I. Preface.
Surgical treatment is one of the oldest and most important tools in the treatment of lung cancer, and it is also the preferred and most effective treatment for early-stage lung cancer. Since Graham successfully performed total lung resection for a patient with central lung cancer in 1933, surgical treatment of lung cancer has a history of nearly 70 years. Surgical treatment of lung cancer has successfully passed the stage of improving resection rates, reducing operative mortality and decreasing the incidence of postoperative complications. At present, the surgical treatment techniques for lung cancer have been perfected, and the surgical procedure has been changed several times, and now it has been basically settled, that is, the standard procedure is anatomical lobectomy + regional lymph node system resection; palliative or incomplete resection should be avoided as much as possible; for lung cancer invading adjacent organs and structures, the lung should be resected together with the whole invaded tissues and organs, even including the resection and reconstruction of part of heart and large blood vessels. In the past 20 years, lung cancer surgical treatment has progressed rapidly with outstanding achievements, which is marked by the recognition of the limitations of surgery in lung cancer treatment, and the view that surgical treatment alone has become obsolete has been widely recognized by surgeons, who have started to combine the multidisciplinary and comprehensive treatment of lung cancer mainly with surgery and achieved good results.
Surgical treatment of lung cancer is determined by the clinical stage and histological examination of lung cancer. As a means of local treatment, surgery can play the most effective role only when the lung cancer is still in the local area and has not spread. The most suitable lung cancers for surgery are stage I and II NSCLC, and some stage IIIA lung cancers, if the invaded local area can be completely removed, can also achieve good therapeutic effect. Therefore, once you have lung cancer, you should not rush to blindly undergo surgery. You should make a correct clinical staging through consultation with experts of the Joint Lung Cancer Treatment Center, so as to formulate a scientific and reasonable standardized treatment plan, so that those lung cancer patients who have distant metastases and should not undergo surgery can avoid the pain of open-heart surgery, and those lung cancer patients who do not have metastases can receive timely and scientific surgical treatment.
II. Indications and contraindications.
Following the new AJCC 2007 clinical staging and the new surgical thinking formulated by the 2007 Chinese Cancer Clinical Guidelines, it is now recognized that stage I, II and IIIa low-volume tumors are suitable for surgical treatment, and stage IIIa high-volume and IIIb tumors need to be treated by adjuvant therapy to lower the stage before surgical treatment. The details are summarized as follows.
1.Stage Ⅰ and Ⅱ non-small cell lung cancer.
2.Partly selected stage III non-small cell lung cancer, the lesion is limited to the ipsilateral thoracic cavity and can be radically resected, or the lesion invades the chest wall, pericardium, and large blood vessels, but the scope is limited and technically can be resected.
3.Lung cancer is highly suspected clinically or the possibility of lung cancer cannot be excluded, but the diagnosis cannot be confirmed by various examinations and it is estimated that the lesion can be resected.
4.Stage III lung cancer without surgical indication, after chemotherapy or radiotherapy, the lesion is obviously reduced and the systemic condition allows, surgery can be considered.
5.Stage I and II small cell lung cancer, after 1 to 2 cycles of systemic chemotherapy, can be treated surgically.
6.Patients with advanced lung cancer have uncontrollable intrapulmonary infection or pulmonary atelectasis, which affects the gas exchange function of the lung, and palliative surgery can be performed to alleviate the symptoms.
On the contrary, after the diagnosis of lung cancer, the following conditions should be considered as contraindications to surgery.
1.Tumor invades surrounding organs and tissues, such as heart and large blood vessels, which cannot be radically removed, or malignant pleural fluid appears.
2.Metastasis to the contralateral lung hilum, mediastinum and supraclavicular lymph nodes.
3.Distant metastasis to liver, brain, bone, adrenal gland, contralateral lung, etc.
4.The systemic condition is difficult to tolerate the surgery, including: severe heart and lung dysfunction, recent cerebrovascular accident, extremely debilitating hyperemia, etc.
Preparation before lung cancer surgery.
Once a lung cancer patient is confirmed to be eligible for surgery through lung cancer diagnosis and staging examination, the attending physician will formulate a series of preoperative clinical examinations related to lung resection.
The first step is to take a detailed medical history and learn about the general health status, any history of drug allergy and previous surgery. Upon admission to the hospital, a series of tests of vital organ functions will be performed, including: blood, urine and fecal routine, electrolytes, liver and kidney function, ECG, pulmonary function, CT of the chest and upper abdomen, MRI of the head, fiberoptic bronchoscopy, necessary pathology (sputum smear, tissue biopsy), isotope bone scan, mediastinoscopy and PET-CT if necessary.
The surgical focus is on pulmonary function and cardiac function tests. Pulmonary function tests are used to confirm whether the remaining lungs can be compensated. Pulmonary function measurements are commonly used clinically for spirometry (VC), maximum ventilation volume (MVV), and expiratory volume in the first second (FEV1). First second expiratory volume as a percentage of expiratory lung volume (FEV1%). It is generally accepted that when VC as a percentage of expected value (VC%) is ≤50%, MVV as a percentage of expected value (MVV%) is ≤50%, FEV1 or FEV1%