I. Chemotherapy
Chemotherapy is the main treatment method for lung cancer, and more than 90% of lung cancers need chemotherapy treatment. The efficacy of chemotherapy on small cell lung cancer is more certain in both early and late stage, and even about 1% of early stage small cell lung cancer is cured by chemotherapy. Chemotherapy is also the main treatment for non-small cell lung cancer, and the tumor remission rate of chemotherapy for non-small cell lung cancer is 40% to 50%. Chemotherapy generally cannot cure non-small cell lung cancer, but can only prolong patients’ survival and improve their quality of life. Chemotherapy is divided into therapeutic chemotherapy and adjuvant chemotherapy. Chemotherapy requires different chemotherapeutic drugs and different chemotherapy regimens according to different histological types of lung cancer. Besides killing tumor cells, chemotherapy also damages normal cells in human body, so chemotherapy needs to be carried out under the guidance of oncologists. In recent years, the role of chemotherapy in lung cancer is no longer limited to patients with inoperable advanced lung cancer, but is often included in the comprehensive treatment plan of lung cancer as systemic treatment. Chemotherapy can suppress the bone marrow hematopoietic system, mainly the decline of white blood cells and platelets, which can be treated with granulocyte colony-stimulating factor and platelet-stimulating factor. Chemotherapy is divided into therapeutic chemotherapy and adjuvant chemotherapy.
Second, radiation therapy
1.Treatment principle
Radiotherapy has the best effect on small cell lung cancer, followed by squamous cell carcinoma and the worst adenocarcinoma. The radiation field of radiotherapy for lung cancer should include the primary foci and the mediastinal area of lymph node metastasis. It should be supplemented with drug therapy. Squamous cell carcinoma has moderate sensitivity to radiation, and the lesion is mainly locally invasive and metastases relatively slowly, so it is mostly treated with radical treatment. Adenocarcinoma has poor sensitivity to radiation and is prone to bloodstream metastasis, so radiation therapy alone is less often used. Radiotherapy is a local treatment and often needs to be combined with chemotherapy. The combination of radiotherapy and chemotherapy can be synchronized or alternated depending on the patient’s condition.
2.The classification of radiotherapy
According to the purpose of treatment, it is divided into radical treatment, palliative treatment, preoperative neoadjuvant radiotherapy, postoperative adjuvant radiotherapy and intracavitary radiotherapy, etc.
3.Complications of radiotherapy
Complications of radiotherapy for lung cancer include: radiation pneumonia, radiation esophagitis, radiation pulmonary fibrosis and radiation myelitis. The complications related to radiotherapy mentioned above are positively related to the dose of radiotherapy, and there are also individual differences.
Complications of radiotherapy for lung cancer include: radiation pneumonia, radiation esophagitis, radiation pulmonary fibrosis and radiation myelitis. These complications are positively correlated with the dose of radiotherapy, and there are also individual differences.
Surgical treatment of lung cancer
Surgery is the first and main treatment method for lung cancer, and it is also the only treatment method that can cure lung cancer. The objectives of surgical treatment for lung cancer are
Completely remove the primary lesion of lung cancer and metastatic lymph nodes to achieve clinical cure.
Removal of the vast majority of the tumor to create favorable conditions for other treatments, i.e., reduction surgery.
Reduction surgery: suitable for a small number of patients, such as refractory pleural cavity and pericardial effusion, to cure or relieve clinical symptoms caused by pericardial and pleural cavity effusion, prolong life or improve quality of life by removing pleural and pericardial implant nodes and removing part of pericardium and pleura. Reduced-status surgery requires concomitant local and systemic chemotherapy. Surgical treatment often requires preoperative or postoperative adjuvant chemotherapy and radiotherapy treatment to improve the cure rate of surgery and patient survival. The five-year survival rate of lung cancer surgical treatment is 30%-44%; the mortality rate of surgical treatment is 1%-2%.
1.Surgical indications
Surgical treatment of lung cancer is mainly suitable for early and middle stage (I-II) lung cancer, stage IIIa lung cancer and part of selective stage IIIb lung cancer with tumor confined to one side of the chest cavity.
(1) Stages I and II lung cancer.
(2) Stage IIIa non-small cell lung cancer.
(3) Partial stage IIIb non-small cell lung cancer with lesions confined to one side of the chest cavity that can be completely resected.
(4) Patients with stage IIIa and some stage IIIb lung cancers that have been downgraded after preoperative neoadjuvant chemotherapy
(5) Non-small cell lung cancer with isolated metastases (i.e. intracranial, adrenal or hepatic), if both the primary tumor and metastases are suitable for surgical treatment and there are no contraindications to surgery and complete resection of the primary tumor and metastases can be achieved
(6) Non-small cell stage IIIb lung cancer with a clear diagnosis, where the tumor invades the pericardium, large blood vessels, diaphragm, and tracheal ramus, where distant or/and micrometastases have been excluded by various examinations, where the lesion is limited, where the patient has no physiological contraindications to surgery, and where complete resection of the tumor-invaded tissue and organs can be achieved.
2.Contraindications to surgery
(1) Stage IV lung cancer with extensive metastases
(2) patients with multiple fused mediastinal lymph node metastases, especially invasive mediastinal lymph node metastases
(3) Stage IIIb lung cancer with contralateral hilar or mediastinal lymph node metastasis
(4) Those with severe visceral insufficiency that cannot tolerate surgical procedures.
(5) Those who suffer from bleeding disease and cannot be corrected.
3.Selection of surgical procedure for lung cancer
The principles of surgical resection are: complete removal of the primary foci and lymph nodes with potential metastasis in the chest cavity, and preservation of normal lung tissues as much as possible.
(1) Lung wedge and partial resection refers to wedge-shaped cancer block resection and partial lung segment resection. It is mainly suitable for early stage lung cancer with small volume, old and weak, poor lung function or low malignancy of well differentiated cancer.
(2) Segmental lung resection is the resection of anatomical lung segments. It is mainly suitable for isolated early lung cancer of peripheral type with old age and poor cardiopulmonary function, or partial central lung cancer with limited lesions located at the root of the lung cancer.
(3) lobectomy lobectomy is suitable for peripheral type and partially central type lung cancer whose lung cancer is confined to one lobe, and central type lung cancer must ensure that no cancer remains in the bronchial stump. If the lung cancer involves both lobes or the middle bronchus, two lobectomies in the upper or lower middle lobe are feasible.
(4) Bronchial sleeve shaped lobectomy This procedure is mainly suitable for central type lung cancer in which the lung cancer is located in the bronchus of the lobe or the opening of the middle bronchus. The advantage of this procedure is that it achieves complete resection of the lung cancer while preserving healthy lung tissue.
(5) Bronchopulmonary artery sleeve shaped lobectomy This type of surgery is mainly suitable for central type lung cancer in which the lung cancer is located in the bronchi of the lobe or the opening of the middle bronchi and the lung cancer also invades the pulmonary artery trunk. In addition to bronchial resection and reconstruction, the surgery also requires simultaneous resection and reconstruction of the pulmonary artery trunk. The advantage of this procedure is that it achieves complete resection of the lung cancer while preserving healthy lung tissue.
(6) Tracheal rung resection and reconstruction When the lung tumor exceeds the main bronchus involving the rung or the lateral wall of the trachea but does not exceed 2 cm, tracheal rung resection and reconstruction or sleeve total pneumonectomy can be performed, and if a lobe of the lung is still preserved, tracheal rung resection and reconstruction with preservation of the lobe should be strived for.
(7) Total pneumonectomy total pneumonectomy refers to the whole lung on one side, i.e. right or left side total pneumonectomy, which is mainly suitable for lung cancer with good cardiopulmonary function, more extensive lesions and younger age, not suitable for lobectomy or sleeve lobectomy. The complication rate and mortality rate of total pneumonectomy are higher, and the long-term survival rate and quality of life of patients are not as good as lobectomy, so the indications for surgery should be strictly grasped.
4.Surgical treatment of recurrent lung cancer
Recurrent lung cancer includes the recurrence of local residual cancer after surgery and the new occurrence of second primary lung cancer in the lung. For recurrence of residual cancer of bronchial stump, re-operation should be pursued and bronchial sleeve molding should be performed to remove the residual cancer.
For the second primary lung cancer occurring after complete lung cancer resection, as long as the lung cancer is suitable for surgical treatment, the patient’s visceral function can tolerate reoperative treatment, and there are no problems in surgical technique, reoperation to remove the recurrent lung cancer should be considered.