Surgery is currently the most important treatment for lung cancer, and its effect is better than other treatments such as radiotherapy, chemotherapy and targeted therapy. However, not all patients are suitable for surgical treatment. Patients are often concerned about whether they are eligible for surgery, especially those who are diagnosed with mid- to late-stage lung cancer. Inability to undergo surgery often indicates a high degree of disease progression or a decrease in the body’s ability to tolerate surgery.
Forced resection without surgery will not only fail to benefit survival, but also add trauma to the already weak body. Therefore, the judgment of surgical conditions is quite important. The following descriptions of surgical treatment in the Chinese Code of Practice for the Treatment of Primary Lung Cancer (2015 edition) are of guidance.
The details are as follows.
Principles of surgical treatment Anatomical pneumonectomy is the main treatment for early-stage lung cancer and an important method for clinical cure of lung cancer at present. Lung cancer surgery is divided into complete resection, incomplete resection and indeterminate resection. Complete resection should be strived for in order to achieve complete removal of tumor, reduce metastasis and recurrence, and perform accurate pathological TNM staging and strive for molecular pathological staging to guide comprehensive postoperative treatment. The following surgical principles should be observed for surgically resectable lung cancer.
(1) Comprehensive treatment planning and necessary imaging examinations (clinical staging examinations, especially accurate N-staging) should both be completed prior to surgical treatment. Adequate evaluation determines the possibility of surgical resection and develops a surgical plan.
(2) Complete resection of the tumor and regional lymph nodes should be achieved as much as possible, while preserving as much functional normal lung tissue as possible.
(3) Television-assisted thoracoscopic surgery is a minimally invasive thoracic surgical technique that has matured in recent years, and VATS and other minimally invasive means are recommended in the absence of contraindications to surgery.
(4) Anatomical pneumonectomy (lobectomy, bronchial and vascular sleeve lobectomy or total pneumonectomy) is feasible depending on the patient’s physical condition. If physical condition does not allow, sublobar resection is performed, of which anatomic lung segmental resection is preferred and wedge resection is also feasible.
(5) Indications for anatomic segmental lung resection or wedge lung resection are.
(i) Patients with advanced age or low lung function, or at major risk for lobectomy;
② CT suggestive of intrapulmonary peripheral type lesion (meaning located in the lateral 1/3 of the lung parenchyma) with a lesion diameter ≤50px and one of the following characteristics: pathologically confirmed adenocarcinoma; CT follow-up of more than 1 year highly suspicious of cancer; CT suggestive of solid component ≤50% in ground glass-like shadow.
(iii) Excision of lung tissue with a cut edge ≥ 50px from the lesion margin or a cut edge distance ≥ lesion diameter, and intraoperative rapid pathology was negative for cut edge;
④Systematic sampling of hilar and mediastinal lymph nodes should be performed before deciding on sublobectomy. At present, the sublobar resection for early-stage lung cancer is still in the clinical research stage, and participation in clinical research is encouraged, and it cannot be promoted as a standard procedure.
(6) In addition to complete resection of the primary lesion, systematic resection of each group of hilar and mediastinal lymph nodes (N1 and N2 lymph nodes) should be routinely performed for complete resection (R0 surgery), and the locations should be marked and sent for pathological examination. A minimum of 3 mediastinal drainage areas (N2 stations) should be cleared or sampled for lymph nodes to ensure whole lymph node resection as much as possible. It is recommended that the right thoracic lymph nodes be cleared to 2R, 3a, 3p, 4R, 7-9 groups of lymph nodes and surrounding soft tissue, and the left thoracic lymph nodes be cleared to 4L, 5-9 groups of lymph nodes and surrounding soft tissue.
(7) Usually the pulmonary veins, pulmonary arteries and finally bronchi should be treated sequentially intraoperatively, or the order of treatment should be decided according to the actual intraoperative situation.
(8) Bronchial sleeve lobectomy is the extent of resection performed to preserve as much lung tissue and lung function as possible under the condition of intraoperative rapid pathological examination to ensure negative margins (including bronchial, pulmonary artery or venous dissection), and the postoperative quality of life of patients is better than that of patients undergoing total pneumonectomy.
(9) In case of recurrence or isolated lung metastasis 6 months after complete lung cancer resection, resection of the recurrent lateral residual lung or lung metastasis is feasible if the extra-pulmonary distant metastasis and cardiopulmonary function and other organic conditions allow.
(10) Patients with stage I and II NSCLC whose cardiopulmonary function and other organic conditions are assessed to be inaccessible for surgery may choose radical radiation therapy, radiofrequency ablation therapy and drug therapy.
Indications for lung cancer pneumonectomy.
(1) Stage I, II and some stage IIIA (T1-2N2M0; T3N1-2M0; T4N0-1M0 completely resectable) NSCLC and stage I SCLC (T1-2N0M0).
(2) Some stage IV NSCLC with solitary contralateral lung metastasis and solitary brain or adrenal metastasis.
(3) Intrapulmonary nodules with high clinical suspicion of lung cancer, which cannot be diagnosed qualitatively by various examinations, may be surgically explored.
Contraindications to surgery.
(1)Those with poor general condition and the function of important organs such as heart, lung, liver and kidney cannot tolerate surgery.
(2) The vast majority of stage IV, most of stage IIIB and some of stage IIIA NSCLC with a clear diagnosis.