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Chapter 27. Thoracic Surgery

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A 65-year-old woman presents to your office with an incidental chest radiograph (CXR) finding of a 2-cm nodule in the periphery of her right upper lobe. This was confirmed by a CT scan and there are no other nodules or adenopathy noted. She has a heavy smoking history and you suspect this could be a lung cancer. Of the following choices, which represents the best first test to order?

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A. Fiberoptic bronchoscopy

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B. Positron emission tomography (PET) scan

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C. Percutaneous image-guided biopsy

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D. VATS

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E. Mediastinoscopy

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It is unlikely you can biopsy a nodule in the periphery of the lung with a standard fiberoptic bronchoscopy. A mediastinoscopy is not indicated at this point, since there are no enlarged lymph nodes. A PET scan will not give you a diagnosis. VATS resection could be a reasonable answer, but you should never go to the operating room without a diagnosis. Image-guided biopsy of a peripheral nodule can be done quickly and safely with a sensitivity >90% for malignancy.

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A 24-year-old man was involved in a high-speed car accident. The patient has right- and left-sided rib fractures and pneumothoraces. Bilateral chest tubes are inserted and there is a large airleak. You suspect an airway injury and perform a bronchoscopy. Indeed, there is a nearly circumferential tear of the distal trachea, which extends past the carina into the proximal left main bronchus. What is the optimal operative approach to surgically repair this injury?

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A. Median sternotomy

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B. Right posterolateral thoracotomy

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C. Left posterolateral thoracotomy

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D. Clamshell thoracotomy

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E. Anterior thoracotomy

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A right posterolateral thoracotomy will give access to the entire trachea, carina, and proximal left-sided bronchial tree.

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You are asked to evaluate a patient who has a history of colon cancer treated by primary resection and adjuvant chemotherapy several years ago. The patient now has pulmonary metastatic nodules that have been biopsy proven. When considering a patient for pulmonary metastectomy, what is the most important concept to keep in mind?

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A. The histology of the primary tumor

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B. Overall time of disease-free interval

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C. The total number of metastasis

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D. Control of the primary tumor

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E. Ability to completely resect the disease

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All of these issues play a role in ...

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