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					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

				
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posted:12/19/2011
language:English
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