Lung nodule surgery, there are nine surgical schemes, how to choose?

(Case data 20 19) Luo, a 60-year-old from Jinhua, has been smoking for 40 years. A few days ago, due to chest CT examination in our hospital, I found nodules in both left and right lungs. His family came to see me to see if his nodules were malignant and needed surgery. The following is a plain scan of the left upper lobe nodule:

After further target scanning, the image is as follows:

It can be seen that it is a typical ground-glass nodule with a diameter of nearly 2.5 cm and a cavity lesion in the middle, but the overall density is still pure ground glass with a little punctate high density. According to past experience, these nodules are basically invasive adenocarcinoma, mainly adherent growth. Some of them are smaller in diameter, less than sub-centimeter, and can also be minimally invasive adenocarcinoma or adenocarcinoma in situ (rare). So I told to consider 90% malignant and suggested surgery. According to the current treatment guidelines, lobectomy and lymph node dissection should be performed for early lung cancer larger than 2 cm. Those less than 2 cm meet one of the following conditions: carcinoma in situ, solid content less than 50%, doubling time more than 400 days, feasible subpulmonary resection, including segmental resection and wedge resection. Obviously, Luo's condition is not suitable for lobectomy. However, he has his own special circumstances. His right lower lung also has a ground glass nodule, most of which is solid. The following is a general scan image of his right nodule:

Further target scanning shows that:

It can be seen that the posterior segment of the right lower lobe (adjacent to the basal segment) is about 8 mm mixed ground glass nodule, and the edge is not only intact, but also the pleura is elongated, which is also a typical malignant sign. Then according to the treatment guidelines, puncture or wedge resection was performed first. If the pathology was invasive adenocarcinoma, right lower lobe resection and lymph node dissection were performed.

The problem now is that both sides are typical malignant, and both sides need lobectomy (pathological basis must be obtained first during operation). If it is hard, lobectomy and lymph node dissection should be carried out in stages. But in fact, for multiple primary cancers, the guide also points out conceptually: surgery should be cautious; Priority is given to major lesions; Keep lung function as much as possible (you can cut less); Try to remove as many lesions as possible at once. But specific to the case, in fact, there is no exactly the same rule to follow. In this case, staged lobectomy is obviously the most standard and thorough, but is it not true, or is it the most reasonable and beneficial for patients? Obviously, there are also different views and considerations. Comprehensive evaluation of age, lung function, patients' wishes, pathological types and requirements of guidelines and specifications can be considered. Generally speaking, there are the following options:

Scheme 1: left wedge resection+right wedge resection (although the trauma is small, it does not conform to the principle of tumor treatment);

Option 2: left tongue resection+right wedge resection (optional, meaning compromise, the left lobe should be removed because its diameter is greater than 2 cm);

Option 3: left wedge resection+right dorsal segment resection (optional, meaning compromise, the right lower lobe should have been removed, because the ground glass nodule is basically solid);

Scheme 4: Staged left tongue resection and right dorsal resection (optional, but the operation needs to be carried out in stages, that is, both sides compromise);

Scheme 5: staged left lobectomy plus right dorsal lobectomy (optional, focusing on left invasive adenocarcinoma with diameter greater than 2 cm);

Scheme 6: left tongue resection and right lower lobe resection by stages (optional, focusing on right invasive adenocarcinoma with many solid components);

Scheme 7: Resection of the left upper lobe and the right lower lobe by stages (although it is most in line with the principle, it has more lung loss, and my personal opinion is that both sides should be early lung cancer, so I plan not to choose).

Scheme 8: Left upper lobe resection+right lower lobe wedge resection (optional, the left side conforms to the principle, and the right side is compromised wedge resection);

Scheme 9: Wedge resection of the upper lobe of the left lung+resection of the lower lobe of the right lung (optional, this is in line with the right principle, and the left wedge resection is a compromise scheme, but it is not suitable because the left lesion is larger than 2 cm).

In fact, all kinds of choices have their own reasons. We sent the case to the professional group and had our own choices and suggestions. My personal opinion is to choose wedge resection of the right dorsal segment and the left upper lobe, based on the following considerations: the patient is 60 years old and still young, and there is still the possibility of tumor recurrence in the future; In terms of size and density, I personally think that density is more important, because pure ground glass does not necessarily have metastasis even if it is large, so under the same invasive adenocarcinoma, choose leaves with high density; The reason why we can't cut the leaves evenly by stages is that we can leave room to prevent the tumor from recurring in the future, and the quality of life after operation is relatively better. Later, two big doctor in the province considered the choice of lingual resection of the left upper lobe and wedge resection of the right lower lobe, so I gave up the idea and planned to do lingual resection of the left upper lobe and wedge resection of the right lower lobe.

The operation is arranged at 10. 17. The results showed that the oblique fissure was dysplasia after entering the chest cavity. It is very difficult to free the lingual artery from the lobar fissure, so we must first treat the lingual vein and then cut off the lingual bronchus. However, at that time, the lingual lung tissue was still lying on the lower side and there was no way to lift it, so the determination of the lung segment plane was not accurate. No lesions were found after pneumonectomy, and after appropriate pneumonectomy (equivalent to upper left) and right wedge resection, ciliated mucinous nodular papillary tumor should be considered first. Postoperative routine pathology: right bronchiolar adenoma, left invasive adenocarcinoma, negative lymph nodes. Looking back, the scheme currently selected is the most reasonable and conforms to the norms or guidelines.

For the same patient with multiple primary cancers, different doctors have too many different options to decide the surgical plan. We hope that our choice will be as beneficial to patients as possible, with minimal trauma and faster recovery.

# Lung nodule surgery #