The histological stage of locally advanced non-small cell lung cancer invading large blood vessels and the left atrium is defined as T4, with a low surgical resection rate and a 5-year survival rate of less than 20% with conservative treatment. However, in some patients without distant metastasis, a comprehensive treatment mainly with surgery will improve the long-term survival rate, and the treatment with extended resection is now mostly advocated. We retrospectively analyzed the clinical data of 32 cases of locally advanced lung cancer invading the heart or large blood vessels in our hospital for surgical treatment, and summarize the report as follows. Subjects and methods I. Study subjects Retrospective summary of 32 cases of locally advanced lung cancer (T4N0 -N2M0) treated by partial atrial or large vessel resection in our department between February 2005 and June 2010. There were 27 male patients and 5 female patients. The age ranged from 48 to 73 years, with a median age of 58 years. Invasion of the superior vena cava and the innominate vein was observed in 5 cases, the pulmonary artery trunk in 4 cases, and the left atrium in 23 cases. There were 13 cases of partial resection of the left whole lung and left atrium, 4 cases of partial resection of the left whole lung and pulmonary artery trunk, 9 cases of partial resection of the right whole lung and left atrium, (2 of which were performed with the assistance of extracorporeal circulation), 1 case of resection of the middle and lower lobes of the right lung and part of the left atrium, 3 cases of partial resection of the right upper lung lobe and superior vena cava with artificial vessel replacement, and 2 cases of superior vena cava repair. Pathological staging: squamous carcinoma in 25 cases, adenocarcinoma in 5 cases, and large cell carcinoma in 2 cases. The cases of distant metastasis were excluded by brain MRI, bone scan and abdominal ultrasound. Surgical methods 1. For tumor invading the root of left pulmonary artery and pulmonary artery trunk, the pericardium was incised longitudinally between the anterior aspect of the pulmonary hilum and phrenic nerve, and the return fold of pulmonary artery and pericardium was separated upward first to free the left pulmonary artery and part of pulmonary artery trunk, and the free range should be more than 1.5 cm from the tumor edge. Clamp the pulmonary artery trunk with a non-invasive curved vascular clamp not exceeding 1/2 of the diameter, and observe the changes of airway resistance, oxygen saturation, blood pressure and heart rate. The left pulmonary artery and part of the pulmonary artery trunk were severed 5 mm from the edge of the tumor, and the severed end was repaired with continuous sutures without injury. 2.Superior vena cava resection and artificial vessel replacement The right upper pneumonectomy was performed with a posterior lateral incision (Figure 1). The left and right innominate veins and superior vena cava were fully dissected. A “Y”-shaped artificial vessel was used, and the proximal end was anastomosed with the superior vena cava near the right atrium, and the distal end was anastomosed with the left and right innominate veins. The superior vena cava was resected with as much prep as possible and with as little vascular block time as possible. We adopt the method of left vena cava-right atrium shunt and left and right vena cava block separately. To deal with the left atrium, firstly, the left atrium wall was sutured and knotted with 4-0 prolene thread, the left atrium wall was clamped with curved vascular forceps 1 cm from the tumor, the tumor was excised 5 mm from the edge of the tumor, and the broken end was repaired with continuous sutures without damage, then the left atrium wall was cut about 1/2, ensuring that the two ends of the cut left atrium opening would not slip off, and the method of cutting part of the left atrium wall was adopted while suturing. Then, the remaining part was cut and sutured. 4.Establishment of extracorporeal circulation In two cases of right central lung cancer, the tumor protruded 2 cm into the left atrium along the inferior pulmonary vein and invaded a large area of the left atrium. Results In this group of 32 patients, the success rate of surgery was 100%, and there were no surgical deaths and no serious complications. The postoperative pathology reported that there was no tumor residue in the bronchus, blood vessels and atrial stump. Postoperative pathological TNM stage: T4N0M0 in 3 cases, T4N1M0 in 11 cases and T4N2M0 in 18 cases. The incidence of surgical complications was 10.67% (3/32), mainly cardiac arrhythmias. The median survival time: 15 months, 19 months for T4N0-N1M0 and 10 months for T4M2MO. 3-year survival rate was 46.15% (6/13). 1 patient survived 5 years tumor-free. Discussion The majority of surgically treated lung cancers are intermediate and advanced, and surgery often involves the possibility of failure to remove the tumor by thoracic dissection. In the last decade or so, with the advancement of surgical techniques, some locally advanced stage IIIA and IIIB non-small cell lung cancers, which were considered unsuitable for surgical treatment in the past, have been treated with expanded surgical procedures to completely remove the tumor, fundamentally improving and eliminating clinical symptoms and improving the patient’s survival quality. Some patients achieved long-term survival with the addition of chemotherapy or radiotherapy. ordula et al. reported a complete resection rate of 38.2% and a 5-year survival rate of 46.2% in 89 cases of locally advanced non-small-cell lung cancer. Lorenzo et al. reported 25 cases of non-small cell lung cancer invading the superior vena cava, all of which underwent tumor resection and superior vena cava resection with prosthetic revascularization or repair, with a 5-year survival rate of 36% in cases with complete tumor resection. Kenji et al. reported that the presence or absence of mediastinal lymph node metastasis in locally advanced non-small cell lung cancer had a significant impact on prognosis. The 5-year survival rates were 6.6% and 36% for cases with mediastinal lymph node involvement and negative mediastinal lymph nodes, respectively. ……Takahashi et al. summarized 49 cases of expanded surgery for lung cancer invading mediastinal organs, and the 5-year survival rate was 18.3% for those with complete tumor resection and 0 for those with incomplete resection. Expanded resection can achieve local radical resection, and its clinical efficacy and survival rate are better than those of medical treatment, and many patients have not only good near-term but also better long-term results after surgery. Therefore, expanded resection for locally advanced non-small cell lung cancer is gradually accepted by surgeons. However, total pneumonectomy with enlarged left atrium and pulmonary artery trunk resection is a difficult operation, and the postoperative complication rate is increased. It is necessary to make accurate judgment on the relationship between the tumor and pulmonary artery and left atrium through CT scan and enhancement examination before surgery. For example, mediastinoscopy or transbronchoscopic mediastinal lymph node biopsy is feasible, and the 5-year survival rate of cases with mediastinal lymph node metastasis is obviously reduced, so it should be chosen carefully. The surgical approach is mostly determined after intraoperative exploration. In cases of partial pulmonary trunk resection, the pulmonary veins and bronchi must be cut and closed before dealing with the left pulmonary artery. In most cases, the distance between the tumor and the vascular clamp is small, so it is technically difficult to cut the vessel to ensure that the tumor is cut cleanly, but also to consider leaving more of the residual vessel wall to prevent the vascular clamp from slipping off. We adopted the method of cutting while suturing: firstly, we sutured and knotted the vessel wall with 4-0 prolene thread, then partially cut the vessel, about 1/2, to ensure that the two ends of the cut vessel opening would not slip off, and sutured the cut part of the vessel with continuous sutures. Finally, the remaining portion of the vessel is then severed, the tumor and lung tissue are removed, and the stump of the vessel is closed with continuous sutures. The pulmonary artery and bronchus must also be dissected and closed before the left atrial pulmonary vein is treated. The pericardium is incised longitudinally 1.0 cm in front of the phrenic nerve, up to the superior border of the pulmonary trunk and down to the plane of the inferior pulmonary vein. If the pericardial fluid accumulation is excessive, the fluid should be released slowly. Do not insert the suction device directly into the pericardial cavity to prevent a sudden drop in intrapericardial pressure and induce cardiac arrest. Try to use the lateral wall clamp to clamp the left atrial wall deeply and take the method of cutting while suturing. In our two cases, the tumor invaded the left atrium, right atrium and atrial septum. Part of the right and left atrium and atrial septum were resected under extracorporeal circulation, and the tumor was completely removed. After the right atrial incision was closed with consecutive sutures, the left atrium was repaired with autologous pericardial pieces, and the operation was successful. There will be some effect on blood pressure heart rate when freeing the root of pulmonary vein and left atrium. If the freeing is difficult, the invasion of the atrial wall is extensive and the clamping of the lateral wall clamp is unsafe, extracorporeal circulation is established as early as possible, the tumor is removed under extracorporeal circulation and the atrial wall is repaired with autologous pericardial pieces. The patient came to the clinic with a very strong desire for relief of symptoms. According to our observation, the clinical symptoms basically disappeared after the enlarged resection operation, and the quality of life of patients improved significantly. The vast majority of patients were very satisfied with this. This also creates the conditions for the next step of continued treatment. For patients with locally advanced lung cancer, treatment with expanded resection surgery such as partial left atrial resection or partial resection of pulmonary artery trunk not only increases the surgical resection rate and improves patients’ clinical symptoms, but also improves survival rate and creates conditions for comprehensive treatment of advanced lung cancer.