1.Surgical treatment Surgery is preferred for non-small cell lung cancer. The aim of surgical treatment is to completely remove the primary cancerous lesions and local lymphatic tissues in the lung, and to preserve the largest amount of healthy lung tissue as possible. Li Jing, Department of General Thoracic Surgery, General Hospital of Ningxia Medical University 1.1 Assessment of surgical resection capacity and surgical ability This is an important part of the preparation before the work of surgical treatment for lung cancer. (1) The basis of resectability is its stage, which needs to take into account the invaded organs, metastasis or not and its location. x-ray examination is the most common and important means to diagnose lung cancer. Chest X-ray fluoroscopy to observe the movement of diaphragm is helpful to determine whether the phrenic nerve is invaded by cancer. Standard tomography can show the bronchial obstruction of central lung cancer, distinguish tumor from inflammation, clearly show the mass and lobar pattern of lung cancer, enlargement of hilar and mediastinal lymph nodes, and show the presence of calcified lesions within the mass. The scope of the CT scan must extend down to the liver and adrenal glands. Fluorodeoxyglucose positron emission computed tomography (FDG-PET) is superior to CT in determining whether the mediastinal lymph nodes are metastatic, characterized by a higher negative predictive value (NPV) than positive predictive value (PPV). It is indisputably recommended for the diagnostic practice of lung cancer and has shown an important place in N and M staging. However, as an expensive test, it is not realistic to apply PET-CT as a routine tool for lung cancer staging in China for universal use at present. The use of low-dose spiral CT scan screening technology has made early diagnosis of lung cancer possible. (2) Surgical capacity is the patient’s ability to undergo surgery and the subsequent reduction in lung volume and lung function. The preoperative examination assesses the patient’s general condition and should include: the patient’s pulmonary function, ventilation diffusion test, cardiac function, and exercise endurance test. Since many lung cancer patients smoke, they often have other diseases and poor respiratory function. In the critical range of surgical capacity, preoperative routine use of physical therapy such as nebulized inhalation to clear tracheal secretions has the potential to improve lung function. 1.2 The surgical approach used for the development of resection depends on the site and size of the tumor. Lobectomy is the removal of the complete lung lobes, segmental resection is the removal of bronchopulmonary segments, wedge resection is used for small peripheral tumors, wedge resection of lung tissue, and sleeve resection is used for tumors involving the main bronchi. Regardless of the surgical method, extrusion and bleeding during surgery can prompt cancer cells to grow locally or expand along blood vessels and lymphatic vessels; at the same time, trauma can temporarily depress immunity, which are all conducive to the formation of metastasis. Therefore, the surgeon should gently and accurately use sharp-based separation and proper suture knots to cut off the relevant blood vessels and bronchi on the basis of mastering the anatomy of bronchi and blood vessels in the hilum. (1) Surgery is the first choice of treatment for patients with stage IA and IB NSCLC. Lobectomy is advocated, and secondary lobectomy (wedge resection, segmental resection) is only indicated for patients with pulmonary insufficiency. Television-assisted thoracoscopic surgical treatment results in less postoperative pain, but there is a lack of sufficient evidence that it can replace conventional surgical treatment. (2) Stage II NSCLC accounts for about 5% to 10% of all NSCLC, and the extent of its lesions is quite variable, including T1-2N1 or T3N0. N1 lymph node metastasis can be treated by sleeve lobectomy or total pneumonectomy, and sleeve lobectomy is more recommended. For lung tumors adjacent to the chest wall or to determine whether the adjacent chest wall is invaded, this should not be confirmed by chest CT alone, but by surgical exploration. Unless it can be determined that there is no extrapleural infiltration, surgery for T3 (chest wall) NSCLC should be expanded beyond the mural pleura for whole chest wall resection; if the T3 (chest wall) tumor infiltration does not extend beyond the mural pleura, survival is the same for extrapleural resection or whole chest wall resection. If it is suspected that the tumor infiltrates beyond the wall pleura, it should be avoided to separate the tumor from the chest wall and then remove the chest wall where the original tumor is attached. (3) When metastatic lesions are found in a single region of mediastinal lymph nodes during open thoracotomy for stage IIIA NSCLC, pneumonectomy as well as mediastinal lymph node resection will be performed as planned if complete resection of the lymph nodes and the primary tumor is technically possible. The number of N2 lymph node metastases and the number of cycles of postoperative chemotherapy are important factors affecting the prognosis of stage IIIA N2 non-small cell lung cancer. (4) Stage IIIB NSCLC includes T4 with any N and M0, or any T with N3, M0. Only a very small proportion of patients with T4N0M0 are suitable for surgery. For those with mediastinal lymph node metastasis, the surgical outcome and quality of life are poor. However, according to Zhou Qinghua et al, for those who infiltrate the adjacent intrathoracic organs without distant metastases, the surgical resection can be expanded to achieve surgical radical treatment with better results than radiation and chemotherapy alone. (5) Stage IV NSCLC is not suitable for surgery. Radiotherapy is a means to kill cancer lesions locally. 75% of patients with locally advanced NSCLC have lost the chance of surgery when they are diagnosed, so they mainly use radiation therapy as the main comprehensive treatment or radiotherapy alone. The effect of conventional segmentation radiotherapy alone is very unsatisfactory. The 5-year survival rate of conventional radiotherapy for advanced non-small cell lung cancer is 3% to 10% and the median survival time is 6 to 11 months. Chen believes that accelerated hyperfractionated radiotherapy shortens the total treatment time and relatively increases the biological dose effect, thus improving the efficacy. Stereotactic gamma-ray whole-body radiotherapy system (whole-body gamma knife) uses gamma-ray geometric focusing method, through precise stereotactic orientation, to focus a certain dose of gamma rays planned on the pre-illuminated target, and destroy the tissues within the target in a one-time, lethal manner to achieve the effect of surgical resection or destruction. The side effects and radiological damage occurring during and after treatment are relatively small. Its treatment of lung cancer can make the tumor localized with accurate high-dose irradiation, and its recent efficacy is remarkable. 2.1 Preoperative radiotherapy can remove subclinical lesions outside the surgical area, such as small metastases in the mediastinum; reduce tumor volume and infiltration with adjacent structures; increase the tissue plane of surrounding anatomy; weaken the viability of tumor cells and reduce the possibility of local implantation and distant metastasis. The expected benefit was to improve resection rates and long-term survival. However, in clinical practice, both of these objectives have not been achieved. Therefore, it can be said that preoperative radiotherapy combined with surgery does not benefit the patient and is no longer routinely used in clinical practice. 2.2 Intraoperative radiotherapy is mainly for stage IIIB NSCLC with estimated incomplete resection, with the aim of improving the total surgical resection rate and reducing local recurrence. This is a one-time high-dose (15-25Gy) irradiation with electronic wires at the residual site of surgery developed in recent years, followed by external high-energy radiotherapy after surgical wound healing. HilarisBS and other physicians at SloanKettering Memorial Hospital in the United States reported that the implantation of medical radioisotope (125I, 222Rn) in tumors that could not be removed by dissecting chest exploration has achieved satisfactory results. 2.3 Postoperative radiotherapy is detrimental to the survival of patients with radically resected stage I-II non-small cell lung cancer, and therefore should not be routinely used. A pilot study was continued in stage III N2 cases. because of the role of postoperative radiotherapy in these advanced patients. Radiotherapy with metal markers can be placed in cases where the cancerous tissue was not completely removed during surgery or where there is residual cancerous infiltration at the bronchial break. Postoperative radiotherapy can improve the survival rate. 2.4 Chemotherapy during radiotherapy studies have found that chemotherapeutic drugs can enhance the cytotoxic effect of radiotherapy. Chemotherapy administered with radiotherapy enhances the effects of radiotherapy by eradicating cells resistant to radiotherapy (S-phase cells and hypoxic cells) to enhance local control, by inhibiting repair of potentially lethal or sublethal damage, or by accelerating cells into the G2/M phase (during which cells become more sensitive to radiation killing cells). It also enhances local control while reducing distant metastasis. 3.Chemotherapy Anti-cancer drugs have the function of inhibiting the growth and reproduction of cancer cells and killing cancer cells, which can be applied alone in advanced lung cancer cases as palliative treatment to relieve symptoms. In more cases, they are used in combination with surgery or radiotherapy to prevent metastasis and recurrence of cancer and improve long-term survival rate. 3.1 Improvement of chemotherapy chemotherapy is one of the main strategies for the multidisciplinary comprehensive treatment of non-small cell lung cancer. According to CALGB9633 in the United States and BR102 in Canada, studies have shown that early-stage patients, third-generation chemotherapy regimens, adequate number of cycles, and timely completion of chemotherapy are important key factors for the success of adjuvant chemotherapy after complete resection for non-small cell lung cancer. Pre-surgical neoadjuvant chemotherapy reduces tumor stage and improves surgical resection rates and may improve long-term survival in patients with stage III NSCLC. numerous clinical studies and meta-analyses by Souquet et al. have shown that chemotherapy significantly improves survival and its quality of life compared to best supportive care. Platinum has been dominant in chemotherapy, and platinum in combination with new chemotherapeutic agents is currently the preferred regimen for the treatment of advanced NSCLC. These new chemotherapeutic agents include gemcitabine (gemcitabin), vincristine (vinorelbine), paclitaxel (paclitaxel), and the GP, NP, and PC regimens, respectively. According to the literature, these chemotherapy regimens have higher efficacy than the traditional commonly used regimens CAP (CTX, ADM, PDD) regimen and EP (VP-16, PDD) regimen, all of which can be used as first-line chemotherapy regimens for the treatment of advanced non-small cell lung cancer. Gemcitabine has cell cycle specificity and is an antimetabolic anticancer drug that acts mainly in the DNA synthesis phase (S phase) and can stop the progression from G1 phase to S phase under certain conditions, and its cytotoxic effect in vitro is dose- and phase-dependent. The mechanism of vincristine is to block the polymerization of microtubule proteins to form microtubules and induce microtubule depolymerization to stop cell growth at mid mitosis. Paclitaxel interferes with the division process of microtubule system and prevents mitosis of tumor cells. Second-line treatment with doxorubicin is recommended for locally advanced or metastatic NSCLC that has progressed after first-line platinum-containing regimen chemotherapy and has appropriate behavioral status; although two large multicenter phase III randomized controlled studies published back-to-back in JClinOncol (2004, 22:777) both showed that gefitinib (Gefinitib) in combination with chemotherapy did not improve the efficacy of advanced non-small cell lung cancer. However, experts continue to recommend gefitinib as second- or third-line therapy alone for non-small cell lung cancer that has failed after platinum and paclitaxel chemotherapy. The main side effects of these chemotherapy regimens are bone marrow suppression, hand-foot syndrome, and neurotoxicity. Excessive duration of therapy can lead to toxicity buildup and cause other treatment-related signs and symptoms. This makes the most appropriate course of chemotherapy for non-small cell lung cancer a very salient issue at this time, with data showing that most patients experience very limited benefit from increasing treatment after 3 to 4 cycles of chemotherapy. The American Society of Clinical Oncology (ASCO) expert panel recommends that even in patients with effective chemotherapy, initial chemotherapy should not exceed 6 cycles. Current thinking:For those patients with stage III unresectable NSCLC selected for combination chemoradiotherapy, the duration of initial chemotherapy is no more than 4 cycles of platinum-containing regimens; for patients with first-line chemotherapy-naïve stage IV NSCLC, chemotherapy should be stopped at 4 cycles. For patients with stage IV NSCLC, chemotherapy should not exceed 6 cycles. Patients with malignant pleural effusion in non-small cell lung cancer can be treated with tetracycline, cisplatin and flumetinol (Cytomel) 3 drugs by thoracic infusion with comparable efficacy to combined chemotherapy alone but with less bone marrow suppression and liver and kidney damage. 3.2 Progress of biological therapy Because of the lack of specificity of chemotherapy and radiotherapy, the efficacy of chemotherapy and radiotherapy is often accompanied by large toxic side effects to patients. Therefore, selecting the specific molecular target of lung cancer cells and applying drugs targeting that target for treatment can achieve significant efficacy while avoiding harm to normal cells. This highly effective and low side effect treatment mode is increasingly recognized by oncology academia and patients. (1) Gene therapy: It is to introduce specific cloned gene fragments into tumor cells to produce inhibitory or killing effects to change the behavior of tumor cells or induce their death. The representative has monoclonal antibody:Herceptin. Combined Herceptin combined with Kenzyme+cisplatin chemotherapy for advanced NSCLC showed that:Herceptin combined with chemotherapy has no significant increase in chemotherapeutic efficacy, but there may be some benefit in patients with HER-2/neu (++++). Angiogenesis inhibitor:Hydroxytalinen, which is a monomeric component isolated and synthesized from the raw material of huachanin that can target to completely kill tumor cells in human body and inhibit tumor angiogenesis. (2) Immunotherapy: By improving the immune recognition ability and immune response of the body, immune resistance or immune suppression can be lifted. Mainly OK432 (sapropterin), high polyglucagon, interferon (IFN), interleukin 2, colony cell stimulating factor. With the rapid development of molecular biotechnology, active specific immunotherapy with lung cancer vaccines has become a promising therapeutic approach for anti-lung cancer treatment. Novel vaccine trials have obtained positive clinical results. However, how to select the appropriate therapeutic target is the next research direction. 3.3 Traditional Chinese medicine is mainly based on deficiency tonicity, detoxification and expectoration of phlegm and elimination of blood stasis. It is mainly used as an adjuvant drug for tumor chemotherapy, with the effects of anti-cancer, whitening and improving immune function, which can improve the quality of survival and prolong the survival period. Huachanin is a typical representative of these drugs, which has the effects of expelling cancer toxins, relieving accumulation and pain, and softening and dispersing nodules. It is also a cell cycle specific drug, mainly acting in S phase. At the same time, Chinese wolfberry polysaccharide, shiitake mushroom polysaccharide and yunzhi polysaccharide are also widely used in clinical practice. At present, there are more studies on ginsenosides and ganoderma lucidum components.