外科学教学课件：原发性支气管肺癌的外科治疗

1、Surgery for Lung Cancer原发性支气管肺癌的外科治疗1EpidemiologyLung CancerWorldwide: most common cancer2,000,000 cases per yearChina: Leading cause of cancer deathestimated 500,000 deaths per year2Cigarette smoking is by far the biggest carcinogen for the development of lung cancer, responsible for 85 percent of

2、all lung cancers.Other risk factors include the following: Family history Environmental and occupational exposure to certain substances Exposure to excessive radiation Previous Lung diseases Poor diet Air pollution?3 signs and symptoms咳嗽 cough咯血 Hemoptysis胸痛或肩痛 Chest pain or shoulder pain气促，哮鸣 Short

3、ness of breath, wheezing反复出现的肺炎或气管炎 Repeated pneumonia or bronchitis出汗和渗出 Swelling and effusion 食欲减退或体重下降 Loss of appetite or weight loss骨关节疼痛 bone and joint pain声嘶 Hoarseness4SVC Syndrome上腔静脉综合征Engorged superficial veins of the neck and upper chest wall.Initial digital subtraction right upper extre

4、mity venogram demonstrates high-grade stenosis in the mid-portion of the SVC and extensive venous collaterals. 5Clubbing finger杵状指Finger ClubbingFinger clubbing (enlargement of the most distant part of the finger and nail) is generally a sign of lung cancer or chronic lung disease.6胸部X线检查Chest X-Ray

5、 filmsCT扫描Computed tomography (CT)支气管镜Bronchoscopy (FOB)细胞学检查Cytology examination(sputum,pleural effusion)经胸针吸Transthoracic needle aspiration (TTNA)核磁共振Magnetic resonance imaging (MRI)正电子发射体层摄影Positron emission tomography (PET)同位素扫描Isotope scan (lung, bone)超声扫描Ultrasound scan( liver, kidney)纵隔镜Media

6、stinoscopy胸腔镜Thoracoscopy (VATS)Diagnostic Techniques7胸部X线检查Chest X-Ray filmsChest x-ray is the most commonly performed diagnostic x-ray examination. lung cancer can be diagnosed or suspected on a chest x-ray. 8The lung mass appears in the medial portion of posterior segment of RUL, contiguous with

7、right hilum and obscuring the boundary with the aortic knob on the right.9A neonate-palm-sized inhomogenous soft tissue shadow can be seen in the right upper lobe. 10In the left upper lobe, a large, sharp-edged shadow is depicted, which widens the middle shadow. 11CT扫描Computed tomography (CT)12CT Im

8、ages13Positron Emission Tomography (PET)正电子发射计算机断层显像14PET Images15Ultrasound scanAbdominal ultrasound is a scanning technique used to image the interior of the abdomen.16Isotope scan (lung, bone)17A bone scan is a test that detects areas of increased or decreased bone metabolism .The test is perform

9、ed to identify abnormal processes involving the bone such as tumor, infection, or fracture.Mediastinoscopy纵隔镜18Thoracoscopy(VATS)胸腔镜Thoracoscopy - a minimally invasive way of accessing the chest through small incision(s) to diagnose and treat lung cancer. It is also called Video Assisted Thoracic Su

10、rgery (VATS).19支气管镜Bronchoscopy (FOB)The procedure provides a view of the airways of the lung and allows doctors to collect lung secretions or tissue specimens (biopsy). 20细胞学检查Cytology examination (sputum, pleural effusion)Squamous cellAdenocarcinomaLarge cell carcinomaSmall cell carcinoma21Lung Ca

11、ncer: Cell TypesNon Small Cell Lung Cancer (NSCLC)Small Cell Lung Cancer (SCLC)22NSCLC: Histologic Cell TypesAdenocarcinoma Squamous Cell CarcinomaLarge Cell Carcinoma23Small Cell Lung Cancer (SCLC)Most aggressive lung cancerResponsive to chemotherapy and radiation but recurrence rate is high even i

12、n early stage24TNM Staging of lung cancer A system for stage grouping of non-small cell lung cancer by primary tumor, regional lymph node, and distant metastasis (TNM) was developed by the International System for Staging Lung Cancer. The TNM system provides information related to the extent of dise

13、ase. 25TNM DEFINITIONST - Primary Tumor: TX T0 TIS T1 T2 T3 T4N - Nodal Involvement: N0 N1 N2 N3M - Distant Metastasis: M0 M126TNM DEFINITIONSTX 原发肿瘤不能评价或痰、支气管冲洗液中找到癌 细胞但影像学或支气管镜没有可视肿瘤 Tumor proven by the presence of malignant cellsTO 没有原发肿瘤的证据 No evidence of primary tumorTis 原位癌 Carcinoma in situ27

14、 T1a T1b Tumor 2 but 3 cm ， not more proximal than the lobar bronchus28 T2a T2bTumor associated atelectasis or obstructive pneumonitis that extends to the hilar region but does not involve the entire lungTumor 5 cm, 7 cm (with or without other T2 descriptors)2930T33132T433Lymph Node Staging3435No re

15、gional node metastasis Metastasis in ipsilateral peribronchial and/or perihilar lymph nodes and intrapulmonary nodes, including involvement by direct extension36ipsilateral mediastinal and/orsubcarinal lymph node(s) including skip metastasis without N1 involvement Metastasis in ipsilateral mediastin

16、al and/or subcarinal lymph nodes37Metastasis in contralateral hilar/mediastinal/scalene/supraclavicular lymph node(s)Metastasis in ipsilateral scalene/supraclavicular lymph node(s)38Malignant pleuraleffusion/nodule(s)3940M141Stage IAT1 N0 M042Stage IBT2 N0 M043Stage IIAT1 N1 M044Stage IIBT2 N1 M0T3

17、N0 M045Stage IIIAT3 N1 M0 T1 N2 M0T2 N2 M0T3 N2 M0 46Stage IIIBT4 Any N M0Any T N3 M0 47STAGE IVThe stage IV category includes only patients with evidence of distant metastasis, M1 disease.48Treatment PlanTreatment for lung cancer is based on the type and stage of tumor , possibility for removing th

18、e tumor, and the patients ability to survive surgery. Options include surgery, radiation, chemotherapy, or a combination of these treatments. 49Lung cancer: Treatment by StageStageDescriptionTreatment OptionsStage I a/bTumor of any size is found only in the lung SurgeryStage II a/bTumor has spread t

19、o lymph nodes associated with the lungSurgeryStage III aTumor has spread to the lymph nodes in the tracheal area, including chest wall and diaphragmChemotherapy followed by radiation or surgeryStage III bTumor has spread to the lymph nodes on the opposite lung or in the neckCombination of chemothera

20、py and radiationStage IVTumor has spread beyond the chestChemotherapy and/or palliative (maintenance) care5051Which treatment is the suitable option for early-staged non-small cell lung cancer? “两个最大”的原则即最大限度地切除肿瘤，最大限度地保留健康肺组织。Surgical treatments principle is complete resection and preserving the ma

21、ximum amount of functional lung tissue.Surgical treatments principle52术式选择Surgery can take several forms: 楔形癌块切除 Wedge resection 肺段切除 Segmentectomy 肺叶切除术 Lobectomy (video clip) 支气管袖状肺叶切除术Sleeve Lobectomy和/或支气 管袖状肺动脉袖状肺叶切除术Sleeve resection 全肺切除 Pneumonectomy53Pulmonary resectionRemoval of a small par

22、t of the lung is a segmental or wedge resection, removal of an entire lobe of the lung is a lobectomy, and removal of an entire lung is a pneumonectomy54Sleeve resectionA sleeve resection can be done by surgically removing the cancerous portion of the airway, leaving enough healthy tissue for the surgeon to reconnect the edges of the bronchi, thus preserving some tissue and pulmonary function. This surgery is used primarily for tumors located either in the right or left upper bronchus .55564R/2R dissection(Video Clip)The resection procedure for lung can