To investigate the surgical approach to lung cancer with malignant pleural fluid. Methods A retrospective analysis of 15 patients treated with elective pleuropulmonary resection among 76 patients with lung cancer with malignant pleural fluid admitted to the Department of Thoracic Surgery of our hospital was performed, and a comprehensive evaluation was conducted in conjunction with literature reports. Results Surgical treatment effectively controlled the pleural fluid and significantly prolonged the mean survival time of the patients. Conclusion The presence of malignant pleural fluid is not an absolute contraindication to lung cancer surgery, and the selection of appropriate surgical treatment can improve the quality of life and prolong survival.
Most lung cancer patients with invasive pleura and malignant pleural fluid at the time of consultation belong to stage IIIb with an average survival of 3 months, which is usually regarded as a contraindication to surgery. In recent years, 76 lung cancer patients with malignant pleural fluid were admitted to our thoracic surgery department, among which 15 cases were treated with surgery-based comprehensive treatment and achieved better results. The results are reported as follows:
1.Data and methods
1.1 Clinical data
Among the 76 patients, 49 were male and 27 were female, aged 33-76 years. The cytopathological classification of pleural fluid, fibrinoscopy and CT lung puncture was 56 cases, including 32 cases of adenocarcinoma, 9 cases of squamous carcinoma, 7 cases of adenosquamous carcinoma and 8 cases of small cell carcinoma. 15 surgical patients, 9 males and 6 females, aged 35-74 years. The lesions were located in the left lung in 6 cases, 3 of which were central; in the right lung in 9 cases, 4 of which were central. The diameter of the mass ranged from 3.0 to 16.0 cm.
There were 12 cases with moderate pleural volume and 3 cases with massive effusion. 4 cases had main bronchial involvement and 10 cases had hilar and/or mediastinal lymph node metastasis. In all cases, no distant metastases were found preoperatively, there were no serious lesions in important organs such as heart, liver and kidney, lung function suggested that at least lobectomy could be tolerated, and lung occupancy and pleural fluid lesions were in the same side of the chest.
1.2 Treatment methods
All surgeries were performed using double-lumen tracheal intubation with intravenous complex general anesthesia and standard posterior lateral incision into the chest. 3 cases of pleural exfoliation lobectomy; 8 cases of limited pleural lobectomy; and 4 cases of total pleural lung resection, 5 of which had intrapericardial vascular treatment. Intraoperative lymph node dissection of the hilum, mediastinum, and inferior bullae was performed simultaneously. Before chest closure, hot distilled water chest irrigation was given. Postoperatively, conventional chemotherapy was given according to the pathological findings. EP (cisplatin + pedialyte glycoside) regimen was used for small cell lung cancer, and GP (Zephyr + cisplatin) regimen was used for non-small cell lung cancer.
2.Results
There was no death in 15 patients after surgery, chest pain and chest tightness were all relieved to different degrees, and pleural fluid disappeared completely in 9 cases, accounting for 75%. Postoperative pathological examination confirmed 4 cases of squamous cell carcinoma, 7 cases of adenocarcinoma, 3 cases of adenosquamous carcinoma, and 1 case of small cell lung cancer. Follow-up results: postoperative survival ranged from 7 to 36 months, with a median survival of 13.8 months.
3.Discussion
Advanced lung cancer can often be accompanied by malignant pleural fluid, mostly of the peripheral type, and the pathological type is mainly adenocarcinoma. According to the latest lung cancer staging criteria established by UICC in 1997, any pleural invasion and malignant pleural fluid is considered stage IIIb, and the prognosis is very poor, and the patient has only 3 months from definite diagnosis to death [1]. For this group of patients. Most of the current popular treatments are pleural puncture and aspiration, closed drainage, intrapleural injection of chemotherapeutic drugs or sclerosing agents, etc. Although they relieve patients’ symptoms to a certain extent, they do not eradicate the root cause of pleural fluid production.
The median survival of primary lung cancer combined with malignant pleural fluid is 5-6 months with conservative internal medicine treatment. The postoperative survival of our cases reached 7 to 36 months, with a median survival of 13.8 months, which is better than that of conservative medical treatment. Similar reports have been made in China. Therefore, lung cancer combined with malignant pleural fluid is not an absolute contraindication to surgery. As long as the cases and surgical methods are selected appropriately, the survival time of patients can be prolonged, the pleural fluid can be effectively controlled and the quality of life can be improved.
We believe that the selection of cases should have the following characteristics.
(1) No metastasis to important organs or distant organs;
(2) Normal function of heart, liver, kidney and other organs;
(3) Preoperative pulmonary function tests suggesting that at least lobectomy can be tolerated;
(4) Pleural metastases;
(5) The lesion is in one side of the chest.
Currently, total pleuropneumonectomy is considered a radical procedure for the treatment of lung cancer with malignant pleural fluid. On the one hand, the resection of the diseased lobe eliminates the tumor itself; on the other hand, the resection of the pleura inhibits the production of pleural fluid. Liang Qingzheng et al [4] reported 62 cases of lung cancer with malignant pleural fluid treated by total pleuropneumonectomy supplemented with chemotherapy, and their survival rates at 1, 2 and 3 years were 93.4%, 48.4% and 25.8%, respectively. Total pleuropneumonectomy has been opposed by some scholars because of the large trauma, much blood leakage and long operation time.
In order to improve its shortcomings, we performed selective pleuropneumonectomy in eight older patients with poor lung function, removing only the pleura where metastatic lesions occurred. This procedure is simple, less invasive, and shorter, and avoids the effects of massive blood leakage and large invasive surfaces on cardiopulmonary function, thus, expanding the indications for the procedure. Zhang Guoliang et al [5] chose limited pleuropneumonectomy lesion resection to treat 14 cases of lung cancer with malignant pleural fluid, and the median survival reached 16.5 months, and also considered this procedure to be of promotional value.
The intraoperative use of hot distilled water irrigation can take advantage of the hypotonicity of distilled water, which has destructive and toxic effects on cancer cells and further reduces the production of postoperative pleural fluid. We believe that surgical treatment of lung cancer combined with malignant pleural fluid is in line with the “tumor reduction principle” of tumor treatment, and the control of pleural fluid is significantly better than that of conservative medical treatment, which is a practical and effective treatment method.