THORACIC ANATOMY:
Lungs and mediastinum
Dr. Carmine Simone
Head, Division of Critical Care
Director, Inpatient Surgical Services
Thoracic Surgeon
Toronto East General Hospital
CXR Anatomy
Pleural and Lung Surface Anatomy
• Note that the pleura
extends just below the
12th rib posteriorly. This is
important in approaching
the kidney surgically from
behind
Thorax – Surface Markings
• Note that the pleura
extends just below the
12th rib posteriorly. This is
important in approaching
the kidney surgically from
behind
Radiology - CXR
• CXR is a good initial imaging
study
• Error rate of 20-50% for
radiologic detection of lung
cancer is generally accepted
• The only reliable indicators of
benign disease in CXR are
presence of “benign”
calcifications, or the absence of
growth over 2 years
• Doubling time for malignant
nodules: 40-360 days
SPN Management Algorithm
Superior Mediastinum
Superior mediastinum
CT scan
Cancer Principles
Azygous Lobe of Right Lung
Medial Surface of Lungs
PET scan
• PET with 18-FDG
– a promising mode of
tumor imaging FDG is
taken up by cells in
glycolysis ↑ activity in
cells with high
metabolic rate (tumors
and inflammation) 96%
sensitivity and 78%
specificity for detecting
malignancy
• Now available for
evaluation of the SPN
Surgical biopsy
• Thoracoscopy for lung
biopsy is very reliable and
relatively low risk
• Patient must be able to
tolerate single lung
ventilation
• Inflammatory lung
diseases at risk of
exacerbation
Cancer Principles
• Diagnosis
• Staging
• Treatment and/or Palliation
Staging Investigations
• CT thorax and upper abdomen
• MRI Brain vs. CT brain
• Bone scan
Staging Investigations
Cervical mediastinoscopy
Cancer Principles
• Diagnosis
• Staging
• Treatment and/or Palliation
Stage I and II
Stage Ia Stage Ib
Stage IIa Stage IIb
N2 disease
Stage IIIa
Chemotherapy
Radiotherapy
Surgery
Summary
• SPN are very common
• Always think of lung cancer as a
diagnosis
• Tissue diagnosis versus surveillance
• Treatment and prognosis is stage
dependent
Case Review – CT chest
Esophageal Perforation - Thoracic
Esophageal Perforation - Thoracic
• Technique of primary closure
of thoracic esophageal
perforations:
• Ipsilateral posterior
thoracotomy
• Elevation of esophagus and
location of esophageal
defect
• Longitudinal incision of
esophageal muscle to
ensure that entire length of
defect is visualized
• 2-layer closure reinforced
with healthy vascularized
tissue
» Intercostal muscle,
pericardial fat,
pedicled diaphragm,
omentum
• Wide debridement of
mediastinum and
decortication of lung
• Insertion of 3 chest tubes
• Gastrostomy and feeding
jejunostomy
Case #6
Case #1
Case #2
Trauma Thoracotomy
THANK YOU