MedCosmos Surgery

Surgery Lecture Notes, Books, MCQ and Good Articles

Saturday, September 6, 2008

Thoracic Surgery MCQ

1. The bronchial circulation:
A. Is the blood supply to the conducting airways.
B. Drains into a peribronchial venous network that may expand considerably with
conditions such as bronchiectasis and chronic obstructive pulmonary disease.
C. Is an especially important consideration in pulmonary transplantation.
D. All of the above.
Answer: D

DISCUSSION: The bronchial circulation is the primary blood supply for the
conducting airways, pulmonary vessels, lymphoid tissue, and squamous cell
carcinomas. In conditions such as mitral stenosis, bronchiectasis, or chronic
obstructive pulmonary disease, the rich peribronchial venous network that drains
the bronchial circulation may expand considerably, creating significant left-to-right
shunts. Whenever the pulmonary artery circulation is obstructed, there is a
tendency for bronchial circulation to increase; thus, the bronchial circulation is an
important consideration during lung transplantation as well as in the surgical
treatment of cyanotic congenital heart disease and chronic pulmonary embolism.

2. Clearance of mucus produced in the tracheobronchial tree in chronic bronchitis

secondary to smoking may:
A. Be hampered by the fact that the amount of mucus is increased by the number
of mucus-producing cells at the expense of ciliated cells.
B. Be slowed if patients have decreased lung volume and are therefore unable to
generate a vigorous cough that would cause an inflammatory process.
C. Cause a decrease in diffusion capacity and associated hypoxemia.
D. All of the above.
Answer: A

DISCUSSION: Chronic bronchitis may have an acute component, and in these

patients therapy with antibiotics and bronchodilators may improve the flow rate as
measured by pulmonary function tests within 3 or 4 days of the cessation of
smoking and treatment of the acute condition. However, the chronic bronchitic
will continue to produce large amounts of mucus, most evident in the morning,
even after the acute process has been resolved. Clearance of these secretions is
hampered by the inability to cough, perhaps secondary to the pain of thoracotomy
or abdominal surgery or by a decrease in the number of ciliary cells that help move
mucus up the tracheobronchial tree. This causes plugging of small airways and
atelectasis, which may progress to pneumonia. For this reason, cessation of
smoking for 3 to 5 days before surgery is very beneficial in preventing pulmonary
complications during the postoperative period.
3. The pulmonary circulation:
A. Is the only vascular system in which the veins do not have the same course as
the arteries.
B. Has a direct connection of vein to adjacent lung tissue by connective tissue
fibers, making the diameter of the tissue fibers dependent upon lung volume.
C. Supplies the metabolic needs of the alveoli.
D. All of the above.
Answer: C

DISCUSSION: Pulmonary artery circulation transports oxygenated blood to the

alveoli level where gas exchange occurs, and it is here that the matching of
ventilation and perfusion is so important during the postoperative period. The loss
of lung volume that generally occurs after all surgical procedures does not return
to baseline for 5 to 7 days and may play an important role in the ventilation-
perfusion ratio. Improving or returning lung volume to normal is performed by
manipulating functional residual capacity (FRC) and preventing atelectasis, which
in turn maintains circulation to the alveolus and optimizes the ventilation-
perfusion ratio.

4. Which of the following screening tests are important for preoperative evaluation
of pulmonary function?
A. History and physical examination.
B. Room air arterial blood gases.
C. Chest film.
D. Vital capacity and forced expiratory volume in 1 second (FEV 1).
E. Cardiopulmonary exercise testing.
Answer: ABCDE

DISCUSSION: The most important clues to impairment of respiratory function are

found in the history and physical examination. A negative history and physical
examination in combination with a relatively normal room air arterial blood gas
and normal chest film are sufficient to screen patients to support the clinical
impression that there is minimal pulmonary disease. Patients with symptoms,
positive physical findings, and/or abnormalities in the arterial blood gases or chest
film can be screened most effectively with an additional evaluation of the vital
capacity and FEV 1. More elaborate tests such as cardiopulmonary exercise testing
are reserved for patients with obvious and marked impairment of pulmonary
function who are being evaluated for the feasibility of surgical intervention.

5. Carbon monoxide diffusion capacity (DLCO) has been shown to correlate with:
A. The thickness of the alveolar lining membrane.
B. The permeability of the erythrocyte to carbon dioxide.
C. Pulmonary emboli.
D. Total alveolar-capillary capacity.
Answer: ABCD

DISCUSSION: The single-breath DLCO is a screening test that has been shown to be
decreased in all of the above examples. It is an estimate of the total capacity of
the functional alveolar microarchitecture and has been demonstrated to be an
independent measure of physiologic capability apart from the FEV 1 and forced
ventilatory capacity.

6. The closing volume is:

A. The volume remaining in the lung at the end of expiration below which alveolar
collapse begins to occur, resulting in physiologic shunting.
B. Higher in young persons.
C. Not changed during surgery.
D. Relative to the oxygen content of mixed venous blood.
Answer: AC

DISCUSSION: The closing volume is conceptually the remaining lung volume at the
end of expiration below which alveolar collapse begins to occur, causing
intrapulmonary right-to-left shunting and thus desaturation of blood in the left
atrium. In a normal young person this closing volume is well below the functional
residual capacity (FRC); thus, such physiologic shunting does not occur until there
is a decrease in the elastic properties of the lung. Although FRC gradually increases
with age, so does the effective closing volume. Eventually some alveoli are being
underventilated (at end-expiration), allowing physiologic right-to-left shunting to
occur. Closing volume is unchanged, but FRC decreases during surgery (i.e.,
shunting occurs). Closing volume has no direct relationship to the oxygen content
of the mixed venous blood.

7. The effect of high positive end-expiratory pressures (PEEP) on cardiac output is:
A. None.
B. Increased cardiac output.
C. Decreased cardiac output because of increased afterload to the left ventricle.
D. Decreased cardiac output because of decreased effective preload to the left
ventricle.
Answer: D

DISCUSSION: Higher levels of PEEP can be associated with decreases in cardiac

output as a consequence of an effective decrease in the preload to the left
ventricle owing to impaired left ventricular filling.

8. Weaning patients from maximum ventilator support usually involves:

A. Weaning PEEP first, tidal volume second, and the fraction of inspired oxygen
(FIO 2) third.
B. Weaning FIO 2 first, ventilator rate second, and PEEP third.
C. Weaning FIO2 first, PEEP second, and tidal volume third.
D. Weaning FIO 2 first, PEEP second, and ventilator rate third.
Answer: D

DISCUSSION: When the inspired oxygen concentration is greater than 60% for more
than 24 to 28 hours, the risk of oxygen toxicity increases. PEEP is usually weaned
to physiologic levels (i.e., 5 to 7 cm. H 2O) before weaning either rate or tidal
volumes. Generally, the optimal tidal volume to achieve alveolar recruitment is
selected and usually is not decreased unless peak airway pressures increase. If
decreases in ventilatory rate are not tolerated, airway pressure support can be
added.

9. Which of the following statements about bronchoscopy is false?

A. The morbidity and mortality are approximately 0.2% and 0.08%, respectively.
B. The most common complications of bronchoscopy are related to premedication
of patients.
C. Adjunctive cancer therapy such as laser treatment and brachytherapy may be
administered via this route.
D. A chronic cough and unilateral wheezing are accepted indications for
bronchoscopy.
E. Early postoperative bronchoscopy for atelectasis is contraindicated following
pulmonary resection.
Answer: E

DISCUSSION: The stated complication rates are true and reported from a
comprehensive review of over 24,000 patients. Although the most common
complications are related to the premedication, significant hemorrhage,
pneumothorax, bronchospasm, and dysrhythmias have been reported. In addition
to laser and brachytherapy, phototherapy and immunotherapy have been given by
bronchoscopy. Unilateral wheezing may represent a bronchial foreign body, and a
chronic cough could signify myriad pulmonary disorders. Accordingly, both are
amenable to diagnostic bronchoscopy. Most thoracic surgeons favor early
bronchoscopy for lobar atelectasis following pulmonary surgery.

10. Flexible bronchoscopy is preferred over rigid bronchoscopy for all of the
following except:
A. Patients with cervical spine injuries requiring intubation.
B. The evaluation of a smoke inhalation injury.
C. Transcarinal needle aspiration of an enlarged subcarinal lymph node.
D. The removal of a bronchus intermedius foreign body from an infant.
E. A cost-effective evaluation of mild hemoptysis.
Answer: D

DISCUSSION: Neither patients with significant cervical spine disease or injuries nor
those with large aortic arch aneurysms should undergo rigid bronchoscopy, given
the greater risk of complications. Even if severe, smoke inhalation injury can be
assessed adequately by flexible bronchoscopy. Transbronchial needle aspiration of
lesions that on computed tomography (CT) look suspicious is safe and quite easily
performed with fluoroscopic guidance. Hemoptysis as a presenting symptom should
be evaluated by flexible bronchoscopy. In contrast, for massive hemoptysis an
airway should be secured for ventilation with a rigid bronchoscope. Similarly, an
airway needs to be maintained while removing endobronchial foreign bodies from
infants or children. Since adequate port sites for instrumentation are also needed,
the rigid bronchoscope is preferred in this setting.
11. Which of the following approaches is/are currently acceptable for the
management of spontaneous pneumothorax?
A. Chest tube replacement alone for the patient with a first episode.
B. Operation on presentation for any patient with a first episode.
C. Video-assisted thoracic surgery (VATS) bleb excision and pleurodesis for
recurrent pneumothorax on the same side.
D. Thoracotomy with bleb excision and pleurodesis for unilateral recurrent
pneumothorax.
E. Operation after a first episode in an airline pilot.
Answer: ACDE

DISCUSSION: Primary spontaneous pneumothorax typically occurs in young patients

with congenital blebs at the apices of the lungs. Rupture of these blebs causes
pneumothorax, which recurs in about 30% of patients. Standard care on initial
presentation is chest tube placement alone. Operation traditionally has been
performed during the initial episode only if there is prolonged air leakage (longer
than 7 days); in patients with bilateral pneumothorax; those who live in an area
where prompt medical care, if needed, is not available; and those frequently
exposed to extremes of pressure (e.g., airline pilots). Both VATS and thoracotomy
approaches to excision of blebs and pleurodesis have been shown to be effective.
The availability of the apparently safer VATS approach has led some to favor earlier
operation.

12. For which patient(s) with a pulmonary infiltrate of uncertain cause would you
favor VATS over open wedge excision?
A. An AIDS patient with a diffuse infiltrate who is ambulatory but requires
supplemental oxygen. Bronchoalveolar lavage is negative.
B. A 64-year-old previously healthy man with increasing shortness of breath, a
diffuse infiltrate, and restrictive lung disease as shown by pulmonary function
studies.
C. A 74-year-old diabetic woman with a rapidly progressing process throughout the
right lung who is ventilator- and pressor-dependent.
D. A 44-year-old man with fever, left-sided infiltrate, and shortness of breath.
E. A 79-year-old man on a ventilator for right lower and middle lobe pneumonia
which has been culture negative.
Answer: ABD

DISCUSSION: Lung biopsy by VATS or minithoracotomy is often indicated in the

work-up of a pulmonary infiltrate that has not been successfully diagnosed by less
invasive studies. This procedure probably is not indicated for cancer patients with
acute pneumonitis, as broad-spectrum antibiotics frequently are successful
treatments. For those who do require the procedure, the choice between VATS and
thoracotomy is determined by the severity of illness. In those who are critically ill
and ventilator dependent, changing the tube to an endobronchial tube for
thoracoscopy may be risky, and in these cases an anterior thoracotomy with single-
lumen ventilation is indicated. These patients, who are frequently heavily sedated
and are likely to remain so for some time postoperatively, are unlikely to benefit
from the greatest advantage of VATS, the reduction of postoperative pain. It is,
then, the ambulatory patient with a chronic interstitial process who benefits the
most from the VATS approach.

13. Which of the following statements about the cause and prevention of
postintubation tracheal stenosis are correct?
A. Postintubation airway stenosis can largely be avoided by providing assisted
ventilation via endotracheal tube rather than tracheostomy tube.
B. Postintubation tracheal stenosis at the cuff level results, more or less equally,
from low blood pressure, advanced age, steroids, high intracuff pressure,
sensitivity to tube materials, gas sterilization elution products, and systemic
disease.
C. In women and smaller men large endotracheal tubes can produce lesions of the
glottis and subglottis that can progress to stenosis.
D. Stomal stenosis is due principally to cicatricial closure of large stomas resulting
from removal of a disk or segment of tracheal wall during tracheostomy.
E. A large-volume tracheostomy tube cuff such as that now used on most available
tubes can become a high-pressure cuff if filled beyond its resting maximal volume.
Answer: CE

DISCUSSION: Use of an endotracheal tube, of course, avoids a stoma and related

complications. Cuff lesions, however, are incurred from cuffs on endotracheal
tubes, cricothyroidostomy tubes, and tracheostomy tubes. A cuff is the common
factor. Endotracheal tubes, on the other hand, cause erosion at the level of the
glottis and subglottis, in particular. Although many factors may play some role in
the origin of airway stenosis, the principal factor is pressure necrosis of the
mucosa, submucosa, and ultimately of the cartilage, with subsequent
cicatrization. Large endotracheal tubes do, indeed, cause necrosis and airway
injury at narrow areas in the upper airway, at glottic and cricoid levels. Such
injuries lead to posterior commissure stenosis, arytenoid fixation, vocal cord
erosion and granulomas, anterior commissure stricture, and subglottic
circumferential stenosis. While excision of a large amount of tracheal wall can
lead inevitably to healing by contraction with narrowing of the tracheal
circumference, the most usual cause of stomal stenosis is erosion of the stoma by
pressure from the tracheostomy tube. This in turn may relate to leverage by
equipment. Additional factors appear to be subsidiary. A large volume, low
pressure tracheostomy tube cuff, such as those currently available, if properly
constructed, will seal the trachea before it is necessary to stretch the cuff by
adding an increasing volume of air. If the cuff is stretched beyond that resting
volume, which usually occludes the normal trachea, high pressures will develop
because the plastic material from which all of these cuffs are now made is not very
extensible. Therefore, the pressure-volume curve rises sharply once the limit of
unstretched volume is passed. A low-pressure cuff then becomes a high-pressure
cuff.

14. Which of the following statements about the treatment of postintubation

airway stenosis are correct?
A. Emergency management of airway obstruction due to stenosis at the level of a
prior tracheal stoma is best accomplished by establishing a new tracheostomy in
normal tracheal tissue just below the scar of the old stoma.
B. Radial lasering and dilatation usually leads to permanent resolution of
postintubation tracheal stenosis.
C. Splinting of a cervical trachea with a silicone T-tube for 6 to 8 months generally
leads to permanent resolution of stricture.
D. Postintubation tracheal stenosis that extends into the subglottic larynx is
treated by resection of a cylindrical sleeve of stenotic airway and end-to-end
reconstruction.
E. Acquired tracheoesophageal fistula due to intubation injury is corrected by
surgical closure of the fistula concurrent with resection and reconstruction of the
damaged trachea.
Answer: E

DISCUSSION: Emergency management of postintubation tracheal stenosis is

accomplished by dilatation under general anesthesia using rigid bronchoscopes and
dilators. Tracheostomy is employed only when the patient requires a prolonged or
a permanent airway before or instead of resection and reconstruction. If a new
tracheostomy is needed it is preferable to place it through the area of existing
stenosisin this case the site of prior tracheostomyrather than to injure normal
trachea that will be needed for resection and reconstruction. If the stenosis is
below the sternal notch, a long tracheostomy tube is inserted at the usual position
(second and third rings) but extends past the now dilated stenotic lesion.
Lasering almost never results in a permanently satisfactory airway; the exception
is the very limited lesion described as a thin, weblike stenosis. Such lesions are
rare. Unfortunately, laser is widely used and often compounds existing damage by
concurrent placement of a tracheostomy tube below the lesion in the normal
trachea. T-tubes are very useful for temporizing when repair is not possible or
must be delayed. It almost never leads to resolution of a stricture unless it is an
extremely limited one. Soon after removal of the T-tube the stricture reasserts
itself.
If the lesion involves the subglottic larynx, complex repair is required to preserve
the recurrent laryngeal nerve's anatomy and function. The posterior cricoid plate is
salvaged and resurfaced with a flap of membranous tracheal wall; the anterior
subglottic larynx is reconstructed with a prow of distal tracheal cartilage and
mucosa.
A tracheoesophageal fistula is managed (after weaning from a respirator) by
layered closure of the esophagus, interposition of a flap of well-vascularized tissue
(such as a pedicled strap muscle), and resection and reconstruction of the
damaged trachea. Since the fistula results from the pressure of a cuff, often
against an esophageal feeding tube, there is circumferential damage to the
trachea at the level of the fistula. Resection and reconstruction are therefore
necessary, in addition to closure of the fistula, for successful treatment of this
complex lesion.

15. Which of the following statements are true?

A. Pyogenic lung abscess occurs most frequently in the lower lobe of the left lung.
B. Anaerobic bacteria are commonly present in pyogenic lung abscess.
C. Operation is usually required to eradicate a pyogenic lung abscess.
D. Penicillin is the treatment of choice for lung abscess.
Answer: BD

DISCUSSION: Pyogenic lung abscess is the result of aspiration of debris from the
oropharynx. Since most patients are unconscious and supine when this occurs, the
aspirated material usually finds its way into the most dependent bronchi. These
are the superior division of the right lower lobe and the posterior segment of the
right upper lobe. The organisms most commonly responsible for pyogenic lung
abscess are the same anaerobic bacteria found in the mouths of patients with poor
oral hygiene. In addition to anaerobic organisms alpha- and beta-hemolytic
streptococci, staphylococci, nonhemolytic streptococci, and Escherichia coli may
be present. Gram-negative rods and staphylococci are particularly common in
hospital-acquired infections. These organisms are almost always penicillin
sensitive. Surgical therapy is rarely necessary to eradicate a pyogenic lung abscess.
Penicillin, alone or in combination with metronidazole, is the drug of choice.
Metronidazole alone probably lacks sufficient activity against anaerobic and
microaerophilic streptococci. Clindamycin is also effective against most anaerobic
bacteria present in pyogenic lung abscesses.

16. Amphotericin B is effective for the following lung infections:

A. Histoplasmosis.
B. North American blastomycosis.
C. Aspergillosis.
D. Mucormycosis.
E. Sporotrichosis.
Answer: ABD

DISCUSSION: Amphotericin B is effective against most fungal infections, including

histoplasmosis and North American blastomycosis. Aspergillosis is caused by the
fungus Aspergillus fumigatus, an organism that is resistant to treatment with
iodides, nystatin, hydroxystilbamidine, and amphotericin B. The treatment for this
fungal infection is a surgical procedure, if the patient's condition permits. Surgical
excision and amphotericin B usually are necessary to treat mucormycosis.
Itraconazole is the drug of choice for sporotrichosis. Itraconazole, ketoconazole,
and fluconazole should be considered as primary or secondary drugs when treating
systemic fungal infections.

17. The following statements are true.

A. A distinguishing roentgenographic appearance of lung abscess, the air-fluid level
can be seen only on roentgenograms obtained in the upright or lateral decubitus
position.
B. The fungus ball characteristic of aspergillosis can be seen roentgenographically
in either the upright or recumbent position.
C. Actinomycosis and nocardiosis are both fungal diseases of the lung that respond
to treatment with the newer azole antifungal agents.
D. The commonest fungal lung infection in the United States is due to Histoplasma
capsulatum.
Answer: ABD
DISCUSSION: An air-fluid level distinguishes a lung abscess. While this can be seen
easily in an upright or lateral decubitus roentgenogram, it cannot be seen when
the patient is recumbent. The fungus ball characteristic of aspergillosis is
identified by its crescent-shaped shadow on a roentgenogram. When the patient
changes from an upright to recumbent position, the fungus ball may also change
position in the cavity in the lung. Both actinomycosis and nocardiosis are bacterial
infections and do not respond to antimycotic treatment. Actinomyces israelli is
treated with penicillin and Nocardia asteroides is sensitive to trimethoprim-
sulfamethoxazole. The most common fungal infection in North America is
histoplasmosis. More than 30 million people have been infected, most of whom are
asymptomatic.

18. Pneumocystis pneumonia is an opportunistic infection caused by Pneumocystis

carinii. Which of the following statements are true?
A. P. carinii is a fungus.
B. Pneumocystis pneumonia is the most common opportunistic infection in patients
with AIDS.
C. The diagnosis of Pneumocystis pneumonia depends on the demonstration of P.
carinii organisms in lung tissue.
D. There is no effective treatment for Pneumocystis pneumonia.
Answer: BC

DISCUSSION: P. carinii is a protozoan that stains with silver methenamine and

resembles a fungus. It responds to antiprotozoal drugs. Pneumocystis pneumonia
occurs in 80% of AIDS patients. The diagnosis is made by demonstrating the
organisms in lung tissue by transbronchoscopic lung or brush biopsy, percutaneous
needle biopsy, or open lung biopsy. Both trimethoprin-sulfamethoxazole and
pentamidine isethionate are effective against P. carinii.

19. Which of the following statements are true?

A. The pleural space does not extend into the neck.
B. Positive intrapleural pressures as high as 40 cm. H 2O and negative pressures as
low as -40 cm. H 2O are possible.
C. The pleural cavities cannot absorb more than 500 ml. of fluid per day.
D. All pleural effusions are of clinical significance and should be investigated.
Answer: BD

DISCUSSION: The pleural spaces extend into the neck as well as retrosternally and
into the costophrenic sinuses. This should be kept in mind when performing
procedures such as subclavian and jugular puncture, to avoid pneumothorax.
Markedly elevated intrapleural pressures are obtained with the Valsalva maneuver,
and extreme negative pressures can be produced with forced inspiratory effort
against a closed glottis. Because of the many microvilli present on the mesothelial
cells that line the pleural cavity, a liter or more of fluid is easily secreted or
absorbed within a 24-hour period. Most pleural effusions are caused by infection,
tumor, or congestive heart failure and should be investigated to determine the
proper course of management.
20. Which of the following statements are true?
A. Chylothorax, or chyle in the pleural cavity, usually is not a serious condition.
B. Chyle is easily identified by its milky appearance, which looks like no other kind
of pleural effusion.
C. The commonest causes of chylothorax are trauma and tumor.
D. The thoracic duct can be ligated with impunity.
Answer: CD

DISCUSSION: Chylothorax is most often the result of trauma; however, spontaneous

chylothorax is also a manifestation of tumor and should be investigated to identify
occult malignancies. Chyle in the thorax is characteristically milky white but can
be mistaken for the pseudochylothorax of rheumatoid disease or tuberculosis. If
necessary, a diagnosis can be confirmed by lymphangiography. This also facilitates
ligation of the thoracic duct, should this become necessary to control the loss of
chyle.

21. Which of these statements about pleural tumors is/are true?

A. The commonest type of pleural tumor is primary pleural mesothelioma.
B. Exposure to asbestos dust is causally related to the development of malignant
mesothelioma.
C. Localized benign mesotheliomas are asymptomatic.
D. Complete pleurectomy for malignant mesothelioma usually results in cure.
Answer: B

DISCUSSION: Pleural involvement by metastatic disease is much more common than

primary pleural tumors. Patients with localized benign pleural mesotheliomas may
have symptoms of arthralgia, clubbing of the fingers, or fever, which usually
disappear after excisional surgery. The evidence relating industrial exposure to
asbestosis and malignant pleural mesothelioma is quite strong. Excisional surgery
for malignant mesothelioma is usually only palliative. Most patients succumb
within 1 to 2 years of the diagnosis, regardless of the kind of treatment they
receive.

22. Which of the following correctly describe a patient with spontaneous

pneumothorax?
A. The patient is almost always elderly and debilitated.
B. An unsuspected primary or metastatic lung tumor may be present.
C. The administration of supplemental oxygen is of little benefit to the patient.
D. The patient should always be treated with an intercostal tube and closed
pleural drainage.
E. Video-assisted thoracic surgery (VATS) should be considered for persistent air
leak in patients with secondary spontaneous pneumothorax.
Answer: BE

DISCUSSION: A patient with spontaneous pneumothorax may be old and debilitated,

but the typical patient is an otherwise healthy young adult, usually one who
smokes. An incidental, unsuspected lung cancer is discovered on rare occasions
when operation is performed to control a persistent air leak. Perhaps smoking is a
common factor. Absorption of air from the pleural space can be facilitated by the
administration of supplemental oxygen. Increasing the oxygen tension lowers the
partial pressure of nitrogen (P N2) of the capillary blood and increases the partial
pressure difference between the pleural space and the pulmonary capillary. If the
pneumothorax results in less than 20% collapse of the lung an asymptomatic
patient can be safely observed; however, a larger or persistent pneumothorax is
best treated with an intercostal tube thoracostomy. Patients with bullous
emphysema may require stapling of bullae and pleurectomy, which can be done by
open thoracotomy or thoracoscopically (VATS).

23. Which of the following statements about spontaneous pneumothorax (PSP)

is/are correct?
A. The risk of recurrence after resolution of the first episode of PSP or secondary
spontaneous pneumothorax (SSP) is 35% to 45%.
B. Patients with PSP are typically tall, thin, young adult males with a history of
smoking.
C. Secondary spontaneous pneumothorax is associated with family history in 10% of
cases.
D. For bleb resection and pleurodesis thoracoscopic thoracotomy and open
thoracotomy provide similar cure rates for patients with primary spontaneous
pneumothorax.
E. Causes of secondary pneumothorax include trauma and iatrogenic needle
puncture.
Answer: ABD

DISCUSSION: Patients with PSP are usually 20- to 40-year-old males with a common
long-chested body habitus. The majority of PSP patients have a history of tobacco
use and 10% have a family history of PSP. The majority of cases of SSP are due to
advanced emphysema in a population of patients aged 50 to 70 years. Additional
causes of SSP include tuberculosis, cystic fibrosis, P. carinii infection, lung cancer,
and lung abscess. For patients with PSP bleb resection and pleurodesis performed
thoracoscopically provides cure rates similar to those of open thoracotomy.
Because of the nature of underlying pulmonary diseases, open thoracotomy
appears to provide better results for patients with SSP.

24. Which of the following are relative contraindications for surgical management
of emphysema?
A. Rapidly progressive dyspnea.
B. Bullae occupying less than one third of a hemithorax on plain chest radiography.
C. Elevated room air PCO 2.
D. Pink puffer patients.
E. FEV 1 less than 35% of predicted value.
Answer: BCE

DISCUSSION: Relative contraindications to operation for bullous emphysema include

patients with carbon dioxide retention, FEV 1 less than 35% of predicted value,
small bullae that occupy less than one third of a hemithorax, and blue bloaters,
who are prone to the sequelae of chronic bronchitis. Patients who have primarily
emphysema (pink puffers) and rapidly progressive dyspnea are usually good
candidates for operation.

25. Which of the following treatments would be appropriate therapy for symptoms
that persist on medical therapy and bronchiectasis involving, in order of decreasing
severity, the left lower lobe, the right middle lobe, and the left upper lobe?
A. Left pneumonectomy.
B. Wedge resection of the left lower lobe.
C. Left lower lobectomy.
D. Simultaneous left lower lobectomy and right middle lobectomy.
Answer: C

DISCUSSION: Pneumonectomy is seldom indicated today for bronchiectasis.

Anatomic resection of involved segments with either segmentectomy or lobectomy
is preferred to nonanatomic wedge resection. Bilateral pulmonary resections
should generally be done as staged procedures, the most symptomatic side being
resected first. Then, the contralateral side is resected only if symptoms persist
during a prolonged course of medical therapy.

26. Which of the following would not be acceptable sequences of preoperative

studies in a patient being prepared for lingulectomy for bronchiectasis?
A. CT alone.
B. CT, bronchoscopy, bronchography.
C. Bronchoscopy alone.
D. Bronchoscopy, bronchography.
Answer: C

DISCUSSION: Bronchoscopy alone is generally not diagnostic for bronchiectasis.

Thin-section, high-resolution CT can diagnose bronchiectasis and define the airway
anatomy sufficiently for resection. Bronchography is performed less frequently
today but can be very useful in diagnosing bronchiectasis and defining airway
anatomy for pulmonary resection.

27. Which of the following statements about pulmonary mycobacterial infection

is/are correct?
A. Worldwide, tuberculosis no longer represents a significant public health
problem.
B. Mycobacterium tuberculosis is responsible for the majority of cases of
pulmonary mycobacterial disease.
C. Mycobacterium kansasii pulmonary infection almost always requires surgical
treatment.
D. Atypical mycobacteria are never primary pulmonary pathogens in humans.
E. Mycobacterium avium-intracellulare is generally resistant to most
antimycobacterial drugs in vitro.
Answer: BE
DISCUSSION: Tuberculosis remains the leading infectious killer in the world today.
M. tuberculosis is responsible for the vast majority of pulmonary mycobacterial
disease. M. kansasii infection responds to multiple drug chemotherapy and
relatively infrequently requires surgical treatment. Atypical mycobacteria can be
primary pulmonary pathogens in humans. M. avium-intracellulare is usually
resistant in vitro to most antituberculosis drugs.

28. Which of the following chemotherapeutic regimens are currently recommended

for the treatment of pulmonary infection caused by M. tuberculosis?
A. Isoniazid, rifampin, pyrazinamide, and streptomycin for 24 months.
B. Isoniazid for 9 months with ethambutol for the first 3 months.
C. Isoniazid and rifampin for 6 months with pyrazinamide added for the first two
months.
D. Isoniazid alternating with rifampin at 3-month intervals for 12 months.
E. Isoniazid and rifampin for 9 months.
Answer: CE

DISCUSSION: Treatment of tuberculosis with a single drug leads to rapid emergence

of drug-resistant organisms. Any treatment regimen that employs only one drug for
a period of time encourages the development of drug-resistant tuberculosis.
Currently, the American Thoracic Society recommends either (1) a 6-month
regimen consisting of isoniazid, rifampin, and pyrazinamide for 2 months followed
by isoniazid and rifampin for 4 months or, alternatively, (2) a 9-month course of
isoniazid and rifampin. Prolonged courses of treatment beyond 9 to 12 months no
longer are considered necessary.

29. Which of the following are appropriate indications for pulmonary resection for
mycobacterial disease?
A. Localized pulmonary disease caused by M. avium-intracellulare.
B. Advanced lobar tuberculous pneumonia with massive hilar lymphadenopathy and
bronchial obstruction in a young child.
C. Localized pulmonary disease due to multiple drugresistant M. tuberculosis.
D. An asymptomatic tuberculous cavity greater than 12 cm. in diameter.
E. Massive hemoptysis from a right upper lobe cavity occurring during an
appropriate course of chemotherapy for pulmonary tuberculosis in a sputum-
negative patient.
Answer: ACE

DISCUSSION: Modern antimycobacterial chemotherapy is very effective. Surgical

treatment of pulmonary mycobacterial disease is rarely necessary; however,
pulmonary disease caused by M. avium-intracellulare or multiple drugresistant M.
tuberculosis is not likely to respond to chemotherapy and should be resected if the
disease is localized. Chemotherapy for tuberculosis is almost invariably curative in
children, regardless of the extent of disease. The size of a tuberculous cavity is not
an indication for resection. Massive hemoptysis from a cavitary lesion is life
threatening and is an indication for pulmonary resection.
30. Which statements about squamous papillomatosis of the trachea is/are correct?
A. It is the most common type of benign tracheal tumor in adults.
B. It is the most common type of benign tracheal tumor in children.
C. Most are treated with segmental tracheal resection.
D. There is no risk of malignant degeneration.
E. It is associated with a herpesvirus.
Answer: A

DISCUSSION: Squamous papillomatosis is the most common benign tracheal and

bronchial tumor in adults. Up to 50% of untreated lesions may degenerate into
squamous cell carcinoma. The lesion is associated with human papillomavirus types
6 and 11, and therefore, interferon therapy is under investigation. Most patients
can be treated successfully by repeated bronchoscopic fulguration, laser ablation,
or cryotherapy.

31. Which of the following statements about pulmonary hamartomas is/are true?
A. Hamartomas are benign chondromas.
B. Most are located in the conducting airways.
C. Wedge resection is curative.
D. A lobectomy is necessary to obtain draining hilar lymph nodes.
E. Hemoptysis is common.
Answer: C

DISCUSSION: Pulmonary hamartomas are benign masses consisting of cartilage,

lymph tissue, fat, and epithelial elements. Eighty per cent are located in the lung
periphery and are treated by a small wedge resection, usually with a
thoracoscope. Most are asymptomatic, and there is no risk of malignant
degeneration.

32. Which of the following statements about typical carcinoid tumors are true?
A. They make up the majority of bronchial adenomas.
B. They frequently have lymph node metastases.
C. The carcinoid syndrome is observed in 33%.
D. Overall survival at 5 years is 90%.
E. Overall survival at 5 years is 50%.
Answer: AD

DISCUSSION: Eighty-five per cent of bronchial adenomas are carcinoid tumors.

Typical carcinoid tumors have few mitotic figures and infrequent lymph node
metastases (fewer than 10%). Only 10% to 15% of patients present with the
carcinoid syndrome (flushing, wheezing, diarrhea). Survival after resection is more
than 90% at 5 years but decreases to approximately 50% for atypical histology.

33. Which is/are true of adenoid cystic carcinoma?

A. It is a common type of salivary gland tumor.
B. Another name is cylindroma.
C. Most patients are completely resected for cure.
D. Different histological types have different prognoses.
E. Tissue invasion is rare.
Answer: ABCD

DISCUSSION: Adenoid cystic carcinomas (cylindromas) are commonly observed

salivary gland tumors that can occur in the conducting airways. The
undifferentiated solid type is associated with distant metastases, of which the
cribriform and tubular types are associated with perineural and submucosal
invasion. Most patients (60%) can be resected for cure.

34. A solitary pulmonary nodule is discovered in an asymptomatic 55-year-old

smoker with no evidence of extrathoracic dissemination. The most appropriate
management would be to:
A. Obtain serial chest films every 3 months to determine the growth potential of
the nodule.
B. Perform transthoracic needle aspiration (TTNA) before considering pulmonary
resection to confirm malignancy.
C. Conduct an extensive systematic evaluation to exclude the possibility that the
nodule represents a metastatic lesion.
D. Proceed with pulmonary resection after ascertaining that the patient would
tolerate removal of the requisite amount of lung.
E. Obtain baseline serum levels of carcinoembryonic antigen and p53.
Answer: D

DISCUSSION: A patient with a solitary pulmonary nodulea single spherical lesion

within the lung represents an important and challenging diagnostic problem in
thoracic oncology. A solitary pulmonary nodule is assumed to be primary lung
cancer until proved otherwise; the differential diagnosis includes metastatic
carcinoma, granuloma, and benign pulmonary tumors. In most cases, solitary
pulmonary nodules should be resected after thorough investigation to establish
that systemic dissemination has not already occurred. CT of the chest, liver, and
adrenals is performed to confirm the location of the tumor, to evaluate the
mediastinum, and to assess the abdomen for systemic disease. If there is no
evidence of metastases on CT, the patient should undergo bronchoscopy, which
may establish the histologic diagnosis and determine resectability if an
endobronchial lesion exists.
Pulmonary function studies are obtained preoperatively to assess the potential for
pulmonary resection. A thorough review of systems is undertaken to rule out
medical contraindications to thoracotomy. TTNA is not performed routinely and
should be reserved for patients with marginal pulmonary function, for whom
thoracotomy would be performed only after verification of a malignant histologic
diagnosis.

35. After thoracotomy, pulmonary resection, and mediastinal lymph node

dissection, a patient is determined to have a squamous cell carcinoma 2 cm. in
diameter, located 1 cm. from the carina along the right mainstem bronchus. Three
peribronchial lymph nodes are positive for cancer, and all other lymph node
stations are negative. The correct stage, according to the TNM system, is:
A. T1N0M0 Stage I.
B. T1N1M0 Stage II.
C. T2N1M0 Stage II.
D. T3N1M0 Stage IIIa.
E. T2N3M0 Stage IIIb.
Answer: C

DISCUSSION: The TNM staging system for carcinoma of the lung provides a
consistent, reproducible description of the anatomic extent of disease at the time
of diagnosis. In the TNM system, T represents the primary tumor and numerical
suffixes describe increasing size or involvement; N represents regional lymph nodes
with suffixes to describe levels of involvement; and M designates the presence or
absence of distant metastases.
TUMOR (T)
TX Occult carcinoma (malignant cells in sputum or bronchial washings but tumor
not visualized by imaging studies or bronchoscopy)
T1 Tumor 3 cm. or less in greatest diameter, surrounded by lung or visceral pleura,
but not proximal to a lobar bronchus
T2 Tumor larger than 3 cm. in diameter, or with involvement of main bronchus at
least 2 cm. distal to carina, or with visceral pleural invasion, or with associated
atelectasis or obstructive pneumonitis extending to the hilar region but not
involving the entire lung
T3 Tumor invading chest wall, diaphragm, mediastinal pleura, or parietal
pericardium; or tumor in main bronchus within 2 cm. of, but not invading, carina;
or atelectasis of obstructive pneumonitis of the entire lung
T4 Tumor invading mediastinum, heart, great vessels, trachea, esophagus,
vertebral body, or carina; or ipsilateral malignant pleural effusion
NODES (N)
N0 No regional lymph node metastases
N1 Metastases to ipsilateral peribronchial or hilar nodes
N2 Metastases to ipsilateral mediastinal or subcarinal nodes
N3 Metastases to contralateral mediastinal or hilar, or to any scalene or
supraclavicular nodes
DISTANT METASTASES (M)
M0 No distant metastases
M1 Distant metastases
The TNM subsets are subsequently grouped in a series of stages of disease to
identify groups of patients with similar prognosis and therapy.

STAGE T N M
Occult TX N0 M0
Stage I T1-2 N0 M0
Stage II T1-2 N1 M0
Stage IIIa T3 N0-1 M0
T1-3 N2 M0
Stage IIIb T4 N0-2 M0
T1-4 N3 M0
Stage IV Any T Any N M1
36. After complete resection of Stage I non-small cell lung cancer (NSCLC), the role
of adjuvant therapy is best summarized thus as:
A. Postoperative radiation therapy improves disease-free survival.
B. Postoperative radiation therapy improves overall survival.
C. Postoperative chemotherapy improves disease-free survival.
D. Postoperative chemotherapy improves overall survival.
E. Adjuvant therapy is not indicated after complete resection of Stage I NSCLC.
Answer: E

DISCUSSION: Prospective randomized trials conducted by the Lung Cancer Study

Group demonstrate that postoperative chemotherapy may be responsible for
significantly longer disease-free survival in patients with Stage III (and perhaps
Stage II) NSCLC. The efficacy of postoperative chemotherapy and radiotherapy in
patients with extensive lymph node involvement or positive surgical margins in
reducing systemic recurrences and prolonging disease-free survival has also been
demonstrated. Adjuvant therapy is not associated with improved overall survival
and has not been shown to be beneficial in patients with Stage I NSCLC.
Radiation therapy is an effective adjuvant treatment in many patients with
carcinoma of the lung. Adjuvant radiotherapy, applied to patients with completely
resected Stage II or Stage III (but not Stage I) NSCLC, has been shown to decrease
local recurrence but has no significant effect on survival. However, postoperative
irradiation may provide a survival advantage in patients who have resection and
are found to have metastases to hilar or mediastinal lymph nodes. Thus, the
purpose of adjuvant radiotherapy is prevention of local tumor recurrence,
especially when lymph node sampling of the mediastinum at thoracotomy is
incomplete.

37. Compared to segmentectomy or wedge resection, lobectomy for NSCLC is

associated with:
A. Similar operative morbidity but higher operative mortality.
B. Similar operative mortality but higher operative morbidity.
C. More severe postoperative pulmonary dysfunction.
D. Lower incidence of locoregional recurrence.
E. Equivalent locoregional recurrence.
Answer: D

DISCUSSION: The risk of recurrence after surgical resection according to the

magnitude of the resection has been analyzed by the Lung Cancer Study Group. In
a prospective, randomized trial involving more than 400 patients with T1N0 lung
cancer, lobectomy was compared to segmentectomy and wedge resection. There
was no significant difference in morbidity and mortality among the procedures.
Furthermore, no difference was observed in postoperative pulmonary function
between patients who underwent lobectomy and those who underwent lesser
procedures. The rate of locoregional recurrence was significantly lower in patients
who underwent lobectomy (5%) as compared with those who underwent either
segmentectomy or wedge resection (15%). In another study, segmentectomy was
compared to lobectomy in patients with Stage I lung cancer. In this study, the rate
of locoregional recurrence was lower in patients who underwent lobectomy (5%),
as compared with those who underwent segmentectomy (23%). Furthermore, there
was a survival advantage in the patients undergoing lobectomy for T2 disease.

38. In contrast to NSCLC, small cell lung cancer (SCLC) is characterized by:
A. Greater response rate to chemotherapy.
B. Inability to achieve surgical cure.
C. Less frequent association with paraneoplastic syndromes at the time of
diagnosis.
D. Lower likelihood of metastases present at the time of diagnosis.
E. Slower growth.
Answer: A

DISCUSSION: For the purposes of staging, estimating prognosis, and selecting

therapy, lung cancer is divided into two categories: NSCLC and SCLC. SCLC is
characterized by more rapid growth, higher prevalence of metastases at the time
of diagnosis, and greater responsiveness to chemotherapy and radiation therapy.
After ascertaining the histological diagnosis of SCLC, staging is performed,
including thorough neurological examination and CT evaluation of the chest,
abdomen, and brain. For most patients with limited-stage disease, treatment is
initiated with six cycles of combination chemotherapy. Radiotherapy to the chest is
usually employed after three initial cycles of chemotherapy and is continued for 4
weeks. Among patients with limited-stage disease, thoracotomy for pulmonary
resection is recommended for the subset of patients with stage I SCLC.

39. Which of the following statements about the diagnosis and staging of
mesothelioma is/are correct?
A. Fluid obtained by thoracentesis is usually adequate for accurate diagnosis.
B. Open biopsy or thoracoscopy should be performed to obtain tissue for diagnosis.
C. Immunohistochemistry should be performed in all cases of suspected
mesothelioma.
D. Chest CT and/or magnetic resonance imaging (MRI) are useful in the staging of
mesothelioma.
E. Head CT and bone scans are useful in the staging of mesothelioma.
Answer: BCD

DISCUSSION: Approximately 90% of patients with mesothelioma develop pleural

effusion, but cytologic specimens from pleural fluid are inaccurate for the
diagnosis of mesothelioma, and open or thoracoscopic biopsy is required. Accurate
diagnosis of mesothelioma is difficult: the epithelial variant must be differentiated
from adenocarcinoma, whereas the sarcomatous form often resembles benign
sarcomas. Immunohistochemistry using a panel of antibodies, and sometimes
electron microscopy, is required for all cases. Relentless local spread is typical,
and chest CT or MRI is essential to evaluate potential local extension into the chest
wall, pericardium, mediastinum, or diaphragm. Metastatic disease is less common
and occurs late (if at all) in the disease course, so head CT and bone scans are
indicated only if clinical findings are suspicious for metastasis.

40. Which of the following statements about therapy for malignant pleural
mesothelioma is/are correct?
A. The role of surgery is confined to biopsy for diagnosis and pleurodesis for
palliation of effusion.
B. Extrapleural pneumonectomy involves resection en bloc of the lung, visceral and
parietal pleura, pericardium, and diaphragm.
C. If a lesion is unresectable by extrapleural pneumonectomy,
pleurectomy/decortication is contraindicated.
D. Neither surgery, chemotherapy, nor radiation therapy as a single therapy
improves survival.
E. Multimodality therapy, combining surgery, chemotherapy, and radiation therapy
may improve survival in select patients.
Answer: BDE

DISCUSSION: In debilitated patients, palliation by pleurodesis is indicated;

however, cytoreductive techniques, including pleurectomy/decortication, and
extrapleural pneumonectomy, are indicated for patients who can tolerate surgery.
For Stage I disease, extrapleural pneumonectomy is offered. If the patient cannot
tolerate pulmonary resection or if the lesion is unresectable by extrapleural
pneumonectomy, pleurectomy/decortication is appropriate. Both cytoreductive
procedures, when used in a multimodality setting, may improve survival in
selected patients. They also improve quality of life by relieving or delaying two
severe symptoms of mesothelioma: dyspnea secondary to lung restriction by the
tumor and pain from tumor invasion. No single modality (surgery, chemotherapy, or
radiation therapy) improves survival.

41. All of the following may be acceptable operative approaches to management of

the thoracic outlet syndrome except:
A. Scalenectomy.
B. Excision of a cervical rib.
C. Thoracoplasty.
D. First rib resection.
E. Division of anomalous fibromuscular bands.
Answer: C

DISCUSSION: Supraclavicular decompression of the thoracic outlet is the preferred

operative approach for the thoracic outlet syndrome. This procedure consists of
extensive anterior scalenectomy, middle scalenectomy, removal of a cervical rib (if
present), and, on occasion, first rib resection. Transaxillary first rib resection has
been widely used as well but is associated with a greater risk for complications.
Numerous fibromuscular anomalies have been described in association with the
thoracic outlet syndrome. Thoracoplasty has no role in the management of this
disorder.

42. Initial conservative (nonsurgical) management of the thoracic outlet syndrome

may include all of the following except:
A. Weight reduction.
B. Improvement of posture.
C. Exercises to strengthen the muscles of the shoulder girdle.
D. Pentoxifylline.
E. Avoiding hyperabduction.
Answer: D

DISCUSSION: The initial management of the thoracic outlet syndrome is

nonoperative. A trial of weight reduction, shoulder girdle strengthening exercises,
improvement of posture, and avoidance of hyperabduction should be
recommended for 4 months or longer. These measures are successful in 50% to 70%
of patients, particularly in young to middle-aged females with poor posture.
Pentoxifylline is a hemorrheologic agent used in selected patients with peripheral
arterial insufficiency and has no known benefit in the thoracic outlet syndrome.

43. Which of the following statements about pectus excavatum are correct?
A. It is the most common congenital malformation of the chest wall.
B. The most frequent presenting complaint is the cosmetic deformity.
C. The manubrium and first and second costal cartilages typically are involved in
the deformity.
D. It may be associated with cardiac defects and other skeletal defects such as
scoliosis.
E. Restrictive alterations in chest wall mechanics and abnormalities in pulmonary
function tests have been documented.
Answer: ABDE

DISCUSSION: Congenital deformities of the chest wall represent a spectrum of

deformities ranging from minor cosmetic defects to gross deformities incompatible
with life. Pectus excavatum, or funnel chest, is the most common of the congenital
deformities of the chest wall, accounting for 90% of such defects. It is
characterized by a concave, posteriorly displaced sternum due to overgrowth of
the costal cartilages. Most commonly the defect begins at the junction of the
manubrium and the body of the sternum and becomes progressively deeper toward
the xiphoid. The manubrium and the first and second costal cartilages typically are
normal. The defects have both physiologic and psychologic consequences and are
often associated with other abnormalities, including congenital heart disease,
Marfan's syndrome, and other skeletal defects, including scoliosis. Patients most
often present because of the cosmetic defect but frequently are found to have
other symptoms, including impaired cardiopulmonary function and scoliosis.
Pulmonary complaints include dyspnea and respiratory tract infections. Restrictive
alterations in chest wall mechanics and abnormalities in pulmonary function tests,
including decreased vital capacity, decreased total lung capacity, decreased
maximal ventilatory volume, and decreased maximal breathing capacity, have
been documented.

44. Surgical correction of pectus excavatum is characterized by which of the

following?
A. Significant cosmetic improvement initially but a high incidence of recurrence of
the defect on late follow-up.
B. An increase in exercise tolerance and respiratory reserve postoperatively.
C. Improvement in FEV 1, vital capacity, and total lung capacity.
D. Improvement in maximal ventilatory volume, total progressive exercise time,
and maximal exercise capacity.
E. Prevention of the development of thoracogenic scoliosis.
Answer: BDE

DISCUSSION: Because of the significant cosmetic and psychological improvement,

subjective increase in exercise tolerance, documented improvement in cardiac and
respiratory status, and prevention of the development of scoliosis following
surgical intervention in these patients, surgical correction should be considered for
all patients with moderate to severe deformity. Cosmetic results of surgical
correction are excellent, and recurrence is uncommon. Objective improvement in
cardiac function has been documented postoperatively, owing to relief of the
sternal compression. Postoperatively, worsening of the FEV 1, vital capacity, and
total lung capacity have been noted, whereas a significant improvement in
maximal ventilatory volume, total progressive exercise time, and maximal oxygen
consumption has also been documented. Following surgical correction there is a
consistent increase in maximal exercise capacity at every level of workload, a
lower heart rate at every workload, and an increase in exercise duration.

45. Which of the following statements about the diagnosis of chest wall tumors
is/are correct?
A. Pain is a common presenting symptom.
B. Firmness and fixation to underlying bone and muscle are important to note in
the physical examination as aids to diagnosis.
C. In general, chest wall tumors are slow growing and produce symptoms late in
their course.
D. CT is the most useful imaging study for making the diagnosis and for planning
surgical resection of chest wall tumors.
E. Angiography should be performed routinely.
Answer: BCD

DISCUSSION: Seventy-five per cent of patients present with a slow-growing,

painless chest wall mass. A firm mass that is fixed to an underlying rib is more
likely to be of bony or cartilaginous origin. Conversely, soft, mobile tumors are
more likely to be of soft tissue origin. CT defines depth of invasion and extent of
tumor and is the most useful imaging modality. Angiography should be employed
selectively, primarily for very large and vascular tumors.

46. Which of the following statements about chest wall resection and
reconstruction is/are correct?
A. Most tumors of soft tissue and bone require 4-cm. margins to be adequately
resected.
B. At least one normal rib above and below the primary tumor should be included
in the resection.
C. Techniques of chest wall reconstruction are directed at the prevention of
paradoxical chest wall movement with respiration.
D. Soft tissue defects are most conveniently addressed by stretching the existing
skin over the defect under tension.
E. Chest wall defects that are covered by the scapula require no special
reconstructive procedures, even if the defects are quite large.
Answer: ABCE

DISCUSSION: Margins of resection of chest wall tumors should be at least 3 cm. of

skin, 4 cm. of muscle, and 6 cm. of bone. Old biopsy sites should be included in
the specimen. A normal rib above and below the specimen should also be included.
Prevention of paradoxical chest wall movement is the primary goal of chest wall
reconstruction. Large soft tissue defects are best managed by myocutaneous
pedicle flaps. In general, defects larger than 5 cm. require reconstruction. Defects
covered by the scapula require no reconstruction.

47. Prolonged extracorporeal membrane oxygenation (ECMO):

A. Is highly successful in the treatment of severe respiratory failure in newborn
infants.
B. Is contraindicated in adult respiratory distress syndrome (ARDS).
C. Causes hemolysis and renal failure.
D. Requires total systemic heparinization (activated clotting time longer than 500
seconds).
E. Is identical to heart/lung bypass for cardiac surgery.
Answer: A

DISCUSSION: The survival rate of newborn infants who are moribund from
respiratory failure with ECMO is 80% to 90%. ECMO is also indicated in ARDS with a
survival rate from 40% to 50%. Hemolysis and renal failure are rare complications.
ECMO requires low-dose partial heparinization, with clotting times in the range of
200 seconds. Several modifications in the conventional heart/lung machine permit
the extension of ECMO from hours to days.

48. Indications for ECMO include:

A. Newborn infants with pulmonary hypoplasia secondary to congenital
diaphragmatic hernia.
B. Meconium aspiration syndrome in full-term babies (at least 35 weeks).
C. Children with pulmonary infection after bone marrow transplantation.
D. Adults with acute viral pneumonia.
E. Adults requiring mechanical ventilation and 100% oxygen for 2 weeks or longer.
Answer: BD

DISCUSSION: At present ECMO is not used for infants smaller than 1500 gm. because
of a high risk of intracranial bleeding. ECMO is very successful in the treatment of
respiratory failure in full-term newborn infants. Immunosuppression is a relative
contraindication to ECMO. ECMO is indicated in adults with acute, potentially
reversible respiratory failure, but mechanical ventilation and high oxygen
concentration for more than 10 days are contraindications.

49. Venovenous ECMO:

A. Avoids major arterial access.
B. Provides cardiac and pulmonary support.
C. Can be accomplished via cannulation at separate venous sites or at a single
venous site using a double-lumen catheter.
D. Provides greater venous drainage than venoarterial ECMO.
E. Maintains the normal pulsatile blood flow to the systemic circulation.
Answer: ACE

DISCUSSION: Venovenous ECMO has become the access technique of choice for
patients with respiratory failure without significant requirement for cardiac
(hemodynamic) support. In neonates, a double-lumen cannula allows ECMO to be
performed through a single incision over the right internal jugular vein. It can also
be performed by separate cannulation of the femoral and jugular veins. In either
configuration, venovenous ECMO avoids cannulation of any major arteries and
maintains the normal pulsatile circulation through the heart and lungs. Venous
drainage is no different with venovenous ECMO.

50. As compared with venovenous ECMO, venoarterial ECMO:

A. Requires cannulation of a major artery and vein.
B. Provides both cardiac and respiratory support.
C. Can be performed with less anticoagulation.
D. Usually maintains a normal pulse pressure.
Answer: AB

DISCUSSION: Venoarterial ECMO can provide total cardiorespiratory support via

cannulation of a major vein and artery (usually the right internal jugular vein and
common carotid artery in neonates). With most roller and vortex pumps, the
arterial inflow from the ECMO circuit is nonpulsatile, and therefore pulse pressure
is often reduced or absent. Venoarterial ECMO requires the same degree of
anticoagulation as venovenous techniques.

51. A 24-year-old male has new onset of chest pain. Chest films demonstrate a
large anterosuperior mass. Appropriate evaluation should include:
A. CT of the chest.
B. Measurement of serum alpha-fetoprotein and betahuman chorionic
gonadotropin.
C. A barium swallow.
D. A myelogram.
Answer: AB

DISCUSSION: Elevated levels of serum alpha-fetoprotein and betahuman chorionic

gonadotropin are indicative of a malignant nonseminomatous germ cell tumor.
Optimal therapy for such a tumor is based on a cis-platinum-containing
chemotherapeutic regimen. After normalization of serum markers, resection of
residual disease is performed. Extensive surgical procedures prior to chemotherapy
are not warranted. Confirmation of the diagnosis can usually be obtained using
needle biopsy techniques. In some institutions patients are treated based on
elevated serum markers alone. CT imaging is useful to evaluate tumor
invasiveness, airway compression, vascular involvement, and the likelihood of
resectability. Barium swallow may be helpful in the evaluation of enteric cysts.
Myelography may be useful in patients with posterior mediastinal masses to
evaluate for spinal column involvement.

52. Systemic syndromes frequently associated with mediastinal tumors include:

A. Myasthenia gravis.
B. Hypercalcemia.
C. Malignant hypertension.
D. Carcinoid syndrome.
Answer: ABC

DISCUSSION: Myasthenia gravis occurs in 10% to 50% of patients with thymoma. The
incidence with which myasthenia gravis occurs in patients with a thymoma
increases with the age of the patient. In males over 50 and females over 60 years
of age, the incidence appears to be greater than 80%. Hyperparathyroidism due to
a mediastinal parathyroid adenoma is a cause of hypercalcemia. Although
parathyroid glands may occur in the mediastinum in 10% of the patients, they are
usually accessible through a cervical incision. A sternotomy is required
infrequently, even in those patients with a mediastinal parathyroid gland. Most
often the adenomas are found embedded in or near the superior pole of the
thymus. Mediastinal paraganglioma may produce significant catecholamines,
predominantly norepinephrine. Catecholamine production causes a classic group of
symptoms associated with pheochromocytomas, including periodic sustained
hypertension often accompanied by orthostatic hypotension, and hypermetabolism
manifested by weight loss, hyperhydrosis, palpitation, and headaches. Mediastinal
carcinoid tumors have been more frequently associated with Cushing's syndrome
because of the production of adrenocorticotrophic hormones. These tumors
uncommonly cause the carcinoid syndrome.

53. A 36-year-old female developed dyspnea on exertion that has progressed over 3
months. Chest film reveals a left anterior mediastinal mass with evidence of
elevated left hemidiaphragm. CT indicates probable invasion of the pericardium.
Paratracheal or subcarinal adenopathy is not identified. Appropriate intervention
in this patient would include:
A. A median sternotomy with radical resection of the tumor, sacrificing the left
phrenic nerve and excising the involved pericardium.
B. A mediastinoscopy with biopsy.
C. A left anterolateral thoracotomy or median sternotomy with generous biopsy of
the tumor.
D. Observation with repeat chest radiography in 3 months.
Answer: C

DISCUSSION: The differential diagnosis of an invasive anterosuperior mediastinal

mass includes thymoma, lymphoma, germ cell tumor, undifferentiated carcinoma,
and carcinoid tumors. These tumors often have a very similar histologic
appearance, which may cause an inaccurate diagnosis based on light microscopy
alone. Use of electron microscopy and immunohistochemistry may be necessary to
correctly determine the specific histologic diagnosis. Frozen section should be used
to determine adequacy of tissue biopsy. Histologic diagnosis based on frozen
section examination in many of these tumors may be erroneous. Although radical
resection of tumor is indicated for thymoma, chemotherapy and radiotherapy are
the modalities used for the treatment of patients with lymphomas and germ cell
tumors. Exact determination of tumor histology by permanent section should
precede radical resectional therapy. Generous tissue biopsy is necessary for the
precise subtyping of lymphomas. Mediastinoscopy is useful in patients with
paratracheal and pericarinal masses or adenopathy, particularly when right-sided.
Observation of a patient with invasive mediastinal mass is not warranted.

54. An 18-year-old male presents with a history of increasing shortness of breath

that worsens in the recumbent position. On physical examination, the neck veins
are noted to be distended, with facial plethora that is accentuated by lying the
patient down. A 2.5-cm. left supraclavicular lymph node is palpable. Chest film
reveals an extensive right anterosuperior mediastinal mass. Appropriate
intervention may include:
A. An urgent biopsy of the mediastinal mass under general anesthesia
with subsequent initiation of th
py.
B. CT.
C. Pulmonary function testing in the sitting and supine positions.
D. A biopsy of the right supraclavicular lymph node under general
anesthesia.
E. A biopsy of the supraclavicular lymph node under local anesthesia.
Answer: BCE

DISCUSSION: Although most patients with a mediastinal mass may undergo surgical
procedures under general anesthesia with a minimal risk, patients with a large
anterior, superior, or middle mediastinal mass, particularly those with posture-
related dyspnea and superior vena caval syndrome, have an increased risk of
developing severe respiratory complications during general anesthesia. Useful
techniques for identifying less symptomatic patients who have significant airway
compression include CT imaging and pulmonary function tests. A reduction of the
tracheal diameter by more than 35% on a CT scan and reduction of peak expiratory
flow during pulmonary function testing are sensitive indicators of functional airway
compression. In patients with airway compression and superior vena caval
obstruction, the risk of general anesthesia is significant. Attempts to obtain a
histologic diagnosis should be limited to needle biopsies or open procedures
performed under local anesthesia. In situations in which histologic diagnosis cannot
be obtained using these methods, therapy may be initiated with radiation,
corticosteroids, and chemotherapy. However, a histologic diagnosis may not be
obtainable in as many as 40% of these patients after initiation of treatment. Some
proceed with biopsy of the mediastinal mass under general anesthesia. However,
alterations in anesthetic management include: (1) induction of anesthesia in a
semi-Fowler's or upright position, (2) availability of rigid bronchoscopy to allow
reestablishment of an adequate airway, (3) use of a long endotracheal tube to
allow advancement of the tube beyond the site of obstruction, (4) avoidance of
muscle relaxants and the use of spontaneous ventilation when possible, (5) lower
extremity intravenous cannulation, and (6) standby cardiopulmonary bypass.

55. A 42-year-old male who is scheduled to undergo elective knee surgery has a
preoperative chest film that demonstrates a 5-cm. posterior mediastinal mass. The
patient denies any neurologic symptoms and physical examination fails to
elucidate any neurologic deficit. CT confirms the presence of a 5-cm. mediastinal
mass in the left costovertebral gutter with minimal enlargement of the seventh
thoracic foramen. Appropriate intervention includes:
A. Resection of the posterior mediastinal mass using a standard posterolateral
incision.
B. A CT with myelography or magnetic resonance (MR) imaging.
C. Two-stage removal of the tumor, performing the resection of the thoracic
component first with subsequent removal of the spinal column component at a
later date.
D. One-stage removal of the dumb-bell tumor, excising the intraspinal component
prior to resection of the thoracic component.
Answer: BD

DISCUSSION: Approximately 10% of neurogenic tumors extend into the spinal

column and are termed dumb-bell tumors because of the characteristic shape.
Although 60% of patients with such tumors have neurologic symptoms related to
spinal cord compression, the significant proportion of patients without symptoms
underscores the importance of evaluating all patients with a posterior mediastinal
mass for possible intraspinal extension. CT, MR imaging, and vertebral tomography
may demonstrate an enlargement of the foramen, erosion of bone, or
intervertebral widening, which are indicative of a dumb-bell tumor. If these
findings are present, CT with myelography or MR imaging is indicated to evaluate
the presence and extent of the intraspinal component. A one-stage removal of the
tumor is recommended, with excision of the intraspinal component prior to
resection of the thoracic component to minimize the risk of spinal column
hematoma.

56. True statements regarding patients with a mediastinal mass include:

A. Asymptomatic patients have a benign mass in over 75% of cases.
B. Symptomatic patients are more likely to have a malignant lesion than a benign
lesion.
C. In a patient with a chest film demonstrating a mediastinal mass, a Tru-cut
needle biopsy is a safe procedure.
D. Seminomas usually produce alpha-fetoprotein.
Answer: AB

DISCUSSION: Seventy-six per cent of the asymptomatic patients with a mediastinal

mass seen in one series over a recent 20-year period had a benign leison. In
contrast, 62% of the symptomatic patients had a malignant neoplasm during this
period. A number of intrathoracic and extrathoracic lesions may have an
appearance similar to a primary mediastinal mass on routine chest films, as do a
large number of cardiovascular lesions. Although angiography was used in the past
for this differentiation, CT with contrast and MRI now distinguish a primary
mediastinal mass from a cardiovascular lesion. Tru-cut needle biopsy of a
cardiovascular lesion may be associated with significant hemorrhagic
complications. Seminomas rarely produce betahuman chorionic gonadotropin and
never produce alpha-fetoprotein. In contrast, over 90% of the nonseminomas
secrete one or both of these hormones.

57. Which of the following would be the least appropriate in the management of
acute suppurative mediastinitis?
A. Wide dbridement.
B. Irrigation under pressure.
C. Topical antibacterials.
D. Long-term systemic antibacterials.
E. Closure with muscle flaps.
Answer: D

DISCUSSION: Acute suppurative mediastinitis is a classic wound problem and forms

a paradigm for principles of management. Wide dbridement is perhaps the most
important step in correcting this type of invasive wound sepsis. Drainage requires
removal of tissue with vascular compromise. Tissue that is infected and can serve
as an ongoing nidus for infection, particularly cartilage, must be removed.
Irrigation is effective only when the irrigation fluid reaches into and flushes out
dbris and bacteria. The irrigation is insufficient if only dilutional and not also
mechanically effective. Since infected tissue tends to become isolated from the
systemic circulation the direct application of antibacterials reaches avascular
areas. Some, such as silver sulfadiazine, penetrate avascular tissue better than,
for instance, ointments or povidone iodine, and such an agent should be chosen.
Wide dbridement and the washing of debris with pressure irrigation make the
wound then available to topical applications, which are often best packed into
these deep, irregular cavities. Long-term systemic antibacterials serve no purpose
and lead to potential resistant bacterial overgrowth. Although systemic
antibacterials provide a measure of protection up to the margin where
vascularized and nonvascularized tissues meet, topical agents are better in the
actual infected site. Once closed, these wounds rapidly become sterilized. Even
the infection at the bone level is far different from traditional osteomyelitis, and
long-term systemic therapy is unnecessary. Muscle flaps are a great advance in
closure technique, since they provide bulky protection, obliterate dead space, and
help vascularize the wound.

58. Each of the following is appropriate for managing acute suppurative

mediastinitis except:
A. Alloplastic material and skin flaps.
B. Rectus abdominis muscle flaps.
C. Omentum.
D. Pectoralis major muscle flaps.
E. Rigid internal fixation.
Answer: A

DISCUSSION: Alloplastic materials may be nonreactive in the laboratory and

biologically acceptable in other areas (artificial hips, breast prostheses). Their
introduction into a contaminated wound, however, would more likely promote
rather than reduce infection. Various meshes and other types of protection
devices are not necessary. Skin flaps alone do not obliterate dead space and have
not been shown either to reduce or resist infection. The rectus abdominis muscle is
a superb source of readily available tissue that can be rotated into very large
cavities. The nature of the muscle allows it to be dressed into irregular cavities.
It has an excellent, easily movable skin territory overlying it, which can also be
transferred if locally available skin is wanting. The omentum has the great ability
to fit into the many irregularities of some defects. For appropriately selected cases
it is excellent. The pectoralis major muscle flaps are the usual initial choice since
they are in the operative field. When the musculotendinous insertion is released
their mobility is often sufficient. Additionally, it avoids the need for abdominal
incisions. The latissimus dorsi muscle as a flap is dependable and includes sternal
defects in the scope of its arc of rotation. It requires rotating the patient on the
operating table and thus is less readily available than the other flaps.

59. Clinical features suggestive of myasthenia gravis include all of the following
except:
A. Proximal muscle weakness.
B. Diplopia.
C. Sensory deficits of the extremities.
D. Dysphagia.
Answer: C

DISCUSSION: Weakness of proximal weight-bearing muscle groups is the hallmark of

the clinical diagnosis of myasthenia gravis. The weakness or fatigue occurs with
repetitive activity and improves with rest. The majority of patients (90%)
experience ocular muscle involvement, manifested as diplopia or ptosis most easily
demonstrated with sustained upward gaze. Cranial nerve involvement is uncommon
but can be present, with symptoms of dysphagia, nasal regurgitation, and
aspiration. Since myasthenia gravis is a disorder of neuromuscular transmission at
the motor end plate, deep tendon reflexes and sensory examination are normal.

60. The diagnosis of myasthenia gravis can be confirmed most reliably using:
A. Antiacetylcholine receptor antibody titers.
B. The Tensilon test.
C. Electromyography (EMG).
D. Single-fiber EMG.
E. Physical examination.
Answer: D

DISCUSSION: Although findings from a careful history and physical examination are
suggestive of the diagnosis of myasthenia gravis, specific diagnostic testing is
required to confirm the diagnosis. Elevated antiacetylcholine receptor antibodies
are present in 85% to 90% of patients with generalized myasthenia but are often
negative in patients with early or ocular myasthenia gravis. The Tensilon test is
also positive in approximately 90% of patients with generalized myasthenia gravis,
but both false-negative and false-positive results occur, especially in patients with
mild or early disease. Standard EMG studies are helpful if positive, but their
overall sensitivity may be as low as 35%. The specialized technique of single-fiber
EMG is the most reliable diagnostic test, being abnormal in 90% of patients with
mild disease and in virtually 100% in patients with severe generalized myasthenia
gravis.

61. All of the following statements are true about the pathogenesis of myasthenia
gravis except:
A. The number of functional acetylcholine receptors at the motor end plate is
reduced.
B. An autoimmune mechanism involving antibodies to the acetylcholine receptor
has been proposed.
C. Complement system involvement has been demonstrated.
D. A nonspecific thymitis may initiate the autoimmune response.
E. Clinical improvement following thymectomy is correlated with decreased
acetylcholine receptor antibody titers.
Answer: E

DISCUSSION: Myasthenia gravis is generally regarded as an autoimmune disorder

due to antibodies directed toward the acetylcholine receptor. A variety of
autoimmune mechanisms have been proposed; the ultimate result is a reduction in
the number of functional acetylcholine receptors at the motor end plate. Proposed
immune mechanisms include complementmediated receptor destruction, antibody-
induced accelerated receptor turnover, and simple receptor blockade. In spite of
these proposed immune mechanisms, the severity of myasthenia symptoms and
improvement following therapy do not correlate with antibody titers. Although the
source of these autoantibodies is not proven, it is generally felt that a nonspecific
thymitis may trigger the autoantibody response, the thymic myoid cells serving as
the source of the antigen.

62. Which of the following statements about the relationship of the thymus and
myasthenia gravis is/are true?
A. Thymic abnormalities are present in up to 80% of patients with myasthenia
gravis.
B. Thymoma is present in up to 20% of patients with myasthenia gravis.
C. Myasthenia gravis will occur in up to 60% of patients with thymomas.
D. Myasthenia patients with thymoma respond more favorably to thymectomy.
E. Thymoma is the most common abnormality of the thymus in patients with
myasthenia gravis.
Answer: ABC

DISCUSSION: The central role of the thymus gland in the pathogenesis of

myasthenia gravis is based on the observation that more than 80% of patients have
histologic abnormalities of the thymus and on the beneficial effect of thymectomy
on patients' symptoms. Of the patients with documented abnormalities of the
thymus the majority have B-cell lymphoid hyperplasia; only 20% have a thymoma.
Conversely, up to 60% of patients with known thymoma will have or ultimately
develop myasthenia gravis. In these patients, with thymoma and myasthenia
gravis, the response to thymectomy is less favorable than in those without
thymoma.

63. Which of the following statements about the results of thymectomy for
myasthenia gravis are true?
A. Patients with ocular symptoms experience clinical improvement in 90% of cases.
B. Clinical remission can be expected in 90% of cases.
C. The response rate to thymectomy for patients with generalized symptoms is
90%.
D. Patients with thymoma experience improvement in 75%.
E. Continued medical therapy is required in 75%.
Answer: C

DISCUSSION: Overall, improvement can be expected in 90% of patients who

undergo thymectomy for generalized myasthenia gravis. In general, the results are
more favorable in patients with mild generalized myasthenia. In patients with only
ocular symptoms, the benefit following thymectomy is less clear; improvement is
documented in 80%. The response rate is even less (30%) in patients with thymoma.
Complete remission occurs in 40% to 50% of patients following thymectomy, and
the remainder require some continued medical therapy.

64. All of the following are true of the treatment of myasthenia gravis except:
A. The transcervical approach to surgical thymectomy is less likely to benefit the
patient with myasthenia gravis.
B. Corticosteroids result in improvement in 80% of patients.
C. Plasma exchange is associated with improvement in up to 90% of patients.
D. Medical therapy with Mestinon (pyridostigmine) is associated with remission in
approximately 10% of patients.
E. Surgical thymectomy, regardless of the approach, is associated with improved
remission and response rates as compared with medical therapy.
Answer: A

DISCUSSION: Although Mestinon therapy results in clinical improvement in most

patients, complete remission can be expected in only 10%. In addition, intolerable
side effects may limit their usefulness. In patients who fail to respond to Mestinon
therapy, and in those who experience significant side effects, corticosteroids can
be utilized, with improvement expected in 80% of patients. Plasma exchange
results in improvement in 90% of patients, but the cost of therapy and its transient
duration of benefit limit the use of pheresis therapy to special circumstances such
as preoperative preparation or in myasthenic crisis. Overall, response rates to
surgical thymectomy range from 80% to 95%, and complete remission occurs in 30%
to 50%. This benefit following thymectomy has not been shown to depend on the
particular technique utilized. Remission and response rates are similar for
transcervical, standard transsternal, and the maximal thymectomy techniques.

65. Which of the following is/are acceptable alternatives in the management of

malignant pericardial effusion?
A. Pericardiocentesis.
B. Subxiphoid pericardiotomy (pericardial window).
C. Thoracotomy with pericardiectomy.
D. Instillation of tetracycline or bleomycin into the pericardial space.
E. Treatment of the underlying malignancy.
Answer: ABCDE

DISCUSSION: In patients with symptomatic malignant pericardial effusions,

management options may be designed to establish a diagnosis, relieve symptoms,
or prevent recurrence. Pericardiocentesis is very successful in removing fluid for
diagnosis and alleviating symptoms; however recurrence rates are greater than
50%. This rate can be reduced to around 20% with instillation of sclerosing agents
such as tetracycline or bleomycin. Surgical techniques, including subxiphoid
pericardiotomy and thoracotomy with pericardiectomy, offer the highest success
rates (approximately 90%) but are more invasive and usually require general
anesthesia. Systemic antitumor therapy with chemotherapy or radiation therapy
can be effective in controlling malignant effusions in cases of sensitive tumors such
as lymphomas, leukemias, and breast cancer.

66. Which of the following statements about cardiac tamponade is/are correct?
A. At least 500 ml. of fluid must be present in the pericardium of an adult to cause
symptoms of tamponade.
B. A drop in systemic blood pressure of greater than 20 mm. Hg during inspiration
(pulsus paradoxus) is a finding specific to cardiac tamponade.
C. The vast majority of patients with cardiac tamponade demonstrate a low QRS
voltage, nonspecific ST T-wave abnormalities, and electrical alternans (alternation
of QRS amplitude) on the electrocardiogram.
D. In trauma victims with cardiac tamponade, the three components of Beck's
triad (hypotension, elevated jugular venous pressure (JVP), and muffled heart
sounds) are almost always present.
E. When the diagnosis is made, treatment must be instituted rapidly and may
include pericardiocentesis, creation of a pericardial window, and identification and
treatment of the underlying cause.
Answer: E

DISCUSSION: Development of tamponade symptoms depends on the rate of

accumulation of fluid. As little as 100 to 200 ml. accumulating rapidly may cause
symptoms, whereas a slowly developing pericardial effusion of over 1 liter may
remain asymptomatic. Pulsus paradoxus is not specific for tamponade; it may
occur in patients with severe congestive heart failure, chronic obstructive
pulmonary disease, hypovolemia, acute pulmonary embolism, or shock.
Electrocardiographic findings of low QRS voltage and nonspecific ST T-wave
changes are common in this condition, but electrical alternans, often considered
pathognomonic of cardiac tamponade, is present in only a small number of
patients. Trauma victims with tamponade frequently lack one or more of the
elements of Beck's triad; for example, associated hypovolemia may lead to low or
normal jugular venous distention. Since cardiac tamponade is life threatening,
therapy designed to drain the pericardial fluid must be provided quickly and the
underlying cause must be established and controlled.

67. Which of the following statements about constrictive pericarditis is/are

correct?
A. Most patients who develop constrictive pericarditis after cardiac operation
present with symptoms within 6 months of the procedure.
B. Results of pericardiectomy for constrictive pericarditis are worse in patients
who develop constriction after mediastinal irradiation.
C. Drainage of asymptomatic pericardial effusions arising from acute pericarditis is
advised to prevent development of constrictive pericarditis.
D. If surgical treatment is planned for constrictive pericarditis it should involve
total or complete pericardiectomy.
E. Echocardiography can usually make the diagnosis by imaging a thickened
pericardium.
Answer: BD

DISCUSSION: The time course in the development of constrictive pericarditis after

cardiac surgery ranges from 1 month to nearly 9 years, but the mean interval from
surgery to presentation is about 23 months. Most series have reported poorer
outcomes from pericardiectomy for postirradiation constrictive pericarditis,
possibly owing to underlying myocardial fibrosis. In this subset, 5-year survival
averages 50%, as compared with 75% for constrictive pericarditis of all causes.
Constrictive pericarditis is a rare complication of acute pericarditis. As a result,
drainage of asymptomatic (nonpurulent) pericardial effusions from acute
pericarditis is not required. Patients with significant symptoms from constrictive
pericarditis should undergo total pericardiectomy, even though this procedure
carries an operative mortality rate of approximately 10%. Limited pericardiectomy
has proven to be ineffective for this condition. It can be difficult to distinguish
constrictive pericarditis from restrictive cardiomyopathy. Echocardiography may
help by demonstrating chamber dimensions and wall motion abnormalities, but CT
and MRI more accurately assess pericardial thickness.

68. The relationship between small-cell and non-small cell lung cancers can be
described by the following:

a. They differ by histology, clinical behavior and cell of origin

b. Of all lung cancers, approximately 80% are non-small cell and 20% are small cell
c. Both cell types are predictably responsive to chemotherapy
d. The International Staging System can be applied to both tumor types
e. The majority of non-small cell cancer patients vs. the minority of small cell
cancer patients are candidates for pulmonary resection
Answer: b

Although small cell and non-small cell lung cancers do differ by histology and
clinical behavior, they probably have a common origin since c-myc or n-myc
amplified small cell lung cancer lines will undergo transition to non-small cell
phenotypes after insertion of an activated ras/gene. The overall incidence of lung
cancers is 80% non-small cell and 20% small cell. Only the small cell carcinoma is
predictably responsive to chemotherapy.
The staging system for small cell lung cancer is based on limited vs. extensive
disease outside of a tolerable radiotherapy portal while the International Staging
System uses TNM descriptors for 4 clinical stages. Unfortunately, only about 30% of
patients with non-small cell lung cancer have potentially resectable tumors.

69. A 62-year-old male smoker presents with right anterior chest pain. There is a 3
cm mass attached to the chest wall with radiographic evidence of rib erosion and
positive cytology for non-small cell carcinoma. Which of the follow is/are true:

a. The patient is inoperable due to tumor size and chest wall involvement
b. Radiation therapy is the preferred initial treatment
c. Operative resection should be performed with en bloc removal of the tumor and
adjacent chest wall as well as a mediastinal lymph node resection
d. Positive mediastinal nodes will have little effect on survival
e. The patient would be classified Stage IIIa
Answer: c, e

Survival after resection for non-small cell lung cancer is related to the stage of the
disease with a strong adverse effect from nodal involvement. This is true even for
large peripheral tumors that extend into the chest wall as in this case where a 40
50% survival would be expected in the absence of nodes (T3N0:Stage IIIa) but only
a 15% survival with nodal involvement. Radiation therapy would be a postoperative
consideration to reduce the incidence of local recurrence. En bloc operative
resection of the involved lobe and mediastinal nodes for staging would offer the
greatest likelihood of cure.

70. For the patient in the pervious question to become an operative candidate
which of the following must be met?

a. Extrathoracic metastases must be able to be controlled by another modality,

e.g. radiotherapy
b. Tumor doubling time must exceed 40 days
c. If there is recurrence at the primary site, it must be treated before the
metastatic disease
d. Even if effective systemic therapy is available, resection of metastases is
preferred
e. If pulmonary reserve is marginal, resection of the maximal number of
metastatic foci should be performed
Answer: c

There are a number of controversial areas in the area of operative approaches to

metastatic disease in the lung, but there is general agreement that any
extrathoracic metastases preclude eligibility for pulmonary resection. Although
tumor doubling time is a measure of its aggressiveness, it is too variable to have
prognostic significance and is generally disregarded as a criterion for resection.
Primary site recurrence must be treated before the metastatic focus to prevent
further seeding. If effective systemic therapy is available as would be expected in
breast and testicular cancer or osteogenic sarcoma, it is preferred over surgical
resection. Similarly, pulmonary resection should not be undertaken unless the
pulmonary reserve will allow all metastatic foci to be resected.

71. Biopsy of the lesion in the previous question is reported as bronchial carcinoid
with no signs of atypia. Which of the follow is/are true?

a. Sleeve resection of the bronchus would be appropriate

b. Lymph node biopsy at time of resection is unnecessary
c. Associated carcinoid syndrome is very unlikely
d. If carcinoid syndrome were found in a tumor this size, hepatic metastases would
be likely
e. When bronchial carcinoid syndrome occurs, right-sided cardiac valves are
affected
Answer: a, c, d

In the absence of atypia, carcinoids are only locally malignant and can be managed
by limited lung and/or bronchial resection. Therefore, a sleeve resection of the
bronchus preserving distal lung would be appropriate. Lymph node sampling at the
time of resection, however, is advisable to ensure that a complete resection has
been performed. The carcinoid syndrome is rarely found except in the presence of
a large primary tumor or hepatic metastases. When the carcinoid syndrome does
occur, it is left-sided cardiac valves that are affected rather than right, which one
would expect with gastrointestinalcarcinoids.

72. In the evaluation and preparation of a 55-year-old smoker for resection of a 3

cm pulmonary adenocarcinoma, the following is/are true:

a. Preoperative cessation of smoking does not reduce postoperative pulmonary

complications
b. Resting PaCO2 is of more value than PaO2
c. FEV1 is of more value than measured vital capacity
d. Diffusion capacity should be measured routinely
e. V/Q lung scan is useful when pulmonary reserve is marginal
Answer: b, c, e

Preoperative cessation of smoking for a period of 2 weeks can reduce pulmonary

complications and should be required. In the preoperative assessment for
pulmonary resection, the PaCO2 is of more value than the PaO2 since an elevated
PaCO2 > 50 mmHg identifies the very high risk patient with chronic lung disease.
Hypoxemia may be secondary to the mechanical effects of the tumor producing
ventilation/perfusion mismatch. The latter can be confirmed by V/Q lung scan
which also serves to identify areas of functioning lung in patients with marginal
pulmonary function. The best screening test for adequacy of pulmonary reserve is
the FEV1. It identifies obstructive pulmonary disease which is more important than
the restrictive lung disease identified by vital capacity measurement. Diffusion
capacity measurement provides little additional information of value.
73. Following resection of a T1N1 squamous cell cancer in a 47-year-old male, the
following is/are true:

a. There is a higher risk of local recurrence than with any other histologic type of
non-small cell cancer
b. The greatest risk to the patient is a distant metastasis
c. Of all metastatic sites, liver is most likely
d. If the patient survives five years, there is a greater risk of a new lung cancer
than recurrence
e. To improve survival, the patient should be considered for adjuvant
chemotherapy
Answer: a, b, d

The risk of local recurrence for non-small cell carcinomas of the lung is much more
common for those of squamous cell histology than the others and averages 20%30%
overall. The greatest risk, however is of distant metastases which occur in 70%80%
of patients, regardless of stage. Almost all recurrences are seen within five years,
and of the distant metastatic sites, the brain is most commonly affected. In this
patient with Stage II disease, radiation therapy would be a consideration to reduce
the incidence of local recurrence, but not chemotherapy. After five years, the
highest risk would be from a new lung cancer rather than a recurrence.

74. A 42-year-old woman with hemoptysis is seen to have a 2 cm mulberry

appearing polypoid lesion in the left mainstem bronchus suspicious for bronchial
adenoma. The differential diagnosis includes which of the following:

a. Mucoepidermoid carcinoma
b. Plasma cell granuloma
c. Carcinoid tumor
d. Adenoid cystic carcinoma
e. Mucous gland adenoma
Answer: all of the above

The term bronchial adenoma includes a spectrum of tumors arising from epithelial
stem cells which vary from the benign mucous gland adenoma to the malignant
adenoid cystic and mucoepidermoid carcinomas as well as the carcinoid tumors of
similar varied behavior. Among these variants, the carcinoid are most common
representing 80%90% of all bronchial adenomas.

75. A 42-year-old man has a solitary coin lesion 2 cm in diameter in the area of
the right upper lobe on a routine chest radiograph. Which of the following is/are
true?

a. A previous radiograph from five years prior showing the lesion to be 1.2 cm in
diameter indicates malignancy
b. If a CT scan shows mediastinal adenopathy, mediastinoscopy is preferable to
thoracotomy
c. In the absence of previous radiographs, the lesion should be followed by serial
films at 6 month intervals
d. Calcification in a concentric or popcorn configuration denotes a benign lesion
e. Needle aspiration showing chronic inflammatory cells denotes a benign lesion
Answer: b, d

In the evaluation of a solitary lung lesion, previous radiographs are important,

particularly if the lesion is new. A coin lesion that is growing slowly does not
necessarily indicate malignancy, since the most common benign tumor,
hamartoma, has a variable pattern of slow growth and typically will show
popcorn calcification. Concentric calcification is also most suggestive of a
benign granuloma. In the absence of previous radiographs, the lesion must be
assumed to be malignant until proved otherwise and should not be dismissed to
follow-up. If a CT scan shows mediastinal adenopathy, then mediastinoscopy with
biopsy is appropriate to make a diagnosis. Needle aspiration results of chronic
inflammatory cells is non-diagnostic.

76. A 2 cm peripheral squamous cell carcinoma in the lung of a 60-year-old male

with a pleural effusion positive for malignant cells would be classified as:

a. T1N0M1
b. T3N0M0
c. T3N0M1
d. T4N0M0
e. T4N0M1
Answer: d, e

The presence of a pleural effusion in association with a primary lung cancer is

usually an ominous sign precluding surgical resection. However, if more than one
sample of the effusion is negative for malignant cells and it is non-bloody, it can be
considered unrelated to the tumor and excluded as a staging element. When the
effusion cytology is positive, the tumor is considered T4 regardless of size or nodal
status.

77. A 53-year-old woman who had a malignant tumor removed 2 years ago presents
with a solitary lung nodule 1.5 cm in diameter. The following is/are true:

a. If the primary tumor originated in the breast, the lesion is most likely to
represent a new primary lung cancer.
b. If the primary tumor was melanoma, the lesion is most likely to be metastatic
c. If the remainder of the lung fields are clear, a CT scan is unnecessary
d. If the primary tumor was in the GI tract, there is very little chance that the
lesion is a new primary lung cancer
e. Fine needle aspiration should always be performed prior to resection of the lung
lesion
Answer: a, b
A new pulmonary lesion in a patient with a history of a previously treated
malignancy poses a diagnostic and therapeutic challenge. A CT scan should always
be obtained since plain radiographs can detect lesions only 9 mm in diameter or
greater. The lesion is most likely to be metastatic if the prior malignancy was
sarcoma or melanoma and most likely to be a new primary lung cancer if the prior
malignancy originated in the head, neck or breast. When the original lesion was in
the GI or GU tract, there is an equal chance that it is metastatic or a new primary.
Fine needle aspiration does not usually alter the plan for excision and is done only
when the patient is not an operative candidate or desires to know the diagnosis.

78. A 61-year-old male presents with a painful mass 3.5 cm in diameter below the
clavicle and attached to the chest wall. The following is/are true:

a. A CT scan is the best study to determine rib destruction

b. The lesion should be removed enbloc without biopsy to minimize the chances
for local recurrence
c. The chances are approximately 40% that the lesion is metastatic
d. If it is metastatic, the most likely primary tumor is in the lung or pancreas
e. Fortunately, less than 50% of chest wall tumors are malignant
Answer: c

Chest wall tumors are uncommon, accounting for only 12% of all body tumors.
About 57% of chest wall tumors are primary, whereas 43% are metastatic. Solitary
metastases most frequently arise from the thyroid gland, the GU tract and the
colon. Overall, about 60% of chest wall tumors are malignant, most arising form
bone or cartilage. The CT scan is of value in demonstrating the relationship
between the mass and contiguous structures, but of little value in determining
bone destruction because of the oblique course of the ribs. Specific rib films are
most helpful. Now that multimodality therapy is available, core needle biopsies
are recommended and have not increased the incidence of local recurrence.

79. Concerning the sternum, the following is/are true:

a. The xiphoid process is the anterior border of the thoracic outlet

b. Gladiolus is the body of the sternum
c. The angle of Louis is at the level of the 2nd costal cartilage
d. The 11th rib is attached via costal cartilage to the xiphoid
e. The sterno-manubrial junction is at the level of T4 posteriorly
Answer: a, b, c, e

The sternum consists of 3 segments, the upper manubrium, the body or gladiolus,
and the xiphoid process which ends in the rectus sheath and has no costal
attachments. The xiphoid marks the anterior border of the thoracic outlet. The
junction of the manibrium and body is the sternal angle or angle of Louis which
corresponds to the level of T4 posteriorly and attaches to the 2nd costal cartilage
anteriorly.
80. A 22-year-old woman recovering from a traumatic head injury is noted to have
bright red bleeding when her tracheostomy is suctioned. The following is/are true
statement(s):

a. Antibiotics should be administered to treat the bronchitis

b. Deflation of the tracheal tube cuff is a useful diagnostic maneuver
c. If massive bleeding occurs, a finger should be used to compress the innominate
artery against the sternum
d. Operative treatment of a tracheoinnominate fistula includes resection and
prosthetic replacement of the innominate artery
e. Tracheal resection is usually required for a tracheoinnominate fistula to prevent
recurrence
Answer: b, c

The complication of tracheoinnominate artery fistula characteristically occurs in

young women and is often heralded by bleeding during the tracheostomy
suctioning. Deflation of the tracheal tube cuff confirms the diagnosis if massive
bleeding occurs. At that point the tracheal tube cuff should be overinflated and a
finger inserted into the tracheostomy incision to tamponade the bleeding.
Throughout this, the airway must be protected. Operative repair through an upper
sternal split requires resection of the innominate and coverage of the oversewn
vessels with viable tissue since the wound is contaminated. No prosthetic material
should be inserted and tracheal resection is not necessary.

81. A 52-year-old alcoholic with fever and a cough productive of purulent sputum is
found to have the opacity on chest film as shown (Fig. 62-15). The following is/are
true statement(s):

a. The findings suggest a parapneumonic empyema

b. If pus is found on aspiration of the pleural space, a chest tube should be placed
c. If pus is found on aspiration, bronchoscopy is a necessary part of the patients
evaluation
d. In this situation, rib resection for drainage is preferred to a large-bore chest
tube
e. Decortication of the lung should be considered if the lung fails to expand within
4 weeks
Answer: a, b, c

The posterior location of the infiltrate and fluid collection is typical of a

parapneumonic empyema. The most important test is pleural aspiration which will
usually yield frank pus, at which time a chest tube should be placed. Formerly, oily
Dionosil was used to perform an empyemagram; this substance is now no longer
commercially available. In the case of parapneumonic empyemas, tube drainage
alone may be sufficient to allow full expansion of the lung. If this is not the case, a
formal rib resection or early decortication should be performed. Decortication or
marsupialization is indicated if the lungs fail to expand after 68 weeks. Every
patient with spontaneous empyema should undergo bronchoscopy to rule out
endobronchial obstruction by foreign body or tumor.
82. The lesion shown (Fig. 62-6) was found on a 32-year-old male on a routine
chest film required for his employment. Which of the following is/are true?

a. The stippled calcification and intact cortex of the rib are characteristic of
osteochondroma
b. The stippled calcification is characteristic of osteogenic sarcoma
c. If the lesion is osteogenic sarcoma, the optimal treatment is resection and
radiation therapy
d. If the lesion is an osteochondroma, it need not be resected in this age group
e. The radiographic picture is typical for Ewing sarcoma
Answer: a

Osteochondroma is the most common benign rib tumor and has a 3:1 male
incidence. The stippled calcification and intact rib cortex are characteristic for
this lesion in contrast to the bone destruction of Ewing sarcoma and combined
bone destruction and sunburst calcification of osteogenic sarcoma. For both
Ewing and osteogenic sarcoma, multimodality therapy using preoperative
chemotherapy followed by resection yields better results than with radiation
therapy. Osteochondromas in prepubertal children can be observed unless they
become painful or enlarged, but are routinely resected in adults.

83. To resect a chondrosarcoma of the chest wall in a 42-year-old man, ribs 24

were removed, leaving a defect 8 x 8 cm. For reconstruction, the following is/are
true:

a. If this were to be posterior, beneath the scapula, reconstruction would not be

required
b. If this defect is anterior, the primary benefit of reconstruction is an improved
cosmetic result
c. Whenever chest wall reconstruction is considered, it should be delayed 612
months to allow detection of recurrent tumor
d. If Marlex is used for reconstruction, no wound drainage tube is necessary
e. If PTFE is used for reconstruction, both pleural and wound tubes should be used
Answer: a, d, e

Skeletal chest wall defects that are full-thickness and occur posteriorly where they
can be covered by the scapula do not require reconstruction. Anterior chest wall
defects do require reconstruction, primarily to stabilize the chest wall and prevent
paradoxical motion. The reconstruction should be immediate for optimal
physiological benefit. Since Marlex mesh is porous, only a wound catheter is
needed as pleural fluid will drain through it. PTFE, however, is a solid sheet
necessitating both pleural and wound drainage.

84. An upright chest film of a cachectic, homeless 47-year-old woman shows

blunting of the right costophrenic angle. The following is/are true:
a. A lateral decubitus film should be obtained to confirm the presence of fluid
rather than a CT scan
b. Tuberculous effusion can readily be identified by stain and culture of aspirated
fluid
c. A pleural fluid glucose level lower than in the serum is diagnostic of empyema
d. Bloody pleural effusion in this patient is diagnostic of an underlying malignancy
e. Pleural fluid cytology report of lumphoma should be viewed with skepticism
Answer: a, e

Although the CT scan is a very sensitive indicator of pleural effusion, a lateral

decubitus is the simplest way to differentiate fluid from pleural thickening or
fibrosis. Tuberculous pleuritis is difficult to diagnose by stain or culture which have
a 30% yield, but the diagnosis is facilitated by needle biopsy of the pleura. Pleural
fluid glucose lower than in serum is characteristic of rheumatoid arthritis,
neoplasms, and tuberculosis as well as empyema. A red-tinged fluid can occur from
needle trauma, but even frankly bloody fluid in this patient may reflect trauma as
well as underlying malignancy. Pleural inflammation induces reactive changes in
mesothelial cells that makes them resemble lymphocytes, so a lymphoma diagnosis
is suspect.

Following shotgun wound of the chest wall, a 39-year-old woman desires

reconstruction without a foreign-body prosthesis. Old incisions prohibit use of her
rectus abdominus muscles. Considering chest wall muscles for reconstruction, the
following is/are true statement(s):

85. The pectoralis major muscle is available and innervated by the medial and
lateral pectoral nerves so named because it describes their relationship to the
pectoralis minor
a. The serratus anterior muscle is available since its absence has no functional
significance
b. There is no serratus posterior muscle
c. The latissimus dorsi muscle is available and supplied by the thoracodorsal artery
d. The latissimus dorsi is innervated by the thoracodorsal nerve with fibers from
C6, C7 and C8
Answer: d, e

The pectoralis major muscle can be used for reconstruction but the medial and
lateral pectoral nerves are named from their respective cords of the brachial
plexus. The serratus anterior muscle holds the scapula to the chest wall and its
absence produces the functional and cosmetically disabling winged scapula. The
serratus posterior muscle is attached to the 7th cervical and first three thoracic
vertebrae posteriorly and functions as an accessory muscle of respiration. The
constancy of the vascular pedicle to the latissimus dorsi and its size allow this
muscle to be used to reconstruct defects of the head, neck, chest wall and pleural
cavity. It is innervated by the thoracodorsal nerve with fibers from C6, C7 and C8.

86. A 38-year-old man presents with facial and upper extremity edema, venous
distention in the neck and arms and a cyanotic appearance. The following is/are
true statement(s):

a. The most likely cause of the problem is mediastinal granulomatous disease

b. A venogram should be obtained to confirm the diagnosis
c. Mediastinoscopy for diagnosis is contraindicated
d. If a malignancy is identified, resection is indicated for palliation
e. If the etiology is benign disease, gradual improvement without operation is to
be expected
Answer: e

Although mediastinal granulomatous disease is one cause of the superior vena cava
syndrome described, the most common cause (75%) is malignant disease. A
venogram adds little information to the typical findings and increases risk from
extravasation of contrast medium subcutaneously from the venous hypertension.
Mediastinoscopy can be used for diagnosis with recognition of increased risk of
bleeding and airway problems from the edema associated with the endotracheal
intubation required for the procedure. If a malignancy is found, operative
resection is usually precluded by the extent of mediastinal invasion. Fortunately, in
the case of benign disease, the symptoms tend to improve with time as chest wall
and mediastinal collaterals enlarge.

87. A 39-year-old woman with hypertension and radicular chest wall pain was
found to have the lesion seen on chest radiograph (Fig. 63-23). The following
is/are true statement(s):

a. The location of the lesion suggests a teratoma

b. High urinary vanillylmandelic acid levels would indicate that the lesion is a
paraganglioma
c. If the lesion was seen on a film 5 years earlier, resection would not be indicated
d. A neurosurgical consultation should be obtained
e. Vasoactive intestinal polypeptide level elevation suggests a ganglioneuroma
Answer: d, e

The posterior mediastinal location of the tumor is most indicative of a neurogenic

tumor while teratomas are characteristically found in the anterior mediastinum.
Neurogenic tumors can undergo malignant degeneration and should be resected,
particularly in this symptomatic patient even if known to be present for years. The
radicular pain suggests the possibility of intraspinous extension of the tumor, and
therefore a neurosurgical consultation is appropriate. Both urinary vanillylmandelic
acid elevation and vasoactive intestinal polypeptide can be produced by
ganglioneuroma but would not be characteristic of a paraganglioma.

Thoracic Surgery MCQ

1. The bronchial circulation:
A. Is the blood supply to the conducting airways.
B. Drains into a peribronchial venous network that may
expand considerably with conditions such as bronchiectasis
and chronic obstructive pulmonary disease.
C. Is an especially important consideration in pulmonary
transplantation.
D. All of the above.
Answer: D

DISCUSSION: The bronchial circulation is the primary blood

supply for the conducting airways, pulmonary vessels,
lymphoid tissue, and squamous cell carcinomas. In conditions
such as mitral stenosis, bronchiectasis, or chronic obstructive
pulmonary disease, the rich peribronchial venous network that
drains the bronchial circulation may expand considerably,
creating significant left-to-right shunts. Whenever the
pulmonary artery circulation is obstructed, there is a tendency
for bronchial circulation to increase; thus, the bronchial
circulation is an important consideration during lung
transplantation as well as in the surgical treatment of cyanotic
congenital heart disease and chronic pulmonary embolism.

2. Clearance of mucus produced in the tracheobronchial tree

in chronic bronchitis secondary to smoking may:
A. Be hampered by the fact that the amount of mucus is
increased by the number of mucus-producing cells at the
expense of ciliated cells.
B. Be slowed if patients have decreased lung volume and are
therefore unable to generate a vigorous cough that would
cause an inflammatory process.
C. Cause a decrease in diffusion capacity and associated
hypoxemia.
D. All of the above.
Answer: A

DISCUSSION: Chronic bronchitis may have an acute

component, and in these patients therapy with antibiotics and
bronchodilators may improve the flow rate as measured by
pulmonary function tests within 3 or 4 days of the cessation of
smoking and treatment of the acute condition. However, the
chronic bronchitic will continue to produce large amounts of
mucus, most evident in the morning, even after the acute
process has been resolved. Clearance of these secretions is
hampered by the inability to cough, perhaps secondary to the
pain of thoracotomy or abdominal surgery or by a decrease in
the number of ciliary cells that help move mucus up the
tracheobronchial tree. This causes plugging of small airways
and atelectasis, which may progress to pneumonia. For this
reason, cessation of smoking for 3 to 5 days before surgery is
very beneficial in preventing pulmonary complications during
the postoperative period.

3. The pulmonary circulation:

A. Is the only vascular system in which the veins do not have
the same course as the arteries.
B. Has a direct connection of vein to adjacent lung tissue by
connective tissue fibers, making the diameter of the tissue
fibers dependent upon lung volume.
C. Supplies the metabolic needs of the alveoli.
D. All of the above.
Answer: C

DISCUSSION: Pulmonary artery circulation transports

oxygenated blood to the alveoli level where gas exchange
occurs, and it is here that the matching of ventilation and
perfusion is so important during the postoperative period. The
loss of lung volume that generally occurs after all surgical
procedures does not return to baseline for 5 to 7 days and may
play an important role in the ventilation-perfusion ratio.
Improving or returning lung volume to normal is performed
by manipulating functional residual capacity (FRC) and
preventing atelectasis, which in turn maintains circulation to
the alveolus and optimizes the ventilation-perfusion ratio.

4. Which of the following screening tests are important for

preoperative evaluation of pulmonary function?
A. History and physical examination.
B. Room air arterial blood gases.
C. Chest film.
D. Vital capacity and forced expiratory volume in 1 second
(FEV 1).
E. Cardiopulmonary exercise testing.
Answer: ABCDE

DISCUSSION: The most important clues to impairment of

respiratory function are found in the history and physical
examination. A negative history and physical examination in
combination with a relatively normal room air arterial blood
gas and normal chest film are sufficient to screen patients to
support the clinical impression that there is minimal
pulmonary disease. Patients with symptoms, positive physical
findings, and/or abnormalities in the arterial blood gases or
chest film can be screened most effectively with an additional
evaluation of the vital capacity and FEV 1. More elaborate
tests such as cardiopulmonary exercise testing are reserved for
patients with obvious and marked impairment of pulmonary
function who are being evaluated for the feasibility of surgical
intervention.

5. Carbon monoxide diffusion capacity (DLCO) has been

shown to correlate with:
A. The thickness of the alveolar lining membrane.
B. The permeability of the erythrocyte to carbon dioxide.
C. Pulmonary emboli.
D. Total alveolar-capillary capacity.
Answer: ABCD

DISCUSSION: The single-breath DLCO is a screening test

that has been shown to be decreased in all of the above
examples. It is an estimate of the total capacity of the
functional alveolar microarchitecture and has been
demonstrated to be an independent measure of physiologic
capability apart from the FEV 1 and forced ventilatory
capacity.
6. The closing volume is:
A. The volume remaining in the lung at the end of expiration
below which alveolar collapse begins to occur, resulting in
physiologic shunting.
B. Higher in young persons.
C. Not changed during surgery.
D. Relative to the oxygen content of mixed venous blood.
Answer: AC

DISCUSSION: The closing volume is conceptually the

remaining lung volume at the end of expiration below which
alveolar collapse begins to occur, causing intrapulmonary
right-to-left shunting and thus desaturation of blood in the left
atrium. In a normal young person this closing volume is well
below the functional residual capacity (FRC); thus, such
physiologic shunting does not occur until there is a decrease
in the elastic properties of the lung. Although FRC gradually
increases with age, so does the effective closing volume.
Eventually some alveoli are being underventilated (at end-
expiration), allowing physiologic right-to-left shunting to
occur. Closing volume is unchanged, but FRC decreases
during surgery (i.e., shunting occurs). Closing volume has no
direct relationship to the oxygen content of the mixed venous
blood.

7. The effect of high positive end-expiratory pressures (PEEP)

on cardiac output is:
A. None.
B. Increased cardiac output.
C. Decreased cardiac output because of increased afterload to
the left ventricle.
D. Decreased cardiac output because of decreased effective
preload to the left ventricle.
Answer: D

DISCUSSION: Higher levels of PEEP can be associated with

decreases in cardiac output as a consequence of an effective
decrease in the preload to the left ventricle owing to impaired
left ventricular filling.

8. Weaning patients from maximum ventilator support usually

involves:
A. Weaning PEEP first, tidal volume second, and the fraction
of inspired oxygen (FIO 2) third.
B. Weaning FIO 2 first, ventilator rate second, and PEEP
third.
C. Weaning FIO2 first, PEEP second, and tidal volume third.
D. Weaning FIO 2 first, PEEP second, and ventilator rate
third.
Answer: D

DISCUSSION: When the inspired oxygen concentration is

greater than 60% for more than 24 to 28 hours, the risk of
oxygen toxicity increases. PEEP is usually weaned to
physiologic levels (i.e., 5 to 7 cm. H 2O) before weaning
either rate or tidal volumes. Generally, the optimal tidal
volume to achieve alveolar recruitment is selected and usually
is not decreased unless peak airway pressures increase. If
decreases in ventilatory rate are not tolerated, airway pressure
support can be added.

9. Which of the following statements about bronchoscopy is

false?
A. The morbidity and mortality are approximately 0.2% and
0.08%, respectively.
B. The most common complications of bronchoscopy are
related to premedication of patients.
C. Adjunctive cancer therapy such as laser treatment and
brachytherapy may be administered via this route.
D. A chronic cough and unilateral wheezing are accepted
indications for bronchoscopy.
E. Early postoperative bronchoscopy for atelectasis is
contraindicated following pulmonary resection.
Answer: E

DISCUSSION: The stated complication rates are true and

reported from a comprehensive review of over 24,000
patients. Although the most common complications are related
to the premedication, significant hemorrhage, pneumothorax,
bronchospasm, and dysrhythmias have been reported. In
addition to laser and brachytherapy, phototherapy and
immunotherapy have been given by bronchoscopy. Unilateral
wheezing may represent a bronchial foreign body, and a
chronic cough could signify myriad pulmonary disorders.
Accordingly, both are amenable to diagnostic bronchoscopy.
Most thoracic surgeons favor early bronchoscopy for lobar
atelectasis following pulmonary surgery.
10. Flexible bronchoscopy is preferred over rigid
bronchoscopy for all of the following except:
A. Patients with cervical spine injuries requiring intubation.
B. The evaluation of a smoke inhalation injury.
C. Transcarinal needle aspiration of an enlarged subcarinal
lymph node.
D. The removal of a bronchus intermedius foreign body from
an infant.
E. A cost-effective evaluation of mild hemoptysis.
Answer: D

DISCUSSION: Neither patients with significant cervical spine

disease or injuries nor those with large aortic arch aneurysms
should undergo rigid bronchoscopy, given the greater risk of
complications. Even if severe, smoke inhalation injury can be
assessed adequately by flexible bronchoscopy. Transbronchial
needle aspiration of lesions that on computed tomography
(CT) look suspicious is safe and quite easily performed with
fluoroscopic guidance. Hemoptysis as a presenting symptom
should be evaluated by flexible bronchoscopy. In contrast, for
massive hemoptysis an airway should be secured for
ventilation with a rigid bronchoscope. Similarly, an airway
needs to be maintained while removing endobronchial foreign
bodies from infants or children. Since adequate port sites for
instrumentation are also needed, the rigid bronchoscope is
preferred in this setting.
11. Which of the following approaches is/are currently
acceptable for the management of spontaneous
pneumothorax?
A. Chest tube replacement alone for the patient with a first
episode.
B. Operation on presentation for any patient with a first
episode.
C. Video-assisted thoracic surgery (VATS) bleb excision and
pleurodesis for recurrent pneumothorax on the same side.
D. Thoracotomy with bleb excision and pleurodesis for
unilateral recurrent pneumothorax.
E. Operation after a first episode in an airline pilot.
Answer: ACDE

DISCUSSION: Primary spontaneous pneumothorax typically

occurs in young patients with congenital blebs at the apices of
the lungs. Rupture of these blebs causes pneumothorax, which
recurs in about 30% of patients. Standard care on initial
presentation is chest tube placement alone. Operation
traditionally has been performed during the initial episode
only if there is prolonged air leakage (longer than 7 days); in
patients with bilateral pneumothorax; those who live in an
area where prompt medical care, if needed, is not available;
and those frequently exposed to extremes of pressure (e.g.,
airline pilots). Both VATS and thoracotomy approaches to
excision of blebs and pleurodesis have been shown to be
effective. The availability of the apparently safer VATS
approach has led some to favor earlier operation.

12. For which patient(s) with a pulmonary infiltrate of

uncertain cause would you favor VATS over open wedge
excision?
A. An AIDS patient with a diffuse infiltrate who is ambulatory
but requires supplemental oxygen. Bronchoalveolar lavage is
negative.
B. A 64-year-old previously healthy man with increasing
shortness of breath, a diffuse infiltrate, and restrictive lung
disease as shown by pulmonary function studies.
C. A 74-year-old diabetic woman with a rapidly progressing
process throughout the right lung who is ventilator- and
pressor-dependent.
D. A 44-year-old man with fever, left-sided infiltrate, and
shortness of breath.
E. A 79-year-old man on a ventilator for right lower and
middle lobe pneumonia which has been culture negative.
Answer: ABD

DISCUSSION: Lung biopsy by VATS or minithoracotomy is

often indicated in the work-up of a pulmonary infiltrate that
has not been successfully diagnosed by less invasive studies.
This procedure probably is not indicated for cancer patients
with acute pneumonitis, as broad-spectrum antibiotics
frequently are successful treatments. For those who do require
the procedure, the choice between VATS and thoracotomy is
determined by the severity of illness. In those who are
critically ill and ventilator dependent, changing the tube to an
endobronchial tube for thoracoscopy may be risky, and in
these cases an anterior thoracotomy with single-lumen
ventilation is indicated. These patients, who are frequently
heavily sedated and are likely to remain so for some time
postoperatively, are unlikely to benefit from the greatest
advantage of VATS, the reduction of postoperative pain. It is,
then, the ambulatory patient with a chronic interstitial process
who benefits the most from the VATS approach.

13. Which of the following statements about the cause and

prevention of postintubation tracheal stenosis are correct?
A. Postintubation airway stenosis can largely be avoided by
providing assisted ventilation via endotracheal tube rather
than tracheostomy tube.
B. Postintubation tracheal stenosis at the cuff level results,
more or less equally, from low blood pressure, advanced age,
steroids, high intracuff pressure, sensitivity to tube materials,
gas sterilization elution products, and systemic disease.
C. In women and smaller men large endotracheal tubes can
produce lesions of the glottis and subglottis that can progress
to stenosis.
D. Stomal stenosis is due principally to cicatricial closure of
large stomas resulting from removal of a disk or segment of
tracheal wall during tracheostomy.
E. A large-volume tracheostomy tube cuff such as that now
used on most available tubes can become a high-pressure cuff
if filled beyond its resting maximal volume.
Answer: CE

DISCUSSION: Use of an endotracheal tube, of course, avoids

a stoma and related complications. Cuff lesions, however, are
incurred from cuffs on endotracheal tubes, cricothyroidostomy
tubes, and tracheostomy tubes. A cuff is the common factor.
Endotracheal tubes, on the other hand, cause erosion at the
level of the glottis and subglottis, in particular. Although
many factors may play some role in the origin of airway
stenosis, the principal factor is pressure necrosis of the
mucosa, submucosa, and ultimately of the cartilage, with
subsequent cicatrization. Large endotracheal tubes do, indeed,
cause necrosis and airway injury at narrow areas in the upper
airway, at glottic and cricoid levels. Such injuries lead to
posterior commissure stenosis, arytenoid fixation, vocal cord
erosion and granulomas, anterior commissure stricture, and
subglottic circumferential stenosis. While excision of a large
amount of tracheal wall can lead inevitably to healing by
contraction with narrowing of the tracheal circumference, the
most usual cause of stomal stenosis is erosion of the stoma by
pressure from the tracheostomy tube. This in turn may relate
to leverage by equipment. Additional factors appear to be
subsidiary. A large volume, low pressure tracheostomy tube
cuff, such as those currently available, if properly constructed,
will seal the trachea before it is necessary to stretch the cuff
by adding an increasing volume of air. If the cuff is stretched
beyond that resting volume, which usually occludes the
normal trachea, high pressures will develop because the
plastic material from which all of these cuffs are now made is
not very extensible. Therefore, the pressure-volume curve
rises sharply once the limit of unstretched volume is passed. A
low-pressure cuff then becomes a high-pressure cuff.

14. Which of the following statements about the treatment of

postintubation airway stenosis are correct?
A. Emergency management of airway obstruction due to
stenosis at the level of a prior tracheal stoma is best
accomplished by establishing a new tracheostomy in normal
tracheal tissue just below the scar of the old stoma.
B. Radial lasering and dilatation usually leads to permanent
resolution of postintubation tracheal stenosis.
C. Splinting of a cervical trachea with a silicone T-tube for 6
to 8 months generally leads to permanent resolution of
stricture.
D. Postintubation tracheal stenosis that extends into the
subglottic larynx is treated by resection of a cylindrical sleeve
of stenotic airway and end-to-end reconstruction.
E. Acquired tracheoesophageal fistula due to intubation injury
is corrected by surgical closure of the fistula concurrent with
resection and reconstruction of the damaged trachea.
Answer: E

DISCUSSION: Emergency management of postintubation

tracheal stenosis is accomplished by dilatation under general
anesthesia using rigid bronchoscopes and dilators.
Tracheostomy is employed only when the patient requires a
prolonged or a permanent airway before or instead of
resection and reconstruction. If a new tracheostomy is needed
it is preferable to place it through the area of existing stenosis
in this case the site of prior tracheostomyrather than to
injure normal trachea that will be needed for resection and
reconstruction. If the stenosis is below the sternal notch, a
long tracheostomy tube is inserted at the usual position
(second and third rings) but extends past the now dilated
stenotic lesion.
Lasering almost never results in a permanently satisfactory
airway; the exception is the very limited lesion described as a
thin, weblike stenosis. Such lesions are rare. Unfortunately,
laser is widely used and often compounds existing damage by
concurrent placement of a tracheostomy tube below the lesion
in the normal trachea. T-tubes are very useful for temporizing
when repair is not possible or must be delayed. It almost never
leads to resolution of a stricture unless it is an extremely
limited one. Soon after removal of the T-tube the stricture
reasserts itself.
If the lesion involves the subglottic larynx, complex repair is
required to preserve the recurrent laryngeal nerve's anatomy
and function. The posterior cricoid plate is salvaged and
resurfaced with a flap of membranous tracheal wall; the
anterior subglottic larynx is reconstructed with a prow of
distal tracheal cartilage and mucosa.
A tracheoesophageal fistula is managed (after weaning from a
respirator) by layered closure of the esophagus, interposition
of a flap of well-vascularized tissue (such as a pedicled strap
muscle), and resection and reconstruction of the damaged
trachea. Since the fistula results from the pressure of a cuff,
often against an esophageal feeding tube, there is
circumferential damage to the trachea at the level of the
fistula. Resection and reconstruction are therefore necessary,
in addition to closure of the fistula, for successful treatment of
this complex lesion.

15. Which of the following statements are true?

A. Pyogenic lung abscess occurs most frequently in the lower
lobe of the left lung.
B. Anaerobic bacteria are commonly present in pyogenic lung
abscess.
C. Operation is usually required to eradicate a pyogenic lung
abscess.
D. Penicillin is the treatment of choice for lung abscess.
Answer: BD
DISCUSSION: Pyogenic lung abscess is the result of
aspiration of debris from the oropharynx. Since most patients
are unconscious and supine when this occurs, the aspirated
material usually finds its way into the most dependent
bronchi. These are the superior division of the right lower lobe
and the posterior segment of the right upper lobe. The
organisms most commonly responsible for pyogenic lung
abscess are the same anaerobic bacteria found in the mouths
of patients with poor oral hygiene. In addition to anaerobic
organisms alpha- and beta-hemolytic streptococci,
staphylococci, nonhemolytic streptococci, and Escherichia
coli may be present. Gram-negative rods and staphylococci
are particularly common in hospital-acquired infections.
These organisms are almost always penicillin sensitive.
Surgical therapy is rarely necessary to eradicate a pyogenic
lung abscess. Penicillin, alone or in combination with
metronidazole, is the drug of choice. Metronidazole alone
probably lacks sufficient activity against anaerobic and
microaerophilic streptococci. Clindamycin is also effective
against most anaerobic bacteria present in pyogenic lung
abscesses.

16. Amphotericin B is effective for the following lung

infections:
A. Histoplasmosis.
B. North American blastomycosis.
C. Aspergillosis.
D. Mucormycosis.
E. Sporotrichosis.
Answer: ABD
DISCUSSION: Amphotericin B is effective against most
fungal infections, including histoplasmosis and North
American blastomycosis. Aspergillosis is caused by the
fungus Aspergillus fumigatus, an organism that is resistant to
treatment with iodides, nystatin, hydroxystilbamidine, and
amphotericin B. The treatment for this fungal infection is a
surgical procedure, if the patient's condition permits. Surgical
excision and amphotericin B usually are necessary to treat
mucormycosis. Itraconazole is the drug of choice for
sporotrichosis. Itraconazole, ketoconazole, and fluconazole
should be considered as primary or secondary drugs when
treating systemic fungal infections.

17. The following statements are true.

A. A distinguishing roentgenographic appearance of lung
abscess, the air-fluid level can be seen only on
roentgenograms obtained in the upright or lateral decubitus
position.
B. The fungus ball characteristic of aspergillosis can be seen
roentgenographically in either the upright or recumbent
position.
C. Actinomycosis and nocardiosis are both fungal diseases of
the lung that respond to treatment with the newer azole
antifungal agents.
D. The commonest fungal lung infection in the United States
is due to Histoplasma capsulatum.
Answer: ABD

DISCUSSION: An air-fluid level distinguishes a lung abscess.

While this can be seen easily in an upright or lateral decubitus
roentgenogram, it cannot be seen when the patient is
recumbent. The fungus ball characteristic of aspergillosis is
identified by its crescent-shaped shadow on a roentgenogram.
When the patient changes from an upright to recumbent
position, the fungus ball may also change position in the
cavity in the lung. Both actinomycosis and nocardiosis are
bacterial infections and do not respond to antimycotic
treatment. Actinomyces israelli is treated with penicillin and
Nocardia asteroides is sensitive to trimethoprim-
sulfamethoxazole. The most common fungal infection in
North America is histoplasmosis. More than 30 million people
have been infected, most of whom are asymptomatic.

18. Pneumocystis pneumonia is an opportunistic infection

caused by Pneumocystis carinii. Which of the following
statements are true?
A. P. carinii is a fungus.
B. Pneumocystis pneumonia is the most common
opportunistic infection in patients with AIDS.
C. The diagnosis of Pneumocystis pneumonia depends on the
demonstration of P. carinii organisms in lung tissue.
D. There is no effective treatment for Pneumocystis
pneumonia.
Answer: BC

DISCUSSION: P. carinii is a protozoan that stains with silver

methenamine and resembles a fungus. It responds to
antiprotozoal drugs. Pneumocystis pneumonia occurs in 80%
of AIDS patients. The diagnosis is made by demonstrating the
organisms in lung tissue by transbronchoscopic lung or brush
biopsy, percutaneous needle biopsy, or open lung biopsy. Both
trimethoprin-sulfamethoxazole and pentamidine isethionate
are effective against P. carinii.

19. Which of the following statements are true?

A. The pleural space does not extend into the neck.
B. Positive intrapleural pressures as high as 40 cm. H 2O and
negative pressures as low as -40 cm. H 2O are possible.
C. The pleural cavities cannot absorb more than 500 ml. of
fluid per day.
D. All pleural effusions are of clinical significance and should
be investigated.
Answer: BD

DISCUSSION: The pleural spaces extend into the neck as

well as retrosternally and into the costophrenic sinuses. This
should be kept in mind when performing procedures such as
subclavian and jugular puncture, to avoid pneumothorax.
Markedly elevated intrapleural pressures are obtained with the
Valsalva maneuver, and extreme negative pressures can be
produced with forced inspiratory effort against a closed
glottis. Because of the many microvilli present on the
mesothelial cells that line the pleural cavity, a liter or more of
fluid is easily secreted or absorbed within a 24-hour period.
Most pleural effusions are caused by infection, tumor, or
congestive heart failure and should be investigated to
determine the proper course of management.
20. Which of the following statements are true?
A. Chylothorax, or chyle in the pleural cavity, usually is not a
serious condition.
B. Chyle is easily identified by its milky appearance, which
looks like no other kind of pleural effusion.
C. The commonest causes of chylothorax are trauma and
tumor.
D. The thoracic duct can be ligated with impunity.
Answer: CD

DISCUSSION: Chylothorax is most often the result of

trauma; however, spontaneous chylothorax is also a
manifestation of tumor and should be investigated to identify
occult malignancies. Chyle in the thorax is characteristically
milky white but can be mistaken for the pseudochylothorax of
rheumatoid disease or tuberculosis. If necessary, a diagnosis
can be confirmed by lymphangiography. This also facilitates
ligation of the thoracic duct, should this become necessary to
control the loss of chyle.

21. Which of these statements about pleural tumors is/are

true?
A. The commonest type of pleural tumor is primary pleural
mesothelioma.
B. Exposure to asbestos dust is causally related to the
development of malignant mesothelioma.
C. Localized benign mesotheliomas are asymptomatic.
D. Complete pleurectomy for malignant mesothelioma usually
results in cure.
Answer: B

DISCUSSION: Pleural involvement by metastatic disease is

much more common than primary pleural tumors. Patients
with localized benign pleural mesotheliomas may have
symptoms of arthralgia, clubbing of the fingers, or fever,
which usually disappear after excisional surgery. The evidence
relating industrial exposure to asbestosis and malignant
pleural mesothelioma is quite strong. Excisional surgery for
malignant mesothelioma is usually only palliative. Most
patients succumb within 1 to 2 years of the diagnosis,
regardless of the kind of treatment they receive.

22. Which of the following correctly describe a patient with

spontaneous pneumothorax?
A. The patient is almost always elderly and debilitated.
B. An unsuspected primary or metastatic lung tumor may be
present.
C. The administration of supplemental oxygen is of little
benefit to the patient.
D. The patient should always be treated with an intercostal
tube and closed pleural drainage.
E. Video-assisted thoracic surgery (VATS) should be
considered for persistent air leak in patients with secondary
spontaneous pneumothorax.
Answer: BE

DISCUSSION: A patient with spontaneous pneumothorax

may be old and debilitated, but the typical patient is an
otherwise healthy young adult, usually one who smokes. An
incidental, unsuspected lung cancer is discovered on rare
occasions when operation is performed to control a persistent
air leak. Perhaps smoking is a common factor. Absorption of
air from the pleural space can be facilitated by the
administration of supplemental oxygen. Increasing the oxygen
tension lowers the partial pressure of nitrogen (P N2) of the
capillary blood and increases the partial pressure difference
between the pleural space and the pulmonary capillary. If the
pneumothorax results in less than 20% collapse of the lung an
asymptomatic patient can be safely observed; however, a
larger or persistent pneumothorax is best treated with an
intercostal tube thoracostomy. Patients with bullous
emphysema may require stapling of bullae and pleurectomy,
which can be done by open thoracotomy or thoracoscopically
(VATS).

23. Which of the following statements about spontaneous

pneumothorax (PSP) is/are correct?
A. The risk of recurrence after resolution of the first episode
of PSP or secondary spontaneous pneumothorax (SSP) is 35%
to 45%.
B. Patients with PSP are typically tall, thin, young adult males
with a history of smoking.
C. Secondary spontaneous pneumothorax is associated with
family history in 10% of cases.
D. For bleb resection and pleurodesis thoracoscopic
thoracotomy and open thoracotomy provide similar cure rates
for patients with primary spontaneous pneumothorax.
E. Causes of secondary pneumothorax include trauma and
iatrogenic needle puncture.
Answer: ABD

DISCUSSION: Patients with PSP are usually 20- to 40-year-

old males with a common long-chested body habitus. The
majority of PSP patients have a history of tobacco use and
10% have a family history of PSP. The majority of cases of
SSP are due to advanced emphysema in a population of
patients aged 50 to 70 years. Additional causes of SSP include
tuberculosis, cystic fibrosis, P. carinii infection, lung cancer,
and lung abscess. For patients with PSP bleb resection and
pleurodesis performed thoracoscopically provides cure rates
similar to those of open thoracotomy. Because of the nature of
underlying pulmonary diseases, open thoracotomy appears to
provide better results for patients with SSP.

24. Which of the following are relative contraindications for

surgical management of emphysema?
A. Rapidly progressive dyspnea.
B. Bullae occupying less than one third of a hemithorax on
plain chest radiography.
C. Elevated room air PCO 2.
D. Pink puffer patients.
E. FEV 1 less than 35% of predicted value.
Answer: BCE

DISCUSSION: Relative contraindications to operation for

bullous emphysema include patients with carbon dioxide
retention, FEV 1 less than 35% of predicted value, small
bullae that occupy less than one third of a hemithorax, and
blue bloaters, who are prone to the sequelae of chronic
bronchitis. Patients who have primarily emphysema (pink
puffers) and rapidly progressive dyspnea are usually good
candidates for operation.

25. Which of the following treatments would be appropriate

therapy for symptoms that persist on medical therapy and
bronchiectasis involving, in order of decreasing severity, the
left lower lobe, the right middle lobe, and the left upper lobe?
A. Left pneumonectomy.
B. Wedge resection of the left lower lobe.
C. Left lower lobectomy.
D. Simultaneous left lower lobectomy and right middle
lobectomy.
Answer: C

DISCUSSION: Pneumonectomy is seldom indicated today for

bronchiectasis. Anatomic resection of involved segments with
either segmentectomy or lobectomy is preferred to
nonanatomic wedge resection. Bilateral pulmonary resections
should generally be done as staged procedures, the most
symptomatic side being resected first. Then, the contralateral
side is resected only if symptoms persist during a prolonged
course of medical therapy.

26. Which of the following would not be acceptable

sequences of preoperative studies in a patient being prepared
for lingulectomy for bronchiectasis?
A. CT alone.
B. CT, bronchoscopy, bronchography.
C. Bronchoscopy alone.
D. Bronchoscopy, bronchography.
Answer: C

DISCUSSION: Bronchoscopy alone is generally not

diagnostic for bronchiectasis. Thin-section, high-resolution
CT can diagnose bronchiectasis and define the airway
anatomy sufficiently for resection. Bronchography is
performed less frequently today but can be very useful in
diagnosing bronchiectasis and defining airway anatomy for
pulmonary resection.

27. Which of the following statements about pulmonary

mycobacterial infection is/are correct?
A. Worldwide, tuberculosis no longer represents a significant
public health problem.
B. Mycobacterium tuberculosis is responsible for the majority
of cases of pulmonary mycobacterial disease.
C. Mycobacterium kansasii pulmonary infection almost
always requires surgical treatment.
D. Atypical mycobacteria are never primary pulmonary
pathogens in humans.
E. Mycobacterium avium-intracellulare is generally resistant
to most antimycobacterial drugs in vitro.
Answer: BE
DISCUSSION: Tuberculosis remains the leading infectious
killer in the world today. M. tuberculosis is responsible for the
vast majority of pulmonary mycobacterial disease. M.
kansasii infection responds to multiple drug chemotherapy
and relatively infrequently requires surgical treatment.
Atypical mycobacteria can be primary pulmonary pathogens
in humans. M. avium-intracellulare is usually resistant in vitro
to most antituberculosis drugs.

28. Which of the following chemotherapeutic regimens are

currently recommended for the treatment of pulmonary
infection caused by M. tuberculosis?
A. Isoniazid, rifampin, pyrazinamide, and streptomycin for 24
months.
B. Isoniazid for 9 months with ethambutol for the first 3
months.
C. Isoniazid and rifampin for 6 months with pyrazinamide
added for the first two months.
D. Isoniazid alternating with rifampin at 3-month intervals for
12 months.
E. Isoniazid and rifampin for 9 months.
Answer: CE

DISCUSSION: Treatment of tuberculosis with a single drug

leads to rapid emergence of drug-resistant organisms. Any
treatment regimen that employs only one drug for a period of
time encourages the development of drug-resistant
tuberculosis. Currently, the American Thoracic Society
recommends either (1) a 6-month regimen consisting of
isoniazid, rifampin, and pyrazinamide for 2 months followed
by isoniazid and rifampin for 4 months or, alternatively, (2) a
9-month course of isoniazid and rifampin. Prolonged courses
of treatment beyond 9 to 12 months no longer are considered
necessary.

29. Which of the following are appropriate indications for

pulmonary resection for mycobacterial disease?
A. Localized pulmonary disease caused by M. avium-
intracellulare.
B. Advanced lobar tuberculous pneumonia with massive hilar
lymphadenopathy and bronchial obstruction in a young child.
C. Localized pulmonary disease due to multiple drugresistant
M. tuberculosis.
D. An asymptomatic tuberculous cavity greater than 12 cm. in
diameter.
E. Massive hemoptysis from a right upper lobe cavity
occurring during an appropriate course of chemotherapy for
pulmonary tuberculosis in a sputum-negative patient.
Answer: ACE

DISCUSSION: Modern antimycobacterial chemotherapy is

very effective. Surgical treatment of pulmonary mycobacterial
disease is rarely necessary; however, pulmonary disease
caused by M. avium-intracellulare or multiple drugresistant
M. tuberculosis is not likely to respond to chemotherapy and
should be resected if the disease is localized. Chemotherapy
for tuberculosis is almost invariably curative in children,
regardless of the extent of disease. The size of a tuberculous
cavity is not an indication for resection. Massive hemoptysis
from a cavitary lesion is life threatening and is an indication
for pulmonary resection.

30. Which statements about squamous papillomatosis of the

trachea is/are correct?
A. It is the most common type of benign tracheal tumor in
adults.
B. It is the most common type of benign tracheal tumor in
children.
C. Most are treated with segmental tracheal resection.
D. There is no risk of malignant degeneration.
E. It is associated with a herpesvirus.
Answer: A

DISCUSSION: Squamous papillomatosis is the most common

benign tracheal and bronchial tumor in adults. Up to 50% of
untreated lesions may degenerate into squamous cell
carcinoma. The lesion is associated with human
papillomavirus types 6 and 11, and therefore, interferon
therapy is under investigation. Most patients can be treated
successfully by repeated bronchoscopic fulguration, laser
ablation, or cryotherapy.

31. Which of the following statements about pulmonary

hamartomas is/are true?
A. Hamartomas are benign chondromas.
B. Most are located in the conducting airways.
C. Wedge resection is curative.
D. A lobectomy is necessary to obtain draining hilar lymph
nodes.
E. Hemoptysis is common.
Answer: C

DISCUSSION: Pulmonary hamartomas are benign masses

consisting of cartilage, lymph tissue, fat, and epithelial
elements. Eighty per cent are located in the lung periphery
and are treated by a small wedge resection, usually with a
thoracoscope. Most are asymptomatic, and there is no risk of
malignant degeneration.

32. Which of the following statements about typical carcinoid

tumors are true?
A. They make up the majority of bronchial adenomas.
B. They frequently have lymph node metastases.
C. The carcinoid syndrome is observed in 33%.
D. Overall survival at 5 years is 90%.
E. Overall survival at 5 years is 50%.
Answer: AD

DISCUSSION: Eighty-five per cent of bronchial adenomas

are carcinoid tumors. Typical carcinoid tumors have few
mitotic figures and infrequent lymph node metastases (fewer
than 10%). Only 10% to 15% of patients present with the
carcinoid syndrome (flushing, wheezing, diarrhea). Survival
after resection is more than 90% at 5 years but decreases to
approximately 50% for atypical histology.
33. Which is/are true of adenoid cystic carcinoma?
A. It is a common type of salivary gland tumor.
B. Another name is cylindroma.
C. Most patients are completely resected for cure.
D. Different histological types have different prognoses.
E. Tissue invasion is rare.
Answer: ABCD

DISCUSSION: Adenoid cystic carcinomas (cylindromas) are

commonly observed salivary gland tumors that can occur in
the conducting airways. The undifferentiated solid type is
associated with distant metastases, of which the cribriform
and tubular types are associated with perineural and
submucosal invasion. Most patients (60%) can be resected for
cure.

34. A solitary pulmonary nodule is discovered in an

asymptomatic 55-year-old smoker with no evidence of
extrathoracic dissemination. The most appropriate
management would be to:
A. Obtain serial chest films every 3 months to determine the
growth potential of the nodule.
B. Perform transthoracic needle aspiration (TTNA) before
considering pulmonary resection to confirm malignancy.
C. Conduct an extensive systematic evaluation to exclude the
possibility that the nodule represents a metastatic lesion.
D. Proceed with pulmonary resection after ascertaining that
the patient would tolerate removal of the requisite amount of
lung.
E. Obtain baseline serum levels of carcinoembryonic antigen
and p53.
Answer: D

DISCUSSION: A patient with a solitary pulmonary nodulea

single spherical lesion within the lung represents an
important and challenging diagnostic problem in thoracic
oncology. A solitary pulmonary nodule is assumed to be
primary lung cancer until proved otherwise; the differential
diagnosis includes metastatic carcinoma, granuloma, and
benign pulmonary tumors. In most cases, solitary pulmonary
nodules should be resected after thorough investigation to
establish that systemic dissemination has not already
occurred. CT of the chest, liver, and adrenals is performed to
confirm the location of the tumor, to evaluate the
mediastinum, and to assess the abdomen for systemic disease.
If there is no evidence of metastases on CT, the patient should
undergo bronchoscopy, which may establish the histologic
diagnosis and determine resectability if an endobronchial
lesion exists.
Pulmonary function studies are obtained preoperatively to
assess the potential for pulmonary resection. A thorough
review of systems is undertaken to rule out medical
contraindications to thoracotomy. TTNA is not performed
routinely and should be reserved for patients with marginal
pulmonary function, for whom thoracotomy would be
performed only after verification of a malignant histologic
diagnosis.
35. After thoracotomy, pulmonary resection, and mediastinal
lymph node dissection, a patient is determined to have a
squamous cell carcinoma 2 cm. in diameter, located 1 cm.
from the carina along the right mainstem bronchus. Three
peribronchial lymph nodes are positive for cancer, and all
other lymph node stations are negative. The correct stage,
according to the TNM system, is:
A. T1N0M0 Stage I.
B. T1N1M0 Stage II.
C. T2N1M0 Stage II.
D. T3N1M0 Stage IIIa.
E. T2N3M0 Stage IIIb.
Answer: C

DISCUSSION: The TNM staging system for carcinoma of the

lung provides a consistent, reproducible description of the
anatomic extent of disease at the time of diagnosis. In the
TNM system, T represents the primary tumor and numerical
suffixes describe increasing size or involvement; N represents
regional lymph nodes with suffixes to describe levels of
involvement; and M designates the presence or absence of
distant metastases.
TUMOR (T)
TX Occult carcinoma (malignant cells in sputum or bronchial
washings but tumor not visualized by imaging studies or
bronchoscopy)
T1 Tumor 3 cm. or less in greatest diameter, surrounded by
lung or visceral pleura, but not proximal to a lobar bronchus
T2 Tumor larger than 3 cm. in diameter, or with involvement
of main bronchus at least 2 cm. distal to carina, or with
visceral pleural invasion, or with associated atelectasis or
obstructive pneumonitis extending to the hilar region but not
involving the entire lung
T3 Tumor invading chest wall, diaphragm, mediastinal pleura,
or parietal pericardium; or tumor in main bronchus within 2
cm. of, but not invading, carina; or atelectasis of obstructive
pneumonitis of the entire lung
T4 Tumor invading mediastinum, heart, great vessels, trachea,
esophagus, vertebral body, or carina; or ipsilateral malignant
pleural effusion
NODES (N)
N0 No regional lymph node metastases
N1 Metastases to ipsilateral peribronchial or hilar nodes
N2 Metastases to ipsilateral mediastinal or subcarinal nodes
N3 Metastases to contralateral mediastinal or hilar, or to any
scalene or supraclavicular nodes
DISTANT METASTASES (M)
M0 No distant metastases
M1 Distant metastases
The TNM subsets are subsequently grouped in a series of
stages of disease to identify groups of patients with similar
prognosis and therapy.

STAGE T N M
Occult TX N0 M0
Stage I T1-2 N0 M0
Stage II T1-2 N1 M0
Stage IIIa T3 N0-1 M0
T1-3 N2 M0
Stage IIIb T4 N0-2 M0
T1-4 N3 M0
Stage IV Any T Any N M1
36. After complete resection of Stage I non-small cell lung
cancer (NSCLC), the role of adjuvant therapy is best
summarized thus as:
A. Postoperative radiation therapy improves disease-free
survival.
B. Postoperative radiation therapy improves overall survival.
C. Postoperative chemotherapy improves disease-free
survival.
D. Postoperative chemotherapy improves overall survival.
E. Adjuvant therapy is not indicated after complete resection
of Stage I NSCLC.
Answer: E

DISCUSSION: Prospective randomized trials conducted by

the Lung Cancer Study Group demonstrate that postoperative
chemotherapy may be responsible for significantly longer
disease-free survival in patients with Stage III (and perhaps
Stage II) NSCLC. The efficacy of postoperative chemotherapy
and radiotherapy in patients with extensive lymph node
involvement or positive surgical margins in reducing systemic
recurrences and prolonging disease-free survival has also been
demonstrated. Adjuvant therapy is not associated with
improved overall survival and has not been shown to be
beneficial in patients with Stage I NSCLC.
Radiation therapy is an effective adjuvant treatment in many
patients with carcinoma of the lung. Adjuvant radiotherapy,
applied to patients with completely resected Stage II or Stage
III (but not Stage I) NSCLC, has been shown to decrease local
recurrence but has no significant effect on survival. However,
postoperative irradiation may provide a survival advantage in
patients who have resection and are found to have metastases
to hilar or mediastinal lymph nodes. Thus, the purpose of
adjuvant radiotherapy is prevention of local tumor recurrence,
especially when lymph node sampling of the mediastinum at
thoracotomy is incomplete.

37. Compared to segmentectomy or wedge resection,

lobectomy for NSCLC is associated with:
A. Similar operative morbidity but higher operative mortality.
B. Similar operative mortality but higher operative morbidity.
C. More severe postoperative pulmonary dysfunction.
D. Lower incidence of locoregional recurrence.
E. Equivalent locoregional recurrence.
Answer: D

DISCUSSION: The risk of recurrence after surgical resection

according to the magnitude of the resection has been analyzed
by the Lung Cancer Study Group. In a prospective,
randomized trial involving more than 400 patients with T1N0
lung cancer, lobectomy was compared to segmentectomy and
wedge resection. There was no significant difference in
morbidity and mortality among the procedures. Furthermore,
no difference was observed in postoperative pulmonary
function between patients who underwent lobectomy and
those who underwent lesser procedures. The rate of
locoregional recurrence was significantly lower in patients
who underwent lobectomy (5%) as compared with those who
underwent either segmentectomy or wedge resection (15%).
In another study, segmentectomy was compared to lobectomy
in patients with Stage I lung cancer. In this study, the rate of
locoregional recurrence was lower in patients who underwent
lobectomy (5%), as compared with those who underwent
segmentectomy (23%). Furthermore, there was a survival
advantage in the patients undergoing lobectomy for T2
disease.

38. In contrast to NSCLC, small cell lung cancer (SCLC) is

characterized by:
A. Greater response rate to chemotherapy.
B. Inability to achieve surgical cure.
C. Less frequent association with paraneoplastic syndromes at
the time of diagnosis.
D. Lower likelihood of metastases present at the time of
diagnosis.
E. Slower growth.
Answer: A

DISCUSSION: For the purposes of staging, estimating

prognosis, and selecting therapy, lung cancer is divided into
two categories: NSCLC and SCLC. SCLC is characterized by
more rapid growth, higher prevalence of metastases at the
time of diagnosis, and greater responsiveness to chemotherapy
and radiation therapy. After ascertaining the histological
diagnosis of SCLC, staging is performed, including thorough
neurological examination and CT evaluation of the chest,
abdomen, and brain. For most patients with limited-stage
disease, treatment is initiated with six cycles of combination
chemotherapy. Radiotherapy to the chest is usually employed
after three initial cycles of chemotherapy and is continued for
4 weeks. Among patients with limited-stage disease,
thoracotomy for pulmonary resection is recommended for the
subset of patients with stage I SCLC.

39. Which of the following statements about the diagnosis and

staging of mesothelioma is/are correct?
A. Fluid obtained by thoracentesis is usually adequate for
accurate diagnosis.
B. Open biopsy or thoracoscopy should be performed to
obtain tissue for diagnosis.
C. Immunohistochemistry should be performed in all cases of
suspected mesothelioma.
D. Chest CT and/or magnetic resonance imaging (MRI) are
useful in the staging of mesothelioma.
E. Head CT and bone scans are useful in the staging of
mesothelioma.
Answer: BCD

DISCUSSION: Approximately 90% of patients with

mesothelioma develop pleural effusion, but cytologic
specimens from pleural fluid are inaccurate for the diagnosis
of mesothelioma, and open or thoracoscopic biopsy is
required. Accurate diagnosis of mesothelioma is difficult: the
epithelial variant must be differentiated from adenocarcinoma,
whereas the sarcomatous form often resembles benign
sarcomas. Immunohistochemistry using a panel of antibodies,
and sometimes electron microscopy, is required for all cases.
Relentless local spread is typical, and chest CT or MRI is
essential to evaluate potential local extension into the chest
wall, pericardium, mediastinum, or diaphragm. Metastatic
disease is less common and occurs late (if at all) in the disease
course, so head CT and bone scans are indicated only if
clinical findings are suspicious for metastasis.

40. Which of the following statements about therapy for

malignant pleural mesothelioma is/are correct?
A. The role of surgery is confined to biopsy for diagnosis and
pleurodesis for palliation of effusion.
B. Extrapleural pneumonectomy involves resection en bloc of
the lung, visceral and parietal pleura, pericardium, and
diaphragm.
C. If a lesion is unresectable by extrapleural pneumonectomy,
pleurectomy/decortication is contraindicated.
D. Neither surgery, chemotherapy, nor radiation therapy as a
single therapy improves survival.
E. Multimodality therapy, combining surgery, chemotherapy,
and radiation therapy may improve survival in select patients.
Answer: BDE

DISCUSSION: In debilitated patients, palliation by

pleurodesis is indicated; however, cytoreductive techniques,
including pleurectomy/decortication, and extrapleural
pneumonectomy, are indicated for patients who can tolerate
surgery. For Stage I disease, extrapleural pneumonectomy is
offered. If the patient cannot tolerate pulmonary resection or if
the lesion is unresectable by extrapleural pneumonectomy,
pleurectomy/decortication is appropriate. Both cytoreductive
procedures, when used in a multimodality setting, may
improve survival in selected patients. They also improve
quality of life by relieving or delaying two severe symptoms
of mesothelioma: dyspnea secondary to lung restriction by the
tumor and pain from tumor invasion. No single modality
(surgery, chemotherapy, or radiation therapy) improves
survival.

41. All of the following may be acceptable operative

approaches to management of the thoracic outlet syndrome
except:
A. Scalenectomy.
B. Excision of a cervical rib.
C. Thoracoplasty.
D. First rib resection.
E. Division of anomalous fibromuscular bands.
Answer: C

DISCUSSION: Supraclavicular decompression of the thoracic

outlet is the preferred operative approach for the thoracic
outlet syndrome. This procedure consists of extensive anterior
scalenectomy, middle scalenectomy, removal of a cervical rib
(if present), and, on occasion, first rib resection. Transaxillary
first rib resection has been widely used as well but is
associated with a greater risk for complications. Numerous
fibromuscular anomalies have been described in association
with the thoracic outlet syndrome. Thoracoplasty has no role
in the management of this disorder.

42. Initial conservative (nonsurgical) management of the

thoracic outlet syndrome may include all of the following
except:
A. Weight reduction.
B. Improvement of posture.
C. Exercises to strengthen the muscles of the shoulder girdle.
D. Pentoxifylline.
E. Avoiding hyperabduction.
Answer: D

DISCUSSION: The initial management of the thoracic outlet

syndrome is nonoperative. A trial of weight reduction,
shoulder girdle strengthening exercises, improvement of
posture, and avoidance of hyperabduction should be
recommended for 4 months or longer. These measures are
successful in 50% to 70% of patients, particularly in young to
middle-aged females with poor posture. Pentoxifylline is a
hemorrheologic agent used in selected patients with peripheral
arterial insufficiency and has no known benefit in the thoracic
outlet syndrome.

43. Which of the following statements about pectus

excavatum are correct?
A. It is the most common congenital malformation of the
chest wall.
B. The most frequent presenting complaint is the cosmetic
deformity.
C. The manubrium and first and second costal cartilages
typically are involved in the deformity.
D. It may be associated with cardiac defects and other skeletal
defects such as scoliosis.
E. Restrictive alterations in chest wall mechanics and
abnormalities in pulmonary function tests have been
documented.
Answer: ABDE

DISCUSSION: Congenital deformities of the chest wall

represent a spectrum of deformities ranging from minor
cosmetic defects to gross deformities incompatible with life.
Pectus excavatum, or funnel chest, is the most common of the
congenital deformities of the chest wall, accounting for 90%
of such defects. It is characterized by a concave, posteriorly
displaced sternum due to overgrowth of the costal cartilages.
Most commonly the defect begins at the junction of the
manubrium and the body of the sternum and becomes
progressively deeper toward the xiphoid. The manubrium and
the first and second costal cartilages typically are normal. The
defects have both physiologic and psychologic consequences
and are often associated with other abnormalities, including
congenital heart disease, Marfan's syndrome, and other
skeletal defects, including scoliosis. Patients most often
present because of the cosmetic defect but frequently are
found to have other symptoms, including impaired
cardiopulmonary function and scoliosis. Pulmonary
complaints include dyspnea and respiratory tract infections.
Restrictive alterations in chest wall mechanics and
abnormalities in pulmonary function tests, including
decreased vital capacity, decreased total lung capacity,
decreased maximal ventilatory volume, and decreased
maximal breathing capacity, have been documented.

44. Surgical correction of pectus excavatum is characterized

by which of the following?
A. Significant cosmetic improvement initially but a high
incidence of recurrence of the defect on late follow-up.
B. An increase in exercise tolerance and respiratory reserve
postoperatively.
C. Improvement in FEV 1, vital capacity, and total lung
capacity.
D. Improvement in maximal ventilatory volume, total
progressive exercise time, and maximal exercise capacity.
E. Prevention of the development of thoracogenic scoliosis.
Answer: BDE

DISCUSSION: Because of the significant cosmetic and

psychological improvement, subjective increase in exercise
tolerance, documented improvement in cardiac and
respiratory status, and prevention of the development of
scoliosis following surgical intervention in these patients,
surgical correction should be considered for all patients with
moderate to severe deformity. Cosmetic results of surgical
correction are excellent, and recurrence is uncommon.
Objective improvement in cardiac function has been
documented postoperatively, owing to relief of the sternal
compression. Postoperatively, worsening of the FEV 1, vital
capacity, and total lung capacity have been noted, whereas a
significant improvement in maximal ventilatory volume, total
progressive exercise time, and maximal oxygen consumption
has also been documented. Following surgical correction there
is a consistent increase in maximal exercise capacity at every
level of workload, a lower heart rate at every workload, and
an increase in exercise duration.
45. Which of the following statements about the diagnosis of
chest wall tumors is/are correct?
A. Pain is a common presenting symptom.
B. Firmness and fixation to underlying bone and muscle are
important to note in the physical examination as aids to
diagnosis.
C. In general, chest wall tumors are slow growing and
produce symptoms late in their course.
D. CT is the most useful imaging study for making the
diagnosis and for planning surgical resection of chest wall
tumors.
E. Angiography should be performed routinely.
Answer: BCD

DISCUSSION: Seventy-five per cent of patients present with

a slow-growing, painless chest wall mass. A firm mass that is
fixed to an underlying rib is more likely to be of bony or
cartilaginous origin. Conversely, soft, mobile tumors are more
likely to be of soft tissue origin. CT defines depth of invasion
and extent of tumor and is the most useful imaging modality.
Angiography should be employed selectively, primarily for
very large and vascular tumors.

46. Which of the following statements about chest wall

resection and reconstruction is/are correct?
A. Most tumors of soft tissue and bone require 4-cm. margins
to be adequately resected.
B. At least one normal rib above and below the primary tumor
should be included in the resection.
C. Techniques of chest wall reconstruction are directed at the
prevention of paradoxical chest wall movement with
respiration.
D. Soft tissue defects are most conveniently addressed by
stretching the existing skin over the defect under tension.
E. Chest wall defects that are covered by the scapula require
no special reconstructive procedures, even if the defects are
quite large.
Answer: ABCE

DISCUSSION: Margins of resection of chest wall tumors

should be at least 3 cm. of skin, 4 cm. of muscle, and 6 cm. of
bone. Old biopsy sites should be included in the specimen. A
normal rib above and below the specimen should also be
included. Prevention of paradoxical chest wall movement is
the primary goal of chest wall reconstruction. Large soft tissue
defects are best managed by myocutaneous pedicle flaps. In
general, defects larger than 5 cm. require reconstruction.
Defects covered by the scapula require no reconstruction.

47. Prolonged extracorporeal membrane oxygenation

(ECMO):
A. Is highly successful in the treatment of severe respiratory
failure in newborn infants.
B. Is contraindicated in adult respiratory distress syndrome
(ARDS).
C. Causes hemolysis and renal failure.
D. Requires total systemic heparinization (activated clotting
time longer than 500 seconds).
E. Is identical to heart/lung bypass for cardiac surgery.
Answer: A
DISCUSSION: The survival rate of newborn infants who are
moribund from respiratory failure with ECMO is 80% to 90%.
ECMO is also indicated in ARDS with a survival rate from
40% to 50%. Hemolysis and renal failure are rare
complications. ECMO requires low-dose partial
heparinization, with clotting times in the range of 200
seconds. Several modifications in the conventional heart/lung
machine permit the extension of ECMO from hours to days.

48. Indications for ECMO include:

A. Newborn infants with pulmonary hypoplasia secondary to
congenital diaphragmatic hernia.
B. Meconium aspiration syndrome in full-term babies (at least
35 weeks).
C. Children with pulmonary infection after bone marrow
transplantation.
D. Adults with acute viral pneumonia.
E. Adults requiring mechanical ventilation and 100% oxygen
for 2 weeks or longer.
Answer: BD

DISCUSSION: At present ECMO is not used for infants

smaller than 1500 gm. because of a high risk of intracranial
bleeding. ECMO is very successful in the treatment of
respiratory failure in full-term newborn infants.
Immunosuppression is a relative contraindication to ECMO.
ECMO is indicated in adults with acute, potentially reversible
respiratory failure, but mechanical ventilation and high
oxygen concentration for more than 10 days are
contraindications.

49. Venovenous ECMO:

A. Avoids major arterial access.
B. Provides cardiac and pulmonary support.
C. Can be accomplished via cannulation at separate venous
sites or at a single venous site using a double-lumen catheter.
D. Provides greater venous drainage than venoarterial ECMO.
E. Maintains the normal pulsatile blood flow to the systemic
circulation.
Answer: ACE

DISCUSSION: Venovenous ECMO has become the access

technique of choice for patients with respiratory failure
without significant requirement for cardiac (hemodynamic)
support. In neonates, a double-lumen cannula allows ECMO
to be performed through a single incision over the right
internal jugular vein. It can also be performed by separate
cannulation of the femoral and jugular veins. In either
configuration, venovenous ECMO avoids cannulation of any
major arteries and maintains the normal pulsatile circulation
through the heart and lungs. Venous drainage is no different
with venovenous ECMO.

50. As compared with venovenous ECMO, venoarterial

ECMO:
A. Requires cannulation of a major artery and vein.
B. Provides both cardiac and respiratory support.
C. Can be performed with less anticoagulation.
D. Usually maintains a normal pulse pressure.
Answer: AB

DISCUSSION: Venoarterial ECMO can provide total

cardiorespiratory support via cannulation of a major vein and
artery (usually the right internal jugular vein and common
carotid artery in neonates). With most roller and vortex
pumps, the arterial inflow from the ECMO circuit is
nonpulsatile, and therefore pulse pressure is often reduced or
absent. Venoarterial ECMO requires the same degree of
anticoagulation as venovenous techniques.

51. A 24-year-old male has new onset of chest pain. Chest

films demonstrate a large anterosuperior mass. Appropriate
evaluation should include:
A. CT of the chest.
B. Measurement of serum alpha-fetoprotein and betahuman
chorionic gonadotropin.
C. A barium swallow.
D. A myelogram.
Answer: AB

DISCUSSION: Elevated levels of serum alpha-fetoprotein

and betahuman chorionic gonadotropin are indicative of a
malignant nonseminomatous germ cell tumor. Optimal
therapy for such a tumor is based on a cis-platinum-containing
chemotherapeutic regimen. After normalization of serum
markers, resection of residual disease is performed. Extensive
surgical procedures prior to chemotherapy are not warranted.
Confirmation of the diagnosis can usually be obtained using
needle biopsy techniques. In some institutions patients are
treated based on elevated serum markers alone. CT imaging is
useful to evaluate tumor invasiveness, airway compression,
vascular involvement, and the likelihood of resectability.
Barium swallow may be helpful in the evaluation of enteric
cysts. Myelography may be useful in patients with posterior
mediastinal masses to evaluate for spinal column
involvement.

52. Systemic syndromes frequently associated with

mediastinal tumors include:
A. Myasthenia gravis.
B. Hypercalcemia.
C. Malignant hypertension.
D. Carcinoid syndrome.
Answer: ABC

DISCUSSION: Myasthenia gravis occurs in 10% to 50% of

patients with thymoma. The incidence with which myasthenia
gravis occurs in patients with a thymoma increases with the
age of the patient. In males over 50 and females over 60 years
of age, the incidence appears to be greater than 80%.
Hyperparathyroidism due to a mediastinal parathyroid
adenoma is a cause of hypercalcemia. Although parathyroid
glands may occur in the mediastinum in 10% of the patients,
they are usually accessible through a cervical incision. A
sternotomy is required infrequently, even in those patients
with a mediastinal parathyroid gland. Most often the
adenomas are found embedded in or near the superior pole of
the thymus. Mediastinal paraganglioma may produce
significant catecholamines, predominantly norepinephrine.
Catecholamine production causes a classic group of
symptoms associated with pheochromocytomas, including
periodic sustained hypertension often accompanied by
orthostatic hypotension, and hypermetabolism manifested by
weight loss, hyperhydrosis, palpitation, and headaches.
Mediastinal carcinoid tumors have been more frequently
associated with Cushing's syndrome because of the production
of adrenocorticotrophic hormones. These tumors uncommonly
cause the carcinoid syndrome.

53. A 36-year-old female developed dyspnea on exertion that

has progressed over 3 months. Chest film reveals a left
anterior mediastinal mass with evidence of elevated left
hemidiaphragm. CT indicates probable invasion of the
pericardium. Paratracheal or subcarinal adenopathy is not
identified. Appropriate intervention in this patient would
include:
A. A median sternotomy with radical resection of the tumor,
sacrificing the left phrenic nerve and excising the involved
pericardium.
B. A mediastinoscopy with biopsy.
C. A left anterolateral thoracotomy or median sternotomy with
generous biopsy of the tumor.
D. Observation with repeat chest radiography in 3 months.
Answer: C
DISCUSSION: The differential diagnosis of an invasive
anterosuperior mediastinal mass includes thymoma,
lymphoma, germ cell tumor, undifferentiated carcinoma, and
carcinoid tumors. These tumors often have a very similar
histologic appearance, which may cause an inaccurate
diagnosis based on light microscopy alone. Use of electron
microscopy and immunohistochemistry may be necessary to
correctly determine the specific histologic diagnosis. Frozen
section should be used to determine adequacy of tissue biopsy.
Histologic diagnosis based on frozen section examination in
many of these tumors may be erroneous. Although radical
resection of tumor is indicated for thymoma, chemotherapy
and radiotherapy are the modalities used for the treatment of
patients with lymphomas and germ cell tumors. Exact
determination of tumor histology by permanent section should
precede radical resectional therapy. Generous tissue biopsy is
necessary for the precise subtyping of lymphomas.
Mediastinoscopy is useful in patients with paratracheal and
pericarinal masses or adenopathy, particularly when right-
sided. Observation of a patient with invasive mediastinal mass
is not warranted.

54. An 18-year-old male presents with a history of increasing shortness of

breath that worsens in the recumbent position. On physical examination,
the neck veins are noted to be distended, with facial plethora that is
accentuated by lying the patient down. A 2.5-cm. left supraclavicular
lymph node is palpable. Chest film reveals an extensive right anterosuperi
mediastinal mass. Appropriate intervention may include:
A. An urgent biopsy of the mediastinal mass under general
anesthesia with subsequent initiation of therapy.
B. CT.
C. Pulmonary function testing in the sitting and supine
positions.
D. A biopsy of the right supraclavicular lymph node under
general anesthesia.
E. A biopsy of the supraclavicular lymph node under local
anesthesia.
Answer: BCE

DISCUSSION: Although most patients with a mediastinal

mass may undergo surgical procedures under general
anesthesia with a minimal risk, patients with a large anterior,
superior, or middle mediastinal mass, particularly those with
posture-related dyspnea and superior vena caval syndrome,
have an increased risk of developing severe respiratory
complications during general anesthesia. Useful techniques
for identifying less symptomatic patients who have significant
airway compression include CT imaging and pulmonary
function tests. A reduction of the tracheal diameter by more
than 35% on a CT scan and reduction of peak expiratory flow
during pulmonary function testing are sensitive indicators of
functional airway compression. In patients with airway
compression and superior vena caval obstruction, the risk of
general anesthesia is significant. Attempts to obtain a
histologic diagnosis should be limited to needle biopsies or
open procedures performed under local anesthesia. In
situations in which histologic diagnosis cannot be obtained
using these methods, therapy may be initiated with radiation,
corticosteroids, and chemotherapy. However, a histologic
diagnosis may not be obtainable in as many as 40% of these
patients after initiation of treatment. Some proceed with
biopsy of the mediastinal mass under general anesthesia.
However, alterations in anesthetic management include: (1)
induction of anesthesia in a semi-Fowler's or upright position, (2)
availability of rigid bronchoscopy to allow reestablishment of an adequate
airway, (3) use of a long endotracheal tube to allow advancement of the
tube beyond the site of obstruction, (4) avoidance of muscle relaxants and
the use of spontaneous ventilation when possible, (5) lower extremity
intravenous cannulation, and (6) standby cardiopulmonary bypass.

55. A 42-year-old male who is scheduled to undergo elective

knee surgery has a preoperative chest film that demonstrates a
5-cm. posterior mediastinal mass. The patient denies any
neurologic symptoms and physical examination fails to
elucidate any neurologic deficit. CT confirms the presence of
a 5-cm. mediastinal mass in the left costovertebral gutter with
minimal enlargement of the seventh thoracic foramen.
Appropriate intervention includes:
A. Resection of the posterior mediastinal mass using a
standard posterolateral incision.
B. A CT with myelography or magnetic resonance (MR)
imaging.
C. Two-stage removal of the tumor, performing the resection
of the thoracic component first with subsequent removal of
the spinal column component at a later date.
D. One-stage removal of the dumb-bell tumor, excising the
intraspinal component prior to resection of the thoracic
component.
Answer: BD

DISCUSSION: Approximately 10% of neurogenic tumors

extend into the spinal column and are termed dumb-bell
tumors because of the characteristic shape. Although 60% of
patients with such tumors have neurologic symptoms related
to spinal cord compression, the significant proportion of
patients without symptoms underscores the importance of
evaluating all patients with a posterior mediastinal mass for
possible intraspinal extension. CT, MR imaging, and vertebral
tomography may demonstrate an enlargement of the foramen,
erosion of bone, or intervertebral widening, which are
indicative of a dumb-bell tumor. If these findings are present,
CT with myelography or MR imaging is indicated to evaluate
the presence and extent of the intraspinal component. A one-
stage removal of the tumor is recommended, with excision of
the intraspinal component prior to resection of the thoracic
component to minimize the risk of spinal column hematoma.

56. True statements regarding patients with a mediastinal

mass include:
A. Asymptomatic patients have a benign mass in over 75% of
cases.
B. Symptomatic patients are more likely to have a malignant
lesion than a benign lesion.
C. In a patient with a chest film demonstrating a mediastinal
mass, a Tru-cut needle biopsy is a safe procedure.
D. Seminomas usually produce alpha-fetoprotein.
Answer: AB

DISCUSSION: Seventy-six per cent of the asymptomatic

patients with a mediastinal mass seen in one series over a
recent 20-year period had a benign leison. In contrast, 62% of
the symptomatic patients had a malignant neoplasm during
this period. A number of intrathoracic and extrathoracic
lesions may have an appearance similar to a primary
mediastinal mass on routine chest films, as do a large number
of cardiovascular lesions. Although angiography was used in
the past for this differentiation, CT with contrast and MRI
now distinguish a primary mediastinal mass from a
cardiovascular lesion. Tru-cut needle biopsy of a
cardiovascular lesion may be associated with significant
hemorrhagic complications. Seminomas rarely produce beta
human chorionic gonadotropin and never produce alpha-
fetoprotein. In contrast, over 90% of the nonseminomas
secrete one or both of these hormones.

57. Which of the following would be the least appropriate in

the management of acute suppurative mediastinitis?
A. Wide dbridement.
B. Irrigation under pressure.
C. Topical antibacterials.
D. Long-term systemic antibacterials.
E. Closure with muscle flaps.
Answer: D

DISCUSSION: Acute suppurative mediastinitis is a classic

wound problem and forms a paradigm for principles of
management. Wide dbridement is perhaps the most important
step in correcting this type of invasive wound sepsis. Drainage
requires removal of tissue with vascular compromise. Tissue
that is infected and can serve as an ongoing nidus for
infection, particularly cartilage, must be removed. Irrigation is
effective only when the irrigation fluid reaches into and
flushes out dbris and bacteria. The irrigation is insufficient if
only dilutional and not also mechanically effective. Since
infected tissue tends to become isolated from the systemic
circulation the direct application of antibacterials reaches
avascular areas. Some, such as silver sulfadiazine, penetrate
avascular tissue better than, for instance, ointments or
povidone iodine, and such an agent should be chosen. Wide
dbridement and the washing of debris with pressure
irrigation make the wound then available to topical
applications, which are often best packed into these deep,
irregular cavities. Long-term systemic antibacterials serve no
purpose and lead to potential resistant bacterial overgrowth.
Although systemic antibacterials provide a measure of
protection up to the margin where vascularized and
nonvascularized tissues meet, topical agents are better in the
actual infected site. Once closed, these wounds rapidly
become sterilized. Even the infection at the bone level is far
different from traditional osteomyelitis, and long-term
systemic therapy is unnecessary. Muscle flaps are a great
advance in closure technique, since they provide bulky
protection, obliterate dead space, and help vascularize the
wound.

58. Each of the following is appropriate for managing acute

suppurative mediastinitis except:
A. Alloplastic material and skin flaps.
B. Rectus abdominis muscle flaps.
C. Omentum.
D. Pectoralis major muscle flaps.
E. Rigid internal fixation.
Answer: A

DISCUSSION: Alloplastic materials may be nonreactive in

the laboratory and biologically acceptable in other areas
(artificial hips, breast prostheses). Their introduction into a
contaminated wound, however, would more likely promote
rather than reduce infection. Various meshes and other types
of protection devices are not necessary. Skin flaps alone do
not obliterate dead space and have not been shown either to
reduce or resist infection. The rectus abdominis muscle is a
superb source of readily available tissue that can be rotated
into very large cavities. The nature of the muscle allows it to
be dressed into irregular cavities. It has an excellent, easily
movable skin territory overlying it, which can also be
transferred if locally available skin is wanting. The omentum
has the great ability to fit into the many irregularities of some
defects. For appropriately selected cases it is excellent. The
pectoralis major muscle flaps are the usual initial choice since
they are in the operative field. When the musculotendinous
insertion is released their mobility is often sufficient.
Additionally, it avoids the need for abdominal incisions. The
latissimus dorsi muscle as a flap is dependable and includes
sternal defects in the scope of its arc of rotation. It requires
rotating the patient on the operating table and thus is less
readily available than the other flaps.

59. Clinical features suggestive of myasthenia gravis include

all of the following except:
A. Proximal muscle weakness.
B. Diplopia.
C. Sensory deficits of the extremities.
D. Dysphagia.
Answer: C
DISCUSSION: Weakness of proximal weight-bearing muscle
groups is the hallmark of the clinical diagnosis of myasthenia
gravis. The weakness or fatigue occurs with repetitive activity
and improves with rest. The majority of patients (90%)
experience ocular muscle involvement, manifested as diplopia
or ptosis most easily demonstrated with sustained upward
gaze. Cranial nerve involvement is uncommon but can be
present, with symptoms of dysphagia, nasal regurgitation, and
aspiration. Since myasthenia gravis is a disorder of
neuromuscular transmission at the motor end plate, deep
tendon reflexes and sensory examination are normal.

60. The diagnosis of myasthenia gravis can be confirmed most

reliably using:
A. Antiacetylcholine receptor antibody titers.
B. The Tensilon test.
C. Electromyography (EMG).
D. Single-fiber EMG.
E. Physical examination.
Answer: D

DISCUSSION: Although findings from a careful history and

physical examination are suggestive of the diagnosis of
myasthenia gravis, specific diagnostic testing is required to
confirm the diagnosis. Elevated antiacetylcholine receptor
antibodies are present in 85% to 90% of patients with
generalized myasthenia but are often negative in patients with
early or ocular myasthenia gravis. The Tensilon test is also
positive in approximately 90% of patients with generalized
myasthenia gravis, but both false-negative and false-positive
results occur, especially in patients with mild or early disease.
Standard EMG studies are helpful if positive, but their overall
sensitivity may be as low as 35%. The specialized technique
of single-fiber EMG is the most reliable diagnostic test, being
abnormal in 90% of patients with mild disease and in virtually
100% in patients with severe generalized myasthenia gravis.

61. All of the following statements are true about the

pathogenesis of myasthenia gravis except:
A. The number of functional acetylcholine receptors at the
motor end plate is reduced.
B. An autoimmune mechanism involving antibodies to the
acetylcholine receptor has been proposed.
C. Complement system involvement has been demonstrated.
D. A nonspecific thymitis may initiate the autoimmune
response.
E. Clinical improvement following thymectomy is correlated
with decreased acetylcholine receptor antibody titers.
Answer: E

DISCUSSION: Myasthenia gravis is generally regarded as an

autoimmune disorder due to antibodies directed toward the
acetylcholine receptor. A variety of autoimmune mechanisms
have been proposed; the ultimate result is a reduction in the
number of functional acetylcholine receptors at the motor end
plate. Proposed immune mechanisms include
complementmediated receptor destruction, antibody-induced
accelerated receptor turnover, and simple receptor blockade.
In spite of these proposed immune mechanisms, the severity
of myasthenia symptoms and improvement following therapy
do not correlate with antibody titers. Although the source of
these autoantibodies is not proven, it is generally felt that a
nonspecific thymitis may trigger the autoantibody response,
the thymic myoid cells serving as the source of the antigen.

62. Which of the following statements about the relationship

of the thymus and myasthenia gravis is/are true?
A. Thymic abnormalities are present in up to 80% of patients
with myasthenia gravis.
B. Thymoma is present in up to 20% of patients with
myasthenia gravis.
C. Myasthenia gravis will occur in up to 60% of patients with
thymomas.
D. Myasthenia patients with thymoma respond more
favorably to thymectomy.
E. Thymoma is the most common abnormality of the thymus
in patients with myasthenia gravis.
Answer: ABC

DISCUSSION: The central role of the thymus gland in the

pathogenesis of myasthenia gravis is based on the observation
that more than 80% of patients have histologic abnormalities
of the thymus and on the beneficial effect of thymectomy on
patients' symptoms. Of the patients with documented
abnormalities of the thymus the majority have B-cell
lymphoid hyperplasia; only 20% have a thymoma.
Conversely, up to 60% of patients with known thymoma will
have or ultimately develop myasthenia gravis. In these
patients, with thymoma and myasthenia gravis, the response
to thymectomy is less favorable than in those without
thymoma.

63. Which of the following statements about the results of

thymectomy for myasthenia gravis are true?
A. Patients with ocular symptoms experience clinical
improvement in 90% of cases.
B. Clinical remission can be expected in 90% of cases.
C. The response rate to thymectomy for patients with
generalized symptoms is 90%.
D. Patients with thymoma experience improvement in 75%.
E. Continued medical therapy is required in 75%.
Answer: C

DISCUSSION: Overall, improvement can be expected in 90%

of patients who undergo thymectomy for generalized
myasthenia gravis. In general, the results are more favorable
in patients with mild generalized myasthenia. In patients with
only ocular symptoms, the benefit following thymectomy is
less clear; improvement is documented in 80%. The response
rate is even less (30%) in patients with thymoma. Complete
remission occurs in 40% to 50% of patients following
thymectomy, and the remainder require some continued
medical therapy.

64. All of the following are true of the treatment of

myasthenia gravis except:
A. The transcervical approach to surgical thymectomy is less
likely to benefit the patient with myasthenia gravis.
B. Corticosteroids result in improvement in 80% of patients.
C. Plasma exchange is associated with improvement in up to
90% of patients.
D. Medical therapy with Mestinon (pyridostigmine) is
associated with remission in approximately 10% of patients.
E. Surgical thymectomy, regardless of the approach, is
associated with improved remission and response rates as
compared with medical therapy.
Answer: A

DISCUSSION: Although Mestinon therapy results in clinical

improvement in most patients, complete remission can be
expected in only 10%. In addition, intolerable side effects may
limit their usefulness. In patients who fail to respond to
Mestinon therapy, and in those who experience significant
side effects, corticosteroids can be utilized, with improvement
expected in 80% of patients. Plasma exchange results in
improvement in 90% of patients, but the cost of therapy and
its transient duration of benefit limit the use of pheresis
therapy to special circumstances such as preoperative
preparation or in myasthenic crisis. Overall, response rates to
surgical thymectomy range from 80% to 95%, and complete
remission occurs in 30% to 50%. This benefit following
thymectomy has not been shown to depend on the particular
technique utilized. Remission and response rates are similar
for transcervical, standard transsternal, and the maximal
thymectomy techniques.

65. Which of the following is/are acceptable alternatives in

the management of malignant pericardial effusion?
A. Pericardiocentesis.
B. Subxiphoid pericardiotomy (pericardial window).
C. Thoracotomy with pericardiectomy.
D. Instillation of tetracycline or bleomycin into the pericardial
space.
E. Treatment of the underlying malignancy.
Answer: ABCDE

DISCUSSION: In patients with symptomatic malignant

pericardial effusions, management options may be designed to
establish a diagnosis, relieve symptoms, or prevent
recurrence. Pericardiocentesis is very successful in removing
fluid for diagnosis and alleviating symptoms; however
recurrence rates are greater than 50%. This rate can be
reduced to around 20% with instillation of sclerosing agents
such as tetracycline or bleomycin. Surgical techniques,
including subxiphoid pericardiotomy and thoracotomy with
pericardiectomy, offer the highest success rates
(approximately 90%) but are more invasive and usually
require general anesthesia. Systemic antitumor therapy with
chemotherapy or radiation therapy can be effective in
controlling malignant effusions in cases of sensitive tumors
such as lymphomas, leukemias, and breast cancer.

66. Which of the following statements about cardiac

tamponade is/are correct?
A. At least 500 ml. of fluid must be present in the pericardium
of an adult to cause symptoms of tamponade.
B. A drop in systemic blood pressure of greater than 20 mm.
Hg during inspiration (pulsus paradoxus) is a finding specific
to cardiac tamponade.
C. The vast majority of patients with cardiac tamponade
demonstrate a low QRS voltage, nonspecific ST T-wave
abnormalities, and electrical alternans (alternation of QRS
amplitude) on the electrocardiogram.
D. In trauma victims with cardiac tamponade, the three
components of Beck's triad (hypotension, elevated jugular
venous pressure (JVP), and muffled heart sounds) are almost
always present.
E. When the diagnosis is made, treatment must be instituted
rapidly and may include pericardiocentesis, creation of a
pericardial window, and identification and treatment of the
underlying cause.
Answer: E

DISCUSSION: Development of tamponade symptoms

depends on the rate of accumulation of fluid. As little as 100
to 200 ml. accumulating rapidly may cause symptoms,
whereas a slowly developing pericardial effusion of over 1
liter may remain asymptomatic. Pulsus paradoxus is not
specific for tamponade; it may occur in patients with severe
congestive heart failure, chronic obstructive pulmonary
disease, hypovolemia, acute pulmonary embolism, or shock.
Electrocardiographic findings of low QRS voltage and
nonspecific ST T-wave changes are common in this condition,
but electrical alternans, often considered pathognomonic of
cardiac tamponade, is present in only a small number of
patients. Trauma victims with tamponade frequently lack one
or more of the elements of Beck's triad; for example,
associated hypovolemia may lead to low or normal jugular
venous distention. Since cardiac tamponade is life threatening,
therapy designed to drain the pericardial fluid must be
provided quickly and the underlying cause must be
established and controlled.

67. Which of the following statements about constrictive

pericarditis is/are correct?
A. Most patients who develop constrictive pericarditis after
cardiac operation present with symptoms within 6 months of
the procedure.
B. Results of pericardiectomy for constrictive pericarditis are
worse in patients who develop constriction after mediastinal
irradiation.
C. Drainage of asymptomatic pericardial effusions arising
from acute pericarditis is advised to prevent development of
constrictive pericarditis.
D. If surgical treatment is planned for constrictive pericarditis
it should involve total or complete pericardiectomy.
E. Echocardiography can usually make the diagnosis by
imaging a thickened pericardium.
Answer: BD

DISCUSSION: The time course in the development of

constrictive pericarditis after cardiac surgery ranges from 1
month to nearly 9 years, but the mean interval from surgery to
presentation is about 23 months. Most series have reported
poorer outcomes from pericardiectomy for postirradiation
constrictive pericarditis, possibly owing to underlying
myocardial fibrosis. In this subset, 5-year survival averages
50%, as compared with 75% for constrictive pericarditis of all
causes. Constrictive pericarditis is a rare complication of
acute pericarditis. As a result, drainage of asymptomatic
(nonpurulent) pericardial effusions from acute pericarditis is
not required. Patients with significant symptoms from
constrictive pericarditis should undergo total pericardiectomy,
even though this procedure carries an operative mortality rate
of approximately 10%. Limited pericardiectomy has proven to
be ineffective for this condition. It can be difficult to
distinguish constrictive pericarditis from restrictive
cardiomyopathy. Echocardiography may help by
demonstrating chamber dimensions and wall motion
abnormalities, but CT and MRI more accurately assess
pericardial thickness.

68. The relationship between small-cell and non-small cell

lung cancers can be described by the following:

a. They differ by histology, clinical behavior and cell of origin

b. Of all lung cancers, approximately 80% are non-small cell
and 20% are small cell
c. Both cell types are predictably responsive to chemotherapy
d. The International Staging System can be applied to both
tumor types
e. The majority of non-small cell cancer patients vs. the
minority of small cell cancer patients are candidates for
pulmonary resection
Answer: b
Although small cell and non-small cell lung cancers do differ
by histology and clinical behavior, they probably have a
common origin since c-myc or n-myc amplified small cell
lung cancer lines will undergo transition to non-small cell
phenotypes after insertion of an activated ras/gene. The
overall incidence of lung cancers is 80% non-small cell and
20% small cell. Only the small cell carcinoma is predictably
responsive to chemotherapy.
The staging system for small cell lung cancer is based on
limited vs. extensive disease outside of a tolerable
radiotherapy portal while the International Staging System
uses TNM descriptors for 4 clinical stages. Unfortunately,
only about 30% of patients with non-small cell lung cancer
have potentially resectable tumors.

69. A 62-year-old male smoker presents with right anterior

chest pain. There is a 3 cm mass attached to the chest wall
with radiographic evidence of rib erosion and positive
cytology for non-small cell carcinoma. Which of the follow
is/are true:

a. The patient is inoperable due to tumor size and chest wall

involvement
b. Radiation therapy is the preferred initial treatment
c. Operative resection should be performed with en bloc
removal of the tumor and adjacent chest wall as well as a
mediastinal lymph node resection
d. Positive mediastinal nodes will have little effect on survival
e. The patient would be classified Stage IIIa
Answer: c, e
Survival after resection for non-small cell lung cancer is
related to the stage of the disease with a strong adverse effect
from nodal involvement. This is true even for large peripheral
tumors that extend into the chest wall as in this case where a
4050% survival would be expected in the absence of nodes
(T3N0:Stage IIIa) but only a 15% survival with nodal
involvement. Radiation therapy would be a postoperative
consideration to reduce the incidence of local recurrence. En
bloc operative resection of the involved lobe and mediastinal
nodes for staging would offer the greatest likelihood of cure.

70. For the patient in the pervious question to become an

operative candidate which of the following must be met?

a. Extrathoracic metastases must be able to be controlled by

another modality, e.g. radiotherapy
b. Tumor doubling time must exceed 40 days
c. If there is recurrence at the primary site, it must be treated
before the metastatic disease
d. Even if effective systemic therapy is available, resection of
metastases is preferred
e. If pulmonary reserve is marginal, resection of the maximal
number of metastatic foci should be performed
Answer: c

There are a number of controversial areas in the area of

operative approaches to metastatic disease in the lung, but
there is general agreement that any extrathoracic metastases
preclude eligibility for pulmonary resection. Although tumor
doubling time is a measure of its aggressiveness, it is too
variable to have prognostic significance and is generally
disregarded as a criterion for resection. Primary site
recurrence must be treated before the metastatic focus to
prevent further seeding. If effective systemic therapy is
available as would be expected in breast and testicular cancer
or osteogenic sarcoma, it is preferred over surgical resection.
Similarly, pulmonary resection should not be undertaken
unless the pulmonary reserve will allow all metastatic foci to
be resected.

71. Biopsy of the lesion in the previous question is reported as

bronchial carcinoid with no signs of atypia. Which of the
follow is/are true?

a. Sleeve resection of the bronchus would be appropriate

b. Lymph node biopsy at time of resection is unnecessary
c. Associated carcinoid syndrome is very unlikely
d. If carcinoid syndrome were found in a tumor this size,
hepatic metastases would be likely
e. When bronchial carcinoid syndrome occurs, right-sided
cardiac valves are affected
Answer: a, c, d

In the absence of atypia, carcinoids are only locally malignant

and can be managed by limited lung and/or bronchial
resection. Therefore, a sleeve resection of the bronchus
preserving distal lung would be appropriate. Lymph node
sampling at the time of resection, however, is advisable to
ensure that a complete resection has been performed. The
carcinoid syndrome is rarely found except in the presence of a
large primary tumor or hepatic metastases. When the
carcinoid syndrome does occur, it is left-sided cardiac valves
that are affected rather than right, which one would expect
with gastrointestinalcarcinoids.

72. In the evaluation and preparation of a 55-year-old smoker

for resection of a 3 cm pulmonary adenocarcinoma, the
following is/are true:

a. Preoperative cessation of smoking does not reduce

postoperative pulmonary complications
b. Resting PaCO2 is of more value than PaO2
c. FEV1 is of more value than measured vital capacity
d. Diffusion capacity should be measured routinely
e. V/Q lung scan is useful when pulmonary reserve is
marginal
Answer: b, c, e

Preoperative cessation of smoking for a period of 2 weeks can

reduce pulmonary complications and should be required. In
the preoperative assessment for pulmonary resection, the
PaCO2 is of more value than the PaO2 since an elevated
PaCO2 > 50 mmHg identifies the very high risk patient with
chronic lung disease. Hypoxemia may be secondary to the
mechanical effects of the tumor producing
ventilation/perfusion mismatch. The latter can be confirmed
by V/Q lung scan which also serves to identify areas of
functioning lung in patients with marginal pulmonary
function. The best screening test for adequacy of pulmonary
reserve is the FEV1. It identifies obstructive pulmonary
disease which is more important than the restrictive lung
disease identified by vital capacity measurement. Diffusion
capacity measurement provides little additional information of
value.

73. Following resection of a T1N1 squamous cell cancer in a

47-year-old male, the following is/are true:

a. There is a higher risk of local recurrence than with any

other histologic type of non-small cell cancer
b. The greatest risk to the patient is a distant metastasis
c. Of all metastatic sites, liver is most likely
d. If the patient survives five years, there is a greater risk of a
new lung cancer than recurrence
e. To improve survival, the patient should be considered for
adjuvant chemotherapy
Answer: a, b, d

The risk of local recurrence for non-small cell carcinomas of

the lung is much more common for those of squamous cell
histology than the others and averages 20%30% overall. The
greatest risk, however is of distant metastases which occur in
70%80% of patients, regardless of stage. Almost all
recurrences are seen within five years, and of the distant
metastatic sites, the brain is most commonly affected. In this
patient with Stage II disease, radiation therapy would be a
consideration to reduce the incidence of local recurrence, but
not chemotherapy. After five years, the highest risk would be
from a new lung cancer rather than a recurrence.

74. A 42-year-old woman with hemoptysis is seen to have a 2

cm mulberry appearing polypoid lesion in the left mainstem
bronchus suspicious for bronchial adenoma. The differential
diagnosis includes which of the following:

a. Mucoepidermoid carcinoma
b. Plasma cell granuloma
c. Carcinoid tumor
d. Adenoid cystic carcinoma
e. Mucous gland adenoma
Answer: all of the above

The term bronchial adenoma includes a spectrum of tumors

arising from epithelial stem cells which vary from the benign
mucous gland adenoma to the malignant adenoid cystic and
mucoepidermoid carcinomas as well as the carcinoid tumors
of similar varied behavior. Among these variants, the
carcinoid are most common representing 80%90% of all
bronchial adenomas.
75. A 42-year-old man has a solitary coin lesion 2 cm in
diameter in the area of the right upper lobe on a routine chest
radiograph. Which of the following is/are true?

a. A previous radiograph from five years prior showing the

lesion to be 1.2 cm in diameter indicates malignancy
b. If a CT scan shows mediastinal adenopathy,
mediastinoscopy is preferable to thoracotomy
c. In the absence of previous radiographs, the lesion should be
followed by serial films at 6 month intervals
d. Calcification in a concentric or popcorn configuration
denotes a benign lesion
e. Needle aspiration showing chronic inflammatory cells
denotes a benign lesion
Answer: b, d

In the evaluation of a solitary lung lesion, previous

radiographs are important, particularly if the lesion is new. A
coin lesion that is growing slowly does not necessarily
indicate malignancy, since the most common benign tumor,
hamartoma, has a variable pattern of slow growth and
typically will show popcorn calcification. Concentric
calcification is also most suggestive of a benign granuloma. In
the absence of previous radiographs, the lesion must be
assumed to be malignant until proved otherwise and should
not be dismissed to follow-up. If a CT scan shows mediastinal
adenopathy, then mediastinoscopy with biopsy is appropriate
to make a diagnosis. Needle aspiration results of chronic
inflammatory cells is non-diagnostic.
76. A 2 cm peripheral squamous cell carcinoma in the lung of
a 60-year-old male with a pleural effusion positive for
malignant cells would be classified as:

a. T1N0M1
b. T3N0M0
c. T3N0M1
d. T4N0M0
e. T4N0M1
Answer: d, e

The presence of a pleural effusion in association with a

primary lung cancer is usually an ominous sign precluding
surgical resection. However, if more than one sample of the
effusion is negative for malignant cells and it is non-bloody, it
can be considered unrelated to the tumor and excluded as a
staging element. When the effusion cytology is positive, the
tumor is considered T4 regardless of size or nodal status.

77. A 53-year-old woman who had a malignant tumor

removed 2 years ago presents with a solitary lung nodule 1.5
cm in diameter. The following is/are true:

a. If the primary tumor originated in the breast, the lesion is

most likely to represent a new primary lung cancer.
b. If the primary tumor was melanoma, the lesion is most
likely to be metastatic
c. If the remainder of the lung fields are clear, a CT scan is
unnecessary
d. If the primary tumor was in the GI tract, there is very little
chance that the lesion is a new primary lung cancer
e. Fine needle aspiration should always be performed prior to
resection of the lung lesion
Answer: a, b

A new pulmonary lesion in a patient with a history of a

previously treated malignancy poses a diagnostic and
therapeutic challenge. A CT scan should always be obtained
since plain radiographs can detect lesions only 9 mm in
diameter or greater. The lesion is most likely to be metastatic
if the prior malignancy was sarcoma or melanoma and most
likely to be a new primary lung cancer if the prior malignancy
originated in the head, neck or breast. When the original
lesion was in the GI or GU tract, there is an equal chance that
it is metastatic or a new primary. Fine needle aspiration does
not usually alter the plan for excision and is done only when
the patient is not an operative candidate or desires to know the
diagnosis.

78. A 61-year-old male presents with a painful mass 3.5 cm in

diameter below the clavicle and attached to the chest wall.
The following is/are true:

a. A CT scan is the best study to determine rib destruction

b. The lesion should be removed enbloc without biopsy to
minimize the chances for local recurrence
c. The chances are approximately 40% that the lesion is
metastatic
d. If it is metastatic, the most likely primary tumor is in the
lung or pancreas
e. Fortunately, less than 50% of chest wall tumors are
malignant
Answer: c

Chest wall tumors are uncommon, accounting for only 12%

of all body tumors. About 57% of chest wall tumors are
primary, whereas 43% are metastatic. Solitary metastases
most frequently arise from the thyroid gland, the GU tract and
the colon. Overall, about 60% of chest wall tumors are
malignant, most arising form bone or cartilage. The CT scan is
of value in demonstrating the relationship between the mass
and contiguous structures, but of little value in determining
bone destruction because of the oblique course of the ribs.
Specific rib films are most helpful. Now that multimodality
therapy is available, core needle biopsies are recommended
and have not increased the incidence of local recurrence.

79. Concerning the sternum, the following is/are true:

a. The xiphoid process is the anterior border of the thoracic

outlet
b. Gladiolus is the body of the sternum
c. The angle of Louis is at the level of the 2nd costal cartilage
d. The 11th rib is attached via costal cartilage to the xiphoid
e. The sterno-manubrial junction is at the level of T4
posteriorly
Answer: a, b, c, e

The sternum consists of 3 segments, the upper manubrium,

the body or gladiolus, and the xiphoid process which ends in
the rectus sheath and has no costal attachments. The xiphoid
marks the anterior border of the thoracic outlet. The junction
of the manibrium and body is the sternal angle or angle of
Louis which corresponds to the level of T4 posteriorly and
attaches to the 2nd costal cartilage anteriorly.

80. A 22-year-old woman recovering from a traumatic head

injury is noted to have bright red bleeding when her
tracheostomy is suctioned. The following is/are true
statement(s):

a. Antibiotics should be administered to treat the bronchitis

b. Deflation of the tracheal tube cuff is a useful diagnostic
maneuver
c. If massive bleeding occurs, a finger should be used to
compress the innominate artery against the sternum
d. Operative treatment of a tracheoinnominate fistula includes
resection and prosthetic replacement of the innominate artery
e. Tracheal resection is usually required for a
tracheoinnominate fistula to prevent recurrence
Answer: b, c
The complication of tracheoinnominate artery fistula
characteristically occurs in young women and is often
heralded by bleeding during the tracheostomy suctioning.
Deflation of the tracheal tube cuff confirms the diagnosis if
massive bleeding occurs. At that point the tracheal tube cuff
should be overinflated and a finger inserted into the
tracheostomy incision to tamponade the bleeding. Throughout
this, the airway must be protected. Operative repair through
an upper sternal split requires resection of the innominate and
coverage of the oversewn vessels with viable tissue since the
wound is contaminated. No prosthetic material should be
inserted and tracheal resection is not necessary.

81. A 52-year-old alcoholic with fever and a cough productive

of purulent sputum is found to have the opacity on chest film
as shown (Fig. 62-15). The following is/are true statement(s):

a. The findings suggest a parapneumonic empyema

b. If pus is found on aspiration of the pleural space, a chest
tube should be placed
c. If pus is found on aspiration, bronchoscopy is a necessary
part of the patients evaluation
d. In this situation, rib resection for drainage is preferred to a
large-bore chest tube
e. Decortication of the lung should be considered if the lung
fails to expand within 4 weeks
Answer: a, b, c
The posterior location of the infiltrate and fluid collection is
typical of a parapneumonic empyema. The most important test
is pleural aspiration which will usually yield frank pus, at
which time a chest tube should be placed. Formerly, oily
Dionosil was used to perform an empyemagram; this
substance is now no longer commercially available. In the
case of parapneumonic empyemas, tube drainage alone may
be sufficient to allow full expansion of the lung. If this is not
the case, a formal rib resection or early decortication should
be performed. Decortication or marsupialization is indicated if
the lungs fail to expand after 68 weeks. Every patient with
spontaneous empyema should undergo bronchoscopy to rule
out endobronchial obstruction by foreign body or tumor.

82. The lesion shown (Fig. 62-6) was found on a 32-year-old

male on a routine chest film required for his employment.
Which of the following is/are true?

a. The stippled calcification and intact cortex of the rib are

characteristic of osteochondroma
b. The stippled calcification is characteristic of osteogenic
sarcoma
c. If the lesion is osteogenic sarcoma, the optimal treatment is
resection and radiation therapy
d. If the lesion is an osteochondroma, it need not be resected
in this age group
e. The radiographic picture is typical for Ewing sarcoma
Answer: a
Osteochondroma is the most common benign rib tumor and
has a 3:1 male incidence. The stippled calcification and intact
rib cortex are characteristic for this lesion in contrast to the
bone destruction of Ewing sarcoma and combined bone
destruction and sunburst calcification of osteogenic
sarcoma. For both Ewing and osteogenic sarcoma,
multimodality therapy using preoperative chemotherapy
followed by resection yields better results than with radiation
therapy. Osteochondromas in prepubertal children can be
observed unless they become painful or enlarged, but are
routinely resected in adults.

83. To resect a chondrosarcoma of the chest wall in a 42-year-

old man, ribs 24 were removed, leaving a defect 8 x 8 cm.
For reconstruction, the following is/are true:

a. If this were to be posterior, beneath the scapula,

reconstruction would not be required
b. If this defect is anterior, the primary benefit of
reconstruction is an improved cosmetic result
c. Whenever chest wall reconstruction is considered, it should
be delayed 612 months to allow detection of recurrent tumor
d. If Marlex is used for reconstruction, no wound drainage
tube is necessary
e. If PTFE is used for reconstruction, both pleural and wound
tubes should be used
Answer: a, d, e

Skeletal chest wall defects that are full-thickness and occur

posteriorly where they can be covered by the scapula do not
require reconstruction. Anterior chest wall defects do require
reconstruction, primarily to stabilize the chest wall and
prevent paradoxical motion. The reconstruction should be
immediate for optimal physiological benefit. Since Marlex
mesh is porous, only a wound catheter is needed as pleural
fluid will drain through it. PTFE, however, is a solid sheet
necessitating both pleural and wound drainage.

84. An upright chest film of a cachectic, homeless 47-year-old

woman shows blunting of the right costophrenic angle. The
following is/are true:

a. A lateral decubitus film should be obtained to confirm the

presence of fluid rather than a CT scan
b. Tuberculous effusion can readily be identified by stain and
culture of aspirated fluid
c. A pleural fluid glucose level lower than in the serum is
diagnostic of empyema
d. Bloody pleural effusion in this patient is diagnostic of an
underlying malignancy
e. Pleural fluid cytology report of lumphoma should be
viewed with skepticism
Answer: a, e

Although the CT scan is a very sensitive indicator of pleural

effusion, a lateral decubitus is the simplest way to differentiate
fluid from pleural thickening or fibrosis. Tuberculous pleuritis
is difficult to diagnose by stain or culture which have a 30%
yield, but the diagnosis is facilitated by needle biopsy of the
pleura. Pleural fluid glucose lower than in serum is
characteristic of rheumatoid arthritis, neoplasms, and
tuberculosis as well as empyema. A red-tinged fluid can occur
from needle trauma, but even frankly bloody fluid in this
patient may reflect trauma as well as underlying malignancy.
Pleural inflammation induces reactive changes in mesothelial
cells that makes them resemble lymphocytes, so a lymphoma
diagnosis is suspect.

Following shotgun wound of the chest wall, a 39-year-old

woman desires reconstruction without a foreign-body
prosthesis. Old incisions prohibit use of her rectus abdominus
muscles. Considering chest wall muscles for reconstruction,
the following is/are true statement(s):

85. The pectoralis major muscle is available and innervated by

the medial and lateral pectoral nerves so named because it
describes their relationship to the pectoralis minor
a. The serratus anterior muscle is available since its absence
has no functional significance
b. There is no serratus posterior muscle
c. The latissimus dorsi muscle is available and supplied by the
thoracodorsal artery
d. The latissimus dorsi is innervated by the thoracodorsal
nerve with fibers from C6, C7 and C8
Answer: d, e

The pectoralis major muscle can be used for reconstruction

but the medial and lateral pectoral nerves are named from
their respective cords of the brachial plexus. The serratus
anterior muscle holds the scapula to the chest wall and its
absence produces the functional and cosmetically disabling
winged scapula. The serratus posterior muscle is attached to
the 7th cervical and first three thoracic vertebrae posteriorly
and functions as an accessory muscle of respiration. The
constancy of the vascular pedicle to the latissimus dorsi and
its size allow this muscle to be used to reconstruct defects of
the head, neck, chest wall and pleural cavity. It is innervated
by the thoracodorsal nerve with fibers from C6, C7 and C8.

86. A 38-year-old man presents with facial and upper

extremity edema, venous distention in the neck and arms and
a cyanotic appearance. The following is/are true statement(s):

a. The most likely cause of the problem is mediastinal

granulomatous disease
b. A venogram should be obtained to confirm the diagnosis
c. Mediastinoscopy for diagnosis is contraindicated
d. If a malignancy is identified, resection is indicated for
palliation
e. If the etiology is benign disease, gradual improvement
without operation is to be expected
Answer: e

Although mediastinal granulomatous disease is one cause of

the superior vena cava syndrome described, the most common
cause (75%) is malignant disease. A venogram adds little
information to the typical findings and increases risk from
extravasation of contrast medium subcutaneously from the
venous hypertension. Mediastinoscopy can be used for
diagnosis with recognition of increased risk of bleeding and
airway problems from the edema associated with the
endotracheal intubation required for the procedure. If a
malignancy is found, operative resection is usually precluded
by the extent of mediastinal invasion. Fortunately, in the case
of benign disease, the symptoms tend to improve with time as
chest wall and mediastinal collaterals enlarge.

87. A 39-year-old woman with hypertension and radicular

chest wall pain was found to have the lesion seen on chest
radiograph (Fig. 63-23). The following is/are true
statement(s):

a. The location of the lesion suggests a teratoma

b. High urinary vanillylmandelic acid levels would indicate
that the lesion is a paraganglioma
c. If the lesion was seen on a film 5 years earlier, resection
would not be indicated
d. A neurosurgical consultation should be obtained
e. Vasoactive intestinal polypeptide level elevation suggests a
ganglioneuroma
Answer: d, e

The posterior mediastinal location of the tumor is most

indicative of a neurogenic tumor while teratomas are
characteristically found in the anterior mediastinum.
Neurogenic tumors can undergo malignant degeneration and
should be resected, particularly in this symptomatic patient
even if known to be present for years. The radicular pain
suggests the possibility of intraspinous extension of the tumor,
and therefore a neurosurgical consultation is appropriate. Both
urinary vanillylmandelic acid elevation and vasoactive
intestinal polypeptide can be produced by ganglioneuroma but
would not be characteristic of a paraganglioma.