NSCLC Surgical Treatment
History and current status of surgical treatment of lung cancer
Incidence.
The incidence of lung cancer has been increasing year by year and was rare in the early 20th century.
By the early 1990s, the incidence of lung cancer in Europe and the United States had taken the first place in malignant tumors.
Nowadays, among the deaths of malignant tumors among urban residents in China, lung cancer has risen to the first place, accounting for 1/3 of the deaths of malignant tumors, and the number of deaths is more than the sum of breast cancer, prostate cancer and colon cancer.
The number of lung cancer patients in China continues to increase
Lung cancer incidence rate in China continues to rise
History of lung cancer surgery.
1933 First total lung resection for lung cancer in the United States
The first total pneumonectomy for lung cancer in China in 1941
In the 1950s, the concept of lobectomy replaced whole lung, achieving the same efficacy as whole lung, and reducing the mortality and complications of surgery.
In the 1970s, bronchoplasty and rhomboplasty were performed.
In the 1980s, lymph node dissection was performed.
In the 1990s, cardiovascular surgery techniques were applied to locally advanced lung cancer, and enlarged resection and cardiac revascularization were performed.
In the last 10 years, surgery-based comprehensive treatment can improve survival rates and individualize treatment.
Current status of lung cancer surgical treatment.
At present, the basic treatment principle of lung cancer is still to strive for early surgical treatment, and to strive for surgery-based comprehensive treatment for patients with intermediate and advanced stages.
With the improvement of surgical skills and monitoring, the resection rate of lung cancer is increasing, complications and mortality rate are decreasing, and the overall 5-year survival rate after surgery has reached 30%-42% (surgery is the first choice of treatment for operable patients, but only 20% of patients are suitable for surgery)
NSCLC Stages and Surgical Treatment
-Stage 1: Early stage lung cancer. Lung tumors are found only in one and have not spread to the lymph nodes.
-Stage II: Tumor has spread to the lymph nodes and is contained in the surrounding lung.
-Stage 3: The tumor has spread outside the lymph nodes to the lung and trachea area, including the chest wall and septum where the cancer begins on the same side.
-Hope stage: The tumor has spread to the lymph nodes on the opposite side of the lung or neck.
-Stage IV: Tumor in the lung has spread to other parts of the body or to the whole body coldly.
Effectiveness of surgical treatment for stage I and II NSCLC
Domestic reported 5-year survival rate after surgery Ⅰa 80%-83%, Ⅰb 62%-65%; the overall 5-year survival rate after stage II surgery is about 50%, but the invasion of dirty pleura is 32%, and the invasion of non-invasive is 58% Foreign bulk follow-up data show that the 5-year survival rate of patients with stage I and II NSCLC treated with surgery is 64.6% and 41.2%, respectively
The efficacy of surgical treatment for stage I and II NSCLC has been recognized and agreed upon.
Lymph node dissection
There are two main modes of mediastinal lymph node dissection for lung cancer
1. Mediastinal lymph node sampling, which mainly emphasizes selective resection of lymph nodes, as well as removal of ipsilateral mediastinal lymph nodes that are suspected to have cancer metastasis. (US blue labeling and isotope tracing are used to find out the anterior lymph nodes)
2. Systematic mediastinal lymph node dissection, which requires the removal of the mediastinal lymph nodes together with the surrounding adipose tissue as a whole.
The use of these two modalities is controversial. Many scholars believe that systematic mediastinal lymph node dissection is necessary for patients with early stage lung cancer.
Treatment of stage IIIA (N2) NSCLC
What is N2 and how should treatment be selected? What is the effectiveness of treatment?
N2 refers to lung cancer with ipsilateral mediastinal or subserosal lymph node metastasis. 40% to 45% of patients present with N2 at the time of consultation.
The treatment options for NSCLC with N2 (stage IIIA) are still divided.
According to the data, the indications for surgical treatment of N2 NSCLC are tumors limited to T1 or T2, non-adenocarcinoma cell types, and no more than three mediastinal metastatic lymph nodes.
For N2 lung cancer, the 5-year survival rate is 20% to 40% with complete surgical resection; 9% to 18% with incomplete resection, with an average of 10%.
Treatment of stage IIIA (T3) NSCLC
Patients with preoperative diagnosis of T3 should be actively examined for metastases in mediastinal lymph nodes. (Whether T3N2 patients are suitable for surgical treatment deserves further study)
Surgical treatment for chest wall invasion: 5%, resection including lung, invaded soft tissue (wall pleura or intercostal muscle) or bone (ribs) and mediastinal lymph node dissection, and the cut edge is >2cm from the tumor.
Treatment outcomes for stage IIIA (T3) NSCLC
Prolonged patient survival Overview of chest wall resection for lung cancer Authors n Factors influencing survival (%) Dilege 43 34(3 years) complete resection, node involvement Roviaro 146 22.7(5 years) performance of radical total resection (1970 – 1979) 14.1(5 years) (1980 – 1989) 42.7(5 years) (1990 – 1999) Facciolo 104 61.4 (5 years) Complete resection, node involvement, and depth of chest wall invasion. Burkhar 94 38.7(5 years) node involvement and sex-related
treatment of stage IIIA (T3) NSCLC
Invasion of the main bronchus without invasion of the bullae: the margin of bronchus resection should be > 1.5 cm from the sarcomere margin of the tumor. if these requirements cannot be met by conventional lobectomy, then sleeve lobectomy or total pneumonectomy should be considered for radical resection.
Deslauriers et al. operated on 1230 patients, 1046 with total pneumonectomy and 184 with bronchial sleeve resection, with 5-year survival rates of 31% for the former and 52% for the latter.
Extended resection for stage IIIb (T4) NSCLC
It is not uncommon for stage IIIB lung cancer to invade the heart, large blood vessels, esophagus, trachea, etc. Without surgical resection, the efficacy of radiotherapy or medical treatment is not good, and most of the patients die within 3-4 months.
Recent studies have found that although the disease is advanced, many patients do not have distant metastases. Selective radical pneumonectomy with dissection, blockage, resection and reconstruction of the invaded large blood vessels, followed by combined radiotherapy and chemotherapy, has been widely used and appreciated. Pulmonary angioplasty
For lung cancer without distant or extensive lymph node metastasis, but simply due to tumor or lymph node invasion of adjacent organs (also known as locally advanced non-small cell lung cancer (LANSCLC)), surgical resection of lesions and affected tissues, and the necessary organ reconstruction is called expanded resection of lung cancer.
The common ones are: intrapericardial treatment of pulmonary vessels, pulmonary arterioplasty, superior vena cava repair or replacement, partial atrial resection, bronchoplasty, rongeur resection and reconstruction, aortic repair and replacement, esophageal resection and reconstruction, extracorporeal circulation assisted lung cancer resection.
Giant lung cancer of the left lung
Lung cancer tracheoplasty and augmentation
Currently, the most common cause of SVCS is lung cancer, and it is reported that more than 80% of SVCS are secondary to right-sided primary bronchopulmonary cancer.
The clinical presentation depends on the urgency of the onset, the location and degree of compression, and the condition of the collateral circulation. SVCS with lung cancer is usually caused by direct invasion of the cancer and compression by enlarged mediastinal lymph nodes, and is a manifestation of advanced lung cancer.
Surgery and postoperative management of patients with lung cancer involving the superior vena cava are relatively complicated, and the indications should be mastered.
Patients are in good general condition and can tolerate surgery. The tumor or local lymph node metastasis is limited and can be removed surgically (no hematogenous metastasis confirmed by examination and not in stage N3; caution should be exercised for extensive stage N2).
Preferably NSCLC, more limited small cell lung cancer (T4N0 stage) should not be a contraindication.
Survival after superior vena cava replacement
Expanded lung cancer resection (T4 aorta)
Expanded aortic partial resection and revascularization carried out in recent years have been seen in several reports, especially Japanese scholars have explored more in this field.Chida et al [29] reported 3 cases of patients with T4N0 undergoing expanded aortic resection, of which 2 cases survived aneurysm-free for 37 and 26 months, respectively, and 1 case had adrenal metastasis for 8 months after surgery. Zhou Qinghua et al. reported 4 patients with enlarged aortic resection with a 5-year survival rate of 33.3%. Since the operation of expanded aortic resection is complicated and the surgery needs to be performed under extracorporeal circulation, the indications should be strictly controlled.
Surgical treatment of stage IV NSCLC
The NSCLC Clinical Practice Guidelines (NCCN) recommend subdividing stage IV NSCLC into two categories: single metastases and multiple metastases.
In cases of single metastases, it is important to obtain a pathological diagnosis rather than a diagnosis based on imaging, including PET.
It is important to distinguish isolated metastases in the brain or adrenal glands or contralateral lung, because for isolated metastases in these three sites, surgical intervention based on systemic therapy is likely to have a better long-term survival benefit than chemotherapy alone.
Surgical treatment of stage IV NSCLC
Adrenal metastases are very common in lung cancer, and data show that 33% of patients with lung cancer are found to have adrenal metastases at autopsy.
Adrenal masses found on preoperative CT scan should be biopsied to exclude benign lesions. If the biopsy confirms adrenal metastasis from lung cancer and the primary lung tumor is a completely resectable stage I or II lesion, surgical resection of the adrenal gland and primary lung cancer may still provide long-term survival benefits.
Surgical treatment of stage IV NSCLC
Isolated pulmonary nodules in different lobes of the ipsilateral lung or contralateral lung outside of the primary lung tumor, even if their pathology is identical,
The NCCN recommends treating them as two primary lung cancers rather than simply classifying them as M1 according to the 1997 staging method.
The NCCN Clinical Practice Guidelines for NSCLC recommend that for NSCLC with a single brain metastasis and a resectable lung lesion, the brain lesion may be surgically resected or treated with stereotactic radiation therapy, while the primary thoracic lesion should be treated according to the staging principles.
Surgical treatment of stage IV NSCLC
The overall median survival time for brain metastases is 11 months, and the 5-year survival rate is 14%.
The median survival time is 20 months and the 5-year survival rate is 21% if both the brain metastases and the primary lung tumor are completely resected.
The mortality rate for surgical resection is 2%.
The main advantages of surgical treatment are: symptom relief, reduction of complications caused by the tumor itself such as extrusion, metastasis, metabolism, pain, and respiratory changes, and opportunities for postoperative and other systemic treatments.
Radiotherapy
Decompression surgery for stage IIIB and IV NSCLC
Malignant pleural effusion and pericardial effusion caused by pleural and pericardial metastasis are common complications of stage IIIB and IV lung cancer. If systemic chemotherapy and local drainage still cannot effectively control malignant exudation, adjuvant surgical treatment can be considered.
Surgical methods: thoracoscopic pericardial resection, thoracoscopic pleural fixation and adhesions or pleural debridement, or wedge resection if the cancer is peripheral.
For pain and fracture caused by bone metastases, if chemotherapy and radiotherapy cannot relieve the pain, local bone resection such as rib resection can be considered for non-weight-bearing bones, while internal fixation or even joint replacement can be considered for weight-bearing bones.
In conclusion, the use of surgical methods to reduce the symptoms and improve the quality of life of patients with advanced lung cancer should not be neglected in the multidisciplinary comprehensive treatment of advanced NSCLC.
Minimally invasive treatment of lung cancer
The goal of minimally invasive surgery is to achieve a new medical paradigm that maximizes the psychological and physical recovery of patients after treatment.
Chest wall perforation with preservation of chest wall muscles is the most commonly used minimally invasive surgical method and is the development direction of surgical procedures for early stage lung cancer.
The dissection of hilar vessels and bronchi and the dissection of mediastinal lymph nodes are performed with thoracoscopic instruments or general surgical instruments.
Total thoracoscopic lobectomy is one of the most important advances in the field of thoracic surgery in recent years and is a major component of minimally invasive thoracic surgery.
Lymph node dissection meets the requirements of open-heart surgery.
Faster recovery
2012 NCCN Guidelines for Non-Small Cell Lung Cancer
VATS is included in the standard of care for early stage lung cancer
The incision is small, the injury is light, the ribs are not removed, the chest is opened and closed quickly, the blood loss during surgery is low, the lung tissue is not crushed and stretched, and the patient’s lung function is less damaged.
It reduces the postoperative pain of patients, reduces the impact on respiratory function, fast recovery, less complications, short hospitalization time and good cosmetic effect.
Neoadjuvant chemotherapy
Some stage III NSCLC, i.e. locally advanced NSCLC, including stage IIIA and stage IIIB lung cancer, fail to be treated by surgery alone mainly because of local tumor recurrence and distant metastasis. Selective surgical treatment strategy, i.e. preoperative neoadjuvant chemotherapy, is a better way to improve the long-term survival rate of NSCLC, which has been promoted by domestic and foreign experts in recent years. It is mainly used for stage IIIa or IIIb NSCLC with large lesions that are estimated to be incompletely resected by surgery, and chemotherapy is used to create conditions for surgery.
Neoadjuvant chemotherapy is viewed as a cytoreductive therapy that can serve the purpose of reducing tumor volume, decreasing tumor load or/and decreasing disease stage, and eliminating subclinical metastatic lesions at an early stage to improve complete surgical resection and local tumor control rate and prolong patient survival through preoperative chemotherapy.
Domestic data reported a controlled study of preoperative chemotherapy for stage III non-small cell lung cancer, and the results showed that the long-term survival rate of preoperative chemotherapy was better than that of the surgery-only group, with 5 and 10-year survival rates of 34.39%, 29.34%, and 24.19%, 2l.64%, respectively. Zhou Qinghua reported that the surgical resection rate was 93.96% in the preoperative neoadjuvant chemotherapy group and 91.94% in the control group, and the survival rates at 1, 3, 5 and 10 years after surgery were 89.35%, 67.46%, 34.39% and 29.34% in the neoadjuvant chemotherapy group, compared with 87.53%, 51.54%, 24.19% and 21.64% in the surgery followed by chemotherapy group. The 5-year postoperative survival rate in the preoperative neoadjuvant chemotherapy group increased by 10.2% and the 10-year survival rate increased by 7.7% compared with the control group. The results showed that preoperative neoadjuvant chemotherapy significantly reduced the disease stage of stage III NSCLC and improved postoperative survival and patient life.