Overview
Lung cancer is one of the most common malignant tumors in the world, and it has become the number one cause of death in malignant tumors in urban population in China. Non-small cell lung cancer includes squamous cell carcinoma (squamous cell carcinoma), adenocarcinoma, and large cell carcinoma. Compared with small cell carcinoma, its cancer cells grow slowly and have a relatively slow diffusion and metastasis.Non-small cell lung cancerAbout 80% of all lung cancers, about 75% of patients are found in the middle and late stages, and the 5-year survival rate is very low.
Cause
Smoking
Smoking is currently considered to be the most important risk factor for lung cancer. There are more than 3,000 chemicals in tobacco, among which multi-chain aromatic hydrocarbons (such as benzopyrene) and nitrosamines have strong carcinogenic activity. Multi-chain aromatic hydrocarbons and nitrosamines can cause DNA damage in bronchial epithelial cells through various mechanisms, which inactivates oncogenes (such as Ras gene) and tumor suppressor genes (such as p53, FHIT genes, etc.), thereby causing cells. Transform and eventually become cancerous.
2. Occupational and environmental contact
Lung cancer is the most important type of occupational cancer. It is estimated that about 10% of lung cancer patients have a history of environmental and occupational exposure. The following nine occupational environmental carcinogens have been shown to increase the incidence of lung cancer: by-products of aluminum products, arsenic, asbestos, bis-chloromethylether, chromium compounds, coke ovens, mustard gas, nickel-containing impurities, vinyl chloride. Long-term exposure to sputum, cadmium, silicon, formalin and other substances will also increase the incidence of lung cancer, air pollution, especially industrial waste gas can cause lung cancer.
3. Ionizing radiation
The lungs are organs that are more sensitive to radiation. The number of people suffering from lung cancer among Japanese atomic bomb survivors has increased significantly.
4. Chronic infection of the lungs
In patients with tuberculosis, bronchiectasis, etc., the bronchial epithelium may become squamous in the process of chronic infection, causing cancer, but it is rare.
5. Genetic factors
Family aggregation, genetic susceptibility, and decreased immune function, metabolic and endocrine dysfunction, etc. may also be
It plays an important role in the occurrence of lung cancer. Many studies have shown that genetic factors may play an important role in people and/or individuals susceptible to environmental carcinogens.
6. Air pollution
The incidence of lung cancer in developed countries is high, mainly due to the pollution of pollutants such as benzopyrene carcinogenic hydrocarbons produced by burning oil and coal and internal combustion engines in the industrial and transportation developed areas. Air pollution and smoking may promote each other's incidence of lung cancer and play a synergistic role.
Clinical manifestation
Early symptoms
(1) Chest pain In the early stage of lung cancer, the symptoms of chest pain are mild, mainly characterized by dull pain, stuffy pain, and not necessarily the location, and the relationship with breathing is also uncertain. If the pain persists, it means that the cancer has the possibility of involving the pleura.
(2) Blood stasis Tumor inflammation caused necrosis, capillary blood vessels will have a small amount of bleeding, often mixed with sputum, intermittent or intermittent appearance. Many lung cancer patients see a doctor because of blood stasis.
(3) Low fever After obstructing the bronchus, the obstructive lobes often have different degrees. The mild ones have only low fever, while the severe ones have high fever. After medication, they can temporarily improve, but they will relapse soon.
(4) Cough Lung cancer is caused by respiratory irritation and irritating cough due to the growth of bronchopulmonary tissue.
2. Late symptoms
Patients with advanced non-small cell lung cancer have fatigue, weight loss, loss of appetite, and other symptoms such as difficulty breathing, cough, and hemoptysis.
an examination
X-ray inspection
X-ray examination can be used to understand the location and size of lung cancer, and may see local emphysema, atelectasis or invasive lesions in the vicinity of the lesion or inflammation of the lungs due to bronchial obstruction.
2. Bronchoscopy
The bronchoscope can directly observe the lesions of the endobronchial and luminal lumens. Tumor tissue can be taken for pathological examination, or bronchial secretions can be taken for cytological examination to confirm the diagnosis and determine the histological type.
3. Cytological examination
Sputum cytology is a simple and effective method for the screening and diagnosis of lung cancer. Most patients with primary lung cancer can find shed cancer cells in sputum. The positive rate of sputum cytology in central lung cancer can reach 70% to 90%, and the positive rate of peripheral lung cancer sputum detection is only about 50%.
4. Thoracotomy
Pulmonary mass can not be confirmed by various examinations and short-term diagnostic treatment. If the possibility of lung cancer cannot be excluded, it should be used for thoracotomy. This avoids delays in the disease and causes lung cancer patients to lose the opportunity for early treatment.
5.ECT check
ECT bone imaging can detect bone metastases earlier. X-ray films and bone imaging have positive findings. For example, if the osteogenesis reaction in the lesion is static and the metabolism is inactive, the bone imaging is negative and the X-ray film is positive. The two complement each other, which can improve the diagnosis rate. It should be noted that the false positive rate of ECT bone imaging for the diagnosis of bone metastasis of lung cancer can reach 20% to 30%. Therefore, the positive ECT bone imaging needs to be the MRI scan of the bone in the positive area.
6. Mediastinoscopy
Mediastinoscopy is mainly used in patients with mediastinal lymph node metastasis, not suitable for surgical treatment, and other methods can not obtain pathological diagnosis. Mediastinoscopy should be performed under general anesthesia. A transverse incision was made in the concave part of the sternum, and the soft tissue before the neck was bluntly separated to reach the anterior space of the trachea. The anterior channel of the trachea was bluntly released, and the observation mirror was slowly passed through the innominate artery to observe the paratracheal, tracheobronchial horn and the bulge. The enlarged lymph nodes in the site were dissected by special biopsy forceps to obtain lymph node tissue for pathological examination.
diagnosis
Early diagnosis of lung cancer is of great significance. For adults over 40 years old, X-ray examinations are conducted regularly every six months. If you have a long-term cough or blood stasis in middle-aged, you should be vigilant and do a thorough examination. If the chest X-ray shows a shadow of the lungs, you should first consider the possibility of lung cancer.
Differential diagnosis
Typical lung cancer is easy to identify, but in some cases, lung cancer is easily confused with:
Tuberculosis, especially tuberculoma (ball) should be differentiated from peripheral lung cancer. Tuberculoma (ball) is more common in young patients, with a longer course of disease, less blood in the sputum, and tuberculosis in the sputum. The imaging is mostly round, found in the tip or the back of the upper leaf, the volume is small, not more than 5cm in diameter, the boundary is smooth, and the density is uneven and calcification is visible. There are often scattered tuberculosis lesions around the tuberculoma (ball) called satellite foci. Peripheral lung cancer is more common in patients over 40 years old, and blood stasis is more common, and 40% to 50% of cancer cells in the sputum are positive. X-ray chest radiographs are often lobulated, with irregular edges, small burr and pleural shrinkage, and rapid growth. In some cases of chronic tuberculosis, lung cancer can occur on the basis of tuberculosis, and further sputum cytology and bronchoscopy must be performed, and if necessary, thoracotomy should be performed.
2. Pulmonary infection
Pulmonary infections are sometimes difficult to distinguish from obstructive pneumonia caused by lung cancer obstructing the bronchi. However, if pneumonia has multiple episodes in the same site, it should be vigilant. It should be highly suspected to be caused by tumor blockage. Patients should be taken for cytological examination and fiber light-guided vascular examination. In some cases, pulmonary inflammation Absorption, when the remaining inflammation is wrapped by fibrous tissue to form nodules or inflammatory pseudotumors, it is difficult to distinguish from peripheral lung cancer, and thoracoscopic exploration should be performed for suspicious cases.
3. Benign tumors of the lungs
Benign tumors of the lungs: such as structural tumors, chondromas, fibroids, etc. are rare, but must be differentiated from peripheral lung cancer, benign tumors have a longer course, most of them are clinically asymptomatic, X-rays are often round Block shadow, neat edges, no burrs, no lobes. Bronchial adenoma is a low-grade malignant tumor that often occurs in young women. Therefore, there are often pulmonary infections and hemoptysis in the clinic. Diagnosis can often be made by fiberoptic bronchoscopy.
MediastinumMalignant lymphoma(lymphosarcoma and Hodgkin's disease)
Clinically, there are often symptoms such as cough and fever. Imaging studies show that the mediastinum is widened and lobulated, and sometimes it is difficult to distinguish it from central lung cancer. If there is swelling of the lymph nodes under the supraclavicular or axillary fossa, a biopsy should be made for a clear diagnosis. Lymphosarcoma is particularly sensitive to radiation therapy, and small doses of radiation therapy can be used in suspicious cases, which can significantly reduce the mass. This experimental treatment contributes to the diagnosis of lymphosarcoma.
treatment
(a) chemotherapy
Chemotherapy is the main treatment for lung cancer, and more than 90% of lung cancers require chemotherapy. The efficacy of chemotherapy for small cell lung cancer is relatively positive in both early and late stages, and even about 1% of early small cell lung cancer is cured by chemotherapy. Chemotherapy is also the main method for the treatment of non-small cell lung cancer. The tumor remission rate of chemotherapy for non-small cell lung cancer is 40% to 50%. Chemotherapy generally does not cure non-small cell lung cancer, only prolonging patient survival and improving quality of life. Chemotherapy is divided into therapeutic chemotherapy and adjuvant chemotherapy. Chemotherapy requires different chemotherapy drugs and different chemotherapy regimens depending on the type of lung cancer histology. In addition to killing tumor cells, chemotherapy also damages normal human cells, so chemotherapy needs to be carried out under the guidance of a oncologist. In recent years, the role of chemotherapy in lung cancer is no longer limited to patients with advanced lung cancer who cannot be operated, but is often included as a comprehensive treatment for lung cancer. Chemotherapy can inhibit the bone marrow hematopoietic system, mainly the decline of white blood cells and platelets, can be appliedGranulocyte colony stimulating factorAnd platelet stimulating factor therapy. Chemotherapy is divided into therapeutic chemotherapy and adjuvant chemotherapy.
(two) radiation therapy
1. Principle of treatment
Radiotherapy is the best for small cell lung cancer, followed by squamous cell carcinoma and adenocarcinoma. The radiotherapy field of lung cancer should include the primary compartment and the mediastinal area of lymph node metastasis. At the same time, supplemented with medication. Squamous cell carcinoma has moderate sensitivity to radiation, local lesions are mainly local invasion, and metastasis is relatively slow, so radical treatment is often used. Adenocarcinoma is less sensitive to radiation and is prone to hematogenous metastasis, so less radiation therapy is less common. Radiotherapy is a topical treatment that often requires combination chemotherapy. The combination of radiotherapy and chemotherapy can be based on the patient's condition, taking concurrent chemoradiotherapy or alternating radiotherapy.
2. 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.
3. The complications of radiotherapy
Complications of lung cancer radiotherapy include: radiation pneumonitis, radiation esophagitis, radiation pulmonary fibrosis, and radiation-induced myelitis. There is a positive correlation between the above-mentioned radiotherapy-related complications and the dose of radiotherapy, and there are also individual differences.
(3) Surgical treatment of lung cancer
Surgical treatment is the first and most important treatment for lung cancer, and the only treatment that can cure lung cancer. The purpose of surgical treatment of lung cancer is to completely remove the primary lesions of the lung cancer and metastasis of the lymph nodes to achieve clinical cure; the vast majority of tumors are removed, creating favorable conditions for other treatments, namely, cytoreductive surgery.
Reduction surgery: suitable for a small number of patients, such as refractory pleural cavity and pericardial effusion, through the removal of pleural and pericardial implant nodules, resection of part of the pericardium and pleura, cure or relieve clinical symptoms caused by pericardial and pleural effusion, prolong Life or improve the quality of life. The reduction surgery requires simultaneous local and systemic chemotherapy. Surgical treatment often requires adjuvant chemotherapy or radiotherapy before or after surgery to improve the cure rate of patients and the survival rate of patients. The five-year survival rate for surgical treatment of lung cancer is 30% to 44%; the mortality rate for surgical treatment is 1% to 2%.
1. Indications for surgery
Surgical treatment of lung cancer is mainly suitable for early and middle stage (I～II) lung cancer, stage IIIa lung cancer and partially selective stage IIIb lung cancer with one tumor in one side.
(1) Stage I and II lung cancer;
(2) Stage IIIa non-small cell lung cancer;
(3) Part of the IIIb stage non-small cell lung cancer with lesions confined to one side of the thoracic cavity;
(4) Patients with stage IIIa and partial stage IIIb lung cancer who have been degraded by neoadjuvant chemotherapy before surgery;
(5) Non-small cell lung cancer with solitary metastasis (ie, intracranial, adrenal or liver), if the primary tumor and metastases are suitable for surgical treatment, no surgical contraindications, and can reach the primary tumor and Completely removed metastases;
(6) The diagnosis of non-small cell stage IIIb lung cancer, tumor invasion of pericardium, large blood vessels, diaphragm, tracheal carina, through various examinations to rule out distant or / and micro-metastasis, lesion limitations, patients without physiological surgery contraindications , can achieve the complete removal of tumor tissue and organs.
2. Surgical contraindications
(1) Stage IV lung cancer with extensive metastasis;
(2) accompanied by multiple groups of mediastinal lymph node metastases, especially those with invasive mediastinal lymph node metastasis;
(3) Stage IIIb lung cancer with contralateral hilar or mediastinal lymph node metastasis;
(4) Patients with severe visceral insufficiency who cannot tolerate surgery;
(5) Those who have a bleeding disorder and cannot correct it.
3. Choice of surgical procedures for lung cancer
The principle of surgical resection is to completely remove the primary tumor and lymph nodes that may be metastasized in the thoracic cavity, and to preserve normal lung tissue as much as possible. Pneumonectomy should be cautious.
(1) Pulmonary wedge and local resection refers to the removal of wedge-shaped cancer blocks and partial segmentectomy. It is mainly suitable for early stage lung cancer with small volume, old and weak, poor lung function or low cancer differentiation.
(2) Segmentectomy is the resection of the anatomical segment. It is mainly suitable for elderly patients with peripheral lung disease with poor cardiopulmonary function or partial central lung cancer with localized lesions located at the root of lung cancer.
(3) lobectomy is suitable for lung cancer is limited to peripheral and partial central lung cancer in one lung lobe. Central lung cancer must ensure no bronchial residual cancer. If the lung cancer involves the two leaves or the middle bronchus, the upper middle or lower middle lobe can be resected;
(4) Bronchial sleeve-shaped lobectomy is mainly suitable for central lung cancer in which lung cancer is located in the bronchus of the lung or the opening of the middle bronchus. The advantage of this procedure is that it achieves complete resection of lung cancer and preserves healthy lung tissue;
(5) Bronchial pulmonary artery sleeve-shaped lobectomy is mainly suitable for central lung cancer where lung cancer is located in the bronchus or middle bronchus of the lung, lung cancer and lung trunk. In addition to the need for bronchial resection, surgery requires simultaneous resection and reconstruction of the pulmonary trunk. The advantage of this procedure is that it achieves complete resection of lung cancer and preserves healthy lung tissue.
(6) tracheal carinal resection and reconstruction of the tumor more than the main bronchus involving the carina or tracheal wall but not more than 2cm, can be used for tracheal carinal resection or sleeve-type pneumonectomy, if you still retain a leaf lobe, Stress strives to preserve tracheal carinal resection and reconstruction of the lobes.
(7) Pneumonectomy refers to one side of the whole lung, that is, right or left pneumonectomy, which is mainly suitable for cardiopulmonary function, extensive lesions, and young age, not suitable for lobectomy or sleeve lobectomy. Lung cancer. The incidence of complication and mortality in pneumonectomy is higher. The long-term survival rate and quality of life of patients are not as good as lobectomy. Therefore, surgical indications should be strictly controlled.
4. RecurrenceLung cancerSurgical treatment
Recurrent lung cancer includes recurrence of local residual cancer after surgery and a second primary lung cancer with new lungs. For the recurrence of residual cancer in the bronchial stump, reoperation should be sought for bronchial sleeve formation to remove residual cancer.
For the second primary lung cancer that occurs after complete resection of lung cancer, as long as the lung cancer is suitable for surgical treatment, the patient's visceral function can tolerate re-surgical treatment, and there are no surgical problems, then the chest should be considered. Surgical resection of recurrent lung cancer.
简体中文