Overview: Lung cancer occurs in the bronchial mucosa epithelium and is also known as bronchial cancer. In recent 50 years, many countries have reported a significant increase in the incidence of lung cancer, and lung cancer has taken the first place among male cancer patients. The etiology of lung cancer is still not completely clear, but a lot of information shows that long-term heavy smoking is an important causative factor of lung cancer. The incidence of squamous and undifferentiated lung cancer is 4 to 10 times higher than that of nonsmokers for those who smoke more than 40 cigarettes per day for many years. Therefore, we should promote non-smoking and strengthen urban environmental sanitation.
Lung cancer originating from the bronchial mucosa epithelium confined to the basement membrane is called carcinoma in situ, which can grow into the bronchial lumen or/and adjacent lung tissues and can spread through lymphatic blood flow or transbronchial metastasis.
The distribution of lung cancer is more in the right lung than in the left lung, and more in the upper lobe than in the lower lobe, and the cancer can occur from the main bronchus to the fine bronchus.
Etiology: Risk factors for lung cancer include smoking (including second-hand smoke), stone wool, radon, arsenic, ionizing radiation, halogenated alkenes, polycyclic aromatic compounds, nickel, etc. The details are as follows.
(a) Smoking: According to a large number of surveys in various countries, the cause of lung cancer is very closely related to smoking paper cigarettes. The incidence of lung cancer in Western European countries at the end of this century is also significantly higher in women with the increasing number of women smokers. The incidence of lung cancer in clinically diagnosed cases of lung cancer is about 80% of those who have smoked more than 20 cigarettes per day for more than 30 years, and the smoking situation in China is very serious in the last 20-30 years. If the necessary measures are not taken to control and discourage smoking, the incidence of lung cancer in China will increase further in the next 10-30 years. Long-term smoking can lead to bronchial mucosa epithelial cell hyperplasia phosphoepithelial growth induced squamous epithelial carcinoma or undifferentiated small cell carcinoma.
(B) air pollution: the incidence of lung cancer in industrially developed countries is higher in urban areas than in rural areas, and higher in mines than in residential areas, mainly due to the pollution of the atmosphere with harmful substances such as benzopyrene carcinogenic hydrocarbons produced by the combustion of oil, coal and internal combustion engines and asphalt road dust in industrial and traffic developed areas. The incidence rate of lung cancer may promote each other to play a synergistic role
(iii) Occupational factors: In the 1930s, the high incidence of lung cancer in the Schneeberg mines in Europe was reported in the literature.
(d) Chronic lung diseases: such as tuberculosis, silicosis, pneumoconiosis, etc. can coexist with lung cancer, and the incidence of cancer in these cases is higher than that of normal people.
(e) Intrinsic factors such as family genetics, lowered immune function, endocrine dysfunction, etc. may also play a role in the development of lung cancer.
Symptoms
I. Early symptoms
Lung cancer does not have any special symptoms in early stage, but only symptoms common to general respiratory diseases, such as cough, sputum and blood, low fever, chest pain and tightness, which can be easily ignored by patients and doctors. The following are the specific manifestations of common symptoms of early lung cancer.
1. Cough. Since lung cancer grows on bronchopulmonary tissues, it usually produces irritating cough due to respiratory tract irritation.
2.Low fever. After the tumor blocks the bronchial tubes, there is often an obstructive lobe of the lung, the degree of which varies from low fever in mild cases to high fever in severe cases, which may improve temporarily after medication but will recur soon.
3. Chest distension and pain. The chest pain in early stage of lung cancer is mild, mainly manifested as boring pain, hidden pain, the location is not certain, and the relationship with breathing is also uncertain. If the distending pain continues to occur, it indicates that the cancer may involve the pleura.
4. Sputum and blood. When tumor inflammation causes necrosis and capillary breakage, there will be a small amount of bleeding, which is often mixed with sputum and appears intermittently or intermittently. Many patients with lung cancer visit the doctor because of sputum blood.
Late stage symptoms of lung cancer
1. Facial and neck edema. There is superior vena cava in the right side of mediastinum, which transmits venous blood from upper limbs and head and neck back to heart. If the tumor invades the right side of the mediastinum and presses the superior vena cava, the jugular vein will initially become angry due to poor return flow, and finally it will lead to facial and neck edema, which needs timely diagnosis and treatment.
2. Hoarseness is the most common symptom. The laryngeal nerve, which controls the left side of the articulatory function, travels down from the neck to the chest and returns upward around the large blood vessels of the heart to the larynx, thus innervating the left side of the articulatory organ.
3.Patients with regional spread of lung cancer almost always have varying degrees of shortness of breath. Normal tissue fluid produced by the lungs and heart muscle is returned by lymph nodes in the middle of the chest. If these lymph nodes are blocked by the tumor, this tissue fluid will accumulate in the pericardium to form a pericardial effusion or in the thoracic cavity to form a pleural effusion. Both of these conditions can lead to shortness of breath. However, the combination of chronic lung disease of varying degrees in many smoking patients makes the identification of shortness of breath difficult. In addition, the loss of respiratory function due to tumor growth in some lung tissues can cause respiratory discomfort due to impaired positive respiratory function, which can be felt only during exercise at first, but eventually even at rest.
Clinical manifestation
The clinical manifestation of lung cancer is closely related to the location and size of the tumor, whether the tumor compresses and invades the neighboring organs and whether there is metastasis, etc. If the tumor grows in the larger bronchus, irritating cough often occurs. Some patients may have symptoms such as chest tightness, shortness of breath, fever and chest pain due to large bronchial obstruction caused by tumor.
When advanced lung cancer compresses adjacent organs and tissues or distant metastasis occurs, it can produce.
① compression or invasion of phrenic nerve, causing ipsilateral diaphragm paralysis
② compression or invasion of the recurrent laryngeal nerve, resulting in vocal cord paralysis and hoarseness
(3) compression of the superior vena cava, resulting in facial, neck, upper extremity and upper thoracic vein rage, subcutaneous edema, and increased venous pressure in the upper extremity
④Invasion of pleura can cause pleural effusion, mostly bloody
(5) Invasion of the mediastinum by cancer and compression of the esophagus may cause dysphagia
(6) Top lobe lung cancer, also known as Pancoast tumor or supraglottic lung tumor, can invade and compress organs or tissues located in the upper part of the thorax, such as the supraclavicular artery of the first rib and the cervical sympathetic nerve of the venous brachial plexus, resulting in chest pain, jugular vein or upper limb venous edema, arm pain and upper limb movement disorders, ipsilateral ptosis, pupil narrowing, eye sunken, facial sweating and other cervical sympathetic syndrome.
In a few cases of lung cancer, due to the endocrine substances produced by the cancer, non-metastatic systemic symptoms may appear clinically: such as osteoarthritis syndrome (pestle and mortar joint pain, osteochondral hyperplasia, etc.), Cushing’s syndrome, myasthenia gravis, male breast enlargement, polymyalgia, and other extrapulmonary symptoms.
Diagnosis
The diagnosis of lung cancer is based on symptoms, signs, x-ray and sputum cancer cell examination (sputum examination), and different steps should be taken according to different situations
(A) Negative X-ray sputum examination
1.Anyone without symptoms but with three high-risk factors (male age ≥ 45 years old and smoking > 400 cigarettes/year) should undergo 70-100mm fluorescence microscopic x-ray or chest fluoroscopy and sputum cytology examination for six months
2, where there is hemoptysis or/and dry choking cough with three major high-risk factors should be repeated sputum cytology examination while giving regular anti-inflammatory treatment; can be considered for fiberoptic bronchoscopy (fibrous bronchoscopy) and television fluoroscopy if repeated sputum examination or microscopy is still negative should be reviewed every two months adhere to a year
(B) X ray negative sputum test positive
1.Exclude upper respiratory tract and esophageal carcinoma
2.Fibronectomy for peeping and sub-segmentation, if there is suspicious local mucosal thickening and roughness or blood stains, brush check and rinse or puncture the mucosa of bronchial wall to look for cancer cells, if local unevenness or roughness is found, bite biopsy should be considered.
3.Change the position of TV fluoroscopy and focus on small nodule foci in hidden areas
4.If no lesion can be detected by the above examinations, sputum electrodialysis and fibrinoscopy should be reviewed every two months, and CT examination can be performed at suspicious places for regular review for at least one year.
(C) X ray positive sputum test negative
1. Those with segmental lobar pneumonia or obstructive pneumonia suspected to be central lung cancer should undergo fibrinoscopy, including trans-fibrinoscopic biopsy (TBB) or selective bronchography; and repeatedly strengthen sputum examination
2. Local tomography should be performed for masses or nodular lesions, and transbronchial lung biopsy (TBLB) or percutaneous lung biopsy or aspiration should be performed for cytological diagnosis if available.
3. Sputum examination at least twelve times continuously
4. Repeated sputum examination is still negative and X-ray is highly suspicious of lung cancer, dissection and frozen section biopsy should be performed
(D) Positive X-ray sputum test
1.Actively prepare for surgery
2. When regional lymph node enlargement is suspected, frontal and lateral tilt stratification films can be taken, and CT can be used if necessary. In large hospitals, CT and frontal and lateral tilt stratification films should be routinely used for liver ultrasound, bone isotope scan and bone marrow aspiration into biopsy smear to facilitate treatment planning.
Examination
1. Chest fluoroscopy and radiography can show variable round shadows and pneumonia and pleural effusion, etc. Chest tomography X-ray, CT and MRI can understand the relationship between the size of tumor and lung lobes and lung segments and bronchi, and if necessary, bronchial oil iodography can be performed.
2. Repeated sputum examination of cancer cells can yield positive results, which can confirm the diagnosis.
3.Bronchoscopy can directly observe the lesion, and biopsy and smear of bronchial secretion can be taken to check cancer cells.
4.Pulmonary puncture with accurate positioning can generally obtain positive results in smear examination of the punctured material, which is of confirmatory value
5.Superficial lymph node aspiration or biopsy: When lung cancer is still unconfirmed or accompanied by widening of the upper mediastinum, subcutaneous suspicious lymph node masses that can be felt on the cervical clavicle and other parts of suspicious cancerous lymph nodes can be aspirated for cytological examination or biopsy to obtain pathological histological confirmation
Classification
Clinically, lung cancer is generally classified into the following four types. The first three are usually referred to as Non-small cell carcinoma (NSCLC), while small cell lung cancer mostly occurs in the larger bronchi, develops extremely rapidly, and is more closely related to smoking. Patients with small cell lung cancer are often found to have spread and metastasized, and the prognosis is very poor.
1.Squamous cell carcinoma (also called squamous carcinoma): it is the most common among all types of lung cancer, accounting for about 50% of the disease age mostly above 50 years old and most of the males mostly originate from the larger bronchial tubes and are often central type lung cancer.
2.Undifferentiated carcinoma: second only to squamous carcinoma in terms of incidence, it is usually seen in men at a younger age and generally originates from larger bronchioles.
Adenocarcinoma: originates from the mucosal epithelium of the bronchus and a few from the mucous glands of the large bronchus. The incidence is lower than that of squamous and undifferentiated carcinoma, and is relatively common in women. Lymphatic metastasis occurs later
4.Alveolar cell carcinoma: originated from bronchial mucosa epithelium, also known as bronchoalveolar cell carcinoma or bronchial adenocarcinoma, is located around the lung field and is the least common among all types of lung cancer, and is more common in women. The former can be a single nodule or multiple nodules; the latter is similar to the nodular type with limited scope of pneumonia, and surgical resection is more effective.
5. Typical carcinoid tumor and atypical carcinoid tumor, etc.
Treatment methods
The treatment of lung cancer is to apply the available treatments in a rational and planned manner according to the patient’s physical condition, the pathological type of the tumor, the scope of invasion and the development trend, so as to improve the cure rate and the quality of life of the patient significantly. The treatment effect of lung cancer depends on early and clear diagnosis.
The treatment methods of lung cancer are as follows
1.Surgical treatment: limited tumor resection can achieve the same efficacy as extensive resection, and lobectomy is generally recommended.
2.Chemotherapy: small cell lung cancer is highly responsive to chemotherapy.
3.Radiotherapy: It has a killing effect on cancer cells and is divided into radical and palliative.
4.Other local treatments: relieve symptoms and control tumor development.
5.Biological palliative mediators: can be used for small cell lung cancer.
6.Chinese medicine treatment: Chinese medicine plays an important role in the treatment of cancer, which can reduce the side effects brought about by western medicine treatment, and at the same time, Chinese medicine also has an inhibitory effect on cancer cells, reduces the patient’s reaction to radiotherapy and chemotherapy, improves the body’s resistance to disease, and plays a supplementary role in consolidating the therapeutic effect, promoting and restoring the body’s function.
Surgical treatment
In the treatment of lung cancer, except for stage IIIb and IV, surgery or striving for surgery should be the leading treatment based on different pathological tissue types, and the comprehensive treatment of radiotherapy, chemotherapy and immunotherapy should be added as appropriate, while the indication scheme for the treatment of small cell lung cancer is subject to continuous revision and improvement in clinical practice.
Regarding the survival period after lung cancer surgery, it has been reported that the three-year survival rate is 40% to 60%; the five-year survival rate is 22.9% to 44.3% and the operative mortality rate is less than 3%. The above is from the “Anti-cancer Pioneer Network” of Shanghai Tang Chinese Medicine www.88vv.com.cn提供良方.
(I) Indications for surgery
1.No distant metastasis (M0) including parenchymal organs such as liver, brain, adrenal gland, skeleton, extra-thoracic lymph nodes, etc.
2.Cancerous tissue has not spread to adjacent organs or tissues in the chest, such as aorta superior vena cava esophagus and cancerous pleural fluid, etc.
3.No paralysis of the phrenic nerve of the recurrent laryngeal nerve
4.No severe cardiopulmonary depression or angina pectoris in the near future
5, no serious liver or kidney disease and severe diabetes mellitus
Those with the following conditions should generally be operated with caution or require further examination and treatment.
(1) Aging with poor cardiopulmonary function
(2) Small cell lung cancer, except for stage I, should be treated with chemotherapy or radiotherapy before determining whether surgery can be performed.
(3)In addition to the primary foci, there are several suspicious metastases in the mediastinum as seen by x-ray.
(2) Indications for thoracotomy Where there is no contraindication to surgery, a clear diagnosis of lung cancer or a high suspicion of lung cancer can be selected according to the specific situation in conjunction with the procedure defined in section I of this chapter. If the lesion is found to be beyond the resectable range during surgery but the primary cancer can still be resected, it is advisable to remove the primary focus.
(C) Naming and meaning of surgical resection of lung cancer
1. Palliative resection (P): where there is still residual cancer in the thoracic cavity at the time of surgical resection (confirmed by pathological histology) or where the resection is considered complete at the time of surgery, such as the bronchial stump is normal to the naked eye but there are residual cancer cells under the microscope, is called palliative resection
Where there is suspected residual cancer tissue in the thoracic cavity, metal markers are used during surgery to facilitate postoperative radiation therapy.
2.Radical resection (R): Radical resection means complete removal of the primary cancer and its metastatic lymph nodes.
Radical lung cancer surgery not only requires the operator to achieve radical treatment under the naked eye, but also requires the complete removal of lymph nodes and the absence of cancer cells in the bronchial stumps under the microscope.
Root 1 (R1): primary cancer and lymph node removal at station 1
Root 2 (R2): primary cancer and 12-stop lymph node dissection
Root 3 (R3): primary cancer and lymph node dissection at station l23
Root 4 (B4): primary cancer and lymph node dissection at station l234
It should be noted that the above four levels of radical treatment refer to the extent of surgical removal of lymph nodes and do not represent the outcome after radical surgery
(d) Selection of lung cancer surgery According to the 1985 International Staging of Lung Cancer, all lung cancer cases in stages 0, Ⅰ, Ⅱ and Ⅲ without contraindications to surgery can be treated surgically. The principles of surgical resection are: complete removal of the primary focus and lymph nodes with potential metastasis in the chest cavity and preservation of normal lung tissue as much as possible.
1.Local resection: it refers to wedge-shaped cancer block resection and lung segment resection, i.e., for small primary cancer, local lung resection can be considered for old and frail patients with poor lung function or low malignancy of well differentiated cancer.
2.Lobectomy: For isolated peripheral lung cancer confined to one lobe without obvious lymph node enlargement, lobectomy is feasible if the cancer involves both lobes or middle bronchus, upper middle lobe or lower middle lobe lobectomy is feasible
3.Sleeve lobectomy and wedge-shaped sleeve lobectomy: this procedure is mostly used for lung cancer in the upper and middle lobes of the right lung. If the cancer is located in the lobar bronchi and involves the opening of the lobar bronchi, sleeve lobectomy is feasible.
4.Total pneumonectomy (generally not right total pneumonectomy): if the lesion cannot be removed by the above methods, total pneumonectomy can be carefully considered
5.Romission and reconstruction: when the lung tumor exceeds the main bronchus and involves the ridge or the lateral wall of the trachea but does not exceed 2 cm: ①Romission and reconstruction or sleeve type total pneumonectomy can be performed; ②If a lobe of the lung is still preserved, the procedure can be preserved according to the situation
(E) Surgical treatment of recurrent lung cancer or recurrence
1, the treatment of multiple primary lung cancer: where the diagnosis of multiple primary lung cancer, the treatment principle according to the second primary foci treatment
2. Treatment of recurrent lung cancer: the so-called recurrent lung cancer refers to the cancer foci occurring within the original surgical scar or the recurrence of intra-thoracic cancer foci related to the primary foci, which is called recurrent lung cancer.
Radiation therapy
(Radiation therapy is best for small cell carcinoma, followed by squamous cell carcinoma and worst for adenocarcinoma, but small cell carcinoma is prone to metastasis, so large irregular field irradiation should be used, and the irradiated area should include the primary site, mediastinum, bilateral supraclavicular area, and even liver and brain, etc. Supplementary drug therapy should be used for squamous cell carcinoma, which has moderate sensitivity to radiation. Therefore, the sensitivity of tumor to radiation therapy is not only affected by the type of pathology, but also by the size of the tumor, the degree of differentiation of the tumor cells, the composition of the tumor cell population, the proportion of the tumor bed, and other factors.
(2) Indications of radiotherapy According to the purpose of treatment, it is divided into radical treatment, palliative treatment, preoperative radiotherapy, postoperative radiotherapy and intracavitary radiotherapy, etc.
1.Applicable scope of radical treatment
(1)Early cases with contraindication to surgery or refusal to surgery or Petri disha cases with lesion scope limited to 150cm2
(2) heart, lung, liver and kidney function is basically normal blood white blood cell count greater than 3 × 109 / 1 hemoglobin greater than 100g / 1
(3) KS ≥ 60 points should be carefully planned and strictly implemented beforehand, do not easily change the treatment plan, even if there is radiation reaction, the goal should be to cure the tumor.
2, palliative care: the purpose of palliative care varies greatly, there are close to the radical treatment of palliative care to relieve patient pain and prolong life and improve quality of life; there are only to alleviate the symptoms of advanced patients or even to cause comforting symptom reduction treatment such as pain, paralysis, coma, shortness of breath and bleeding. In the case of large radiation reactions or a decrease in KS score, the treatment plan can be modified as appropriate to reduce the symptoms of the irradiation site usually available in high doses with less division.
3.Pre-surgical radiotherapy: aimed at improving the rate of surgical resection and reducing the risk of tumor dissemination during surgery; for patients with no difficulty in surgical resection, high-dose pre-surgical radiotherapy with less division can be used; if the tumor is huge or invasive, it is estimated that there is difficulty in surgical resection, conventional segregated radiotherapy can be used.
4.Post-surgical radiotherapy: It is used for cases where the tumor is not completely resected by surgery, a silver clip should be placed on the local residual foci to mark them for accurate positioning during radiotherapy.
5. Intraluminal short-distance radiotherapy: it is suitable for cancer foci confined to large bronchial tubes, and can be used to improve the therapeutic effect by placing the catheter at the bronchial foci with iridium (192Ir) for brachytherapy and external irradiation through fibrinoscopy.
Metastasis of lung cancer
Metastases of different organs can occur in the late stage of lung cancer, which can cause corresponding symptoms and often bring great pain to patients and even threaten their lives. The most common clinical metastases include the following parts.
1. Lung cancer brain metastasis lung cancer patients with unexplained headache, vomiting, visual impairment as well as personality and temperament changes may be caused by intracranial hypertension or brain nerve damage caused by lung cancer metastasis to the brain. It is commonly seen in small cell lung cancer and adenocarcinoma types. Headache is the most common symptom, vomiting mostly occurs when the headache is intense and is characterized as jet vomiting; visual disturbance indicates that the tumor has affected the compression or invaded the optic nerve. In addition to the above common symptoms, lung cancer brain metastasis may also cause diplopia, paroxysmal black clouding, sudden collapse, impaired consciousness, increased blood pressure, slowed pulse, and in severe cases, brain herniation due to tumor compression may lead to respiratory arrest, endangering the life of the patient. In addition, due to the common application of brain CT examination for lung cancer patients in recent years, many asymptomatic brain metastasis patients have been detected, which can gain time for treatment. Therefore, brain CT should be included as routine examination for patients diagnosed with lung cancer to detect brain metastasis as early as possible.
2.Bone metastasis of lung cancer: about 50% of lung cancer patients will eventually develop bone metastasis in multiple locations. Bone metastases are usually asymptomatic in the early stage, and bone isotope scan can detect the lesioned bones. The symptoms of bone metastases are related to the location and number of tumor metastases. For example, the chest pain caused by lung cancer rib metastases is mostly manifested as pain with limited chest wall area and clear pressure points. Spinal metastases cause pain in the middle of the back or at the lesion site, while bone metastases in the extremities or trunk cause limited pain in that area. Bone metastasis is not the direct cause of life threatening lung cancer patients, but if the tumor metastasizes to the weight-bearing bones of the body, such as cervical, thoracic and lumbar spine, it can cause serious consequences of paralysis. Therefore, patients with bone metastasis of lung cancer should be treated in time.
3.Liver metastasis of lung cancer: liver is also a common metastatic site of lung cancer, about 28-33% of lung cancer has liver metastasis. Liver metastasis is the invasion of primary lung cancer cells into the liver through blood circulation and planting and growing in the liver, and liver metastasis can be single or multiple nodal metastases. The most common symptom is pain in the liver area, which is persistent pain, and may be accompanied by loss of appetite, indigestion and other signs of impaired liver function.
4.Lung cancer kidney and adrenal metastasis: kidney and adrenal gland are the result of blood metastasis in the late stage of lung cancer, about 17%-20% of lung cancer patients have kidney and adrenal metastasis, which are often asymptomatic, some patients may have pain in kidney area, but rarely affect kidney function.
5.Metastasis to other parts of lung cancer: In addition to the above common metastasis sites, the less common metastasis sites include metastasis to skin, subcutaneous tissue, muscle, abdominal cavity, heart and other parts, and the symptoms are often related to the metastasis sites. For example, metastasis to the heart may cause chest tightness, palpitation or even shortness of breath, syncope, heart rhythm disorder and other symptoms.