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Chapter 27. Thoracic Surgery

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?

A. Fiberoptic bronchoscopy

B. Positron emission tomography (PET) scan

C. Percutaneous image-guided biopsy

D. VATS

E. Mediastinoscopy

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.

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?

A. Median sternotomy

B. Right posterolateral thoracotomy

C. Left posterolateral thoracotomy

D. Clamshell thoracotomy

E. Anterior thoracotomy

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

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?

A. The histology of the primary tumor

B. Overall time of disease-free interval

C. The total number of metastasis

D. Control of the primary tumor

E. Ability to completely resect the disease

All of these issues play a role in ...

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