Question 21#

The primary site for male patients with malignant pleural effusions is:

A. Gastrointestinal tract

Malignant pleural effusions may occur in association with a number of different malignancies, most commonly lung cancer, breast cancer, and lymphomas, depending on the patient's age and gender (Tables below).

Primary organ site or neoplasm type in male patients with malignant pleural effusions:

Primary organ site or neoplasm type in female patients with malignant pleural effusions:

Question 22#

Eosinophilic granulomas are associated with:

A. Langerhans cell histiocytosis (LCH)

Eosinophilic granulomas are benign osteolytic lesions. Eosinophilic granulomas of the ribs can occur as solitary lesions or as part of a more generalized disease process of the lymphoreticular system termed Langer hans cell histiocytosis (LCH). In LCH, the involved tissue is infiltrated with large numbers of histiocytes (similar to Langerhans cells seen in skin and other epithelia), which are often organized as granulomas. The cause is unknown. Of all LCH bone lesions, 79% are solitary eosinophilic granulomas, 7% involve multiple eosinophilic granulomas, and 14% belong to other forms of more systemic LCH. Isolated single eosinophilic granulomas can occur in the ribs or skull, pelvis, mandible, humerus, and other sites. They are diagnosed primarily in children between the ages of 5 and 15 years. Because of the associated pain and tenderness, they may be confused with Ewing sarcoma or with an inflammatory process such as osteomyelitis. Healing may occur spontaneously, but the typical treatment is limited surgical resection with a 2-cm margin.

Question 23#

A chylothorax is likely to be present in a patient whose pleural fluid analysis results show a triglyceride level of::

A. 80 mg/100 mL

Laboratory analysis of the pleural fluid shows a high lymphocyte count and high triglyceride levels. If the triglyceride level is greater than 1 10 mg/100 mL, a chylothorax is almost certainly present (a 99% accuracy rate). If the triglyceride level is less than 50 mg/mL, there is only a 5% chance of chylothorax. 

Question 24#

Osteosarcoma of the rib:

A. Is considered non-operable if pulmonary metastases are present

While osteosarcomas are the most common bone malignancy, they represent only 10 to 15% of all malignant chest wall tumors. They primarily occur in young adults as rapidly enlarging, painful masses; however, osteosarcomas can occur in older patients as well, sometimes in association with previous radiation, Paget disease, or chemotherapy. Radiographically, the typical appearance consists of spicules of new periosteal bone formation producing a sunburst appearance. Osteosarcomas have a propensity to spread to the lungs, and up to one-third of patients present with metastatic disease. Osteosarcomas are potentially sensitive to chemotherapy. Currently, preoperative chemotherapy is common. After chemotherapy, complete resection is performed with wide ( 4-cm) margins, followed by reconstruction. In patients presenting with lung metastases that are potentially amenable to surgical resection, induction chemotherapy may be given, followed by surgical resection of the primary tumor and of the pulmonary metastases. Following surgical treatment of known disease, additional maintenance chemotherapy is usually recommended.

Question 25#

Excisional biopsy of a chest wall mass is allowed if:

A. Needle biopsy was nondiagnostic

1. Needle biopsy: Pathologists experienced with sarcomas can accurately diagnose approximately 90% of patients using FNA cytology. A needle biopsy (FNA or core) has the advantage of avoiding wound and body cavity contamination (a potential complication with an incisional biopsy).
2. Incisional biopsy: If a needle biopsy is nondiagnostic, an incisional biopsy may be performed, with caveats. First, the skin incision must be placed directly over the mass and oriented to allow subsequent scar excision; skin flaps and drains should be avoided. However, if the surgeon believes a hematoma is likely to develop, a drain is useful for limiting soft tissue contamination by tumor cells. At the time of definitive surgical resection, the en bloc resection includes the biopsy scar and the drain tract along with the tumor.
3. Excisional biopsy: Any lesion less than 2.0 cm can be excised as long as the resulting wound is small enough to close primarily. Otherwise, excisional biopsy is performed only when the initial diagnosis (based on radiographic evaluation) indicates that the lesion is benign or when the lesion has the classic appearance of a chondrosarcoma (in which case, definitive surgical resection can be undertaken).