(The article contains a display of surgical specimens, please click and read with caution)
Foreword: Although it has been nearly 2 weeks since he officially joined the Hangzhou Cancer Hospital affiliated to Zhejiang University School of Medicine, there are some procedures to go through due to the change of practicing physician and other related procedures. , it also takes some time, so I visited the outpatient clinic twice before. I received patients with pulmonary nodules who came from Beijing, Nanjing, Guizhou and other provinces. I also received patients from Ningbo and Shaoxing in the province. , Jinhua and other places who come to the hospital specifically for treatment. Of course, there are also some friends who have been treated in other provincial hospitals in Hangzhou. They learned about our expertise in the diagnosis and treatment of pulmonary nodules through introductions from friends or from the Internet. Work hard and come to the hospital for consultation again. There are about 15 patients with pulmonary nodules in each outpatient clinic. Although the number of patients is not large, we communicate carefully and all the friends come back satisfied. They feel that the trip is worthy of the trip and they have a better understanding of their condition. understanding. There are also many appointments for follow-up visits or surgeries. But today is the first time that lung cancer surgery is actually carried out in a new workplace. Let’s share his situation as one of the most important and meaningful landmark events after the job change.
Patient A, male, 77 years old, was found to be occupying the left upper lobe during examination. He usually had no respiratory symptoms, and the tumor screening indicators were normal. However, the dynamic electrocardiogram showed more than 10,000 premature atrial beats, bradycardia, and the longest interval of 2.3 seconds. We consulted a cardiology department before the operation and thought it would be better if a clinical pacemaker could be installed, but there were no absolute contraindications to cardiac surgery. After full communication with the patient's family, it was decided not to install the pacemaker for the time being. Let’s take a look at his lesions:
The left upper lobe is occupied. The green arrow shows obvious ground glass components, and the tumor-pulmonary border is very clear. There are solid components in the middle (pink arrow), and there are also blood vessels entering the lesion (orange arrow) ). The overall density is uneven.
The lesion is solid density at larger levels, with shallow lobulation signs on the surface (brick-colored arrows), and blood vessels entering (orange arrows). There are also spiculation signs on the outside, but they are not so typical (purple arrows)
lesions The surface is uneven, and there is a bronchial truncation sign pointed by the yellow arrow. The overall density is high.
The edge of the lesion is low in density, with blood vessels passing through and disorder
The lesion is visible in the mediastinal window, with a clear outline.
Image judgment:
Solid occupying of the left upper lobe. If there is ground glass component at the edge, and there are more typical vascular signs, lobulation signs, spiculation signs and bronchial truncation signs, malignant tumors should be considered first. Since there were no obvious signs of distant metastasis in other related examinations, the local area could be surgically removed.
Other examination conditions:
Bronchoscopy : No obvious abnormalities were found under conventional bronchoscopy ;
Bronchoscopy cytology: No malignant tumor cells were found in the left upper lobe anterior segment-subsegment endoscopic smear;
Head MRI: Within two It is basal ganglia area , lateral ventricular white matter area lacunar cerebral infarction is considered, and it is recommended to follow up;
vascular color ultrasound: bilateral carotid artery plaque formation with local moderate stenosis; bilateral lower limb arterial intimal thickening with multiple Plaque formation; the deep veins of both lower limbs were unobstructed;
abdominal color ultrasound: no obvious abnormality in the liver, gallbladder, pancreas and spleen;
cardiac color ultrasound : left ventricular diastolic hypofunction; aortic valve regurgitation; widening of the ascending aorta; arrhythmia ; LVEF: 60%; FS: 32%;
Coronary artery situation: Mediastinal window shows extensive calcification of the anterior descending branch (calcification is also present in the initial segment of the right coronary artery)
Clinical decision:
Such a mass in the left upper lung is considered to be lung cancer. , but he is 77 years old and has frequent atrial premature beats, bradycardia and coronary artery calcification , so the cardiac risks are still considerable. However, after careful questioning of the medical history, it was found that he could live and work normally, could go up to the third floor in one breath, and had never had any symptoms such as chest tightness, breathlessness, or precordial pain.From the perspective of body function, the activity tolerance is good and the surgical tolerance is good; but from the imaging perspective, the risk of cardiac events is relatively high, and the occurrence of acute myocardial infarction or cardiac events cannot be completely eliminated. If considered from a more stable perspective, further coronary CT or coronary angiography is needed. If the stenosis is severe, stent implantation or coronary artery bypass grafting is also required. But we should really deal with the heart condition whose symptoms are not obvious at present. What should we do with the upper left lung tumor ? It is solid, and if it is malignant, it is more likely to be invasive cancer. Watching and waiting may miss the opportunity for surgery. After repeated and detailed communication with the patient’s family, the patient chose surgical treatment and postponed the installation of a pacemaker. Then let’s look at the pros and cons of the choice of surgical plan:
1. Before surgery, a puncture biopsy is needed to clarify the pathology and determine the malignancy before surgery: This is the option that many doctors will choose. The advantage is that after puncture has pathological evidence, it can be Direct resection of the left upper lobe and lymph node dissection saves the time of waiting for pathological results during the operation, and also saves the time and cost of cutting the malignant lung lobe through wedge incision in two steps, as well as the cost of cutting and staplers. However, the disadvantages are: first, the possibility of false negatives; second, puncture complications and risks; third, the potential for needle tract dissemination; and fourth, time cost.
2. Step-by-step intraoperative wedge resection and rapid sectioning, and then lobectomy and lymph node dissection after confirming malignancy: This is more in line with the standard, but the disadvantage is that if 3-4 nail cassettes are used up by wedge resection first, This will cost an additional 6,000-8,000 yuan in out-of-pocket materials costs. However, this type of lesion is relatively malignant from the imaging point of view, and it is likely that the lung lobes will need to be removed anyway; secondly, at such an age, combined with the heart condition and severe calcification of the coronary arteries, surgery is very difficult. The time is relatively long, the risks are high, postoperative recovery is poor, and postoperative quality of life is poor.
3. Direct left upper lobectomy and lymph node dissection: the advantage is that it saves cost and time, and the operation is performed as a radical resection. However, the disadvantage is still the influence of age and heart condition, and the risk and postoperative quality of life are relatively poor. And if the tumor does not have a high-risk subtype in the end, and there is actually no lymph node metastasis or , there is no difference in prognosis between resection of the lobes and resection of only the lesions (on the premise of negative margins) (if there are hematogenous micrometastases, lobectomy cannot achieve the same outcome. de facto cure). Another point is that if the lesion is benign, it is not cost-effective to remove the lung lobes, which is a pity.
4. Perform a large wedge resection of the upper lobe to ensure the margins. If the quick section during the operation indicates malignancy, mediastinal and hilar lymph node sampling or dissection will be performed without further resection of the lung lobes: the disadvantage of this is that groups 11 and 12 cannot be obtained. Group lymph nodes are sent for medical examination, and the postoperative staging may be inaccurate. The advantages are: simple surgery, low risk, quick recovery, good postoperative quality of life, rare postoperative complications, and minimal economic costs. As we have said before, if there are hematogenous micro-metastasis, lobectomy or wedge resection are both palliative surgeries and cannot be cured; if there are no hematogenous micro-metastasis, but there is group 11 or 12 lymph node metastasis, then lobectomy is more effective. Accurate staging can accurately provide auxiliary treatment after surgery (this age is already 78 years old, and it is not certain whether he will receive postoperative adjuvant treatment); if there is mediastinal lymph node metastasis, wedge incision plus sampling or dissection can also clarify the status of N2 , can guide postoperative adjuvant treatment; if there is no hematogenous or lymph node metastasis, no intra-air cavity dissemination, and the tumor is limited to the lesion, in fact, the therapeutic effects of wedge incision and segmental or lobular incision should be the same in theory.
Comprehensive opinion:
After full communication with the patient’s family and explaining the pros and cons of various surgical techniques, the family chose the fourth option, which was “ VATS partial left upper lobe resection, or mediastinal lymph node sampling or dissection.” .This consideration is based on the following factors: 1. The lesions contain ground glass components. The prognosis of those with ground glass is obviously better and the degree of malignancy is lower. It is estimated before surgery that the lesions will be mainly acinar type with some adherent type. ; 2. He is 77 years old. Although he is usually in good health, once the balance is broken, the functional reserve of each organ is actually poor, and the risk of lobectomy is significantly higher than that of wedge resection; 3. There are more than 10,000 premature atrial contractions in the heart, and If there is a long interval of more than 2 seconds, and there is extensive coronary artery calcification, there is a risk of acute myocardial infarction . Even if the symptoms are not obvious at ordinary times, the risk is still greater; 4. If the tumor actually has micro-metastasis, it will not reach the goal anyway. Radical cure; if in fact there is no metastasis, wedge cutting and leaf cutting have the same effect anyway. Different surgical procedures mainly have different basis for accurate staging. Such a plan selection can maximize the patient's interests and quality of life and minimize the scope of lung tissue resection. It is also the result of compromise with the effect of tumor treatment. Personally, I think this is the relatively best plan, and there are always trade-offs.
Final result:
On the afternoon of July 13, 2022, our thoracic surgery team performed "single-port thoracoscopic left upper lobe partial resection plus lymph node sampling (dissection)". During the operation, it was found that there was extensive adhesion in the chest, and the lesion was located near the junction of the proper segment of the upper lobe and the lingual segment. The lymph nodes in the 4th, 7th, 8th, 9th, and 10th groups were all homogeneous and soft, and no metastasis appeared to the naked eye. The operation went smoothly, and the postoperative quick section pathology report showed: poorly differentiated cancer.
The picture above shows the appearance of the general specimen of the lesion. The white thing in the middle is the tumor
The picture above shows the scene during single-port minimally invasive thoracoscopic surgery
In this case, it was found during the operation that the lymph nodes did not have obvious fibrosis or calcification, and the tissue was relatively loose. If Lobectomy is also relatively simple, but after comprehensive evaluation, the surgical team and the patient agreed that the current surgical plan was the most individualized and beneficial to the patient. This is also the philosophy we have always adhered to: weigh the pros and cons and strive to maximize the interests of patients, rather than pursuing "higher" technology.
