The incidence and mortality of lung cancer are rising rapidly, which is a worldwide trend. In many developed countries, lung cancer is the first common malignant tumor in men, and the second and third common malignant tumors in women. Smoking, passive smoking, environmental pollution, especially air pollution, are the chief culprits of this grim reality, but they are all long-standing problems that have not been solved. May 3 1 This year is the 20th World No Tobacco Day, but it is still far away. Smoking is considered to be the most important carcinogen of lung cancer. Another epidemiological trend is the significant change of lung cancer tissue types between men and women. The incidence of squamous cell carcinoma in men has greatly decreased (leading to a corresponding increase in the proportion of lung adenocarcinoma), and the incidence of adenocarcinoma in women has continued to increase. Lung cancer seriously harms people's health and threatens people's lives, but so far the treatment effect of lung cancer is very unsatisfactory. In the past half century, the incidence and mortality of lung cancer in all countries of the world have obviously increased. Respiratory symptoms such as irritating cough and blood in sputum often appear in the early stage, and the rapid progress of the disease is related to the biological activity of cells. The onset age of this disease is mostly over 40 years old, and the peak age of onset is between 60 and 79 years old. The prevalence of male and female is about 2.3: 1.
Causes of lung cancer
Roughly divided into the following categories
■⑴Smoking has been recognized as the most important carcinogen of lung cancer. In Europe and America, the risk of lung cancer due to smoking is about 90%. In 1980s, the risk of male lung cancer in Shanghai attributed to smoking was 70% ~ 80%. About 30% of female lung cancer is attributed to smoking and passive smoking. The risk of smoking cigarettes is higher than that of smoking cigars or pipes, and it is also higher than that of smoking bamboo hookah and long pipe hookah. The risk of smoking filter-free cigarettes or high-tar cigarettes is higher than that of smoking filter-tip cigarettes or low-tar cigarettes. The age at which you start smoking is an important factor. The earlier you start smoking, the greater the risk of lung cancer. The death rate of lung cancer in people who smoke for 60 years is about 100 times higher than that in people who smoke for 20 years. The smoke produced after cigarette ignition contains more than 3,000 kinds of toxic chemicals, the most important of which are nicotine, carbon monoxide, cyanide, various carcinogens, radioactive isotopes and heavy metal elements in cigarette tar. Carcinogens produced by tobacco combustion include benzopyrene, nitrosamine, β-naphthylamine, cadmium and radioactive polonium. There are also cancer-promoting substances such as phenolic compounds. The mortality rate of non-smoking women suffering from lung cancer due to their husbands' passive smoking is higher than that of non-smoking women (no passive smoking) 1~2 times. When smoking and occupational or environmental carcinogens have carcinogenic effects on people at the same time, the result is greater than the combined carcinogenic effects of individual factors, which is called synergistic effect. Smoking and drinking also play a synergistic carcinogenic role. If you smoke an average of 20 cigarettes a day, the risk of lung cancer is 20 times higher for smokers who have smoked for 20 years than for non-smokers. People who started smoking before the age of 20 died of lung cancer 28 times more than non-smokers.
Occupational causes of lung cancer: In 1970s, the incidence and mortality of lung cancer were extremely high in some industrial cities where factories were concentrated. At that time, some cities ranked first in various malignant tumors. At present, it is considered that occupational exposure to the following substances is related to the occurrence of lung cancer: asbestos, arsenic compounds, chromium compounds, nickel compounds, dichloromethyl ether, ionizing radiation, mustard gas and polycyclic aromatic hydrocarbons in soot, tar and oil. It is suspected that the factors related to lung cancer are beryllium, cadmium, lead, vinyl chloride, acrylic eye, chlorotoluene, thiomethane, glass fiber, silica dust, talcum powder, formaldehyde and so on. , as well as casting, rubber production, welding, construction, painting, production and application of certain pesticides, petroleum refining and other occupations. For example, the mortality rate of lung cancer among asbestos workers is 7 times higher than that of the general population, while the risk of smokers among asbestos workers is 50~90 times higher than that of the general population, which is caused by the synergistic effect of smoking and asbestos.
■⑶Environmental pollution such as air pollution: If industrial waste gas is not handled properly, it can pollute the environment and atmosphere inside and outside factories and mines. In addition, a lot of coal, diesel, gasoline, asphalt pavement and motor vehicles burned every day in cities will lead to air pollution in densely populated areas. It is disturbing that environmental pollution is still one of the important causes of illness and death of urban and rural residents. More than 0/0% of lung cancer cases in general cities/KLOC are caused by air pollution. Cooking fume and soot pollution in the kitchen is one of the reasons why non-smoking women suffer from lung cancer. In recent years, stone, paint, floor glue, plastic ornaments and adhesives used in indoor decoration have brought indoor pollution.
⑷ Indoor radon pollution: Radon is a radioactive substance, which widely exists in natural soil, rocks and building materials. It is the product of the decay of uranium and radium. Radon isotopes and their decay products are called radon daughters. As long as there is radon, there will be daughters, and radon and its daughters will endanger people's health. Radon can enter the room through the foundation, cracks in buildings, joints in building materials and loose parts of pipes entering the room, and radon may also escape into the room in building materials. The standard of radon concentration in indoor air in China is 100 baker/cubic meter. Starting from 1994, our country investigated 1524 office buildings and rooms in 14 cities, and found that the radon content exceeded the standard, accounting for 6.8%, and the highest was 596 beck/m3. During the period of 1990, the monitoring of basement in Beijing showed that 2.5% indoor radon concentration exceeded 200 beck/m3. Internationally, it is believed that the death rate of lung cancer of people exposed to radon concentration of 300~500 beck/m3 is twice as high as that of people with normal exposure level. Some studies estimate that there are about 24,000 cases of radon-induced cancer in the United States every year. In the United States, the harm of radon is considered to be the second largest lung cancer factor after smoking. The world health organization estimates that 5%~ 15% of all lung cancer patients in various countries are caused by indoor radon exposure.
■ Other risk factors of lung cancer: previous lung diseases, such as tuberculosis, pneumonia, chronic bronchitis and emphysema. However, compared with the above four factors, the previous disease history has less effect. The blood selenium content of residents in high incidence areas of lung cancer is low. Studies at home and abroad have proved that a certain amount of selenium can inhibit and prevent cancer.
Under the influence of internal and external factors, multi-gene mutation of oncogenes and tumor suppressor genes in human body causes multi-stage damage and repair errors of cells, which eventually leads to cancer. It is known that oncogene ras, myc, Rb and tumor suppressor gene p53 are related to the occurrence of lung cancer. After residents are exposed to the factors that cause lung cancer in the environment, most people have a long incubation period, about 20 to 30 years. Doctors often use a smoking index of more than 400 to enter the high incidence of lung cancer. Smoking index = average number of cigarettes per day × years of smoking. For example, someone started smoking at the age of 25 and smoked 20 cigarettes a day on average for 20 years (20 cigarettes ×20 years =400). At the age of 45, he entered a period of high incidence of lung cancer. Early lung cancer often has no obvious and special symptoms. The common early symptom is cough, mostly irritating dry cough, similar to chronic smoking cough, which can not attract the attention of patients. Cancer grows gradually in the lungs.
clinical picture
According to the frequency of occurrence, the most common pulmonary symptoms are: ① cough, mostly dry cough, no or little phlegm, accounting for 67% ~ 87% of all symptoms. Cough as the first symptom accounted for 55% ~ 68.4% of all cases. ② Hemoptysis occurred in 365,438+0.6% ~ 58.5% cases, mostly intermittent, with bloodshot or blood spots in sputum, and massive hemoptysis was rare. The first symptom was 1/3 of the total cases. Most people still attach importance to blood in sputum, which is one of the main reasons for patients to seek medical treatment. Doctors must make a careful diagnosis. X-ray, sputum exfoliative cytology and fiberoptic bronchoscopy are routine examinations when necessary, so don't take them lightly. ③ Chest pain accounts for 34.2% ~ 62% of cases, mostly dull pain, and 24% of cases begin with this symptom. If the pain is severe, the possibility of rib invasion of pleural implant should be considered. ④ Shortness of breath, appearing in 10% ~ 50% of cases, about 6.6% patients started with shortness of breath, which was caused by tumor blocking bronchus in the early stage, and may be relieved after short-term adaptation to shortness of breath. If the trachea is serious, it means pleural effusion or pericardial effusion, compression of trachea or carina or extensive lung metastasis, and the course of disease is late. ⑤ The incidence of fever is 6.6% ~ 39%, of which 265,438 0.2% comes from fever. Often accompanied by a low fever. The reason is that the tumor blocks the bronchus, leading to atelectasis of the distal lung segment, lobe and even the whole lung. If there is a secondary infection, the fever can last. This kind of obstructive pneumonia, sometimes X-ray manifestations such as lobar pneumonia, anti-inflammatory treatment is sometimes effective, and the diseased lung dilates and is misdiagnosed as simple pneumonia. However, inflammation often reignites in the original site from time to time. Segmental inflammation occurs repeatedly in a fixed part of the lung, so medical staff should be reminded that this inflammation is a symptom, which is caused by the tumor's substance blocking the bronchial cavity.
Severe chest pain, hoarseness, superior vena cava compression syndrome, brachial plexus nerve, sympathetic nerve, phrenic nerve invasion, dysphagia caused by esophageal compression, pericardial tamponade, severe bone pain, headache, liver pain, etc., are all late symptoms caused by tumor invasion and organ damage.
diagnose
■ 1.x-ray diagnosis is the most commonly used method to diagnose lung cancer, and its positive detection rate can reach over 90%. Including fluoroscopy, plain film, tomography, chest computer-aided tomography (CT), magnetic resonance imaging (MRI), bronchography and other methods. Because of its high resolution, CT is widely used. Bronchography and pulmonary angiography used in the past have been gradually replaced by them. The clinical principle is to check according to the above order from simple to complex, from less cost to more cost. The wide application of CT began in the 1970s. It is better than ordinary chest radiograph in understanding the lesion site, the relationship with surrounding organs, small pleural implantation or a small amount of effusion, segmental atelectasis, mediastinal lymphadenopathy, and tiny metastasis of lung cancer, but it also has its limitations. Because swollen lymph nodes are not necessarily equal to metastasis, inflammatory lymph nodes with a diameter greater than 1.5cm and cancerous metastatic lymph nodes with a diameter less than 0.5cm are often encountered, so only a single swollen lymph node can be suspected and cannot be considered as a surgical taboo. Of course, when it has merged into a ball, it should be diagnosed as metastasis. Ordinary chest radiographs show large lesions (slightly larger than the actual volume), which can clearly show their density, boundary, pleural changes, central liquefaction and other changes, so it is necessary to take plain films first, and then do chest CT if there is confusion. Abdominal CT is very helpful for observing the metastasis of abdominal organs, such as liver, kidney and adrenal gland.
The early X-ray manifestations of lung cancer are not ① isolated spherical shadow or irregular small piece infiltration; ② When inhaling deeply under fluoroscopy, the unilateral ventilation is poor and the mediastinum moves slightly to the affected side; ③ expiratory localized emphysema; ④ Mediastinal oscillation occurs during deep breathing; ⑤ If lung cancer progresses to block the lung segment or lobar bronchus, the gas at the distal end of the blocked part will be gradually absorbed, resulting in segmental atelectasis, which will form pneumonia or lung abscess if complicated with infection. General section can not only observe the tumor shape, density, location, hilar and mediastinal lymphadenopathy more clearly, but also understand the occlusion, stenosis, external pressure and intratubular tumor of larger bronchus (above lung segment).
Late lung cancer can be seen: huge tumor nodules in lung field or hilum, lobulated, generally uniform in density, with burrs at the edges, sometimes liquefied at the center, and thick-walled, eccentric and uneven cavities on the inner wall. When the tumor blocks the lobe or the common bronchus appears lobar or atelectasis, a large amount of pleural effusion can be seen when the pleura is involved, and rib damage can be seen when the chest wall is invaded.
Alveolar cell carcinoma, also known as bronchiolar carcinoma, is rare in women. Isolated type is often small-scale infiltration, slow growth is still easy to be misdiagnosed as tuberculosis. However, careful follow-up observation shows that the shadow continues to grow, no matter how slow the process is, it is still an important basis for the diagnosis of lung cancer. It should not be difficult to distinguish growth retardation tumor from miliary tuberculosis.
■2. The positive detection rate of fiberoptic bronchoscope is 60% ~ 80%, and the positive detection rate is much better than that of hard bronchoscope when the image is enlarged by optical fiber illumination. Pay attention to the activity of vocal cords, the shape and activity of carina, and the changes of bronchial orifice at all levels (generally up to grade 4 ~ 5) such as tumor, stenosis and ulcer. And cytological brush examination, bite biopsy, local lavage, etc. This kind of examination is generally complete, and it has also been reported that 9% ~ 29% patients have bleeding after biopsy. When you encounter a tumor with suspected carcinoid and intuitive blood supply, you should be cautious to avoid biopsy trauma.
■3. The cytological examination of sputum exfoliation is simple and easy, but the positive detection rate is only 50% ~ 80%, with a false positive of 1% ~ 2%. This method is suitable for the diagnosis of high-risk groups. In order to improve the detection rate, we should pay attention to it from the beginning of expectoration. First of all, we should teach patients to cough up real sputum from the "deep" of the lungs, not just saliva, and stimulate sputum with drugs when necessary. Secondly, when the sputum is fresh, the smear should be fixed before staining and reading.
■4. Percutaneous lung puncture is suitable for peripheral lesions, but it is not suitable for thoracotomy for various reasons. Other methods can not establish histological diagnosis, and most of them are used in internal medicine. Thoracic surgery is rarely used because it has the means of thoracoscopy and thoracotomy. At present, fine needle is the first choice, which is safer to operate and has fewer complications. The positive rate of malignant tumor is 74% ~ 96%, and that of benign tumor is 50% ~ 74%. Complications include pneumothorax 20% ~ 35% (about14 needs to be treated), a small amount of hemoptysis 3%, fever 1.3%, air embolism 0.5%, needle channel implantation 0.02% ~.
■5. Mediastinoscopy 1954 Haken first performed mediastinoscopy, 1959 Carens further improved the technology and laid the foundation for modern mediastinoscopy. A transverse incision was made in the suprasternal recess, and the soft tissue before the neck was bluntedly separated to reach pretracheal space, and then the anterior tracheal passage was bluntedly separated. An observation mirror was placed behind the innominate artery to observe the swollen lymph nodes beside trachea, tracheobronchial angle and carina. After a trial aspiration with a slender needle proved that it was not a blood vessel, the living tissue was dissected and peeled off with a special biopsy forceps. The positive rate of case department in comprehensive large group was 39%. Another author reported that 25% of cases were exempted from unnecessary exploration. However, some authors reported that the false negative rate reached 8%. This is mainly because metastatic lymph nodes are not within the scope of mediastinoscopy. At present, the consistent view is that mediastinoscopy should be performed when CT shows lymph node enlargement in groups 2, 4 and 7, such as anterior, lateral and subcarina of trachea. The operation was performed under general anesthesia, with a mortality of about 0.04% and a complication of 65438 0.2%. Complications include pneumothorax, recurrent laryngeal nerve paralysis, bleeding and fever.
■6. Magnetic resonance imaging (MRI) is a new imaging diagnostic technique compared with CT. In the diagnosis and regular examination of lung cancer, the relationship between the central tumor and the surrounding organs and blood vessels can be clearly displayed. The anatomical structure of large blood vessels can be well displayed without contrast agent, so as to judge whether the tumor has invaded the blood vessels or oppressed the surrounding blood vessels. For example, 1/2 larger than the perimeter is difficult to remove. MRI can also clearly show when the tumor invades the soft tissue.
■7. Bone imaging or emission computed tomography (ECT) Because of the increase of blood flow at the bone lesion, bone formation is active and metabolism is vigorous, and 99mTc-MDP (dimethyl diphosphate) which is pro-bone appears in the bone lesion, and the lesion is found 3 ~ 6 months earlier than the ordinary X-ray film, so bone imaging can find bone metastasis earlier. If the lesion has reached the middle stage, the decalcification of bone lesions has reached more than 30% ~ 50% of its content, and both X-ray and bone imaging have positive findings. If the osteogenic reaction is static, metabolism is inactive, bone imaging is negative and X-ray is positive, they can complement each other and improve the diagnostic degree.
■8. Using 2 [18F] fluoro -2- deoxy -d- glucose (FDG) as whole-body positron emission tomography (PET), unexpected chest metastasis can be found. There is no false positive rate in cases of chest metastasis, but there are false positive findings in PET examination of mediastinal granuloma or other inflammatory lymph node lesions. This condition needs to be diagnosed by cytology or biopsy. But there is no doubt that PET can make preoperative periodicity more accurate.
Comprehensive treatment of lung cancer
■ Preoperative radiotherapy
Its theoretical basis is: ① Clearing subclinical lesions outside the operation area, such as tiny mediastinal metastases; ② Reduce tumor volume, reduce infiltration with adjacent structures and tissues, and increase anatomical tissue plane; ③ Weaken the vitality of tumor cells and reduce the possibility of local implantation and distant metastasis. Its expected benefit is to improve the resection rate and long-term survival rate. However, the results of clinical practice backfired, and the above two goals were not achieved. Therefore, preoperative radiotherapy combined with surgery can be said to have not benefited patients, and it is not always used routinely in clinic.
■ Intraoperative radiotherapy
Medical radioisotopes (125I, 222Rn) were implanted into tumors that could not be removed by open chest examination, and satisfactory results were obtained, which have been reported by doctors such as Hilaris BS of Kettering Memorial Hospital in Si Long, USA. In a group of 105 cases, the mortality rate was 5%(52/ 105). Compared with the two isotopes, the tumor shadow disappearance rate and local control rate of 125I are better than that of 222Rn. The results of 9 groups of intraoperative radiotherapy including 2 128 cases were summarized. It shows that postoperative radiotherapy has an important damage to the survival rate, and its risk rate is 1.2 1(95% confidence interval is 1.08 ~ 1.34). The death risk of 2 1% is relatively increased, which is equivalent to 7% damage to the 2-year survival rate, from 55% to 48. This harmfulness is particularly prominent in cases of stage I ~ II N0N 1. The destructive effect on stage Ⅲ N2 patients is not obvious. The report thinks that postoperative radiotherapy is harmful to the survival rate of stage ⅰ ~ ⅱ non-small cell lung cancer after radical operation, so it is not suitable for routine use. The report also mentioned that the radiation dose and radiation scheme do not affect the results, that is, there is no evidence that one scheme is less harmful than the rest. The authors suggest that the experimental study should be continued only for stage Ⅲ N2 cases. Because of the role of postoperative radiotherapy in these advanced patients. There is no conclusion at present, and it is meaningless to repeat the same experiment in patients with early non-small cell lung cancer resection.
■ Surgery assisted preoperative and postoperative chemotherapy.
1. Preoperative adjuvant chemotherapy In the 1970s, the first solid tumor, early germ cell tumor, achieved remarkable results. After chemotherapy, combined with surgical resection of residual lesions, the survival rate has been surprisingly improved. This fact has opened an attempt by oncologists to transfer the treatment mode of germinoma to other solid tumors. After the multi-drug regimen was effective in the treatment of non-small cell and small cell lung cancer, the clinical trial of the so-called "new adjuvant" method was quickly carried out. The earliest new adjuvant regimen was tested by the Toronto team in a few cases of small cell lung cancer. Multi-drugs preoperative chemotherapy, postoperative surgery and postoperative consolidation radiotherapy. Retrospective comparison shows that this comprehensive therapy can improve the survival rate of very early small cell lung cancer. The American Lung Cancer Research Group and other medical centers have applied classical methods to non-small cell lung cancer. Preoperative multi-drug chemotherapy contains platinum compounds and preoperative self-esteem, aiming at ⅲ a cases. Retrospective comparison of comprehensive treatment improved the median survival rate and final survival rate. With the advent of more effective drugs, the effective rate of single induction chemotherapy is 70%, and CR is 10%. Retrospective comparison shows that the survival rate of all effective early cases has been improved compared with the cases treated only by surgery in the same period. The randomized phase III clinical trial with induction chemotherapy as the experimental group has achieved results in three small-scale studies. Compared with the simple operation group, its curative effect has been significantly improved.
At present, one of the problems to be solved is whether induction chemotherapy combined with surgery is effective in early clinical stage Ⅰ B (T2N0M0, Ⅱ (T 1N 1M0, T2N 1M0, TN0M0). Secondly, how many cycles of induction chemotherapy is appropriate is still inconclusive. To be sure, it is only effective for chemotherapy, and cases with clinical TNM stage decline (early stage) can benefit. If the optimistic results induced by multiple drugs before operation are confirmed in well-designed prospective clinical trials, most lung cancer cases with the possibility of radical resection will receive this multidisciplinary comprehensive treatment in the future.
2. Postoperative adjuvant chemotherapy The attempt to assist single drug after radical resection of lung cancer was proved to be ineffective. The 5-year survival rate of drug (cyclophosphamide and methotrexate) group was similar to that of control group (cyclophosphamide group was 24.9%, cyclophosphamide+methotrexate group was 25.7%, and control group was 23.5%). Later, it was proved that the combined application of CAMP and CAP could prolong the disease-free survival rate of stage ⅱ and ⅲ non-small cell lung cancer after operation. The question to be answered is whether postoperative adjuvant chemotherapy after induction chemotherapy is effective?
■ Combined treatment of traditional Chinese medicine
Traditional Chinese medicine believes that this disease is caused by the deficiency of vital qi and the invasion of the lungs by evil drugs. Therefore, the treatment mainly focuses on promoting qi and blood circulation, resolving phlegm and softening hardness, or benefiting qi and nourishing yin, resolving phlegm and clearing heat. For example, if after radiotherapy and chemotherapy, the blood stasis toxin is unclear, and the blood stasis toxin is bound to the lung and blocked in the airway, then the patient will have shortness of breath, cyanosis, chest pain, lung falling is uncomfortable, and lung collateral heat injury will bring blood in the sputum. The first treatment method should be used, that is, promoting qi and blood circulation, resolving phlegm and softening hardness, and treating with "Xuanfei Huayu Decoction". Herba Ephedrae (9g), Radix Glycyrrhizae (10g), Herba Houttuyniae (30g), Lumbricus (18g), Radix Salviae Miltiorrhizae (18g), Radix Paeoniae Rubra (18g) and Flos Carthami (10g). Prunella vulgaris (30g), fried pangolin (10g), oyster (30g) and seaweed (18g) have moderate hardness. If you take 6~8 doses, shortness of breath, chest pain will be obviously relieved, cough will still exist, blood in the sputum will be bloodshot, upset, dry mouth, loose stool, red tongue and rapid pulse. Used to gradually remove blood stasis and toxins. When the image of yin deficiency and phlegm poison is revealed. Treating Radix Adenophorae (30g), Radix Ophiopogonis (18g), Radix Rehmanniae (18g), Radix Scrophulariae (18g), Cortex Moutan (12g), Bulbus Fritillariae Cirrhosae (12g) If phlegm and blood are not exhausted, Radix Notoginseng (3g) and Radix Paeoniae Alba (12g) can be added to stop bleeding. If the patient is seriously injured after lung cancer surgery, it will lead to deficiency of both qi and yin and phlegm heat will not be removed. The second treatment method should be used, such as benefiting qi and nourishing yin, resolving phlegm and clearing heat, promoting pulse and dispersing phlegm and detoxicating. Radix Codonopsis (30g), Radix Adenophorae (18g), Radix Astragali (18g), Radix Ophiopogonis (18g), Fructus Schisandrae Chinensis (18g), Rhizoma Dioscoreae (18g), and Radix Polygoni Multiflori (.
Matters needing attention in treatment
Surgical indication
Surgical treatment has been recognized as the first choice for lung cancer treatment, and radical resection is the only treatment that can cure lung cancer patients and return to normal life. According to the analysis of surgical treatment effect accumulated over the years, the following items are surgical indications for lung cancer:
■ 1. Non-small cell lung cancer with clinical stages I, II and III A, that is, T-grade non->; 3. When the tumor only invades diaphragm, chest wall, pleura and pericardium, and approaches carina with atelectasis. The upper limit of lymph nodes is N2, and there is metastasis in ipsilateral mediastinum, but it has not spread further. M is 0 and there is no distant metastasis.
■2. The indications of small cell lung cancer require that it be divided into stage I and stage II. If radical resection can be achieved for the newly discovered N2 lesions during operation, we should not give up our surgical efforts. Postoperative adjuvant chemotherapy for small cell lung cancer.
■3. If there is no cytopathological evidence of lung shadow, according to the medical history, physical examination and imaging examination, the possibility of canceration is greater than that of benign lesions, and the patient should be persuaded to undergo surgical exploration. If the nature of the naked eye is still uncertain after thoracotomy, rapid pathological or cytological examination can be done. Our view is that we should take a more positive attitude and explore lung masses with uncertain diagnosis as soon as possible. Rapid intraoperative examination can provide reliable basis for accurate diagnosis and surgical resection range. That is, it is a reliable basis for the local resection range of benign lesions. That is, local resection of benign lesions is beyond reproach, which not only removes the disease but also removes the patient's ideological concerns.
■4. Although the disease stage is very late, T reaches Grade 4, N reaches Grade 3, and even M is 1 (such as isolated brain metastases), palliative surgery can be performed to alleviate the symptoms of hypoxemia caused by uncontrollable lung inflammation, high fever or atelectasis affecting ventilation function, as a last resort exception.
Surgical contraindications
The surgical indications of lung cancer have been introduced above, and the surgical contraindications are simply those cases beyond the above indications, such as all kinds of T4 tumors that have invaded the mediastinum, heart, great vessels, trachea, esophagus, vertebral body, carina or other nodules in the same lobe, or malignant pleural effusion. Grade n reached grade 3, with lymph node metastasis in the contralateral hilum, mediastinum, clavicle and armpit. Distant metastasis has occurred, reaching liver, bone, brain and adrenal gland, and m is 1 hour. The patient has serious complications, such as severe chronic lung infection, emphysema, hypoventilation, cardiac insufficiency, heart failure, angina pectoris and/or myocardial infarction within 3 months, and cerebrovascular accident within 3 months.
Perioperative preparation
When the doctor diagnosed the possibility of lung cancer and suggested surgical treatment, and the patient accepted the doctor's advice, the important link of surgical treatment should begin.
Respiratory tract nursing
Lung cancer patients are mostly elderly people, and complications such as chronic bronchitis and emphysema occur due to long-term smoking. Therefore, it is urgent to persuade patients to quit smoking. It is generally known that the benefit is related to the success or failure of the operation, and patients will cooperate and resolutely quit smoking. When patients have chronic bronchitis, cough with yellow sputum, or partial atelectasis or even obstructive pneumonia due to tumor blockage, corresponding antibiotics should be given as soon as possible according to the drug sensitivity test of pathogenic bacteria to control preoperative lung inflammation and keep the body temperature below 37.5℃. In addition to systemic application of antibiotics, local drug atomization inhalation therapy can also achieve good therapeutic effect. Some patients with tuberculosis infection should be fully prepared two weeks before operation to prevent postoperative immunocompromised patients from relapse or low dispersion of tuberculosis infection due to lack of anti-tuberculosis drug protection.
Psychological nursing
In order to enhance heart function, energy mixture (glucose, insulin, potassium chloride, vitamin C, coenzyme A, creatinine, etc. It can be given properly before operation to protect the myocardium. If there is water-electrolyte disorder, it should be corrected. Patients with arrhythmia should be treated differently according to the types of arrhythmia. Digitalis drugs should be used first for atrial supraventricular arrhythmia, and quinidine or verapamil should be used if the effect is not obvious. Lidocaine in the treatment of ventricular premature beats. According to the situation, nitroglycerin, salvia miltiorrhiza and other drugs to dilate coronary artery were added, and oxygen therapy was given at the same time. In order to improve cardiopulmonary function, patients can be instructed to go upstairs for exercise, that is, patients can climb stairs at a medium speed, from less to more, and gradually increase the load. Generally speaking, if the patient can walk up three floors without stopping, breathing no more than 20 times/minute and heartbeat no more than 100 times/minute, then the patient can probably tolerate lobectomy.
Measurement of pulmonary ventilation function
The following indicators are taboo or need to be carefully considered: ① The maximum ventilation rate is less than 50% of the expected value; ② forced expiratory volume at the end of FEV in the first second 1
Key points of surgical operation
The success of surgical treatment of lung cancer mainly depends on strict and thorough perioperative management and skilled operation of the operator. On the basis of mastering the anatomy of hilar bronchus and blood vessels, gently and accurately separate and properly suture and cut off the related blood vessels and bronchus. The operation principle is as follows:
■ 1. Thoroughly explore and understand surgical tumors. In addition to the nature, location and degree of invasion of the tumor, we should also know whether the hilar and mediastinal lymph nodes are enlarged or fused into a group. If necessary, tumor and/or frozen biopsy is feasible to determine whether there is metastasis. If there is pleural effusion or other suspicious lung or pleural nodules, we should also pay attention to frozen biopsy, and we must rule out the possibility of tumor spread, that is, we must rule out that the lesion has reached stage ⅲ b or ⅳ, which is not suitable for surgical resection.
■2. The operation must be gentle to avoid iatrogenic blood diffusion caused by squeezing and rubbing the lump.
■3. The practice of the principle of vein ligation first proves that it is a bit too careful to ligate and cut off the pulmonary vein in order to prevent cancer cells from flowing into the systemic circulation and spreading to the whole body. There is no difference in the long-term effect between the case of ligating vein first and the case of ligating pulmonary artery branch first, and the latter also avoids the shortcoming of blood stasis in lung tissue.
■4. The treatment of vascular branches cannot memorize the number of pulmonary artery branches described in the anatomy textbook by rote, because there are great differences among individuals. Surgeons should never be satisfied that the number of vascular branches ligated conforms to the description in the book. The only phenomenon indicating the completion of ligation branch is that the trunk retracts to the root of hilum. Also note that sometimes there are very fine branches, and a slight negligence in anatomy may lead to bleeding.
■5. Some patients with abnormal pulmonary veins lack lower pulmonary veins, and only one pathway in lung blood leads to upper pulmonary veins. The exact incidence is unknown, and it mostly occurs in the left lung. Therefore, when the upper lobe of the left lung is removed, it is necessary to confirm the existence of the inferior pulmonary vein, so as to avoid the residual pulmonary circulation after ligation and cutting of a single pulmonary vein, the lung tissue is highly congested and heparinized, and the patient has hemoptysis and needs to be operated again.
■6. Among 22 cases of N2 in thoracic surgery and bronchial stump/kloc-0 in cancer hospital, 3 cases were positive, and none survived for 3 years. In sleeve lobectomy group 135 cases, 3 cases were found to have unclean margins after operation, and the distances between margins and tumors were 1.5 cm, 2 cm and 2 cm respectively. During the follow-up, 5 cases of anastomotic recurrence were found. Because pathological examination can't make continuous sections, the estimated residual cancer rate is actually higher than that of pathological report. These facts show that the distance between the margin and the tumor should be more than 2 cm, not
■7. Sleeve lobectomy Take sleeve lobectomy of the right upper lobe as an example. After thoracotomy, the location, volume and invasion degree of the tumor should be explored first. When it is confirmed that the tumor is located in the hilum of the lung, does not invade the main bronchus or the mediastinum separated from the middle bronchus, and has no N2 lymph nodes, it can be judged that sleeve resection is appropriate from the anatomical and oncological points of view. The 5-year survival rate was 65438 06.6%, which was significantly lower than 62.5% in stage ⅰ and ⅱ. Incision of hilum, ligation and cutting off branches of pulmonary artery and pulmonary vein. In order to solve the problem that the outlet bronchus and its adjacent right main bronchus have different cutting methods. The main bronchus should be cut off vertically, and the middle branch gas should be cut off obliquely. Usually, hilar cancer invades the outer side wall of the common or intermediate bronchi, and its inner side wall is often obliquely cut from the outside to the inside, that is, more open side (inner side) walls are reserved, so that the diameter of the lower cut end can be increased to the size close to that of the upper cut.
Thin absorbable synthetic suture is used in anastomosis, and the tubercle or lateral membrane eversion is interrupted first. Because it is farthest from the surgeon, it can only be exposed when the side is opened, so it must be stitched first. It is also because if there is leakage in this part after anastomosis, it is almost impossible to repair. It is performed under direct vision, so it must be sutured correctly and tightly to achieve a successful anastomosis. The suture spacing is about 2mm, and the knot is tied outside the lumen, and the tightness is appropriate. Second, sew the front. In order to bridge the inconsistency of the diameters of the two cross-sectional ports, the suture spacing at both ends can be adjusted during anastomosis.