外科学教学课件：Lung cancer.ppt

Lung CancerAnatomyLobe (肺叶肺叶)Segment(肺段肺段)Lung CancerMalignant neoplasms arise in bronchial epithelium(broncho-pulmonary carcinoma，，支气管肺癌支气管肺癌)•Most frequent cause of cancer death (14% of all cancer diagnoses, 28% of death)•Male/female: 3-5/1(?! Increasing in women )Etiology (risk factors)•Smoking (22-fold/12 % increased risk for death in men/women, second hand)•Occupational exposure(randon, nickle, asbestos, chronium, arsenic, radiation ) •Air pollution•Genetic factors •Predisposing pulmonary diseaseSmoking as a risk factorNCCN guidelines for lung cancer screeningLocation of Lung cancerRight>left, upper>lower1.Central Type (中央型中央型) centrally located, close to the pulmonary hilum, arises in epithelium of bronchus proximal to the segmental bronchus.Location2.Peripheral type（外周型）（外周型） peripheral located, arises in bronchial epithelium distal to the segmental (including segmental) bronchus. Histologic Subtypes1.Small-cell lung cancer (SCLC) 20%2.Non-small-cell lung cancer (NSCLC)•squamous cell carcinoma (SCCA,30%)•adenocarcinoma (ACC, 45%)•BAC ( Use of BAC（细支气管肺泡癌）（细支气管肺泡癌）terminoloy is stronly discouraged , new terminology AIS, MIA））•large-cell carcinoma Histologic SubtypesMetastasis•Direct spread•Lymphangetic spread •Hematogeous spread: bone, brain, adrenal gland, liver, •ACA trend to metastasize earlier than SCCClinical Manfestation（（Early））Asymptomatic!Patients are most commonly first seenwith symptoms in advanced stage Clinical Manifestation (Advanced)1.Nonspecific manifestations2.Pulmonary thoracic manifestations3.Non-pulmonary thoracic manifestations4.Metastatic manifestations5.Non-metastatic (paraneoplastic) syndroms Poor general status•Anorexia•Fatigue•Weight loss ( >5% )Nonspecific ManifestationsPulmonary manifestations•Cough (irritation or compression)•Hempotysis (blood streaking of sputum痰中带血痰中带血)•Dyspnea (occlusion, atelectasis(肺不张肺不张), pleural /pericardial effusion) •Wheezing(partial occlusion of a bronchus)•Pneumonic symptoms (bronchitis, atelectasis or post-obstructive pneumonia)•Lung abscess (pneumonia or necrotic infection)Nonpulmonary thoracic manifestations 1.Chest wall ( chest pain, Pancoast’s tumor (Honor’s syndrom: miosis, ptosis, anhidrosis) )2.Diaphragm invasion3.Mediastinal structures invasion•phrenic nerve •recurrent laryngeal nerve dysfunction•superior vena cava syndrome•pericardial invasion•eophageal invasion •vertebral body or spinal invasion•Metastatic manifestations central nervous system, bone, viscera •Paraneoplastic syndromes(non-metastatic manifestations) osteoarthropathy（骨关节病）（骨关节病） acropachy(杵状指杵状指), Cushing’s sign, hypercalcemia Nonpulmonary Extra-thoracic manifestations Diagnosis•Multidisiplinary evaluation(thoracic surgeon, radiologist, pulmonologist)•Risk factors(smoking …)•History •Physical examination•Diagnostic examinationNoninvasive Examination•Cytological diagnosis Sputum cytology•Imaging diagnosis1.Chest film2.CT 3.MRI4.Radionuclide scanning5.FDG-PET (Positron Emission Tomography)Invasive Examination•Bronchoscopy•EBUS(超声引导气管镜超声引导气管镜)•Transthoracic needle aspiration•Pleural effusion cytology•LN biopsy•Mediastinoscopy•Thoracoscopy: video-assisted thoracoscopy (VATS) •Thoracotomy TNM Staging International Union Against Cancer (UICC)•Primary Tumor(T)•Regional Lymph Nodes(N)•Distant Metastasis(M)Patients with similar survival outlooks were grouped together TNM Staging TNM Staging TNM Staging TNM Staging Treatment•Surgical procedure (20%)•Radiotherapy•Chemotherapy•ChemoradiationØTargeted therapy(VEGF monoclonal anitbody or EGFR small molecular inhibitors --TKI )ØImmunotherapyØChinese medicineIndication for Surgery•No distant metastasis•No cachexia（恶液质）（恶液质）•Resectability•No severe vital organ complication•Acceptable life span expectationResectable and medically fitIndication for Surgery•Stage Ia lobectomuy+mediastinal lyphadenectomy alone•Stage Ib, IIa, IIb, early IIIa lobectomy +mediastinal lyphadenectomy+adjuvant therapy•Stage IIIa neoadjuvant therapy+lobectomy + adjuvant therapySurgical approach To resect the mass and to reserve the normal lung parenchyma•Lobectomy+LN resection•Sublobectomy + LN samplingüWedge resectionüSegmentectomy•Pneumonectomy•Minimal invasive procedures(微创微创) (VATS,胸腔镜辅助胸腔镜辅助)Minimal invasive (VATS) ApproachLong-term Results•Operation first choice, 5 year survival rate 30-40% Stage I, II, II, IV 65%, 40%, 15%, 5% in selected patients 100%•Radiotherapy 3-year survival rate: 10%(SCLC, SCCA)•Chemothrapy not effective except for SCLC  Ground-glass Opatcity (GGO,磨玻璃样病灶磨玻璃样病灶) Ground-glass Opatcity (GGO,磨玻璃样病灶磨玻璃样病灶)GGO生长缓慢33•pGGN直径增加34•GGN出现新的实性部分四川大学华西医院35•GGN体积增大，同时出现新的实性部分四川大学华西医院36Thank you。