

Jason: Thymoma. Yep. Thymoma is most common of those. So let's say you have a male[00:21:00] who presents with a mediastinal
mass. What else do you need to look for on your physical exam?

Patrick: So you need to do a scrotal exam.

Jason: Yeah. And you look for testicular masses for a germ cell tumor. Great. And what for germ cell tumors, what are the most common,
what's the most common type of a germ cell tumor?

Jason: Teratoma. Okay. And we already said it, but again, where is this located? Anterior medius sinum. Okay. Okay. So there's a lot of
it's very confusing. There's association between thymomas and myasthenia gravis. So can you explain that association and how do we,
like a way to remember that?

Patrick: Yeah 50 percent of all thymomas are malignant, 50 percent of these are symptomatic, and 50 percent of these will have
myasthenia.

Patrick: Okay,
Jason: what about the con, so that's a good 50, thymomas, 50 percent malignant, 50 percent symptomatic, and 50 percent with my,
myasthenia. Now, what about patients? They flip it. Patients who have [00:22:00] myasthenia, what percentage of patients with
myasthenia have a thymoma?

Patrick: So only 10% of patients with myasthenia will have a thymoma.

Jason: Okay. Okay. So 10% of patients with 50% of thymoma have myasthenia, but only 10% of patients with myasthenia have a
thymoma. But interestingly, if you take all comers of patients with myasthenia, how what percentage of them with will improve with a
thymectomy? 80%. Yeah. Okay. Somebody smarter who understands this stuff better than me can explain to me how that works, but 80
percent of my students patients will improve with a time back to me.

Jason: Let's say you do that, you perform a thymectomy and you have a post thymectomy myasthenia crisis. What is the treatment?

Patrick: Yeah, so you have two choices here. You can do urgent plasmapheresis, or you can give them IVIG.

Jason: IVIG. So that's treatment of post thymectomy myasthenia crisis. Okay. Sticking again within the mediastinum superior abena cava
syndrome.

Jason: What are causes of superior abena cava [00:23:00] syndrome?

Patrick: So by far the most common cause is malignancy, which is 60%, and it's generally from small cell lung cancer, and then followed
by

Jason: lymphoma. Okay, so yeah, you're definitely worried about malignancy. Most common small cell lung cancer also lymphoma is of a
possibility as well.

Jason: What are some non malignant causes of superior vena cannabis syndrome?

Patrick: Yeah, so we definitely see some of this in vascular with our secondary to indwelling intravascular devices such as, central lines
and tunneled dialysis catheters. You can also have fibrosine mediastinitis or sub sternal...

Patrick: Thyroid goiters or sarcoidosis.

Jason: Okay. And how do we how are these patients going to be, present a superior vena cava syndrome patients? How do they, what
do they look like?

Patrick: Yeah. So their face is big and swollen. Generally it can be half their face. You can be the whole face. They're gonna have dilation
of the neck veins.

Patrick: They're gonna have arm swelling and they can get laryngeal and tracheal broncho, tracheal bronchial compression.

Jason: Okay. How do you [00:24:00] diagnose SVC syndrome?

Patrick: So you start with chest x-ray, but generally you're gonna have a CT with contrast, plus or minus venography.

Jason: Okay. And treatment.

Patrick: So you position the patient to reduce the edema you give steroids. Plus or minus anticoagulation. But for a patient with sort of a
cancer related cause, you're gonna do an emergent radiation if they're very symptomatic.

Jason: Yep. This is like the one radiation oncology emergency.

Jason: This is the reason why radiation oncologists have pagers. Emergent radiation of symptomatic okay. So moving on outta the
mediastinum now and into the lung. So let's talk about some lung masses, which are obviously a very complicated topic. And again, we're
not thoracic surgeons are not being tested on the outside as a thoracic surgeon.

Jason: So you really don't, you are pretty basic understanding. We'll get you a long way on the outside. So let's just start with screening
recommendations. So what are screening recommendations for lung [00:25:00] masses?

Patrick: So they recommend an annual low dose CT scan for patients 50 to 80 years old with a greater than 20 pack year history who
currently smoke or quit within the past 15 years.

Jason: Yeah. Okay. That's cool. So low dose CT, if you're 50 to 80 and you have a 20 pack year smoking history it is one of those. If you
quit smoking after 15 years, your risk actually returns back to the general population. It is encourage your patients to quit smoking. Lung
cancer is still the number one cause of cancer related deaths in the United States.

Jason: And what is the strongest prognostic indicator for patients with lung cancer? What's a bad prognostic factor? Yeah, if you have
nodal involvement. Okay, so yeah, so nodal involvement is a bad prognostic indicator so lung cancer can metastasize and it tends to go to
some specific regions, so what's the most common site of metastasis for lung cancer

Patrick: Unfortunately it's the brain.

Jason: Okay. Where else? Where else [00:26:00] can it

Patrick: go? Yeah, so you can see it in the supraclavicular nodes and you can also see it in the contralateral lung, and you can see it in
the bone, the liver, and the adrenal

Jason: glands. Yeah. Yeah. It's important to remember that they like to ask about that adrenal association, and most, most often that's
asked in, in, in the reverse is you have an adrenal mass, that you're concerned that it's a metastasis.

Jason: You want to make sure that you're getting a chest CT and looking for any lung masses because lung cancer can metastasize to
the adrenal gland. Okay.

Jason: So Kevin, let's say you have a patient who has an incidentally noted solitary pulmonary nodule on imaging done for some other
reason. So what's the workup for that solitary pulmonary nodule? Yeah.

Patrick: So previous imaging is critical in this situation as in a lot of situations. And so you want to look to see if they have any previous
scans.

Patrick: If it's been stable or it's highly calcified you can consider no further workup.

Jason: Yeah, always compare that, prior imaging if it's been [00:27:00] stable for years and it looks benign, then you don't really need to
do anything and your radiologist. There's a whole, recommendation guidelines based on solitary pulmonary nodules.

Jason: Radiologist will help you out with this, but let's say, in general. You have a a solitary pulmonary nodule that's not stable. It's
growing. And the patient is a surgical candidate. So how do you break down these patients or some general recommendations?

Patrick: Yeah. Generally if it's been growing and they're acceptable risk and they have a low risk, you can consider a serial CT at three,
six, 12 and 24 months.

Patrick: If they're an immediate risk, you can do a pet CT. And a trans thoracic or a bronchoscopic biopsy. And if they're high risk, you're
going to do a VATS biopsy with frozen section and then lobectomy if malignant.

Jason: Yeah, that's good. That's nice in general. So again, you're going to classify them as low intermediate or high risk.

Jason: And if they're low, you may need some serial imaging. If they're intermediate or high, you may need to do a biopsy. And[00:28:00]
then obviously a more definitive procedure. A resection anatomic resection given, of course that they don't have any metastatic diseases
as well.

Jason: So like all cancers, you want to name it, stage it and then treat it. Okay. Sticking with the topic of lung cancer, what's the most
common type of lung cancer? So your non small cell. Yeah, that's makes up about 80 percent of your non small cell cancer. And then
what else? What other kind of can lung cancer can you have?

Patrick: So you can have your adenocarcinoma.

Jason: Okay. Or squamous cell. So you can have your squamous cell where, or adeno car adenocarcinoma. And your non-small cell. So
squamous and small cell or more central. Whereas adenocarcinoma is more peripheral. There are some associated syndromes. We call
these those paraneoplastic syndromes with these lung cancers.

Jason: So let's say for squamous cell cancer, what's the paraneoplastic syndrome that's associated with squamous cell cancer?

Patrick: [00:29:00] This might be the most high yield thing in all of the thoracic chapter. It's the PTH related peptide causing
hypercalcemia. Yeah,

Jason: and it's important to understand that mechanism.

Jason: So it's not from, it's not from lytic lesions from metastasis that's causing that hypercalcemia in squamous cell. It's parathyroid
hormone related peptide that's causing that hypercalcemia. So sometimes I like to ask you about the mechanism, so make sure you
understand that. What about the paraneoplastic syndrome that's associated with small cell?

Jason: Yeah, so this is the

Patrick: ACTH and ADH

Jason: secretion. Okay, so ACTH is most common, is actually the most common peroneoplastic syndrome. It's associated with small cell
and again, as well as ADH secretion.

Like I said, with lung cancers, you need to name it, stage it. Let's talk a little bit about staging a lung cancer. This is if you're, this probably
isn't one I would commit to memory, the TNM staging for the outside, at [00:30:00] least there are those cancers that you do need to
memorize the TNM staging, breast, colorectal but likely not lung cancer for the outside, but we'll go over it briefly.

Jason: So Kevin, what are the T stages for lung cancer?

Patrick: So if your T one through T four, so T one, it's, if it's less than three centimeters, T two, three to five centimeters, T three, five to
seven, or invading the chest wall or pericardium, and then T four is greater than seven centimeters or invading the media

Jason: signum.

Jason: Okay. And your end stages. nodal stages?

Patrick: So really, you just have one that's important here. And so it's the N3 if it's supraclavicular or cervical lymph nodes.

Jason: Okay. And of course, metastasis, either M0 or M1. We talked about a little briefly, but they like to spread to the brain most
commonly, but also the adrenals, contralateral lung or bone.

Jason: Okay. Like we said, you need to name it, stage it, and then treat it. The staging of lung cancer is pretty complex. And, the T and M
staging and the [00:31:00] different stages are very depending on what type of lung cancer is small cell versus non small cell. We're just
going to talk about some general principles with treatment.

Jason: So let's. So let's talk about those, early stage one cancer. So stage one and two, or, those cancers with that don't have a lymph
node or just a metastasis. How do we treat those, Kevin?

Patrick: Yeah. So in this situation, resection or definitive radiation, if they're not a surgical

Jason: candidate.

Jason: Okay. So for the most part, yeah. Those patients are going to get resected as long as they're a surgical candidate. So how about
locally advanced tumors? These are the stage stage three. So maybe local lymph node involvement. Yeah.

Patrick: So these patients can be resected after neoadjuvant chemo radiation.

Jason: Yeah, so those patients will typically need neovagelin, chemo XRT, chemo radiation and then followed by resection as long as
they respond. An important indicator or important distinction is those stage 3B. So those either have, a T4 tumor invading [00:32:00] those
mediastinal structures or, dissonant lymph nodes and 3 lymph nodes.

Jason: What what do we do with those patients? So

Patrick: the stage 3b with T4 and 3 lymph nodes require

Jason: chemoradiation. Yes, chemoradiation is in general going to be the answer to that. There are a few caveats there. It's very
advanced, but just, for those to the outside, I would go with chemoradiation.

Jason: And then stage 4.

Patrick: Yes, so stage 4, you want to consider palliative resection versus radiation.

Jason: Okay Kevin. So let's say we have a lung cancer that invades into the thoracic inlet. And you have a patient who presents with
shoulder and arm pain and Horner's syndrome or SBC syndrome. There's a name for that. What kind of tumors are we dealing with
there?

Patrick: Yes, this is the classic Panko's

Jason: tumor.

Jason: Yes, this is your Panko's tumor. So again, patients with tumors that invade into thoracic inlet and cause problems such as
Horner's or SPC. And how do we treat [00:33:00] those? So

Patrick: these are treated with chemo radiation followed by resection.

Jason: Okay. So I think it does it for our thoracic review.

Jason: So Kevin you have a patient with the presents or is referred to you with a pericardial cyst.

Jason: Do you have to resect that?

Patrick: Yeah, no. If they're asymptomatic, you can find them at the right cusp of bronchial angle.

Jason: Okay, great. How about bronchogenic cyst?

Patrick: Yes and you can find them at the, they're generally posterior to the Karina.

Jason: Okay. So pericardial cysts don't necessarily need to be resected if asymptomatic, but bronchogenic to do.

Jason: Okay. So Kevin, the most common lung tumor in adults?

Patrick: Generally it's going to be benign hematoma.

Jason: Okay. And and what's the pathognomonic finding on a chest x ray?

Patrick: Yeah, so it's gonna be popcorn lesions, plus or minus the calcifications. Yeah, you're

Jason: looking for those popcorn lesions.

Jason: Okay. [00:34:00] And treatment?

Patrick: You don't need any treatment. You just repeat the CT in six months to confirm the diagnosis.

Jason: Okay. What's how about the most common malignant lung tumor? So

Patrick: it's gonna be your squamous cell carcinoma. Okay.

Jason: How about the most, and let's talk about children now. So most common lung tumor in children,

Patrick: that'll be your hemangioma
Jason: and for, that's benign. So how about malignant

Patrick: for malignant? It's carcinoid.

Jason: What type of lung cancer mimics pneumonia?

Patrick: So that's your bronchi alveolar cancer, and it grows along the alveolar walls and is usually multifocal.

Patrick: Okay.

Jason: How do we treat post pneumonectomy syndrome?

Patrick: You can use a tissue expander. It's placed in the post pneumonectomy

Jason: site. Okay, great. To avoid that post pneumonectomy syndrome, use tissue expanders. Okay, last one. What conduit has the best
patency rate for [00:35:00] cabbages? That's

Patrick: Your mammary artery, your internal mammary artery, or the IMA.

Patrick: Okay,

Jason: perfect. Okay, that wraps it up for thoracic abscites thanks for listening.