Thoracoscopic lung segmental resection for early stage small lung cancer “Lung cancer” is now recognized as the “king of cancers” in the world. Why are more and more people around us suffering from cancer? What should we do if we are unfortunate to have cancer? When can we stop talking about cancer …… The First Hospital of Hebei Medical University, Department of Thoracic Surgery, Ren Yingchun Here are some news: January 10, 2013, Beijing Times: According to the 2012 China Tumor Registry Annual Report released by the National Tumor Registry, 6 people are diagnosed with cancer every minute, and the incidence of lung cancer is the first. May 31, 2012 International Online News: On the eve of World No Tobacco Day, China’s Ministry of Health released its first report on the health hazards of tobacco. The report shows that China has 300 million smokers and 740 million nonsmokers suffer from secondhand smoke, and more than a million people die each year from smoking-related diseases. 2012-2013 winter and spring seasons, China’s widespread hazy weather, PM2.5 has become a new term familiar to the Chinese people, China’s leading respiratory disease expert Zhong Nanshan pointed out that hazy weather directly leads to lung cancer. 2012-10-16 seekmedicine.com: Recently, the China Lung Cancer Prevention and Control Alliance screened 1200 people over 40 years old, who smoke 400 cigarettes per year and have nodules in their lungs for tumor markers, and the final results will be promoted for early diagnosis of lung cancer. China’s 12th Five-Year Plan emphasizes the importance of improving hospital access and testing standards, and the demand for diagnostic testing in China is expected to increase significantly over the next five years. Due to the global trend of aging population and the increasing prevalence of cancer-causing behaviors, lung cancer has become the most common cancer among men, and the mortality rate of lung cancer among women in developing countries has reached a level similar to that of cervical cancer. With the accelerated industrialization, frequent pollution incidents and tobacco exposure, the incidence of lung cancer has increased rapidly in China’s cities and towns. Even in developed countries in Europe and the United States, only 20-30% of lung cancer patients have the chance to be removed surgically, and 70-80% are already in the advanced stage of cancer when they are diagnosed, with a five-year survival rate of only about 15%. In order to deal with this number one killer of human beings, developed countries have actively adopted screening for people at high risk of lung cancer (over 40 years old, 400 cigarettes per year, nodules in the lungs, previous history of tumors, family lung cancer, close exposure to asbestos, helium and other occupations), which has statistically reduced lung cancer death rates by about 20%. As seen in the fourth news above, our government’s knowledgeable people recognize that only early detection, diagnosis and treatment can fundamentally improve the plight of lung cancer treatment. Let us look at two cases: Patient 1, male, 76 years old, had recurrent chest tightness for nearly two months, and a small nodule of 1.0×0.5 cm in the posterior segment of his left upper lung tip was shown on spiral thin-layer CT, and the imaging features were very consistent with the manifestation of lung cancer. Due to years of suffering from chronic emphysema, severe smoking and poor pulmonary function, he could not tolerate general lobectomy surgery, which caused a big problem to the clinical surgeon. After active multidisciplinary consultation and meticulous preoperative preparation, thoracoscopic resection of the posterior segment of the left upper apical lung and mediastinal lymph node dissection were successfully performed. The surgery was successful, with the aim of maximizing tumor removal while preserving healthy lung tissue, protecting lung function, and improving the patient’s quality of life. After careful postoperative care, the patient recovered very quickly and was discharged from the hospital five days after surgery. Patient 2, male, 54 years old, had left knee pain for more than half a year. A chest radiograph revealed a right lower lung nodule, and spiral thin-layer CT showed a 1.0×0.8 cm ground glass nodule (GGO) in the posterior basal segment of the right lower lung. The general condition was good, and the function of the heart and lungs and other organs were normal. Considering the low invasive, less metastatic and inert tumor characteristics of bronchoalveolar carcinoma, thoracoscopic resection of the posterior basal segment of the right lower lung was performed, with rapid postoperative recovery, mild pain and no significant complications. In the former case, thoracoscopic lung segmental resection was a last resort, as the patient was too old and had poor cardiopulmonary function to tolerate lobectomy, which was a compromise lung segmental resection. In the latter case, the patient had good cardiopulmonary function and was able to undergo lobectomy. However, the patient’s lung cancer was bronchoalveolar lung cancer (BAC): low invasive, less metastatic, and inert tumor characteristics. Thoracoscopic resection of the posterior basal segment of the right lower lung was an intentional lung segment resection, which is an individualized minimally invasive surgical option for early small lung cancer. The era of surgical treatment of lung cancer began in 1933 when Graham performed a successful total lung resection for a patient with lung cancer. And to date, surgery is still the treatment of choice for early-stage non-small cell lung cancer (NSCLC), with 5-year survival rates of 53% to 57% and 48% to 56% for stage I and stage II patients, respectively. For early-stage lung cancer eligible for lung segmental resection, the indication given by the NCCN limits it to lung cancer with peripheral nodes ≤2 cm in diameter, i.e., stage T1aNOM0 in the UICC 2009 version of the TNM staging system for lung cancer. The 5-year survival rate of lung cancer patients at this stage can be increased to a gratifying 88%-96% after thoracoscopic lung segmental resection! Early diagnosis of lung cancer: Due to the progress of medicine and the improvement of the understanding of biology and genetics of lung cancer, the emergence of new diagnostic and treatment tools, and the improvement of public health care awareness, especially with the common application of spiral high-definition CT, more and more early isolated pulmonary nodules (SPNs) in the lung are now detected, and more and more patients with early lung cancer are contacted in clinical work. Treatment of early-stage lung cancer: lobectomy has long been the gold standard for the treatment of lung cancer. The overall understanding of lung cancer, its anatomical configuration, patient selection, treatment guidelines and even the techniques of surgery are now far better than any before. The cell subtypes, anatomical structures, possible chances of lymph node spread, and surgical anatomical views of lung cancer are different than before, followed by adjuvant therapy, and a large body of domestic and international literature demonstrating the potential of lung segmental resection for early stage non-invasive lung cancer to replace lobectomy. In today’s world of increasingly sophisticated surgical standards and minimally invasive incisions, the widespread use of lung segmental resection is imminent, and as a minimally invasive lung cancer surgeon, it is essential to have such knowledge and skills. On the other hand, the literature reports that about 1/3 of lung cancer patients are older than 70 years old, and the number of elderly bronchopulmonary cancer patients is gradually increasing due to the growing trend of aging in China. These patients are often combined with one or more systemic diseases, most commonly lung diseases such as chronic bronchitis, emphysema or even pulmonary heart disease. Traditional lobectomy can dramatically increase postoperative complications, morbidity and mortality, while thoracoscopic lung segmental resection allows timely treatment of this group of patients. FAQ: What is segmental lung resection and what is the rationale for it? The anatomical basis of segmental lung resection for early stage lung cancer: Segmental bronchus is the branch of lung lobe bronchus, and each segmental bronchus, its branches and the lung tissue it belongs to together constitute a bronchopulmonary segment (referred to as lung segment). The right lung can be divided into 10 segments, and the left lung can be divided into 8 segments. The lung segments are wedge-shaped, with the base on the surface of the lung and the tip at the root. Each lung segment has its own artery and bronchus. Two adjacent lung segments share a common vein. Because each lung segment has a relatively independent blood supply circulation system and independent bronchial branches, they can function anatomically as relatively independent units. It is anatomically feasible to separate the bronchi and pulmonary arteries of a lung segment by dissection and to remove the corresponding lung tissue. The literature reports that each lung segment has a volume of approximately 0.3L, with 2-5 segments per lobe, and that lung segment resection can theoretically preserve 0.6L-1.2L of lung tissue. The greater significance is that it allows lung cancer patients to retain the opportunity for reoperation and surgery for multiple nodules and lesions in both lungs. Which lung cancer patients can undergo thoracoscopic lung segmental resection? Indications for lung segmental resection can be divided into two levels: first, disease factors: 1, early peripheral type lung cancer or lung hairy glass lesions that cannot be excluded as lung cancer; 2, benign central type lesions; 3, metastatic lung cancer, partial central type; 4, multiple early lung cancer or hairy glass lesions, non-parenchymal lesions. Second, patient factors: 1, those who have poor lung function and cannot undergo lobectomy; 2, those who wish to preserve better lung function. *Patients must meet the following conditions: 1) in case of lung cancer, the lesion is less than 2 cm; 2) the location of the lesion must be within the lung segment to be resected, and the cut edge must be negative and a safe distance from the tumor; 3) the arteriovenous and bronchial separation and truncation of the lung segment does; 4) the lymph node clearance of the parabronchial lymph nodes of the lung segment still needs to be performed carefully. What are the advantages of thoracoscopic surgery versus traditional open chest? In the 1990s, a landmark event in the field of thoracic surgery was the widespread implementation of television thoracoscopic minimally invasive surgery. Thoracoscopic lung surgery has a clearer view and adequate exposure angle, which can reduce damage to blood vessels and lung tissue, help reduce postoperative atrial fibrillation, pulmonary air leak, and lung infection, help patients actively cough up and excrete sputum after surgery, and enable patients to recover earlier after surgery and shorten their hospital stay. Is thoracoscopic lung segment resection difficult? Is it dangerous? Can segmental lung resection be performed for other lung diseases? The difficulty of total lumpectomy: 1, the lung segment only refers to the existence of structures in the anatomical sense, in fact, there is no clear demarcation of the lung segment (no pleural envelope), it is the lung tissue plane that needs to be created by the operator with the inter-segmental vein as the boundary and relatively few blood vessels, 2, there are many variations of pulmonary arteries and bronchi, which means that the access of each case of thoracoscopic lung segment resection surgery and the scope of resection needs to be designed individually. The surgery requires a high level of operator: advanced techniques (surgical skills, lung anatomy, sophisticated interpretation of imaging examinations and a combination of all three) are required to complete lung segment, expanded lung segment, and superlung segment (lung subsegment) resection for early stage lung cancer. Also, lobectomy is not appropriate for some benign lung diseases such as inflammatory pseudotumor, malformation, tuberculosis bulb, pulmonary cyst, bronchiectasis, slow fungal infections, bronchial adenoma, sclerosing hemangioma, intrapulmonary type lung isolation, congenital cystic adenomatoid malformation, congenital segmental bronchial atresia, and so on. Studies have shown that thoracoscopic segmental lung resection is a safe and feasible surgical procedure due to its minimally invasive, less painful, and faster recovery than thoracoscopic lobectomy, with comparable postoperative complications and 1/3 less than traditional open-heart surgery. What can be done for early diagnosis and early treatment of lung cancer? Regular health checkups, 1-2 times/year; quit smoking if you are a high-risk group: over 40 years old, 400 cigarettes per year, nodules in the lung, previous history of tumor, history of chronic obstructive pulmonary disease, hemoptysis, family history of lung cancer, close contact with asbestos, helium and other occupations, you need regular CT examinations (1 time/3-6 months), follow up for 2 years, if small nodules in the lung increase, or solid components increase you should operate as early as possible. In conclusion, different surgeries are used according to different stages of lung cancer, and clear diagnosis and treatment are the individual needs of each lung cancer patient. The total thoracoscopic (VATS) lung segmental resection surgery has become one of the most minimally invasive procedures in lung cancer surgery, but it has not been widely promoted due to the strict indications and high requirements for the operator. In recent years, with the accumulation of experience in VATS lung segmental resection for early-stage lung cancer, its advantages have gradually emerged, enabling patients with early-stage lung cancer to receive personalized and minimally invasive treatment, improving the 5-year survival rate, improving the quality of survival, and preserving the chance of reoperation.