Thoracic Surgery – Pulmonary, Pleural, Chest Wall and Diaphragm
This domain tests operative selection and staging for lung, pleural, chest-wall and diaphragmatic disease. The exam favours anatomic reasoning: what is resectable, what is benign, and what must be staged before incision.
Core rules
- A solitary pulmonary nodule needs risk assessment, prior imaging and PET-CT or biopsy when malignancy is plausible; do not resect undiagnosed low-risk lesions blindly.
- Lung cancer resection follows oncologic principles: complete resection, negative margins and systematic nodal sampling; sublobar resection is selected for limited reserve or small peripheral lesions in selected patients.
- Pleural effusion requires transudate/exudate classification and pleural fluid analysis; empyema is drained and may need decortication.
- Chest-wall tumors require en-bloc resection with reconstruction; diaphragm rupture is repaired after stabilization.
Worked example
A 58-year-old smoker has a 2.2 cm spiculated upper-lobe nodule and no mediastinal nodes on CT. PET shows uptake. The correct sequence is staging, multidisciplinary review and anatomic resection with nodal dissection if fit. A wedge biopsy alone is inadequate oncologic treatment for a fit patient with proven or highly suspected cancer.
Traps
Do not call a pleural effusion malignant without cytology or biopsy; do not perform limited resection for a fit patient with adequate reserve without oncologic justification; do not forget nodal staging; do not repair a diaphragmatic rupture before treating associated instability.