肺癌手术讲座课件

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,肺癌手术在肺癌综合治疗中的地位和展望,上海市胸科医院,二十世纪的鼠疫,肺癌,发病率、死亡率急骤上升,五年生存率,3cm,，侵及主支气管但距隆突,2cm,；,侵及脏层胸膜，肺不张或阻塞性肺炎扩展到肺门未达全肺,T3,侵及胸壁、横膈、纵隔胸膜或壁层心包；侵及主支气管距隆突,2cm,但未及隆突；全肺不张和阻塞性肺炎,T4,侵及纵隔、心脏、大血管、气管、食管、椎体或隆突；恶性胸腔或心包积液；同侧同叶的卫星灶,肺癌的,TNM,N,胸内淋巴结,N0,无胸内淋巴结转移,N1,同侧支气管周围、肺门淋巴结；原发灶直接扩展到肺内淋巴结,N2,同侧隆突下、纵隔淋巴结,N3,对侧纵隔、肺门淋巴结；锁骨上淋巴结,M,远道转移,M0,无远道转移,M1,有远道转移,肺癌的,TNM,分期,0,期,Tis,N0 M0,IA,期,T1 N0 M0,IB,期,T2 N0 M0,IIA,期,T1 N1 M0,IIB,期,T2 N1 M0,T3 N0 M0,IIIA,期,T1-2 N2 M0,T3 N1-2 M0,IIIB,期,任何,T N3 M0,T4,任何,N M0,IV,期 任何,T,任何,N M1,肺癌分期的确立,对国际标准,TNM,分期达成共识,手术本身有助于进行正确分期,有利于制定合理的治疗方案,手术适应症相对统一,预测预后,手术操作技术改进,VAB BAV AVB,气管残端术中冰冻切片检查,减少医源性播散,气管外科的开展,扩大手术的适应范围,合理切除病灶,各式袖形、肺叶、隆突、全肺、隆突重建,手术安全性的提高,正确评估心肺功能储备,手术技巧的改进、提高,麻醉技术的提高,术后重视呼吸道的管理,对高龄病人处理能力的提高,降低了手术死亡率,40%,1.6%,减少了并发症,54%6.4%,减少了剖胸探查率,5.1%3.0%,围手术期治疗水平的提高,慎於术前 精於术中 勤於术后,非小细胞肺癌的治疗原则,I,期 根治性手术,II,期 手术,+,术后化疗,+,术后放疗,叶间淋巴结,N1 5,年生存率,65%,肺门淋巴结,N1 5,年生存率,39%,III,期,NSCLC,IIIA,期 可切除性病变 手术,+,辅助治疗,大块肿瘤 多学科治疗,5,年生存率,1523%,IIIB,期 局部侵犯严重，无法手术切除,大部分采用放疗,5,年生存率,67%,肺癌的转移,随着病期的进展，最终发生转移的可能增大,脑 骨 肝 肾上腺,47%36%22%15%,手术和放、化疗,1995:BJM,肯定以顺铂为主的术后化疗,1998:Lancet,否定术后,60,Co,的放疗,2001:ASCO,术后化疗不能延长,N2-NSCLC,生存期,诱导化疗意义,减少耐药的肿瘤细胞数,肿瘤血供尚未破坏,了解肿瘤对化疗药物的反应,缩小瘤体，便于切除,清除潜在的微转移灶,化疗和手术,针对,N2,的非小细胞肺癌，实施诱导化疗,+,手术,手术完全切除率,60%,术后,5,年生存率,20-25%,术后化疗以,4,个疗程为主，含铂方案具有生存,优势倾向,Effect of Chemotherapy to Operation for Lung CancerNSCLC,Method,Lung Cancer,100 cases,(Chemotherapy,Operation）group,59 cases,86.44%MVP regiment,（Operation,Chemotherapy）group,41 cases,73.17%MVP regiment,Chemotherapy course,Course,Chemo,OP,OP,Chemo,1-2 course 98.30%48.77%,3-4 course 1.70%48.77%,Operation Time,Chemo,OP,141.8646.64,-p,0.05,OP,Chemo,137.5030.74,Blood Lose during Operation,Chemo,OP,588.14632.07,-p,0.05,OP,Chemo,490.00276.24,Drainage volume after Operation,(first day postoperative),Chemo,OP,426.61187.98,_ p,0.05,OP,Chemo,470.13199.20,Conclusion,(1)Chemotherapy increase the risks of operation,(general,condition),(2)Fibrosis is an underlying risk factor for blood loss,its,necessary to pay more attention on carefully hemostasia,(3)To decrease the risks of postoperative complication,sufficient interval after chemotherapy,preoperative,prepare and proper management after operation are,the key factors,对,SCLC,外科手术的认识,单纯手术是否有益？,先手术后综合能否提高疗效？,诱导,+,外科,能否长期带病生存？,小细胞肺癌的治疗,I-II,期 局限期,手术,化疗,4+,综合,一般,N1,以上期别,化,2,手术,化,4+,综合,手术辅以综合为当前争取疗效、争取根治,的必要途径,Surgical treatment for small cell lung cancer,Method,Lung Cancer,145 cases,(Chemo/Radio,Operation）group,64 cases,(Operation,Chemo/Radio）group,81 cases,Operative Style,Lobectomy,69,Pneumonectomy,68,Sleeve Lobectomy 7 Segmentectomy 1,The Survival rate of SurgeryChemo/Radio Therapy Group,1year 3years 5years,Ia,100.00%50.00%50.00%,Ib 100.00%42.90%28.60%,IIa 100.00%85.70%71.40%,IIb 86.70%46.70%13.30%,IIIa 52.50%5.00%5.00%,IIIb 40.00%0.00%0.00%,Survival rate of Chemo/Radio,Surgery therapy Group,0,20,40,60,80,100,120,1,2,3,4,5,5 Year,Survival time,%,Ia,Ib,IIa,IIb,IIIa,IIIb,The Survival rate of SurgeryChemo/Radio Therapy Group,1year 3years 5years,Ia,100.00%87.50%50.00%,Ib 66.60%16.70%,Iia,80.00%80.00%60.00%,Iib,90.00%20.00%20.00%,IIIa,79.10%20.80%4.20%,IIIb,72.10%9.00%9.00%,Conclusion,1.,Surgery should be the first choice of treatment for,early TNM staging patients,2.Operation,should be considered as treatment method and combined with chemotherapy for SCLC,肺癌,提倡以外科为主的综合治疗,手术 化学疗法 放射疗法,免疫生物 中医中药,提高,5,年生存率,10%,3040%,