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ORIGINAL ARTICLE
Year : 2014  |  Volume : 51  |  Issue : 6  |  Page : 29-32
 

Different limited resection of pulmonary lobe methods under the thoracoscopy in the treatment of early nonsmall cell lung cancer occurred in the old age


Department of Thoracic Surgery, Navy General Hospital of PLA, Beijing, China

Date of Web Publication24-Feb-2015

Correspondence Address:
Dr. W Wang
Department of Thoracic Surgery, Navy General Hospital of PLA, Beijing
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.151995

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 » Abstract 

Objectives: The objective was to explore clinical effect of limited resection of lung lobe under the thoracoscopy in the treatment of early nonsmall cell lung cancer occurred in the old age. Methods: A total of 150 patients with nonsmall cell lung cancer in the old age is treated by limited resection of lung lobe under thoracoscope. It can be divided into segmental resection group and wedge resection group by surgical methods, to make a comparative analysis of operation time, intraoperative blood loss, hospital stays, and complications during the perioperative period. And there will be postoperation follow-up on survival, relapse and death situation etc., Results: 10 cases are changed to make other operation because of maladaptation to limited resection, and a total of 140 patients have undergone limited resection. Operation time and hospital stays of wedge resection group are shorter than those of segmental resection group (P < 0.05); compared with the bleeding and indwelling drainage tube time in two groups, differences have no statistical significance (P > 0.05). Compared with cases of complications, recurrence and death for groups of segmental resection and wedge resection group, the differences have no statistical significance (P > 0.05). Conclusion: Limited resection of lung lobe in the early treatment of nonsmall cell lung cancer occurred in the old age under the thoracoscopy is safe and feasible.


Keywords: Limited resection old age, nonsmall cell lung cancer, thoracoscopy


How to cite this article:
Li X C, Wang W, Liu J Q, Wen F, Yue C Y. Different limited resection of pulmonary lobe methods under the thoracoscopy in the treatment of early nonsmall cell lung cancer occurred in the old age. Indian J Cancer 2014;51, Suppl S2:29-32

How to cite this URL:
Li X C, Wang W, Liu J Q, Wen F, Yue C Y. Different limited resection of pulmonary lobe methods under the thoracoscopy in the treatment of early nonsmall cell lung cancer occurred in the old age. Indian J Cancer [serial online] 2014 [cited 2021 Dec 1];51, Suppl S2:29-32. Available from: https://www.indianjcancer.com/text.asp?2014/51/6/29/151995



 » Introduction Top


Lung cancer has become a malignant tumor with the highest fatality rate in China and about 80% of which belong to nonsmall cell lung cancer. [1] Studies show that nonsmall cell lung cancer are in the majority of the elderly and 30-40% of them is above 70 years old. [2] The elderly patients with lung cancer are a special group, and often diagnosed as the early stage patients because their physiological factors and body function are relatively degraded than young people, but they give up a radical cure because of intolerance to pulmonary lobectomy. On the other side, other diseases such as chronic obstructive pulmonary disease, hypertension, and coronary heart disease often occur in the elderly, which makes the treatment of aged patients with lung cancer much more complicated. [3],[4] Thoracic surgery physicians have accepted thoracoscopic surgery because of its advantages, such as small trauma, fewer complications, and quicker recovery. [5],[6],[7]] We make an analysis of operation situation and safety of the aged patients with nonsmall cell lung cancer who has been treated by limited resection under the thoracoscopy in our hospital from April 2010 to May 2013.


 » Methods Top


Inclusion criteria accepting criteria

(1) Age: ≥ 70 years old; (2) a definite diagnosis of nonsmall cell lung cancer is made according to pathology or cytology; (3) TNM staging of I-n (AJCC/UICC standard in 2002); (4) tumor diameter of 2 cm presented by chest computed tomography (CT) of all patients before operation; (5) exclusion of distant metastasis through bronchoscopy, bone scan, craniocerebral nuclear magnetic resonance, and CT scan abdomen; (6) Karnofsky of physical condition >70; (7) Tolerable partial resection of pulmonary lobe surgery by cardiopulmonary function evaluation; (8) The clinical research report is passed by hospital ethics committee, and all patients (or family) are informed of this and sign the consent form and be able to do follow-up clinic. Exclusion criteria: (1) Have severe basic diseases, intolerance to surgery; (2) diagnosed as central type lung cancer by iconography X-ray, CT or magnetic resonance imaging display; (3) the equidistance between tumors and the main bronchus, lobe bronchus, esophagus, large blood vessels and heart smaller than 10 mm; (4) patients not suitable for thoracoscope surgery with extensive pleural adhesion.

General background

A total of 150 patients with nonsmall cell lung cancer in the old age who conform to the above standard is treated by limited resection of lung lobe under the thoracoscopy in our department from April 2010 to May 2013. It can be divided into segmental resection group and wedge resection group by surgical method. There are 72 cases in segmental resection group, of which 42 cases are male, 30 cases are female, the age of 70-85, the average of (72.5 ± 9.6). Pathological types: 32 cases of adenocarcinoma, 18 cases of squamous carcinoma, 10 cases of adenosquamous carcinoma, 10 cases of large cell carcinoma, and 2 case of basal cell carcinoma; TNM staging: I a period of 12 cases, I b period of 20 cases, II period of 20 cases, II b period 20 cases. There are 68 cases in wedge resection group, of which 38 cases are male, 30 cases are female, the age of 71-87, the average of (73.1 ± 9.3). Pathological types: 34 cases of adenocarcinoma, 16 cases of squamous carcinoma, 15 cases of adenosquamous carcinoma, 2 cases of large cell carcinoma and 1 case of basal cell carcinoma. TNM staging: I a period of 10 cases, I b period of 24 cases, II a period of 18 cases, II b period of 16 cases. Gender distribution, age, staging situation of the disease, and histological classification of two groups of patients are no statistically significant differences (P > 0.05).

Surgical methods

According to different basic diseases of patients, preoperative specialist consultation, and detailed assessment of important viscera function can be made before operation, and the operation principle and contraindications should be strictly grasped. Deep breathing and expectoration exercise before operation ought to be conducted with full preparations. Use general anesthesia, and intubation tube is inserted into double-laparoscopic trachea in patient's lateral position; fiber bronchoscope can be used to locate if necessary, to achieve satisfactory isolation of the right and left lung, with ventilation pattern of single lung. (1) Three-hole method is used for segmental resection, and the specific steps are: 1-2 cm incision should be made in 7 th intercostal space or 8 th intercostal space of midaxillary line as observation hole. 2 cm incision should made in auscultation triangle area as assistant handle hole, and main handle hole is located in anterior axillary line a little front of 4 th intercostal space or 5 th intercostal space, which can be appropriately adjusted to incision of 2-4 cm in light of chest depth and tumor location of patients. The operation order is to propel from hilus pulmonis to the pulmonary parenchyma, and then to dissect pulmonary artery, static affectionately, bronchus till the branch of pulmonary segments. Arteries and veins of pulmonary segments are usually processed with 5 mm Hem-o-lok, and linear cutting sewing machine is used when the diameter of blood vessels are bigger; bronchus of pulmonary segments is often treated by linear cutting sewing machine under thoracoscopy. In according to the different pulmonary segments and development situation of pulmonary fissures, processing order of the arterial pulse, venous pulse, and bronchus can be different. (2) Wedge resection: Take the 7 th intercostal space of axillary midline as observation hole, to probe the mass position and choose different handle hole, and adhesion should be separated by electricity hook or excavator, with local excision of tumor and lung tissue; the pleura around tumor and hanging tumor of lungs group should be incised if the tumor is too large, and residual lung tissue should be repaired and stitched after the removal of the tumor. The satisfaction of specimens cut by wedge and the cleanness of cut edge need to be checked. After limited pneumonectomy of all patients, make fast pathologic examination of lymph node during operation, and thoracic lymph nodes should be cleaned to try to reduce the operation time. Pull out urine tube after 4-8 h of the operation; eat food after 8 h after operation; get out of bed in the early stage; pull intrathoracic drain for 3-5 days; clinical follow-up every 6 months 2 weeks after conventional operation.

Observation item

Observe operation time, intraoperative blood loss, hospital stays, complications of two groups during the perioperative period, and there will be postoperation follow-up of survival, relapse and death and other cases. Complications during perioperative mainly record occurrences of heart failure, arrhythmia, pneumonia, bronchopleural fistula, respiratory failure, pulmonary infection and perioperative death of two groups (perioperative death is the death after 30 days of operation). Follow-up visit mainly includes local or distant recurrence and death. Local recurrence is the relapse within the same pulmonary lobe or the relapse of mediastinal lymph node; distant recurrence is the relapse of other pulmonary lobes or relapse outside ipsilateral chest.

Statistical methods

Use SPSS (Released 2009. PASW Statistics for Windows, Version 18.0. SPSS Inc., Chicago, IL, USA) 18.0 to count software, t-test for measurement data, and enumeration data according with the normal distribution can be tested using Chi-square or for the exact probability.


 » Results Top


Operation completion of two groups As to segmental resection group, there is 2 case maldevelopment of puhnonary fissure, 4 cases of obvious adhesion, and they are all transferred to pulmonary lobectomy surgery with small incision assisted by thoracoscopy. As for pulmonary wedge resection group, there are 2 cases of suspected local transfer that pulmonary lobectomy surgery with small incision assisted by thoracoscope is conducted halfway; there are 2 cases who cannot bear partial pulmonary lobectomy, tolerating resection then; thoracoscopic localized pulmonary resection is successfully performed for the rest 140 patients, with operation lesion resection rate of 90.6%, no perioperative death, and no serious postoperative complications occur, no transit operation of total pulmonary lobectomy by thoracotomy.

Operation comparison between two groups, there are no statistically significant difference (P > 0.05) [Table 1].
Table 1: Comparison between two groups on operation situation and length of stays (xs)

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Postoperative complications and follow-up situation comparison within 1-year, compared with cases of complications, recurrence and death for two groups, the differences, are of no statistical significance (P > 0.05) [Table 2].
Table 2: Postoperative complications and follow-up of patients within a year of two groups percentage

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[Table 2] postoperative complications and follow-up of patients within a year of two groups' percentage (%).


 » Discussions Top


Malignant tumor has become the first cause of death of urban residents in our country, accounting for 25.0% of all deaths, and has showed a trend of sustained growth, in which the biggest rise lies in lung cancer. [8] Lung cancer has replaced liver cancer to become the first cause of death of malignant tumor in China, accounting for 22.7% of all malignant tumor death. [9] Research has shown that among patients with lung cancer over the age of 70, the survival rate of those not treated through surgery is only 6% within 2 years, while others through surgical treatment can amount to 35.6%. [10],[11],[12] So age is not the absolute surgery taboo, on the contrary, for elderly patients with lung cancer, surgical resection is still an effective cure method. [13],[14],[15],[16] However, physiological degeneration changes due to age of elderly patients with lung cancer merging other basic pathological changes, often affect its tolerance ability of lung cancer surgery, and rigorous assessment and preparation are required to be made for patients before operation. We mainly focus on maximum of reservation of lung function and maximum of lesion removal, which are also key problems of great emphasis on the choice of operation method. [17] At present, treatments of nonsmall cell lung cancer in the seniors from I to II periods are mainly surgical treatment, radiotherapy, chemotherapy, and comprehensive therapy, etc. Traditional surgery ways of lung cancer mainly include open-heart simple pulmonary lobectomy, composite pulmonary lobectomy, excision of pulmonary segments, wedge resection of goiter, sleeve resection of pulmonary lobe, carina molding, and so on. [18],[19],[20] Most elders' patients cannot tolerate due to big traumas, so they give up treatment. With the development of video-assisted thoracoscope and surgeon's proficiency in the operation technology, thoracoscope surgery provides elderly patients with another option of radical surgery due to its advantages of small trauma, weak pain, rapid recovery and shorter hospitalization time, etc. [21],[22],[23],[24],[25] In lung cancer diagnosis and treatment guidelines of National Comprehensive Cancer Network in 2006, pulmonary lobectomy under thoracoscope has been formal listed to radical surgery methods of nonsmall cell lung cancer, which has fully recognized therapeutic effect of early stage of lung cancer on thoracoscopic pulmonary lobectomy. [26] Clinical practice guidelines of nonsmall cell lung cancer of 2010 version set by National Comprehensive Cancer Network have clearly put forward that limited resection can be implemented for selective patients (i.e., pulmonary segments resection and pulmonary wedge resection). [27]

Maturity of thoracoscopic pulmonary lobectomy surgery provides a wealth of experience for limited resection of lung cancer. [28],[29] In pneumonoresection surgery, any incomplete pulmonary lobectomy excision, that is, limited pneumonectomy excision, advantages of thoracoscopy combined with limited resection of lung cancer operation can maximize lung function protection of the elderly patients. [30],[31] The most commonly used operations of limited resection of lung cancer are pulmonary segments excision and pulmonary wedge resection. Among lung cancer patients, 11.5% will suffer primary lung cancer again, in which primary lung cancer of two kinds of the pathological nature is found in 2.3% patients. [32],[33] Thoracoscopic pulmonary segments excision enables these patients more tolerable of excision of one-staged multiple ipsilateral and bilateral lesions or two lung cancer surgeries. [34],[35] The most prominent advantages of pulmonary wedge resection are that it can reduce excision extension of lung, and can keep more lung tissues; patients can keep better lung function and quality of life after surgery. [36],[37] Pulmonary wedge resection should pay attention to the issue that the smaller the lesion is, and the more difficult the location of the lesion will be. Besides, the complexity of pulmonary wedge resection is related to the location of the lesion. [38],[39]

In a word, totally thoracoscopic limited resection in the treatment of early nonsmall cell lung cancer occurred in the old age, combined with secure and feasible lymph node dissection and merits of video-assisted thoracoscope surgery, such as minimal invasion, short time of operation and weak pain, offers a brand new platform for local resection of lung cancer. However, due to the few number of cases that we observe, short follow-up time and less randomness, future discussion is still needed to be continued in the exploration. Furthermore, we must know clearly the advantages and limitations of each operation so that we can conduct normal choice of operation indication, to optimize benefits of the patients. [40],[41],[42]

 
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42.
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    Tables

  [Table 1], [Table 2]

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