Some special methods for the study of lymphatic collectors and mediastinal organs: mediastinoscopy, parasternal mediastinotomy — the clinic has not developed much of its practical application. This is due to the fact that the verified defeat of lymph nodes located in the mediastinum of regional groups by metastases is not, in our opinion, a contraindication for performing extended and combined operations, as well as involvement in the blastomatous process on a limited extent of the esophageal muscular membrane, superior vena cava, and auricle , the initial sections of the main bronchi and the wall of the trachea, pericardium, vagus and phrenic nerves, etc., which can be assumed on the basis of a special assessment with condition of the mediastinum.
and conducted anesthesia screening. Since 1975, the clinic has received an endoscopic examination by fibrobronchoscopes of the company ”(Japan).
When detected in patients with resectable forms of lung cancer of exudative pleurisy, the latter requires clarification of its nature, since in almost half of the cases it is not a manifestation of pleural carcinomatosis. The leading role in determining its character is the study of exudate on tumor cells, which allows obtaining a positive response in 80% of cases. In 45.4–, 9% of cases, dissemination can be detected by computed tomography, including cases with even a small localized lesion. However, the possibility of diagnostic errors requires morphological confirmation of the results of the study, if the data of computed tomography affect the choice of treatment method.
In such cases, as well as with negative results of cytological examination of the pleural fluid, especially in patients with glandular or undifferentiated lung cancer, thoracoscopy is shown. The method allows you to visually assess suspicious areas, sighting to take material for a biopsy. With metastatic lesions of the pleura, its diagnostic value is 93—%.
In the presence of pleural effusion in patients with lung cancer, as a rule, puncture of the pleural cavity was performed, followed by biochemical and cytological examination of the exudate. With questionable results of cytological examination of pleural exudate, thoracoscopy was performed. Application was mainly limited to cases of diffuse exudative pleurisy with hemorrhagic exudate for differential diagnosis with primary tumors of the pleura and the exclusion of its carcinomatosis. To clarify the prevalence of the blastomatous process, thoracoscopy was rarely used, since its diagnostic capabilities for determining the nature and extent of extrapulmonary lesions, in our view, are not sufficiently informative.
Involvement in the tumor process of supraclavicular lymph nodes, especially the opposite side, indicates the neglect of the disease and, as a rule, is a contraindication to the implementation of surgical intervention.
To identify the condition of the lower cervical lymph nodes, a prescal biopsy is used, in which the cellulose of the second cellular tissue space of the neck with lymph nodes located in it is removed under local anesthesia or under anesthesia. The latter are subjected to a thorough histological examination, its positive results indicate that cancer has gone far and is useless, in most cases, lung resection. For large, well-palpable lymph nodes, a possible option for their morphological assessment is puncture biopsy, which makes it possible to detect tumor metastases cytologically in 70% of cases.
With the involvement of ultrasonoscopy for the localization of the pathological process and control of the advancement of the biopsy needle, the study and clinically non-palpable lymph nodes of the neck became available. At the same time, it should be noted that in a number of observations during cytological examination of punctate, it is not possible to determine the histological form and degree of differentiation of the tumor. Given the importance of these parameters for the development of therapeutic tactics for locally advanced lung cancer, ultrasound signs of involvement of the neck lymph nodes in the tumor process require the diagnosis of a prescal biopsy followed by their histological examination to clarify.
Surgical method of final diagnosis of hematogenous lung cancer metastases to the abdominal organs and retroperitoneal space, in
In doubtful cases, is diagnostic laparotomy. The clinic used it in the I and partially in the II work periods, in cases when all available diagnostic methods, including laparoscopy, were not informative. The operation was performed immediately before the thoracotomy from a small upper or medium access. After performing an audit of the abdominal cavity and retroperitoneal space, conducting, if necessary, urgent morphological studies, the question of the possibility of performing an operation on the lung was decided.
The development and introduction of new diagnostic methods into clinical practice: video laparo-and suprarenoscopy, ultrasound and computer X-ray tomography, made it possible to precisely localize and perform targeted biopsy of suspicious lesions located even in the depths of parenchymal organs. Therefore, indications for diagnostic laparotomy significantly narrowed.
Thus, the use of modern methods of radiation diagnostics and instrumental studies prior to surgery has significantly expanded the possibilities of diagnosing the local prevalence of the tumor process and allows us to establish quite accurately a number of contraindications to surgical treatment, which we include: damage to the bone structures of the thoracic spine; germination of the tumor in the esophagus with lesions of the mucous membrane; extensive damage to the bifurcation of the trachea with the involvement in the process of the mouth of the main bronchus of the opposite lung or side wall of the trachea with a length of more than four cartilaginous semirings; the presence of carcinomatosis pleura; germination of the tumor in the chest wall with a lesion of more than 3 ribs; swelling of the apex of the lung with signs of damage to the brachial nerve plexus and (or) circulatory disorders in the upper limb;the presence of metastatic lesions of the supraclavicular lymph nodes of the opposite side; defeat tumor process of the contralateral lung and its lymphatic collectors. Surgical treatment is not shown also in the presence of morphologically confirmed distant hematogenous metastases.
In some cases, preoperative examination allows to either suspect or establish the fact of tumor damage of an extrapulmonary anatomical formation, but it is not always possible to accurately determine its nature and extent. Clinical experience shows that quite often, even the presence of symptoms indicating tumor lesion of various formations, such as superior vena cava syndrome, hoarseness, high standing of the diaphragm dome, etc., is not a reliable indicator of patient inoperability.
The difficulty of determining the local prevalence and generalization of lung cancer in advanced stages of the disease is due to both the limits of diagnostic capabilities, currently used research methods, and the characteristics of the course of the disease, among which paracancic inflammatory changes that significantly affect the clinical course and radiographic picture of the disease. Modern methods of radiation and instrumental diagnostics, of course, expand the possibilities of pre-operative examination of patients and establish the true nature and extent of tumor lesions. However, not rarely, they give the doctor only indirect conclusions about the presence of tumor germination of various vital organs and anatomical structures, its nature and volume.
Therefore, the obtained data of radiation and instrumental methods of research can not always finally decide the question of the length and nature of the prevalence of the tumor process, and hence the possibility of performing radical surgical treatment. Only on the basis of a comprehensive assessment of the clinical picture of the disease, the results of various mutually complementary research methods, most often in cases of questionable functional operability, can we reasonably refuse surgical treatment. In all other cases, in the absence of absolute signs of inoperability, the data obtained should be taken into account in the preparation and conduct of surgical intervention. Apparently, the final decision in patients with advanced stages of lung cancer about the local spread of the tumor and resectability, in some cases,can only be in the process of performing an intraoperative revision. The fact that in 10—% of observations, during operations I had to revise ideas about the local prevalence of the tumor process — this confirms.