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(Case information 2019) Luo from Jinhua is 60 years old and has a history of smoking for 40 years. A few days ago, a chest CT scan in our hospital revealed nodules in both the left and right lungs. His family came to me and asked me to see if his nodule was malignant and whether he needed surgery. The following is a plain scan of the nodule in the upper lobe of his left lung:

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. There are cavitary lesions in the middle, but the overall density is still mainly pure ground glass, with some punctate high density. According to past experience, such nodules are basically invasive adenocarcinoma, which mainly grows adherently. Some of them are smaller in diameter, within subcentimeter, and may also be microinvasive adenocarcinoma or adenocarcinoma in situ (rarely). So I told him that 90% of the cases were considered malignant and surgery was recommended. According to current treatment guidelines, early-stage lung cancer larger than 2 cm should undergo lobectomy and lymph node dissection. For tumors within 2 cm, if one of the following conditions is met: adenocarcinoma in situ, solid component less than 50%, and doubling time greater than 400 days, sublobar resection, including segmental resection and wedge resection, can be performed. Obviously Luo's condition is not suitable for sublobar resection. However, he has a special situation. He also has a ground glass nodule in his right lower lung, most of which are solid. The following is a plain scan image of the nodule on his right side:

< p> Further target scan showed:

A mixed ground-glass nodule of about 8 mm in the dorsal segment of the right lower lobe (near the basal segment side) with uneven edges and pleural traction was seen, which is also a typical sign of malignancy. So for the lesions on the right side, according to the treatment guidelines, puncture or wedge resection should be performed first. If the pathology is invasive adenocarcinoma, right lower lobectomy and lymph node dissection should be performed.

The current problem is that both sides are relatively malignant, and unilaterally requires lobectomy (pathological evidence needs to be obtained during the operation). If it is more rigid, lobectomy plus lobectomy should be performed in stages. Lymph node dissection. But in fact, for multiple primary cancers, the guidelines also point out conceptually: surgery should be cautious; priority should be given to treating the main lesion; lung function should be preserved as much as possible (less surgery can be performed); and as many lesions as possible should be removed at one time. But when it comes to individual cases, there are actually no identical rules to follow. In this case, staged lobectomy is obviously the most standard and the most thorough, but isn't it really the most reasonable and most beneficial to the patient? Obviously everyone has their own opinions and considerations. Comprehensive evaluations such as age, lung function, patient wishes, pathological type, and guideline requirements can be considered. In general, there are the following options to choose from:

Option 1: left wedge resection + right wedge resection (although the trauma is small, it is not in line with the principles of tumor treatment);

< p> Option 2: Left lingual segment resection + right wedge resection (optional, meaning compromise, the left upper lobe should have been resected because its diameter is greater than 2 cm);

Option 3: Left side Wedge resection + right dorsal segment resection (optional, meaning compromise, the right lower lobe should have been resected because the dense ground glass nodule is basically solid);

Plan 4: Staged surgery Left lingual segment resection + right dorsal segment resection (optional, but the surgery needs to be performed in stages, which is equivalent to a compromise on both sides);

Option 5: Staged left lobectomy + right lobectomy Lateral dorsal segment resection (optional, focusing on left invasive adenocarcinoma with a diameter greater than 2 cm);

Plan six: staged left lingual segment resection + right lower lobe resection (optional, Focus on right-sided invasive adenocarcinoma with more solid components);

Plan 7: Staged left upper lobectomy + right lower lobectomy (although it is most consistent with the principle, there is more lung loss, and my personal opinion is due to the two Both sides should be considered to be early-stage lung cancer, so do not choose)

Option 8: Left upper lobe resection + right lower lobe wedge resection (optional, doing this on the left side is consistent with the principle, while the right side is a compromise option) Wedge resection);

Option 9: Wedge resection of the left upper lobe + resection of the right lower lobe (optional, it is in principle to do so on the right side, wedge resection on the left side is a compromise, but because the lesion on the left side is larger than 2 cm, seems inappropriate).

In fact, each choice has its own reasons. We sent this case to the professional group, and each one also had his own choices and suggestions. My personal opinion is to choose wedge resection of the right dorsal segment + left upper lobe, based on the following considerations: the patient is 60 years old, which is still relatively young, and there is still the possibility of recurrence of tumors in the future; in terms of size and density, I personally think Density is more important, because pure ground glass may not metastasize even if it is larger. Therefore, for the same invasive adenocarcinoma, lobectomy is chosen for patients with high density. The reason why lobectomy cannot be performed uniformly in stages is because in case of recurrence of tumors in the future, it is still possible to perform lobectomy. It can leave some leeway, and the quality of life after surgery is relatively better.

Later, two doctors in the province considered the option of lingual segment resection of the left upper lobe + wedge incision of the right lower lobe, so I gave up my idea and planned to perform left lingual segment + wedge incision of the right lower lobe.

The operation was scheduled for October 17. After entering the chest, it was found that the oblique fissure was poorly developed. It was very difficult to free the lingual artery from the leaf fissure. So we had to reverse the lingual vein first, and then cut off the lingual bronchi, but the tongue The segmental lung tissue was still lying underneath, and there was no way to lift it up, so the determination of the plane of the lung segment was inaccurate. After cutting out the lung segment, no lesions were found. Later, proper segmental resection (equivalent to left upper lobe resection) was performed, and lymph nodes were dissected. , a quick section during surgery showed: invasive adenocarcinoma. Pathology after wedge incision on the right side first considered ciliated mucinous nodular papillary tumor. Postoperative routine pathology: bronchiolar adenoma on the right side, invasive adenocarcinoma on the left side, and negative lymph nodes. Looking back, the current plan chosen is the most reasonable and complies with the norms or guidelines.

When the same patient has multiple primary cancers, different doctors have too many different choices when determining the surgical plan. We hope that our choice will not violate the principles and be as beneficial to the patient as possible. A little, the trauma can be as small as possible and the recovery can be faster.

#pulmonary nodule surgery#