Thoracic Surgery

General Principles

S.L. Burlacu Ovidiu

Asist.Univ. Petrache Ioan
Surgical anatomy of the thoracic cavity
A. The chest wall:
- sternum, 12 ribs, vertebral column
- the inferior border: the diaphragm
- the superior border: apertura thoracis superior (the dome)
The most important element for all the doctors is the intercostal space

B. The lungs:
- The right lung with its 3 lobes (upper, middle and lower) and 2 fissures
- The left lung with 2 lobes (upper and lower) and 1 fissure
- Both lungs are formed by segments (10)
- Tracheobronchial tree: trachea, carina, the main right and left bronchus, lobar
bronchus and s.o
Surgical anatomy of the thoracic cavity
C. The mediastinum
- There are many classifications:
- superior (communications with the neck – mediastinitis!)
- anterior (between sternum and anterior pericardium – thymus gland!)
- middle (between the anterior percardium and the vertebral column – lymph
nodes!)
- posterior (the spaces delineated by the costovertebral synuses – esophagus,
nervous roots)
General thoracic procedures
non- invasives and invasives
A. Non- invasives
— Radiologic procedures:
- the routine examination consists in 2 radiographies: postero- anterior and
lateral
- the importance of the radioscopy (fluoroscopy)
— Other imagistic procedures
- computed tomography (CT)
- magnetic resonance imaging (MRI)
- positron emission tomography imaging (PET) – neoplasm, lymph nodes
- radionuclide studies: ventilation/perfusion study with Xe 133
- ecography
 General thoracic procedures
non- invasives and invasives
— Laboratory investigations:
- the complete examination of the sputum
- the usual hematologic examinations

B. Invasive procedures
— Endoscopic procedures
- laringo and bronchoscopy (diagnostic and therapeutic)
- esophagoscopy
— Thoracentesis
— Needle biopsy of the pleura, lung CT guided
— Biopsy of scalene node
— Transthoracic needle aspiration CT guided
— Mediastinoscopy and thoracoscopy (insertion of a lighted instrument)
Disorders of the chest wall
A. Chest wall deformities
1. Pectus excavatum
- is a funnel chest, the most common deformity
- functional cardiac or respiratory impairment may be present
- surgery is indicated for functional or esthetic purposes
- more than 50 procedures (Ravitch – Nuss)
2. Sindromul Poland
- unilateral absence of costal cartilages, pectoralis major, brest
- surgery is indicated: reconstruction of the thoracic wall
3. Thoracic outlet syndrome
- neurovascular bundle compression: fibromuscular bands, scalene muscle, the first rib,
cervical ribs)
- diagnosis: pain, paresthesia, Rx, CT, velocity in the ulnar nerve
- physical therapy 3-6 months, surgery (first rib resection, scalenectomy)
Disorders of the chest wall
B. Chest wall tumors
1. Benign tumors
- chondroma is the most common benign tumor of the chest wall, appearing at the
costochondral junction
- osteochondroma occurs on any portion of the rib
- fibrous dysplasia most common posteriorily, not painful and slow-growing
1. Malignant tumors
- primary tumors are sarcomas (tumors of connective tisue): fibrosarcoma, lipo, chondro,
Ewing sarcoma, myeloma)
- can be metastatic (from renal cacinoma) or by extension (cancer of the lung)
- surgical treatment: wide excision (“five” rule), stabilisation of the chest, reconstruction
of the chest with autologous, or proshetic grafts)
Disorders of the pleural space
A. Spontaneous pneumothorax
- a subpleural bleb ( or a preexisting lesion) ruptures into the pleural space with air
accumulation and lung collapse
- young adults and patiens with chronic obstructive pulmonary diseases) are most
commonly affected
- symptoms: chest pain + nonproductive cough + dyspnea
- dignosis: clinical and radiological examination
- treatment: chest tube drainage or open or VATS surgery
- surgical procedure: stapling of apical blebs, pleural abrasion

B. Pleural effusions
- causes: congestive heart failure, infections of the pleura and lung, tumors (primary or
secondary)
- thoracentesis, pleural drainage, thoracoscopy, thoracotomy
Disorders of the pleural space
C. Pleural empyema
- defines pus in the pleural cavity
- evolves in 3 phases: serous, fibrinopurulent, chronic
- diagnosis: clinical, Rx and thoracentesis (pus or effusion with pH under 7,2)
- medical treatment: aspirations + antibiotics (I stage)
- surgery: debridement of the loculations, decortication through VATS (II stage or
thoracotomy in III stage)

D. Pleural tumors
- mesothelioma: related to asbestos exposure
- two forms: localised (usually benign) and diffuse (malignant)
- diagnosis: pain+ dyspnea, Rx and CT, pleural biopsy
- treatment: surgery (decortication/pleurectomy, or pleuro pneumonectomy),
oncological treatment
Pulmonary infections
A. Lung abscess
- may be a primary infection, or more usually secondary to aspiration
- the microorganisms involved are anaerobic
- diagnosis: fever, cough+pus, Rx, CT
- medical treatment (3 months)
- surgery: failure in medical therapy, hemorrhage, rupting in empyema)

B. Bronchiectasis
- bronchial dilatations after repeated pulmonary infections
- localized in the lower lobes
- excessive sputum production, CT, bronchoscopy with bronchoghraphy
- medical treatment with AB+ pulmonary toilet
- surgery: segmental resection in localized disease
Pulmonary infections
c. Tuberculosis
- a high incidence in Romania (Ist place in Europe)
- etiology: BK
- 95% of cases are treated using chemotherapeutic agents
- in 5-10% of cases surgery is needed: pulmonary resections (prefered today),
collapse of the lung (thoracoplasties), mioplasties
- the main indications: bronchopleural fistula, destroyed lung, aspergiloma,
posttubercular syndrome, bronchiectasis

d. Hydatid cyst
- etiopatology: Echinoccocus granulosus
- clinical aspects
- diagnosis
- treatment
Solitary pulmonary nodules
— Also called “coin lesions”
— Well circumscribed peripheral nodules
— Are manifestations of neoplastic, granulomatous or infectious pulmonary
diseases
— Are less than 3 cm in diameter and usually is asymptomatic
— If the patient is younger than 40 years of age 60 % is benign
— If calcification is present, a malignant lesion should be suspected
— CT s very important in diagnosis
— Tissue biopsy is mandatory for diagnosis
— If a benign lesion is suspected, radiological follow-up is indicated
— Surgery: excision (wedge or lobectomy)
 Lung cancer - etiology
— Tobacco - 90% of cancers are in smokers
- Latent period 20-25 years
- Dose-related (heavy smoker 25x risk of non-smoker)
— 2nd hand smoke - risk enhanced 25% in non-smoking “passive smokers”
— Industrial exposure - arsenic, chromates, nickel, asbestos, silica, iron, coal, organic
chemicals (benzopyrene, vinyl chloride, chloromethyl ether), radioactive emissions
— Atmospheric pollution – radon
— Genetic factors - specific “lung cancer genes” not yet identified
- ras- and myc- oncogenes associated w/ growth regulation
 Lung cancer - pathology
— Squamous cell carcinoma
— Most common (40-70%), centrally located, more common in men
— Local metastases, plentiful eosinophilic cytoplasm, keratin "pearls", bridging.
— Adenocarcinoma
— Less common (5-15%), peripherally located, more common women
— Distant metastases, vacuolization, mucus synthesis, glandular differentiation
— Undifferentiated carcinoma - two subtypes (20-30%)
— Large cell carcinoma: aggressive clinical behavior, moderate cytoplasm, no mucus or
keratin
— Small cell carcinoma: nonsurgical lesion, high incidence of metastases, spindle or oat
shaped cells, dense nuclei, sparse cytoplasm
— Bronchoalveolar carcinoma
— Uncommon (3-7%) adenocarcinoma variant, favorable prognosis, alveolar
"scaffolding", tends to recur as a second primary tumor
 Lung cancer – clinical manifestation
— Symptoms - bronchopulmonary (cough - most common 75%, hemoptysis - 33%,
dyspnea, wheezing or stridor, postobstructive infectious symptoms)
- extrapulmonary intrathoracic (pain, dyspagia, pleural effusion, pericardial
effusion, superior vena cava syndrome)
- extrapulmonary metastatic (adrenal, bone, liver, brain metastases)
- extra pulmonary nonmetastatic ( i.e. paraneoplastic):
• carcinomatous neuromyopathy is the most common paraneoplastic syndrome
with 15% of patients with lung cancer affected
• mysthenia gravis - like syndrome
• polymyositis
• Cushing's - small cell
• SIADH - small cell
• hypercalcemia - squamous
• gynecomastia - small cell
— Signs - clubbing is the most common
- hypertrophic pulmonary osteoarthropathy
— Tumor Makers/ Oncogenes - generally not help for diagnosing lung cancer
 Lung cancer – diagnostic evaluation
— Chest X-ray
— findings proceed symptoms by 7 months
— sensitive to 1 cm
— squamous (obstructive pneumonitis, collapse, consolidation, 20% have cavitation)
— adenocarcinoma (peripheral, < 3 cm, bronchoalveolar have parenchymal changes)
— large cell (60% are peripheral, 2/3 > 4 cm)
— small cell (80% hilar abnormalities, 2/5 associated parenchymal changes)
— Thoracic CT scan
— best for evaluating the mediastinal adenopathy and adrenals
— chest wall invasion is poorly seen
— paraesophageal and inferior pulmonary nodes not well seen
— nodes < 1 cm have a 7% chance of being malignant
— nodes > 1 cm have a 55-65% chance of being malignant
— MRI - better than CT at evaluating vascular invasion and chest wall invasion especially superior
sulcus
— Ultrasound - TEE for evaluating mediastinal adenopathy
— PET - may help determine malignant vs. benign peripheral nodules and lymph nodes
— Bone Scan - helpful in stage IIIA and IIIB disease
 Lung cancer – staging process
— Histology
— small cell vs. non-small cell (histology is predictive of yield, i.e. squamous is more
often positive followed by adenocarcinoma, and finally small cell)
— Sputum
— 20- 70% sensitive, but tumor location plays a significant role
— when cytology is positive it predicts the cell type with 85% accuracy
— Bronchoscopy
— direct visualization or positive biopsy in 25-50% of patients with lung cancer
— Fine needle aspiration
— percutaneous or transbronchial (84-95% accurate with peripheral lesions)
— VATS
— Mediastinoscopy
— Thoracotomy
 Lung cancer – staging classification
A. International Staging System for Non- Small Cell Carcinoma
— T (Primary Tumor)
— Tx - positive cytology only
— To - no evidence of tumor
— Tis - carcinoma in situ
— T1 - size < 3 cm, no pleural invasion and distal to lobar bronchus
— T2 - size > 3 cm OR any size invading the visceral pleura, associated atelectesis or pneumonitis to the
hilum, >2 cm from the carina
— T3 - any size with chest wall, diaphragm, mediastinal pleura, or pericardium, (i.e. locally metastatic to
resectable ipsilateral hemithorax) OR < 2 cm from the carina
— T4 - invasion of the mediastinum, heart, great vessels, vertebral body, esophagus, or carina
— N (Nodal Involvement)
— N0 - no nodes
— N1 - peribronchial or ipsilateral hilar
— N2 - ipsilateral mediastinum or subcarinal
— N3 - any contralateral node, ipsilateral supraclavicular or scalene nodes
— M (Distant Metastasis)
— Mo - no mets
— M1 - distant mets
B. Small Cell Carcinoma
— localized - disease of the ipsilateral hemithorax including the supraclavicular nodes and a positive
pleural effusion
— extensive - disease beyond the ipsilateral hemithorax
Lung cancer – staging classification
Stage T N M
IA T1 N0 M0
IB T2 N0 M0
II A T1 N1 M0
II B T2 N1 M0
T3 N0 M0
III A T3 N1 M0
T1-3 N2 M0
III B T4 Any N M0
Any T N3 M0
IV Any T Any N M1
 Survival after Surgical Resection in Lung
Cancer

— Stage IA (511) - 67%

— Stage IB (549) - 57%
— Stage IIA (76) - 55%
— Stage IIB (375) - 39%
— Stage IIIA (399) - 23%
— Factors influencing survival in N2 disease
— Multiple levels of involvement
— Nodal vs extranodal disease
— Superior vs inferior mediastinum
— Bulky clinical vs discrete CT nodes

— Recurrences - 80% within 2 years

— Second primary 3-4% per year, especially in high risk patients
Lung cancer – principles of treatment
— Manifestations of Preoperative Inoperability
— Distant metastases (absolute)
— Malignant pleural effusion (absolute)
— Superior vena caval syndrome
— Horners syndrome
— Vocal cord paralysis
— Phrenic nerve paralysis

— Surgery
— for stages I A to III A with curative intent, but N2 disease should be treated with neoadjuvant
chemotherapy
— for the rest of the patient, multimodality treatment to extend life and improve quality of life, surgery
just for highly selective cases with curative intent

— Chemotherapy ideally with a platinum-based regimen

— Radiotherapy

— Novel therapeutic agents