1、Disorders of Lungs,BeiJing Friendship Hospital Dept. of Cardiothoracic Surgery Gao Zhi,History,1912 Morriston Lobectomy(肺叶切除术) 1933 Graham Pneumonectomy(全肺切除术) 1956 Thomas Sleeve lobectomy (支气管袖状成形肺叶切除术) 1937 Wang Datong Lobectomy 1941 Zhang Jizheng Pneumonectomy,Surgical Procedures,Repairing Biopsy
2、 Pulmonary Resection Pneumonectomy , Lobectomy , Sleeve lobectomy, segmentectomy(肺段切除) , wedge resection（楔形切除） Lung Transplantation Video-Assisted Thoracoscopy Surgery (VATS),Thoracic Surgeons must DO,Diagnosis & Evaluation Preoperative Preparations cooperation Anatomy & Operation Postoperative Moni
3、toring,Operative Indications,Congenital pulmonary disease Pulmonary Infection Tumor Pulmonary vascular disease Pulmonary bullae(肺大庖) , pulmonary emphysema（肺气肿） interstitial lung disease,Bronchiectasis(支气管扩张),Cause: infection pertussis(百日咳), measles (麻疹),TB, pneumonia bronchial obstruction Pathology:
4、 persistent abnormal dilation of bronchi cylindrical (柱状) saccular(囊状) varicose(混合) lower lob upper lob,Clinical Manifestation,Persistent cough， purulent sputum（脓痰） Hemoptysis Repeated respiratory infection Audible rales over the involved lung field Osteoarthropathy (骨关节病) clubbing(杵状) anaemia (贫血)
5、malnutrition(营养不良),Diagnosis,History and physical finding X-ray Brochography（支气管造影） define the brochial anatomy for potential pulmonary resection,thin-section high-resolution CT noninvasive sensitivity & specificity 95%,Surgical Treatment Indication,Locate in one segment or lob segmentectomy or lobe
6、ctomy Involve 2-3 lobs pnoumonectomy -rarely today Bilateral disease-one side is greater the side with greater involvement is resected Bilateral disease-two side is same bilateral resection ,interval 6 months Bilateral disease- life-threatening hemoptysis lobectomy,contraindication,General status no
7、t good Cardiac, pulmonary, renal function Widespread pulmonary disease Combined with emphysema ,asthma, pneumocardial disease (肺心病),Preoperative Preparations,Examination sputum culture (痰培养) Anti-infection & reducing sputum volume antibiotics , sputum volume50ml/d postural drainage , atomization(雾化)
8、 Support therapy high protein ,blood transfussion,Operative methods,Dual-lumen endotracheal tube segmentectomy or lobectomy bleeding , contamination Bronchial resection Locate in segment Postoperative treatmentMonitoringExpectoration(咳痰),Surgical Treatment of Pulmonary tuberculosis,Collapse therapy
9、(萎陷疗法) artificially induced pneumothorax , phrenic nerve division extraperiosteal thoracoplasty Pulmonary resection more effective,Pulmonary resection,Indication 1) tuberculous cavity (结核空洞) thick walled cavity, tensive cavity,massive cavity , cavity in lower lob 2) tuberculoma(结核球) 3) trapped lung(
10、毁损肺) 4) tuberculous bronchial stenosis or bronchiectasis 5)recurrent severe hemoptosis due to drug-resistant localized TB 6)persistently positive sputum culture after thoracoplsty,Contraindication,Active TB Lower cardiopulmonary reserve Combined TB in other organs,Perioperative Teatment,Administrati
11、on of additional anti-TB chemotherapy before operation Endobronchial TB（支气管内膜结核） or not while positive sputum culture chemotherapy after operation 6-12 months Thoracoplasty if residuary cavity（残腔） or residuary disease in remaining lung,Complications,Bronchialpleural fistula Causes: 1) endobronchial
12、TB, 2) Stump(残端) infection 3) false treatment of stump Cavitation with air in it Pulmonary abscess TB spread,Thoracoplasty,Indication: 1)cavity in upper lob cant endure lobectomy 2) cavity in upper lob TB lesion in middle & lower lob 3) Widespread in one side positive sputum culture drug-resistant c
13、ant endure pneumonectomy,Contraindication,tensive cavity, thick walled cavity, cavity in middle & lower lob Tuberculoma Children with TB,method,Upper to low 3-4 / every time Interval 3 weeks Range : posterior -transverse process(横突) anterior - costal cartilage(1st3rd rib) pressure dressing after ope
14、ration prevent paradoxical breathing（反常呼吸）,Lung cancer,Broncho-pulmonary carcinoma Morbidity(发病率) & mortality（死亡率） Male/female : 3-5 :1 40 yrd,Etiology,Smoking : 4-10 times of the non-smoker Environment(环境): Asbestos(石棉), chromium（铬）, nickel（镍）, arsenic（砷）air pollution, radiation exposure: SCLC Immu
15、ne state , metabolism代谢 heredity遗传 infection Oncogene（癌基因），anti-oncogene（抑癌基因）,Pathology,Rightleft Upperlower Central lung cancer(中心型) peripheral lung cancer (周围型),Classification,Non-small cell lung cancer (NSCLC) 1) squamous cell carcinoma (鳞癌) 2) adeno-carcinoma (腺癌) 3)large cell carcinoma Small c
16、ell lung cancer(SCLC) Uncommon tumors of the lung : adeno-squamous carcinoma (腺鳞癌)bronchial carcinoids（类癌）, carcinosarcoma（癌肉瘤）,Metastasis,direct diffusion jacent tissue lymphatic metastasis common hematogenous metastasis advanced stage ,SCLC, adeno, liver,bone,brain, adrenal gland（肾上腺）,Clinical man
17、ifestation,Cough, hemoptysis（咯血） weight loss dyspnea（呼吸困难） pneumonia chest wall pain,advanced stage 1）phrenic nerve（膈神经） 2) recurrent laryngeal nerve（喉返神经） hoarseness 3）superior vena cava (上腔静脉),4）pleural effusion (胸水） 5) mediastinium esophagus(食管) 6) pancoast tumor （肺上沟癌） Horner,Paraneoplastic Synd
18、romes （副癌综合症）,hormonal intermediate frequently associated with SCLC & carcinoids Hypertrophic pulmonary osteoarthropathy (骨关节病) Cushing myasthenia gravis（重症肌无力） Myoneuralgia(肌肉神经痛),Diagnosis,X-ray and CT Centra lung cancer(中心型) obstructive pneumonia mass atelectasis肺不张 bronchial stenosis lymph node
19、effusion,peripheral lung cancer (周围型) solitary pulmonary nodule （孤立肺结节） sentus （毛刺）cavitas （空洞）,Sputum cytology(细胞学) for central hemoptysis reapeated Bronchoscopy for central biopsy, brushing, washing transbronchial aspiration (穿刺） Mediastinoscopy (纵隔镜检查) biopsy for mediastinal lymph node 1cm,PET/CT
20、 （positron emission tomography） increased glucose metabolism sensitivity & specificity 95% distinguishing benign from malignant nodules evaluation of mediastinal LN,Transthoracic needle aspiration(穿刺活检) for peripheral invasive benign result not exclude malignancy Indication: 1)poor candidate for tho
21、racotomy yet require definitive diagnosis 2)suggestive SCLCComplication : pneumothorax(气胸) ，hemothorax(血胸) infection,Biopsy of metastasis lesion supraclavicular(锁骨上) cervical(颈部) axil(腋部) subcutaneous(皮下) LN & nodule Pleural effusion cancer cell Thoracotomy & thoracoscopy undetermined diogniosis sta
22、ging,Revised definition of TNM,Primary Tumor (T) TX Primary tumor cannot be assessed T0 No evidence of primary tumor Tis Carcinoma in situ T1 Tumor 3 cm or less in greatest dimension, surrounded by lung or visceral pleura T2 Tumor with any of the following features of size or extent:More than 3 cm i
23、n greatest dimensionInvolves main bronchus, 2 cm or more distal to the carinaInvades the visceral pleuraAssociated with atelectasis or obstructive pneumonia,T3 Tumor of any size that directly invades any of the following: chest wall , diaphragm, mediastinal pleura, pericardium; or tumor in the main
24、bronchus less than 2 cm distal to the carina, but without involvement of the carina; or associated atelectasis（肺膨胀不全） or obstructive pneumonitis（肺炎） of the entire lung,T4 Tumor of any size that invades any of the following: mediastinum, heart, great vessels, trachea, esophagus, vertebral body（椎体）, c
25、arina; or separate tumor nodules in the same lobe; or tumor with a malignant pleural effusion,Regional Lymph Nodes (N) NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Metastasis to ipsilateral peribronchial （同侧支气管旁）and/or ipsilateral hilar lymph nodes,N2 Metastasis
26、 to ipsilateral mediastinal and/or subcarinal lymph node(s) N3 Metastasis to contralateral mediastinal（对侧纵隔）, contralateral hilar, ipsilateral or contralateral scalene, or supraclavicular （锁骨上）lymph node(s),Distant Metastasis (M) MX Distant metastasis cannot be assessed M0 No distant metastasis M1 D
27、istant metastasis present,Stage grouping,IA T1N0M0 IB T2N0M0 IIA T1N1M0 IIB T2N1M0 IIIA T1N2M0，T2N2M0，T3N1M0 T3N2M0 IIIB Any T, N3 M0 ; T4, Any N,M0 IV Any T Any N M1,Differential diagnosis（鉴别诊断）,Pulmonary TB: tuberculoma（结核球）- peripheral LC miliary(粟粒)TB-bronchioalveolar carcinoma （细支气管肺泡癌BAC） LN i
28、n hilum（肺门）-central LC Infection bronchial pneumonia pulmonary abscess,Other tumor benign tumor :hamartoma（错构瘤） fibroma（纤维瘤） chondroma（软骨瘤） angioma（血管瘤） Bronchial adenoma(腺瘤) Mediastinal lymphosarcoma（纵膈淋巴肉瘤） lymphadenectasis （淋巴结肿大） sensitive to radiation mediastinoscopy,Treatment,Combined therapy
29、surgery, radiation & chemotherapy For NSCLC : surgery : surgery+ adjuvant therapya: surgery ? + radio-chemotherapyb: concurrent（同步） radio-chemotherapy: systemic chemotherapy (PS2)single-agent chemotherapy (PS2) For SCLC chemotherapy-surgery-chemotherapy chemotherapy-radiation -surgery-chemotherapy c
30、hemotherapy-radiation -chemotherapy,Surgery,The overall plan and needed imaging studies should be determined before any non-emergency treatmentWedge resection or segmentectomy if physiologically compromisedLobectomy or bilobectomy standard,Pneumonectomy if physiologically feasible Sleeve lobectomy L
31、ung-sparing anatomic resection preferred over pneumonectomyExpanded Resection pleura ，chest wall ,atrium , great vessel （大血管）,Prognostic factors,Tumor histology Stage grouping Operative method Residual tumor (残留) Age General condition Immune status,Contraindication,Distant Metastasis brain, bone ,li
32、ver, adrenal gland General status not good Cardiac, pulmonary, renal function Widespread hilar ,mediastinal LN Serious invasion Distant LN metastasis,Radiation,For Local tumor Adjuvant radiation Palliative radiation (姑息的) Contraidication: cachexia（恶病质）,severe emphysema, widespread metastasis , wide-
33、range tumor,cavitas（空洞）,Chemotherapy,Indicated in PS 0-2 patients with advanced LC, and in combined modality therapy in locally advanced LC First-line : Cisplatin(顺铂) ,carboplatin(卡铂) combination with : paclitaxel(紫杉醇), gemcitabine（吉西他滨）, vinorelbine（长春瑞滨）, irinotecan（依立替康）, etoposide（足叶乙甙） Second-line: Docetaxel（多烯紫杉醇） Pemetrexel（培美曲塞 ）,Molecular targeted therapy(靶向治疗),EGFR(表皮生长因子受体） Iressa(易瑞沙) Tarceva (特罗凯）VGFR(血管表皮生长因子 ) Avastin（贝伐单抗） Endostar （恩度）,
