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So I think it is recording now. So, hi, everyone. Um Welcome to s um second session of the Cardiothoracic week. So this week we have um Queens University Belfast presenting. Um My name is Prudence and I'm one of the education coordinators. Um So for this session, we have Donovan presenting about a thoracic surgery. So we're happy to have him have uh present this talk today. So I'm gonna hand over to you now. Thank you. Thank you very much Prudence. Uh Good evening. Everybody said I'm Donovan Campbell, one of the fourth year medical students here at Queens and under supervision of Mister Man who put together a slide on thoracic surgery and this is following on from Monday night where James is talking about cardiac surgery. So hopefully the slides work. OK, just put in the chat any time throughout if slow, slow down, speed up anything like that. Um Yeah, thank you to all our sponsors helping us with the other teaching series. So, Thoracic surgery is a hybrid lecture. So it's an anatomy thorax as well as the clinical application of it. So we'll be going through the mediastinum all four proportions of it uh, we're going through the thoracic wall and work our way down to the tracheobronchial tree into the lungs and having a look at the pra, well, look at the arteries, veins and nerves and lymphatic system. Very important thoracic and the clinical aspect will focus around lung cancer. So there is a lot more, of course, but the main bulk of thoracic surgeon's job is gonna be dealing with lung cancer day today. So we're gonna focus on that. Look at how you classify lung cancer, what risk factors? There are the clinical features as well as investigations you can do to just find it and quickly touching on the metastatic disease and management options with spoiler. There's gonna be a fair bit of surgery. So start with the mediastinum and anatomy. So when a layperson thinks of the chest, we're gonna think of the mediastinum and this is a central compartment of the thoracic cavity and the imaging green breaks up or sorry, the image on the right breaks it up nicely in four compartments. There's the superior and all three of these together is the inferior mediastinum, which can be further broken down into the anterior, middle and posterior. So what divides superior and inferior is this imaginary line here? And that's known as the thoracic plane of Ludwig. And it extends from the sternal angle from right to T four T five under vertebral space at the post area. And the important part of all of this is working out the borders and the inferior mediastinum is very nice because you've got in red here, the Pericardial sac containing middle mediastinum and that's gonna be your marker for the inferior mediastinum. So we'll start with the superior, the borders. So superior is a basically act with thoracic inlet. Some place is called the thoracic aperture. And the impair is that the marginal line right here. Again, the transverse pain of lig the anterior, you've got the manubrium part of the sternal body. There, it is it the top portion and posterior is the vertebral body. T one to T four. And the lateral aspect of the superior mediastinum, which is the lateral aspect of all parts of mediastinum is gonna be the pleura of the lungs. So contents, these are always quite tricky to remember and I like the moms. So the way I remember this one in the first year was private, left bubble with PVT left and bottom. So, superior mediastinum is virtually everything in it. So the phrenic nerve vagus nerve and we'll explore them a little bit later. Thoracic duct quant as well. The left recurrent laryngeal nerve which loops of course under the aorta comes back up the esophageal groove with the vein aortic arch, thymus, trichia lymph node and esophagus. So I know that's an awful lot to learn to take in. But hopefully, mnemonic makes it a little bit easier then moving to the anterior main. This one's perhaps overlooked a little bit, but the clinical relevance of it helps bring it altogether I find. So the borders of it start the lateral again. So the lungs may, the front this time was moving further down is the sternal body and the transverse thoracis muscles who are now beneath the manubrium sternum body posterior is very cardium, nice and easy. Um The ruth there's that thing again, you're gonna be saying in your sleep, transverse plane of Ludwig and the floor is the diaphragm. Was quite nice to remember for all areas of the inferior mediastinum contents. I've got no fancy mnemonic, but there's not too many of them. And the clinical relevance really explains quite well. So especially in younger people very prominent this the thymus also about the sternal pericardial ligaments, very important more so in cardiac surgery. So when you go through a median sternotomy, you can then dissect through the sternal pericardial ligaments with instruments or just by putting your fingers through, we have the lower pole of the thyroid gland, uh internal thoracic vessels again, very, very important cardiac. One of the main grafts and the parasternal lymph nodes, no, for the anterior mediastinum. Remember all the T's. So this is how you're gonna remember what can go wrong here. You have teratoma, thymic carcinomas are very famous, thymoma. We think of my senior gravis, you have thyroid carcinomas and to make it fit terrible lymphomas, all these. So, and this image shows a thymus. So you see the widened mediastinum in the chest X ray. We're more used to looking at adults where if we've seen this would be a immediate consult with a senior. This is actually normal in a pediatric patient, middle media item. We're not focus on this too much James covered a great depth on Monday, but this is the heart essentially. So got the heart and great vessels as well as the pericardiophrenic vessels and the arch of the Zygo, which wanted to later, very, very important thoracic anatomy got the carina, the mean bronchi on the right and left, frantic nerve and shameless slug. But there we go Monday evening covered all of that great detail. Now, moving on to the posterior mediastinum start again with the borders, so lateral, nice and easy meal to the front. Now we do have the pericardium on to the back. We have the remaining thoracic vertebrae. So that's T five right down T 12, the roof, the same roof for all the transverse planes look big and it's the same floor for all the inferior mediastinum of the diaphragm. There is a mnemonic now dates and vagus again, the vagus kinda works. So d at es you got the descending aorta and then we have the Zygo hemizygotes. Yes, thoracic duct, esophagus and a very important sympathetic chain as well as the vagus. And this is a vagus nerve and that's anterior and posterior trunks, quite a bit of clinical evidence, but I wanna focus just on aortic aneurysms. There's all the different esophageal conditions, but mostly for cardio surgeon would be aneurysms. So keep moving on to the thoracic wall and we'll start at the front portion of the sternum. So the green, blue and purple for the nu body and the xiphoid process start with the neighboring and it's the one you can feel yourself, the jugular notch of the NRI press down the base of your neck. And it is where both clavicles join. And you can see the clavicular notches, they're nice and filled in this image and as well, the first red, OK. I hope you can see one point. And so all of the first rib joined and the second rib joins, but it joins half and half with the sternal body. So that's called da f half and half. Then we have the body discern which correlates with ribs two through the seven. And then finally, we have T 10 uh sorry xiphoid, which correlates at T 10. And that's this funny structure, which is the cartilage most of her life. And then because we're a mature adult around 40 it ossifies completely and thinking right into this throughout the cage now, and that will be focusing on your ribs. So we've got typical and atypical ribs the way I think about them, typical ribs 3 to 9 and what makes them typical. They have a head, neck and body, atypical ribs is 1 to 1011, 12. Uh it can put uh interesting fact, I guess with each of the atypical ribs. So rib, one only has one ft for articulation of it, corresponding vertebrae, typically ribs joined with their corresponding vertebrae and the vertebra above, but red B is not gonna have anything above it. E two interesting one, this would be great if you can say in an not spotter test or just show off in the dissection. Lab. Good too is a tuberosity from which cirratus anterior originates the boxer's muscle. Uh rib 10 only has one facet and ribs, 1112. So ribs have no neck and only contain one facet and thoracic surgery. One of the most frightening conditions when it comes in in the trauma is a flailed chest and that is the condition where two or more ribs located next to each other are fractured in three or more places. So it creates this almost island of floating bone which isn't attached to the rest of the rib cage. And you can imagine during inspiration and expiration, how that may affect the underlying tissue of the heart and lung. It causes this paradoxical breathing which will show you in the next slide. And in very extreme cases can cause hemodynamic compromise, which is where thoracic need to be consulted on this type of injury. So, on inspiration, the flail segment says without the presses in on an expiration when the rest of the uh rib cage comes in and down. It then starts to protrude. II did have a video here of a field. Yes, but it's not gonna work as a PDF. Bye. Yeah, apologies on that. We'll talk very quickly in the Zoic vertebrae. This is, it's again an entire lecture itself. But how do you remember? I remember it because it looks hardship. I know people have said it looks like the head of a giraffe personally. I can't see it. But if you, if that works for you, um but typically you have a damage faucet of the head of the ribs and in this case, it is a corresponding rib on the rib below the opposite too. If it was a rib, it's a corresponding vertebrae and the vertebrae above. Now, this is one is really, really high technical relevance, especially for medical students. There's the three layers of muscle that operate between each rib and these are the intercostal muscles, external, internal and innermost. And very importantly is these structures right here, the intercostal vessels they run posterior, slightly inferior to the rib. So uh chest pain insertion, you have to make sure that you can locate a rib and go over the red when inserting a drain. If you go under, you can imagine nerve, it'll be extremely painful for the patient. Plus it'll be bleeding. So we always locate the red and go over. Um where do you pull the chest, try and see if they lovely So moving on more to the juicier part of uh the thoracic anatomy, the check your bronchial tree and we'll start in the middle of the tia that horseshoe shaped ring of cartilage the whole way down with the TCA muscle to the posterior. Uh This image I think showed quite nicely the bifurcation into the thicker, shorter, right main bronchus and the longer thinner, left main bronchus. So if you swallow a foreign object, where's it gonna go a thicker option? So the right main bronchus and as well, clinically for aspiration, pneumonias be more likely to go down the right hand side as well. We've got the bifurcation of the trachea, which happens about t four t five level, the same as the transverse plane of blue big. And that's also known as the Kana and you have secondary bronchi. So secondary bronchi are also known as lobar bronchi and these correlate to a lobe. So it gives a bit of a, the game up for what's coming next. But lobar bronchi, there's three on the right and only two on the left. So that corresponds to three lobes on the right, two on the left. Then after that, you've got tertiary or the better name segmental bronchi, which correlate to segments of the lung. So you have 10 on the right on the left, you do have normal anatomical variants, it can go from 8 to 10. And after you have bronchioles working right, right down into the alveoli. So go the first question then that for you thinking of the trachea and the main bronchi, what type of cells do they consist of? And I will hopefully start up the pool here. Good. So hopefully you can, I see the pool here and even if you don't know, no shame, I can't see. Nobody can see you just have a guess. Guess I give you a couple more seconds now I can close. Good. So most people get this right. So stop the Yeah. So right answer the ciliated pseudostratified columnar epithelium. Um This gives a nod to the second job of the Jacob bronchial tree. So the first obviously is facilitation for aspiration. So air in and out second is so the airway isn't a sterile environment. We're breathing in all sorts from the air. So some of them harmful toxins and dirt need removed. And that's done through this e your mucociliary escalator. So cilia, that'll be the ciliated little hair like projections and that works by just flushing any dirt up and then we can cough it and sneeze it out. It's then stratified or pseudostratified. So is there multiple layers or does it appear like there is and it only appears like there is, there's only the one and beneath you have the basement membrane which just image unfortunately is cut out. But so it's ciliated super like columnar, a good job. Congrat all the questions. So a little image from the perspective of a bronchoscope looking at the tea. So this is the very, very top and this is your anatomic landmark. When you're looking down a bronchoscope, is your vocal cords. Now, in a real person, they appear much wider than they do here. And even for if um i anesthetist look to intubate a patient, they will locate the vocal cord as well and just dissect it go straight through and you're into the tea, the bottom of the trachea looks like this. This is the carina. Here. There's your second right name. Bronchus. Center left. Main Bronchus importantly is a tachy ostomy. So there's a percutaneous or surgical tracheostomy. We got out by surgical and this can be done in emergency situations, plan situations. Again, it's a massive topic in itself, but it facilitates breathing where there's an issue in the upper airway and it could be temporary or permanent. It's a tool used by some uh thoracic surgeons where it will be put in in theater temporarily. This could be in a patient that would struggle to bring up uh sputum postoperatively. So you'd be hoping to minimize the risk of postoperative infection. Um There's a little schematic with how uh tracheostomy is placed, lungs and pleura very quickly. So lungs, the right lung, three lobes, left, two lobes and what breaks these up. So we'll start with the left. That's a little bit easier. You have upper and lower or superior and inferior, low and they are split by this, the oblique fissure. Uh there's a cardiac in to your heart here, right hand side a little harder if you've got three lobes, of course. So upper middle, lower, superior, middle, inferior and between your upper and middle lobe, you have horizontal fissure. So that's new. And between the inferior and middle, we have a oblique fissure and posteriorly, the oblique fissure would separate the inferior and upper as well. Here we go with the pleur, we've got two layers of visceral and parietal. The visceral think of it almost like a cling film over the surface of the lung. And the parietal is in the more outer layer of the pleura. And in between, you've got the pleural cavity, which is extremely important to remember for a pneumothorax and especially important to remember for attention you th to the emergency presentation we got deviated to and all the rest. Um You can also get hemothorax. It's very important long impressions. Now, that's a very busy slide. This type of thing you might need to look yourselves after, but we'll start here on the left. It's everything that presses in on the lung and would leave the structures or leave the shape that you can see on the lung tissue. So easiest place to start is here, left ventricle big and bulky. It presses and leaves quite the mark coming up through. The aortic valve starts the aorta, the aorta, the aortic arch which is impressed around the hilum and then which area you've got the descending aorta at the bottom of both. You have your diaphragmatic surface and you can see some of the head and neck vessels branching off and red is, is probably most uh high yield from this slide is known what is in your hilum lung. So you've got airways. So your bronchi, you've got your vascular and lympho. So right and left, main bronchi, left bronchi, right, bronchi, your pulmonary artery and veins. And remember, AOA ve in for being in your pulmonary artery runs with deoxygenated blood to the lungs and it brings back oxygenated blood in the pulmonary veins into the left atrium. The case and body where this is different. Then the way I like to think of the arteries and veins is two tier system. So you've got the big famous pulmonary artery and vein. But then you also have the pulmonary artery and the or sorry, the bronchial artery and veins. We'll come on to them later. Nephrotic and nerves on the right hand side much the same. But your arch this time is a Zygo arch, Zygo, the arch. And you can see it runs into the S VC and as you see, it'll drain into the right atrium also that surface. But again, there's a lot on these legs. So it might be worth looking over later long segments. So if you know these brilliant, I don't think it'll ever be as medical school. But these the, so the tertiary bronchi each supply one of these a segment of the lung and this is more for completeness to look over after. So, arteries, a two tiered system. So we've got the pulmonary arteries coming from the pulmonary trunk out of the right ventricle. We also have these bronchial arteries. These come from the systemic circulation, which is thoracic aorta and they supply the bronchi quite important is thoracic. So during lung resection, it's quite important to be on top of these for bleeding because they do bleed a lot as they're coming from the aorta. And the other one potentially on the side would be the intercostal arteries which we alluded to earlier, the anterior and posterior. So it's a quite a nice slide for putting in context where all the anatomy is in relation to themselves. But I'll look at this slide first. So what arteries do you need to know? Do you know the aorta and three branches that come off the aortic arch? The big phallic left, common left. And how do you remember subclavian? This is the first mnemonic I did in first year. It's not mine. But the first one I learned is that CD and these are all the arteries that come off the Subclavian. So your vertebral internal thoracic, which is the one that we'll be focused on thyrocervical trunk and cost cervical trunk and then posterior, dorsal scapular. So again, pulmonary arteries, they have deoxygenated blood and the pulmonary vein, but oxygenated blood flows into the left atrium. No, the venous supply very, very complex. But for this slide, if you know your S VC and IVC are your two main veins and clinically, if you know what to look out for with this, you'll be doing quite well. So superior vena cava obstruction, there's a oncological emergency shown in this image here where there's a lung cancer in the right upper lobe, which is compressing on the S VC. So it's not allowing the blood to drain into the rad atrium. So it backs up so it backs up to the person's head to their arms. So you get swelling in your arms and hands, you get a red swollen face and it's quite a distinctive sign. This peper sign where you ask the patient to elevate their arms above their head and this exacerbates the flushing of the face. Bye. This slide is to focus on the azygos vein. You have the zygosphene. Which one do you think of it? Think of the right hand side of a person on hemi as that goes, think of the left hand side. And this is to keep things even and more interesting, you have an accessory hemizygotes. So he hemizygotes, uh superior left thorax, hemizygotes, the inferior left thorax, your Zygo is the right hand side and it runs up into the SPC here, the hemizygosity hemizygote, they both drain into the Zygo vein first So, talking more in depth, you have your bronchial arteries, so your bronchial arteries, you're gonna have bronchial veins and the right hand side again, the right hand side, zygosphene, left hand side and because it's left superior of the accessory hemi zygosphene. So we look at the nervous system right car with the pulmonary praxis, uh not from parasympathetic and sympathetic nerves. Parasympathetic comes from the vagus nerve and digest nerve, your sympathetic comes from the sympathetic trunks. So what does the vagus nerve? What's the parasympathetic? Do it stimulates secretions from the bronchial glands as well as that, it contracts smooth muscles. So if you contract smooth muscle, you vasodilate vessels sympathetic, they, they stimulate relaxation of the bronchial smooth muscle. So if you're relaxing, you're gonna construct vessels and the visceral afferent also conducts ap and impulse to the sensory ganglion of the vagus nerve. So that's one as well. When you're putting in a chest drain, you want to numb the area up. So we use local anesthetic and you can be off it because it is extremely, extremely painful, very sensitive area. So the pal pleur and this is e especially where. So when you're inserting the aesthetic in, you feel the pop, when you go through the pleura, the aspirate and then as you're pulling back, you're administering the anesthetic. And what you're trying to do is get a good covering of the parietal blurry here because this is the area that's sensitive to pain, the vessel. On the other hand, it is not sensitive to pain, but it is, it feels stretched. So if you're doing it right, putting in chest pain, the patient shouldn't be in pain, but they'll have the sensation that something is there and that's coming from the stretch. Ok. So, lymphatics is a very, very busy slide. But again, there's very little to take away from at our current stage. The color distribution in this picture is probably the most important thing. So the red here correlates to the thoracic duct. So it starts with the systemic kyli where it's drained all the lymph from the abdomen. And it works its way up here just to your left arm side of your neck, just lateral to your internal jugular vein. And throughout the dark drains then into there, it is the left subclavian vein. So and it makes up three quarters there of the body in the green. The other remaining quarter is drained by the right lymphatic duct. Very important clinically. Now to know is a kind of thorax. So this is when there is leakage of that lymph tissue into the thorax and a main cause is IOP to. So the surgeons themselves perhaps poking around, it can cause injury to the lymphatic system cause neorx. But there's many other reasons as well. This image is extremely important when it comes to staging a lung cancer, which we'll get onto later on and eight uh lobe has a corresponding node and these nodes drain centrally. And in the case of lung cancer, it spread centrally. So you start with having nodes beside the lobe that contains the lung cancer. But in more advanced cases that has spread into the mediastinal lymph nodes and in very severe cases to the other side. And this is one again just to put it all together quickly on the esophagus. I know the upper gi guys in a couple of weeks will be, will be chatting about this. But what they want to focus on is this box right here, the high yield uh clinical relevance. So Barret's esophagus, there's a lot of questions come up in past me, questions about this and it is metaplasia. So it is now converted to columnar epithelium, gastric columnar epithelium from squamous epithelium at the lung or the esophagus usually has um another quite good fact to know is the cancer. So Barrett's esophagus would be premalignant. Almost the cancer that would ensue is adenocarcinoma. However, the most common cancer in the esophagus is skin esoph carcinoma, but again, will not focus too much on this. There is one question I'd like to ask you on the esophagus at what level does the esophagus pass through the diaphragm? Again, I'll fire up a pool about this. Let's see. OK. So there we go. So what level does the esophagus pass through the diaphragm? Good stuff. One of the things is no one, the diaphragmatic opening is what passes through them and they will out. Yeah. Spot on. They all got it too easy. I'll close the vote here. Right. We move on. Remember? Esophagus? 10 ladders T 10. And to go through the other. So T eight is a cable hiatus which has the inferior Vena cava as well as the right brown. Um eight va has eight ladders. The esophageal hiatus, esophagus 10 ladders T 10 also contains the right and left uh vagus nerves as well as common. The other way, the esophageal branches from the left gastric artery in the T 12 aortic hiatus, 12 bladders. It contains the aorta thoracic duct as well as the zygosphene. And one of the first things they love to teach us here in queens anatomy. See 345, keep the diaphragm alive. So TriC nerve envi it in the diaphragm. So now as the vessel stopped her off, some thoracic anatomy a lot more now at the aspects. So we'll start with lung cancer classification. So, with lung cancer, you have small cell, non small cell carcinoma with non small cell being by far the most common. And when you break it down further, the most common type of lung cancer overall is adenocarcinoma followed by squamous cell carcinoma, which did used to be the most common when we used the old cigarettes and didn't the filters in them. And more rarely, you have large cell carcinoma. Extremely rarely. You have carcinoid tumor switch. There's a query. Are they nonsmall cell? Are they their own type of tumor? This is uh for just all right. Yeah. So that's a homemade table. You take a photo of it. Look at it the week before an exam. You can be quite helpful, but we'll break it down. So, adenocarcinoma, this is the most common type of lung cancer now. And it is proliferate peripherally located, which is very important And when it comes to treatment and you'll get an exam question where there'll be a patient with lung cancer and they'll have a line about um being a nonsmoker. What type of lung cancer is it? Cancer will be adenocarcinoma although 80% are smokers. But if you get a question of a nonsmoker, it'll be adenoma. Adeno means glandular. So these form from glandular structures are shown over here in histology. And what are you gonna look out for if your signs and symptoms? So, we have this image here in quite extreme cases, hypertrophic osteoarthritis, we have this triad of finger filming, bony, swelling, hand arthritis. So, due to the structures where the counts originates their mucus secreting, so you have an awful lot of mucus brought up. Interesting thing to look out for is G of como. So if you're doing your respiratory exam, when you're first having, look from the bottom of the bed, you can comment. Does this male patient have agan como the second most common squamous cell carcinoma and this is typically central. So that's quite a good way of differentiating too. You find your squamous cells centrally less is associated with smoking. Less is the one you get with smoking. It is a lot of cool buzz words, which is very helpful for remembering histology. It is this very distinctive, it's called AK and P and it is the one that causes hypercalcemia. So what do you look for? Your stones? Bones grows and bones. So you might have a confused patient who's constipated. They have bone pain and they're getting renal or gau and calculi, it causes quite profound finger clubbing. Again, you're starting your respiratory exam. You start after the bottom of the bed, you start with the hands and work your way up. When you get to the stage where you're ordering a chest X ray, you can look for this cavity lesion show over here. It also has your hypertrophic pulmonary osteoarthropathy with the triad but less common and interest and differential. I haven't noticed this but different taxes have this included. It's actually hard to visualize in a chest X ray, but Adeno is easier to see. And I presume that would be down to anatomically where it's located with peripheral lesion being easier to see on chest X ray. Then you have large cell carcinoma and this is we're moving away from it in Madison saying a diagnosis of exclusion, but that's what is known as. So if it's not a, no, it's not squamous. It's gonna be a large cell and it is unfortunately a very aggressive type of nonsmall cell and you get it in both peripheral or sample locations, but more so in the periphery and the problem with it and why it's so aggressive, it metastasized quite early and it metastasized to the central nervous system and the gi tract. So you have bony pain, headaches and seizures. Histology shows it quite well. You have these large cells, prominent nucleoli and as white cytoplasm, you do your chest x-ray. What do you see? You can see hilar and mediastinal lymphadenopathies. Uh interestingly, it may secret a beta ecg I'm not sure if you would be retaining, ordering that investigation and the thing with it. Yeah, there's a poor prognosis due to metastasizing quite early. Now, this is a very, very important uh cancer to know about. It's the one that above all else, even though a large cell has a poor prognosis, you do not want to get a small cell carcinoma. They're very rapidly growing and they too have early metastases even more. So in large cell and they are associated again smoking. So these are tumors that are found centrally. And there are another one that has a lot of buzzwords to learn associated with it. They cause ectopic ed itch secretion which can be seen in the un a of hyponatremia. Um It can also cause a Cushing's Syndrome by ACTH been released it hasn't as good histology, I would say as salt and pepper chromatin being the side to look out for. But an exam favorite is the part of plastic syndrome. Yeah, associated with a small cell carcinoma. So you have Lambert Eaton Myosin syndrome and then limbic cit is quite rare. Keep an eye out later on for questions when it comes to managing, they're quite difficult to manage. So as they are very, very aggressive and they spread it early, most patients are immediately onto a chemotherapy and immunotherapy regime. And this is because we come on to the gold standard treatments aren't eligible because it's too widespread. And then patients with a very extensive disease, they'll be unfortunately straight on to palliative chemotherapy fa like to carcinoid tumor. They're quite rare, although I have seen a few of them, they originate from neuroendocrine cells like small cell carcinomas and they secret hormones like serotonin, which is quite important. So you can get this phenomenon of Carcinoid syndrome where you'll have facial flushing and diarrhea would be the main to look out for. You can also get weight gain, high BP and really, really high BP and it can be very high an investigation. The buzzword investigation is this urinary five hydroxy acid but that, but it's a metabolite of serotonin and it's not usually done the 24 hour urinary free cortisol is a bit of a hamling to do so remember investigations and it is associated with quite a good prognosis. It's, there's even a discussion whether it is cancer or not. But for now it is. So we know to risk factors, we all know, but these men want smoking, but not only can you give yourself lung cancer from smoking, secondhand smoke, you can give it to the people around you. On top of that, you have genetic causes. You have very famous stuff. I think that's part of the world of asbestos uh and your different uh types of pollution as well as rad on gas, which comes from the earth. So general signs and symptoms. What are you gonna get during your respiratory history and exam symptoms? It's a persistent cough. So it's a cough, it could be dry, it could be productive, but it's not leaving hemoptysis is a red flag if anybody coughing up blood, especially if they're a more elderly person with smoking history. Yeah, red flag. If you have shortness of breath, the pain in nature associated is more pruritic. So when you breathe in, you can have current infections and your constitutional signs is fatigue as well as weight loss. Your two red flags and that's un unintentional weight loss. Always make sure and ask, are they intended to lose weight or not? You have your finger open and when you're looking at the fingers, look for is any tar stain staining from cigarette use? It's a monophonic wheeze. So you get this when one airway is being compressed on. In this case by a tumor, you get polyphonic wheeze and things like uh asthma where a lot of the airways are constricted. Uh particular types of and locations of lung cancer can cause a hoarseness and get ptosis or the seizure all depending on where the tumor is. So, what investigations do you want to do? This is my homemade interpretation of the nice guidelines. But you're gonna start with every patient getting a chest X ray. I know that's suspicious CT and you wanna do a CT cap to look for metastases immediately. Um And if the CT indicates that the tumor is peripherally located, there's several options to get a tissue sample. So the whole idea with investigations is you have to locate where this potential lesion is and then you have to get a tissue diagnosis of what it is. So per peripherally CT FNA, which is CT guided fine needle aspiration, it is. Whereas radiologist put a very fine needle and they, I mean, it's in the CT guides the needle into the tumor and you take a small sample relatively new as navigational bronchoscopy as is I see it done with thoracic surgeons where a scope is passed down as you get in a flexible bronchoscopy scope is passed down, but it's guided using a machine on the outside. And it's like playing a game, you follow a line that runs through the trach Bronchial tree to the location of the tumor, central tumors, flexible bronchoscopy, and you can pass forceps through a bronchoscope and you take a sample if you get from your CT and your tissue biopsy, that this is a curative and what we mean by curative will come on to when we get the staging. If you have an attempt to cure, you need a, a PAP CT positron emission tomography and this lights up any tumors throughout the body bright yellow. So you're not messing if it's not a curative uh tumor, you're gonna have to discuss ad MDM about what other options that you would go down if CT or sorry if pet CT um is inconclusive, you can go on and sample lymph nodes using evos and endobronchial ultrasound or in quite rare cases, you have a surgical procedure, maybe a stenoscia where you can sample central lymph nodes. So from the image previously, with lymph nodes, this would be your four R and 4 L, your para tracheal lymph nodes, you'll be sampling for median stenoscia. So a CT pap pap lights up very well because why not? We need to know how to do a chest X ray for OS. So remember you're pneumonic doctor ABCD, all know this very well. So when it comes to tissue sampling, is the lesion central or is it peripheral? So centrally, you can start with this a flexible bronchoscopy and that's the image you can see this is your EBUS, your endobronchial ultrasound, which is much the same only it has a, a small ultrasound at the end which on an image on a monitor allows you to locate a tumor. Um This is a meeting stenos procedure. But if a battery pitch in the next slide of that, there's your CT FNA and your navigational bronchoscopy. This is your main stenos copy. So an incision is made just above the jugular notch. And first thing you have to do is clear the pretracheal fascia. And that's what's been done in this image. And from there, you'll be able to pass the media steno the media stenos through and again, like a bronchoscope, you can pass four steps through and retrieve some of the lymph node tissue to histology very quickly, just looking at metastatic disease from lung cancer. So, where's the common side of metastases? Number one there, which makes sense surrounding it. And you have the brain, especially small cell carcinomas and your large cell carcinomas. That'll be going to the central nervous system you have in your adrenal glands, bones and then other lymph nodes and putting that together, knowing where the metastases are. You're allowed to come up with this staging for lung cancer. It's at and M system tumor node metastases, it's very complex. Again, we'll not be asked to go through this. But typically if there's metastases surgery that goes down isn't indicated or if you have N two disease, which is ipsilateral. So the cancer has spread into the mediastinal lymph nodes by doing surgery and removing the tumor won't cure the lung cancer. So it'll just recur after and a huge procedure. So it's best to explore other options. What are the options? So, surgery is the gold standard and the question you have to ask with surgery is respectability, followed up by operability. So all well and good. Have a lovely peripherally located lesion that you can remove surgically no issue. But the most important thing is your patient. If you have a patient, heart failure, renal failure, you can't operate on them. So you need to make sure that the patient is operable, different types of surgery which will come on to but your openings are that. So that's your keyhole, minimally invasive surgery. You have your open. So and on the increase, you have your robotic assisted arthroscopic surgery with the unfortunate acronym, different types of surgeries you can perform, which will Montu and you have chemo radiotherapy and relatively new immunotherapy. So there's loads and loads of different types of surgeries and it all depends case to case on the size of the lesion where it's at. And currently, Lobectomy is the gold standard. So it's removal of the entire lobe and why I say currently is there's a lot of work being done on research and segmentectomy. So, Segmentectomy, you just remove one of the segments and this can only be done for very small tumors that are caught early on um the research currently, although it's not in guidelines is if it is small enough to be moved by a segment, go far, you're leaving behind more good lung. So the person should have a better postoperative outcome. The risk that you need to ensure that doesn't happen though is uh reoccurrence. So you need to make sure that you have a clear margin when you're resecting, you also have bi lobes, you take two. So of course, you can do this in the right lung. A pneumonectomy where you're remove an entire lung, a wedge resection which is just clip off a little bit of a lung sleeve, resection very, very cool procedure. Sleeve. So you remove a lobe and a segment of the main bronchus and you just stick together what's left like a sleeve, chest wall. So I haven't seen one but it would be where there's an invasion of the chest wall. And the one that commonly does this is sarcoma. An interesting fact, if you have somebody say with breast cancer and they've had surgery to remove the breast cancer. And with breast cancer, you do radiotherapy to the area, radiotherapy can cause cancer. And it would be most likely to be sarcoma, which is uh soft tissue, the counter. So, pre op how you work the patient up, number one thing is stop smoking if you're not gonna stop smoking. Now, I don't know when, but this is the time and it's very important because postoperatively, patients that are still smoking, do worse investigations. On top of all the other ones we discussed, you wanna do pulmonary function tests and X ray stress test to see what their cardiovascular function is and their respiratory function bloods retains surgical bloods. And if you haven't already done so do a staging ct or staging pet move towards some rehabilitation. I think that's an area that could be explored a lot more in thoracic surgery and you'll have input from your dietician underneath the list. Um Quite a uh interesting thing you can do. You can pull up a tab on saca score and input some of's mortality risk for surgery. Now, the different types of surgery, they go on all these videos quite a long time and I appreciate them already only type for time so that this is a minimum invasive surgery. This is now the most common type of thoracic. Uh and uh thoracic approach where you make you can do it through one port, 23 would be the routine you can do four depends on the location of the tumor and you pass this a camera down one of the incisions that allows you to visualize the inside. Now, the next couple of slides have some intraoperative photos. So it's a shout out to anybody that might be a bit squeamish. This is what it looks like intraoperatively in thoracic surgery in an ideal world is what it looks like more commonly or you a bit more oozing, not bleeding, but oozing. And this here is a stapler and this is what you used to clamp across different vessels before you resect part of the lung. So first you need to make sure with an instrument that you can pass through underneath. In this case, an artery before you pass a stale through to clamp it off. Last thing you wanna do is have your stapler break or go through another different uh structure that was meant to be resected. So you make sure that you can visualize this instrument, go to the other side and you can pass through your stale and you have your three things really to uh stable across your bronchus, your artery and your vein or your bronchi depends where you're at. So you three things to staple thoracotomy. It's been done less and less but still being done. It's your open procedure. We have a huge scar afterwards, but it's much better for visualizing, especially if you have like difficult tumors or in patients that have say for some reason, got a lung that stuck to the p and that's all stuck to the chest wall, say a postradiotherapy patient. And you've got your different approaches for se cogn your posterior thoracotomy, posterior lateral would be the most common, gives you great visualization, very rarely done. And if you say it, you know that the patient is imminently gonna die is a clamshell where you cut a person essentially in half. And this is for emergencies or rarely nice uh transplant. You can do transplant m invasive even though. And this would have been the very early days of cardiothoracic surgery where they were utilizing this approach. Although you can hide the incision quite well. Always an upside like robotics is a area that's been studied highly. Uh I just wanted to include some of the benefits. You have smaller scars, less blood loss, less pain, shorter hospital stays because of the greater dexterity. So you don't need a big scar because the robot can rotate through 360. That's brilliant. Don't need issue with it, pe robot. So there's Davinci A I would be one of the best ones used very expensive. They're 1.5 2 million and the cost of running per operation is scary. I was over in Edinburgh and one of the surgeons chatting was saying that the cost of doing a robotic procedure is like flying from Edinburgh to Rome back to Edinburgh. That's the carbon footprint on a plane. Again. Definitely videos you can watch on robotic surgery postoperatively for uh foundation doctors. This is gonna be the main thing at home is pain management, different techniques. You have epidural paravertebral morphine and that would be through PCA. Um If I have paracetamol, NSAID S the most important thing in thoracic surgery is pain management. So if a patient is experiencing a lot of pain, they're not gonna be coughing a lot because it's so painful cough. If you're not coughing, your sputum is gonna sit and become infected and they'll get a horrible postoperative infection. And as well, you get this, you're not able to eat and drink properly, you'll get the, so, um, you'll also get an aspiration pneumonia postoperatively. So, as well as pain management, what else can you do? K use MDK? So, you've got physios can go for early mobilization as well as this. If you walk around the thoracic board, you'll see dozens of leaves. This is instead of spirometry for the idea you blow in, try to get all the balls to the top and that'll help expand the lung out to the chest wall again, chest patients. Yeah, it's good. It's short term pain, long term game. But what do you wanna look out for is infections? So keep close eye to the news chart for any temperature spikes, nausea. And this is all your typical postoperative. So, fluid volume, laxatives, flexing, and very importantly, psychological sports. So can you imagine? And the these people, they've had a horrendous diagnosis, gone through all these investigations and procedures in a very short space of time. And so psychological support could be very important for them other management options. So we have radiotherapy, which is very useful for unresectable, so unresectable or inoperable patients. Um, it can be used in positive case as well and there's all the different types but the one I want to focus on is Saber. So stereotactic ablative radiotherapy done here. And it's extremely, extremely good. I think in years to come, we're gonna see research come out where this is gonna match uh surgical resection for peripheral non small cell tumors. And it's done using this a linear accelerator again, another very expensive but kit but you can put a price on life and it works by targeting a lesion from all different angles and were all different uh doses of radiation meet is where the tumor is and it will just burn the tumor while sparing a lot of the normal tissue surrounding it. It's brilliant. Also with chemotherapy, it can be used uh adjuvant, neoadjuvant or palliative. Usually for non small cell, you have a regime including uh platinum based chemotherapy and the thing to look out for is a toxic taddy or in this case, it's a gentleman. But all your chemotherapy toxicity is very important. How you need to learn this. There's a table which outlines some of the common side effects of surgery, radiotherapy and chemotherapy. Now, I had to rein this back in because I kind of went overboard on making this. But immunotherapy is probably the next stage of thoracic surgery and uh thoracic oncology in general. It is harnessing the patient's own immune system to help target the cancers and different types. It's again, it's his own real specialty. To be honest, you have targeted antibodies and immunomodulators and immunomodulators. They have a lot of funding, especially in America. Some of the huge trials going on are involving the lab and Emrouz Aab and there's been fantastic trials that show positive signs. So I think as these are used more and more and tweaked more and more they'll be integrated into common uh treatment plans more often, some of them are already first line as you can see the target antibodies for some of the lung cancers. So all our bits and pieces to be aware of panco tumors gain question bank finest. These are any type of lung cancer but they are apical tumors. So more than likely gonna be one of your uh peripheral lesions to your adenocarcinomas. And these make up, they're quite rare, 3 to 5% of lung cancers, but they can get quite large and it can compress the brachial plexus. What we all love to learn in first year and this is seen with severe pain in the shoulder or scapula and then pain in the arm and weakness in the hand. Um It is this fantastic syndrome when it compresses the sympathetic ganglion known as Horner syndrome with another fantastic triad that we all like to learn meiosis ptosis are hidrosis. Another one very common, unfortunately, in this part of the world is mesothelioma, uh calci to meet the celium layer, which is in the pleural cavity and this is associated with asbestos. So here we've got Ireland and Wolf like shipyard. But any beer shipguard Walker or actually look out for retired mechanics because tires used to be made with asbestos features, normal feature of lung cancer. But look out for this chest wall pain and 30% have a pleural effusion. So if you hear that stoney dull uh noise and percussion have a little suspicion for it. And yeah, normal chest X ray you got act have looked up there and there is an infusion. You can take a sample of that. There's currently a Mars two trial ongoing looking at management options and this is something like watch this space. And now it's focusing on the surgical management. Uh you can get industrial compensation. So chest X ray, I'll give it it won't be a question. But you can say nice left lung large, you see all there, you see lung markings, all very nice right hand side. You can hardly see the lung and you can see this consolidation the whole way. And then this line here, this, this is a plural fusion right there and that's what looks like. No, again, if this is more so in person, I would be asking another spot diagnosis of what this is. But if anybody wants to put it into the chat, I actually want chat and can go for it. This is, I'll ask where is what this is and where does it most commonly originate from? You see all these punched out circular lesions and both lungs. Um, this is quite a sinister picture. Unfortunately, for a patient, this is called countable metastases. Yeah. Oh, yeah. Bring yourself breath as well. So, uh, Raped has a nicely mnemonic heart crest and this is all the sites of, uh, metas, but the main one. Yeah, renal cell carcinoma. And that'll be your exam answer. The last thing I want to do. I think there's a big future in thoracic for this procedure. Lung volume reduction surgery. So in patients that have very advanced emphysema where the elastin and their lungs all broke down and their lung tissue is too big to be functional. You can offer this procedure where you resect an area of lung tissue that isn't functional. And the idea is the tissue is left behind, the functional tissue can now expand and work better, relieving the symptoms, especially the profound breathlessness you get with advanced emphysema and a lot of time, unfortunately, it is done through median sternotomy. It's not the most plasma procedure. But I think with more experience that would be done through minimally invasive pro so has an awful lot of teaching and yeah, thanks everybody for that. I've got cases coming up. What I used, it was all of them to put this together, empty textbooks. Absolutely fantastic. You can get them, you didn't hear this from me by the way, but you can get them. If you type them into Google, you get the free copies Uh, yeah, thank you, Tab. Do our local rep and mister Manew for, uh, help me put this together. Uh, yeah, we'll come back to this maybe at the end after cases. But yeah, you can email me anytime, any questions, ask surgery, oncology, cardio, thoracic, anything at all. I, I'll be down anytime but we'll get stuck in the cases. Um, I'll leave you to read it. I'll give it about a minute and then I'll open the pool on this one and take it from there grand. So I'll open the pool at night. You know, there's a lot of attack in that. So we'll give it another minute. Yeah. Ok. So it was just then or stop for what options we have. And the right answer is superior vena Caval obstruction. Now, I can understand why people would run for Carcinoid syndrome, but go back. I flushed explains both, but an elevated JVP is due to that back pressure. So how uh pet you here, the tumors, uh it's compressed. No, not SPC. So where's the blood that has to go back? And you'll get an elevated JVP as a result of that. But incredibly important uh condition to know about. This is one of the conditions that you'll be given your 8 g of dexamethasone and getting somebody seen your ASAP. But yeah, you get the swelling, the face, neck and arms and due to the back pressure going into your head, you get a raised intracranial pressure, headaches. So it's worse when you're bending over, lifting something, coughing, sneezing, laughing. Um Yeah, your JVP will be up. So, next question. Ok, I'll give another minute to read and now open up the pool. So something we haven't touched on until now. Yeah. And then the book and hopefully the main topic of tonight's, uh, presentation doesn't give the answer right. Too early. Very good. Yeah. Stuff most people got in that one. Let's see, close the fall now a couple of seconds by your diet cause. So what are options? No, sir. Bronchial carcinoma or lung cancer of some sort. So this is referring to lights criteria or aural effusion where you've got. First thing you need to figure out is this a fusion, an exudative or a transfusion exudative means it's coming from the lung rep pleur itself. Transudative is coming from somewhere else. And the way I like to remember trans, it's down to failures. So, liver failure and heart failure and renal failure would be your main mom's hair exudative. Number. One thing that you want to exclude is a lung cancer. It could also be due to infection in the lung. Uh Rare case would be ap embolism. You would really be seeing too many fusions for that, but you definitely need to rule out uh malignancy. So what do you do? In this case, we were given the protein. So do you do plural over serum protein? And what the this is the magic numbers. Nah 0.5 is above or below. And in her case, it works out at naught 0.63. That's both. So it's actually sedative. And given the examples were malignancy bronchial carcinoma. That's quite good to know. Comes up a lot in exam. I find. So another case for you, give me another minute before I open up the pool. Good stuff. A couple of nice pz words that give the game up this one open to pull up and let me know in the chat if you want a couple more minutes or anything at the reading questions before I put the polls on. Very good and keep back close attention to his gentleman's podcast right here. Um Past few seconds. Very good. So a little divided on this one and most these we're picking up on the smoking history. So that would leave it between small cell or squamous out here, squamous cell carcinoma. But why? So remember your hypercalcemia and it can present itself quite vaguely. So somebody comes in with abdominal pain, especially with left iliac fossa. There's all the weird and wonderful diverticulitis, IBD, all the rest of it. But common is common is it just constipation and the abdominal fullness would also point towards this. Again, the type one finger clubbing, there's type 1 to 4 finger clubbing and that's associated with squamous on smoking history as well and cat and hard and lesions. So nice, shorter case this time. Yes. Uh, speed up on the p this one good. We'll keep a couple more seconds and we'll do this. Good. Very good. Most people got this so close the pool night and somebody was very early on, uh, lung cancer got you the sake of surgery for this person. Um, what I at, at this stage? So, are they operable at this stage? Yes, we have no indication things. They're not. So next case, let you redo it for a moment. OK. I'm gonna let open the po little bit trickier, but we didn't touch on it. Uh Very good. Not catching anybody. You I guess so close for less occupation. So this gentleman has Methio. He's a retirement count. The old tires used to have asbestos in it and there's a latent period of 30 to 40 years. So even though he's retired, it'll have been brewing in the system. So next case you're doing very well on this uh start to pull. I'm sorry, is thinking more of the paraneoplastic syndromes now associated very good and most people got this one all night. So it's a two parter. You need to know what this patient have a man what antibodies associated with that condition. So they have voltage gated calcium channel auto antibodies because they have Lam and Myosin syndrome. And that's a perineoplastic syndrome of small cell lung cancer. Uh that presents quite similarly to myasthenia gravis and the addition of you've hyperreflexia, you autonomic symptoms. So your dry mouth impotence and difficulty urinating and why is the mycin in Gravis like Atos is very, very common. It's not that common in my. So, oh, for you, sweet sir. There, there the pull out and if you're thinking it's intentionally vague, you spot on. Ok. Very good. Yeah, everybody got this from that close the ball. What are you thinking? Adenocarcinoma. So all that we can really get from this is that this 80 year old gentleman, unfortunately, probably has a lung cancer and there's very little else to go up. So, what's the most common lung cancer that somebody would have? What's the most likely diagnosis? It would be the most common adenocarcinoma as well. The sputum was trying to hint towards it. So I don't know why we got these slides afterwards. No, to see him, fell following him up. I'll give you nine minutes to see us. Hold up. I check here, I'll hand it a little check here. But if you remember for my homemade uh investigation. So, a adopted from the nice guidelines. Got an answer for this one, the one that's under cured. And again, most people smashing us. Very good. I'll close the ball. Uh, what we're looking at here is APA T scan. So we're looking to see is there any metastases throughout the body that would prevent from operating? Very good? You'll be glad to hear last one. Best to last. That's fine and start the process when I powerful everybody getting that one. That uh very good, very good up close the all. So like a small cell lung cancer, this is indicating towards a complication of that. We have uh central nervous system issues. What are you thinking, limbic encephalitis? So associated with small cell we get and uh subacute minor memory deficits, behavioral changes, hallucinations alter consciousness, um T seizures if you see that Friday at stage is not a good sign. Uh Buzz word is anti antibodies. And then he explains as do the other slides, why there other options weren't uh correct in this case or what they're associated with. So, housemate, that's all the slides for this one. So thanks again for hosting, putting this together. Thank you for Abdo Mister Man. And yeah, everybody. Thank you for participating. Great. Thanks Donovan. That was really informative and the cases are really helpful. Definitely. Um So if everyone could provide some feedback, please, that would be really helpful. Um So I've sent it out in the chat and after the feedback, you will also receive a certificate of attendance. Um So please stay tuned for the upcoming weeks next week. We've got upper gi um and that will be on the Monday and the Wednesday, I believe. But please follow us on Metal Twitter and Instagram to stay updated with our newest teachings. And thank you once again to Donovan and also um Queens University. Um Has anyone got any questions. If not, I believe we can close it there. Thank you. Yeah, great. Thanks, Donathan. Great. Thanks everyone.