Evaluating the effectiveness of various treatments for lung cancer with the greatest
authenticity can only be given on the basis of studying remote
results. Admittedly, life expectancy is the main criterion for judging the feasibility of surgical treatment of patients with far
advanced stages of the disease. Five-year lifespan of cancer patients
is scientifically based in the evaluation of long-term results.
From 1720 patients, having completed the treatment, was discharged from the clinic.
1473. For five years or more, long-term outcomes of surgical treatment have been studied.
854 patients operated in the first and second periods of the clinic and 298 patients
underwent expanded and expanded combined resections of the lungs in 1987—
years This made it possible to evaluate the results of the treatment. Is established
that out of 1,152 patients more than five years lived 309 people (26.8%). Moreover, indicators
five-year survival rates were robust and almost identical in
various periods of the clinic. So, after the advanced combined
resections, out of 105 patients discharged from the clinic in the first period, more than five years lived
23 patients (21.9%), in the II period of 140 —30 patients (21.4%), in the III period — out of 105 –
23 (21.9%). After extended resections, out of 309 patients discharged from the clinic in I
86 years (27.8%) lived for more than 5 years, in the II period from 300 —82 patients (27.3%) and in III
the period of 193 —55 (28.4%). In connection with this circumstance, we consider
long-term results of surgical treatment of all patients together.
Finding out the causes of death of cancer patients is always difficult.
task: not everyone who died after discharge from the hospital before the expiration
a five-year term conducts a post-mortem examination, assuming that
the cause of death of patients is always obvious — the progression of the blastomatous
process.
We have accurate information about the causes of death in only 105 patients,
operated in the clinic in 1983-1996. and deceased up to 3 years after
statements. The main part — 78 people — have ended from hematogenous metastases.
tumors, in another 6 patients they were combined with a local recurrence of lung cancer.
21 (20%) patients died from other diseases and signs of tumor development in them
detected.
Comparing the clinical picture of the course of the disease in operated patients,
victims from the generalization of the tumor process, and in patients who had
denied surgery, and after trial thoracotomy, it should be noted that she
has significant differences. As a rule, after surgery, patients have
a period of relative well-being: pain in the chest disappears, fever, agonizing
cough with sputum, hemoptysis. Some of them in this period receive
opportunity to return to their normal activities if it is not related to
physical exertion. The duration of remission may be the most
varied in duration — from one month to several years. At
disease progression the clinical picture manifests itself
local and general symptoms of hematogenous metastasis, which depend on
localization and volume of tumor lesions. The clinical picture of the course of cancer
lung in non-operated patients is mainly characterized by local
symptoms of the tumor process: paracancous inflammation, lesion
extrapulmonary anatomical structures and organs of the chest cavity, intensive
lymphogenous metastasis. Remissions in these patients were not observed, and their
the condition was characterized by constant progressive deterioration.
Thus, if early generalization of the tumor process does not occur,
surgery for some time allows you to save patients from
local manifestations of progression of the tumor, sposbstvuta for a period
remission process of psychological adaptation.
Of the 1152 patients discharged from their clinic, died before the expiration of five years
843 patients. In the first year after surgery, 354 patients died (30.7%), in year 2 —300 (26.1%), in year 3 —99 (8.6%), in
4 year —59 (5.1%), and at 5 —31 (2.7%). The vast majority of them died in
during the first two years after surgery —56.8%. Average life expectancy
deaths before the expiration of the 5-year period amounted to 15.3 ± 0.9 months.
Survival of patients after advanced combined resection of the lung
presented in table 28.
Of the 1152 patients discharged after completion of treatment, 785 did not have further
used any additional methods of antitumor treatment.
128 patients after advanced combined resections 239 after extended
Resection was performed radiation treatment. Postoperative irradiation started
in 1– months after the surgical stage of treatment. Radiation therapy was performed with
the use of remote irradiation on megavolt sources (linear
accelerator —LU-4.3 MeV) and TV cameras (“Raucus” and “Beam”).
When forming the dose fields, the maximum impact was calculated
on the stump of the remote lung, on the lymph nodes of the mediastinum. At location
tumors in the upper lobes of the lung, given the characteristics of regional lymphatic drainage,
spent the irradiation of the supraclavicular regions. Planning postoperative radial
treatment, always sought to limit the impact on a healthy lung
or the remainder of the resected lung. For this, before the start of irradiation
radiographic radiographs of the organs of the chest cavity were performed in several
projections and tomometric measurements applied the data obtained to
the made scheme of cutting the body at the level of the trachea bifurcation. According to this scheme, outlined
the most rational fields of exposure and their location. Usually used
two opposite fields from the side of the operation at an angle of 140-170 o with respect
central axis to the first. The dimensions of the irradiation fields were formed 8´10 cm 2,
8´13 cm 2 10´12 cm 2. RIP (source-surface distance) was most often 50—
cm.
The dose rate, depending on the capabilities of the equipment, was up to
1 Gy / min Most patients (342) were irradiated under simple conditions.
fractionation with a single focal dose ranging from 1.5 Gy to 2.0 Gy. Total
on the center patients received a dose of 40 – Gr. Usually during the week the patient received up to
10 Gr. the duration of treatment ranged from four to seven weeks. Region
lung root, bronchus stump, regional mediastinal lymphatic collectors
were captured by isodose 100—%. From the opposite side (healthy lung)
isodose did not exceed 30%.
Upon irradiation of the supraclavicular regions, fields with dimensions of 6´8 cm 2 and
8´10 cm 2 with a RIP of 50 cm. Single doses ranged from 2 Gy to
5 Gy and were due to the general condition, age and state of the cardiac
vascular system of the patient. Total on the supraclavicular lymphatic region
nodes brought a dose of 30 Gy to 50 Gy.
In the course of radiation therapy and after it, all patients, along with
clinical examination, performed control laboratory,
radiological and other special studies. Evaluated condition
main indicators of hemodynamics, respiration, hematopoietic function, changes in
sides of the chest cavity. In some cases, radiotherapy supplemented
using anti-inflammatory drugs, as well as drugs
improve the activity of the cardiovascular system, respiratory organs,
hematopoiesis, beneficial effects on metabolic processes.
Of the 367 patients who received a course of postoperative radiotherapy,
343 pneumonectomies were performed and in 24 patients partial lung resections.
In patients undergoing pneumonectomy, pneumonia in the remaining lung did not develop, any features in the formation of fibrinothorax from
there was no operation. And in patients who have undergone partial lung resections, after
complete irradiation diagnosed as a rule, acute radiation pneumonia in
the remaining portion of the lung. They were accompanied by a characteristic clinical picture,
and on radiographs the infiltrative component prevailed with the appearance of plots
lobular infiltration in the root zones or changes worn
interstitial and mixed. Further, with the normalization of
patients, these radiological changes persisted throughout
one to two months after the end of the course of radiation therapy. All patients in
subsequent formation of radiation pneumosclerosis of the lung remnant, that
or a different severity.
According to the main indicators characterizing the blastomatous process in the lung,
groups of patients undergoing combined treatment and only surgical
comparable to each other. Five-year survival of patients undergoing
advanced combined resections after combined treatment amounted to
19.6% and 22.1% after surgical treatment. In patients with advanced
resections five-year survival rates were respectively 28.7% and 25.6%.
As can be seen from the above data, the results of the combined treatment
practically did not differ from the results of treatment of patients who received only
surgical treatment (p> 0.05 in both groups). Perhaps this is due to the fact that
In some cases, the reason for referring patients to radiation therapy was
doubts about the radicality of surgery. However, received
data indicate the absence of any significant influence
postoperative radiation therapy for long-term results of treatment of patients after
operations for advanced stage of lung cancer. In this regard, we
We consider the results of surgical treatment of patients of these two groups together.
on the example of patients undergoing advanced combined resection,
undertaken with the most common blastomatous process.
The life expectancy of patients after surgical treatment depends on
many factors. The main ones are: the histological structure and degree
differentiation of tumor cells, tumor size, metastasis by
regional lymphatic collectors, stage of the disease. Last in
summarizes the prevalence of lung cancer.
Differences in patient survival at various times after surgery in
Depending on the histological structure of the tumor are presented in Fig. 61.
As can be seen from the presented data, extrapulmonary spread of cancer
lung eliminates the recognized effect on the outcome of the disease of such a sign
as the degree of differentiation of the tumor. When the tumor grows into extrapulmonary
formations and organs of the thoracic cavity are almost no differences in performance
five-year survival between high, moderate, and low-differentiated
forms of epidermoid cancer and adenocarcinoma. The only exceptions are
undifferentiated forms of lung cancer in which long-term results
surgical interventions are much worse. So, the five-year survival rate at these
histological forms of lung cancer reaches only 5.1%. Special
adverse results were obtained for small cell lung cancer —n’t one of
operated patients did not survive the two-year milestone after surgery. Average
life expectancy of patients undergoing surgery and
discharged from the clinic, was only 9.6 ± 1.04 months, which is practically not
differs from the life expectancy of non-operated patients.
The defeat of lung cancer metastases of regional lymphatic reservoirs in
largely determines the peculiarity of the surgical intervention performed in this disease, and, admittedly, is one of the most important
prognostic factors in the fate of the operated patients. Metastatic disease
lymphatic collectors of the mediastinum noticeably reduces the performance of a five-year
survival rate of operated patients (18.0% and 29.5)%. Given the fact that
most of our patients at the time of surgery
massive lymphogenous metastasis was determined, this factor is one
from leading in forecasting long-term results extended
combined lung resections for cancer.
Admittedly, the large size of the tumor and, especially, its rapid growth,
is an unfavorable prognostic sign. Tumor size
are considered in all classifications of lung cancer and are an important parameter when
determining the stage of development of the disease. Study of life expectancy
operated patients depending on the size of the primary tumor in the lung
showed that with an increase in tumor size, the five-year survival rates
gradually decrease. However, this trend is marked within statistically
insignificant quantities. But with “giant” tumors exceeding in size 6 and
more cm across, the long-term results of surgical treatment of patients were
significantly worse (10.2%) and differed significantly from the total five-year
survival of patients after advanced combined resections for
lung cancer
According to the data obtained, the clinical and anatomical form of the tumor did not exert
significant impact on the long-term results of surgical treatment of patients.
So the five-year survival rate at central cancer was 22.6%, while at
peripheral 24.4% (p <0.05). With advanced stages of lung cancer,
Apparently, the location of the tumor in different parts of the lung does not affect the
biological features of its growth and distribution. Come to the fore
such signs of the blastomatous process, such as the size of the tumor, its defeat
extrapulmonary anatomical structures and organs of the chest cavity, the nature and
extensive metastasis, the presence of undifferentiated forms
histological structure of the tumor.
Not found significant differences in terms of five
survival after advanced combined resections depending on
hand defeat, and, consequently, the implementation of surgical intervention
(22.8% on the left, -20.5% on the right).
Despite their high relevance in forecasting remote
results of surgical interventions for lung cancer of individual indicators or
characteristics of malignant growth, the most complete picture of
the prevalence of the tumor process gives an estimate of the stage of the disease.
The existing and current classification of malignant tumors by
TNM, (its fourth edition) is significantly different in grouping by
stages of lung cancer from the classification common in our country
clinical stages of the disease (approved by the Presidium of the Scientific Council of the Ministry of Health
USSR in 1956, expanded and supplemented in 1985). Main differences
touched the grouping according to the stages of the disease in case of a far-reaching blastomatous
defeat. In accordance with the modern classification system TNM,
The only criterion for determining the fourth stage of lung cancer is
the presence of distant metastases (M 1). The local prevalence of the tumor in
the presence of lesions of extrapulmonary anatomical structures and organs of the thoracic
cavity, now determines only belonging to III A or III B stages
diseases. The presence of pleural carcinomatosis, the local spread of the tumor to
main vessels of the thoracic cavity, trachea, esophagus, vertebral bodies, lesions of the medial contralateral lymph nodes, pressed and
supraclavicular, even the opposite side, is regarded as stage III
diseases. In fact, in accordance with the new classification system TNM series
clinical observations, which we previously regarded as stage IV disease,
relate to stage III.
In all operated patients, advanced combined resections of the lungs
performed on the advanced stages of lung cancer, while in 14 of them –
with stage IV disease. The presence of distant metastases has been established in
9 patients in the process of performing surgical interventions or
postoperative period. In 5 patients with stage IV lung cancer, surgery was
performed on urgent indications in connection with the occurrence of pulmonary hemorrhage.
Lung resections in this category of patients we consider as palliative.
operative interventions. Of the 14 patients operated on, only one survived for 1 year.
after operation. The average life expectancy of this category of patients
amounted to 6.75 ± 1.42 months, which is not significantly different from the average
life expectancy of non-operated patients (p> 0.05).
In all operated patients with stage III B disease, blastomatous
the process was characterized by the multiplicity and extent of lesions of the extrapulmonary
anatomical structures and organs of the chest cavity, massive lymphogenous
metastasis. In 8 patients, belonging to stage III determined the presence of
exudate in the pleural cavity hemorrhagic in nature with the presence in it
tumor cells. The amount of exudate ranged from 150 ml to 600 ml.
In 14 operated patients there were metastatic lesions of the supraclavicular
lymph nodes: in 9 — from the side of the same name, in 5 — with damage
lymph nodes of the opposite side. 10 out of 14 operated patients
tumors were located in the upper lobes of the lungs. All patients performed wide
cervical lymphadenectomy. Although surgery was allowed in all patients
with III In the stage of lung cancer, remove all the affected at the time of surgery
tumor tissue, extended combined lung resections in these patients, all
it should be attributed to the conditionally radical.
The long-term results of such operations turned out to be significantly worse than with III A
stage of the disease. Only 8,2% lived for 5 years and more at stage III B of the disease and
26.8% —in III A. Hemorrhagic pleurisy with the presence of tumor cells in
exudate was an unfavorable factor significantly affecting the results
surgical treatment. 5 of 8 operated patients lived no more than 1 year, two
died at 2 and only one patient lived 4 years after the operative
interventions. However, the average life expectancy in these patients was
15.1 ± 6.7 days, which is significantly longer than the average life expectancy
non-operated patients (p <0.001). If lymph nodes are affected
supraclavicular areas of 14 operated patients only 1 survived five years
after operation. Nine patients died at 1 year after surgery, and in this
the number included all five patients with the presence of supraclavicular lymphatic lesions
knots of the opposite side. Three patients died within the second year after
surgical intervention. At the same time, the average life expectancy
operated patients, calculated at the end of the fifth year after surgery, amounted to
13.3 ± 5.1 months, which is significantly different from the average life expectancy
non-operated patients (p <0.001). It should, however, be recognized that
variations amounted to V = 128%, and indicates a significant difference in individual
indicators of life expectancy in operated patients.
Thus, studying the long-term results of advanced combined
resections for lung cancer, depending on the stage of development of the disease, suggests that surgical interventions are justified and
appropriate in patients with stage III A lung cancer. They allow 26.8%
patients who underwent surgery, live 5 years or more. Five year old
Survival in patients with III B in the stage is significantly worse — 8.2%. Operative
interventions in this category of patients should be considered as conditional
radical Apparently, it is necessary to specify the indications for such
operations.
The accumulation of hemorrhagic exudate in the pleural cavity with the presence in it
tumor cells characterized by a significant development of blastomatous and
paracancic changes and characteristic of advanced stages of the disease.
However, this feature, taken in isolation, is not absolute.
contraindication to surgery and does not always indicate a
generalization of the tumor process. Extended combined lung resections
in combination with subtotal pleurectomy, although they have poor distant
results allow to significantly extend the life of the operated patients.
In relation to patients with the presence of metastases in supraclavicular lymphatic
nodes, we can not make final conclusions due to the small number
clinical observations and significant differences in long-term results in
individual patients. Studies in the clinic suggest that
metastasis to supraclavicular lymph nodes is not indicative of
compulsory hematogenous spread of lung cancer. Metastases in supraclavicular
lymph nodes for a long time may be the only ones that go beyond
the limits of the pleural cavity and mediastinum. At the same time, the defeat of the lymph
knots of the opposite side is an extremely unfavorable sign in
relation to the long-term prognosis of surgical intervention. Extended
combined pulmonary resections in combination with a wide cervical lymphadenectomy
allow you to extend the life of individual patients and can be recommended for
perform a small number of them. The question of the feasibility of such an operation in
Each case should be solved individually, taking into account all other
signs characterizing the tumor process, the age and condition of the patient.
Given the characteristics of lymphogenous metastasis in cancer of the upper lobes
lung, it seems appropriate with this localization of the tumor and the presence of
lesions of the upper mediastinal lymphatic collectors expand
the amount of surgery due to the performance of cervical lymphadenectomy at
the absence of clinically detectable lymph node metastases
supraclavicular areas.
Advanced combined operations for stage IV lung cancer, of course,
are palliative. Long-term results of survival and average
life expectancy in patients who have undergone such surgery
practically do not differ from similar indicators in non-operated patients.
Indications for such operations, in our opinion, should be put only in
In exceptional cases, as a rule, for urgent reasons: pulmonary
bleeding, pronounced paracancidal process, etc., in the absence of large
technical difficulties to perform lung and extrapulmonary resection
anatomical structures and organs of the chest cavity.
Gender and age undoubtedly reflect the uniqueness of the physiological state,
hormonal and immunobiological features of the human body, in
To a certain extent determine the incidence and development of lung cancer. Both
These indicators were taken into account when analyzing the remote results of surgical
treatment. As the analysis of the long-term results of surgical treatment showed,
there were no significant differences between the five-year survival rates of post-expansion combined resections in men and women (21.2% and
24.6%; p> 0.05), however, in women this indicator was somewhat higher. Practically
the average life expectancy was the same (p> 0.05)
patients who died in the first five years after surgery in men and women, equal
respectively —14.1 ± 0.9 and 14.6 ± 0.98 months.
According to current ideas, the development of lung cancer in young people
occurs especially violently, with frequent and extensive metastasis. Also, for
this category of patients is more characteristic of the prevalence of poorly differentiated
histological forms of the structure of the tumor. These circumstances have a direct
effect on long-term results of treatment. The lowest among our patients
the five-year survival rate was in the group of patients aged 45 years and
under. Although its difference in relation to the overall five-year indicator
survival was statistically insignificant, it was significantly inferior to the similar
survival rate of patients aged 45 to 60 years, where the results were
the best. Noteworthy is the tendency to decrease
five-year survival in a group of patients over 60 years old. Most likely this
due to the death of patients at various times after surgery due to age and
associated diseases, and not with the progression of the tumor process. it
the assumption is indirectly confirmed when analyzing the dynamics
long-term survival of patients after surgery at various ages
groups (Fig. 62).
As evidenced by the data, in elderly patients
survival rates were highest in the first three years after surgery,
compared with patients of other age groups. By the end of the fourth year, they
almost on par with the age group of 46— years, and a year later they became more
lower than in this group of patients. For patients aged 60 and over
it turned out to be a characteristic gradual, almost even decline
survival at various times after surgery. So, mortality in the first year
reached only 25%, but kept relatively high numbers for
5 years after surgery —9.4%.
For patients of other age groups, a sharp decrease was found.
survival rates in the first two years after surgery, and then after three years –
their gradual stabilization due to a decrease in mortality in these periods. Such
The trend was especially characteristic of young patients, in whom
mortality in the first two years reached 73%, mainly due to high lethality
in the first year after surgery, equal to 54%. Behind
4 and 5 years, the total mortality in this group of patients was only 5.4%. By-
It seems that the outcome for the underlying disease in the vast majority
young patients are determined within the first three years after
surgical treatment.
In the problem of surgical treatment of patients with lung cancer, the question of the impact
volume of lung resection for long-term results is one of the key
planning operations, and sometimes determining the operability of patients. According to
a number of authors (Bezhan L. and Zitti E. Gr., 1981; Mancuso N. et al., 1990), scope of operation
by itself does not have a decisive effect on long-term results, since
partial resections are always performed in patients with less common
tumor process. Therefore, better remote references are given in the literature.
results after partial resections of the lungs are largely due to
selection for these operations of patients with earlier stages of the disease. At
comparing the long-term results of surgical treatment is relatively
homogeneous contingents of patients (stage of the disease, histological structure of the tumor, the state of regional lymph nodes), they are approximately
similar after pneumonectomy and partial resection of the lungs (Mezhevikin N.I.,
1977).
It is believed that partial resections of the lungs are justified and no less radical than
pneumonectomy in peripheral cancer as well as in central cancer
segmental or distal lobar bronchus without metastases to regional
lymph nodes or also with single metastases, which mainly corresponds to
early stages of the disease (Drukin E.Ya., 1985; Kharchenko V.P., 1975;
Kolesnikov I.S. et al., 1988). Thanks to the work on the development of technology
lymphadenectomy for partial resections of the lungs, bronchooplastic operations
it became possible to perform partial resections in patients with advanced
stages of lung cancer, even in cases of extrapulmonary tumor lesions
anatomical structures and organs of the chest cavity. Although with such lesions
pneumonectomies are performed in most cases, partial combined
resections of the lungs are the operation of choice in 8.1–31.2% of patients.
Long-term results of advanced combined pneumonectomy (20.9%)
and extended lobectomy (25.6%) on our material are not statistically different
apart, although there is a slight increase in the five-year
survival after partial resections of the lungs. This fact we explain all the same
circumstances that partial lung resections were performed on patients with the least
common tumor process, mainly with high and
medi-differentiated forms of the histological structure of the tumor. Main
operation of choice, from our point of view, in the presence of extrapulmonary
tumor spread, especially in the presence of metastases, in regional
lymph nodes, the extended combination should remain
pneumonectomy.
The prevalence of the tumor process is the nature and
sizes of tumor lesions of various extrapulmonary anatomical structures and
organs of the thoracic cavity. The presence of their multiple lesions suggests
neglect of the blastomatous process, its aggressiveness, and is reflected in
long-term results of treatment. So, there is a steady downward trend.
five-year survival rate in patients undergoing multiple
resections, compared with those after a single – (23.8% and 18.1%).
It should be noted that the comparison of long-term results after different types
multiple resections revealed that five-year survival rates in these
groups are almost identical. Judge the role of tumor lesions of one or another
organ and their influence on the fate of operated patients, as do many authors,
on our material is extremely difficult. So, in patients
who underwent surgery and were discharged from the clinic, in 38.4%
these lesions were multiple and included from one to four
lesions of various anatomical structures and organs of the chest cavity.
Therefore, for the analysis of individual results of advanced combined resections
depending on the nature of the tumor lesions, we only consider
solitary at which resection of any one anatomical
education or organ of the chest cavity.
Long-term results of surgical treatment were the best in patients
undergoing resection of vascular-atrial (25.6%) and mediastinal-esophageal
type (31.4%). This circumstance is quite explicable, considering that single
resections of these types were mainly represented by resections of the pericardium and
mediastinal pleura with fragments of nerve trunks. Resection of the pulmonary veins with
Atrial, pulmonary arteries, superior vena cava, aorta and esophagus were almost always multiple, with a wide variety of combinations.
Our data confirm the poor prognosis noted earlier by other authors,
so-called parietal-diaphragmatic resections. Five year indicator
survival rate in this group was only 8%, which is significantly lower than similar
indicators among all other categories of patients. Although patients who were
performed resection of the parietal-diaphragmatic type more often than in other patients
the lesions were solitary and there were no metastases in the regional
lymph nodes), the long-term results of treatment were especially
unfavorable. Apparently, the germination of the tumor in the chest wall should
considered a negative prognostic factor, often combined with
generalization of the tumor process. However, it should be noted that the forecast
surgical treatment is significantly affected by the depth of invasion of the tumor into the thoracic
wall. So, out of 25 patients in whom a tumor sprouted ribs, only 2 survived.
five year term. All the others died in the first three years after the operation.
To evaluate remote functional outcomes of surgical treatment.
lung cancer 48 patients in the period from 8 to 10 years after the operation was carried out
comprehensive clinical and functional examination. For the period of examination the average
patient age was 69.3 ± 3.2 years. None of them showed signs
disease recurrence or distant metastasis. All patients besides
clinical and radiological examination, ultrasonoscopy,
The respiratory function was investigated and the main indicators were determined.
central hemodynamics using hGI using functional
load tests.
Of the 48 patients examined, 20 were performed advanced pneumonectomy.
(of these, 11 are extended combined) and 28 are expanded partial
resections of the lungs (15 of them are advanced combined).
In terms of physiological rest in the examined patients who underwent
pneumonectomy, satisfactorily stored pumping function of the heart
at almost normal values ​​of one-time performance of the heart. So,
the magnitude of the shock index was 42.2 ± 3.1 ml. m – in persons who have suffered
right pneumonectomy and 44.1 ± 4.1 ml. m – in patients undergoing left-sided
pneumonectomy. The average shock index was 43.5 ± 2.9 ml. m – at
mathematical expectation of the proper value for this group of 45.6 ± 8.4 ml. m –
Cardiac index was 3.61 ± 0.11 l. m – min -. We have not noted reliable
differences between patients undergoing surgery left and right. Also not
revealed a significant difference between patients undergoing advanced and
extended combined pneumonectomy.
In the study of respiratory function found vital
lung capacity (VC) was 67.0 ± 8.0%, oxygen absorption (PO 2) –
132.0 ± 16.0 ml. min -, and the utilization of oxygen from 1 liter of air (CRO 2) –
14.2 ± 2.1. At the same time, and during these periods after surgery, it was consistently high
coefficient of respiratory changes in stroke volume of the left ventricle (CDI). Him
the value was 1.53 ± 0.16.
Given the volume of surgical interventions, the age of patients
the presence of concomitant and competing diseases, this result follows
recognize quite satisfactory. However, such an assessment concerns only the results.
survey conducted under statistical conditions. Use the same
functional stress tests found a significant limitation
reserve of blood circulation and respiration.
So, normal in healthy people when performing standard physical activity
the minute volume of blood circulation (IOC) increases by 25–%, approximately equally providing an increase both due to increase in heart rate (HR), so
and by increasing the stroke volume. Our patients have either complete
the absence of an increase in the IOC, or its insignificant increase (2–5 times less
norm), while the latter was ensured mainly by the increase in heart rate. Dynamics
changes in cardiac index (SI) in response to standard physical
the load in this category of patients is shown in Figure 63.
It should be noted that every second patient noted, the so-called
“Paradoxical” reaction to the load at which the MI not only did not increase, but
decreased, and the maintenance of the IOC was provided only by the increase in tachycardia. At
this, if this occurred against the backdrop of increased systemic arterial tone, then
latent left ventricular failure was diagnosed; if on the background
reduction of CIT, it was rightly suspected latent right ventricular
failure. An indirect confirmation of this can be the fact that in
static conditions of physiological rest only in 6 patients found
qualitative rheographic signs of pulmonary hypertension. Holding
stress tests found this symptom in another 8 patients.
We analyzed and compared the results of the functional examination in
remote period of patients who underwent partial advanced lung resections
(28 patients). Statistical data processing revealed heterogeneity of sampling with
very significant sigmatic interval. Last prompted to distribute
patients in two groups: “A” —with relatively satisfactory parameters
functions of external respiration and blood circulation and “B” —with a pronounced degree
voltage functioning of these systems. Subsequent retrospective analysis
confirmed the validity of such a distribution. At the same time, in both groups in about
the same ratio included patients after extended and extended
combinatorial lobectomy. Thus, the group “A” included 9 patients who underwent
extended partial resections of the lung, and 10 — extended combined; at
group “B” —4 and 5 patients, respectively. In patients with group “A”, MD was
43.1 ± 3.6 ml. m -, SI = 3.8 ± 0.22 l. min – m -, KDI = 1.42 ± 0.11, GEL = 74 ± 9.0%,
PO 2 = 144.0 ± 14.0 ml. min -, CRO 2 = 16,8 ± 1.9. These indicators, to a certain extent,
exceeded similar in patients undergoing pneumonectomy. Best
functional outcome in this category of patients was confirmed by the data
functional load test (Fig. 64).
In patients with “B” group, MD was 32.5 ± 5.4 ml. m -, SI = 2.94 ± 0.38 l. min – m -,
CDI = 1.92 ± 0.24, GEL = 62.0 ± 8.0%, PO 2 = 121.0 ± 9.0 ml. min -, CRO 2 = 13.2 ± 2.1. So
The significant difference in these groups was due to the fact that the patients in the group
“B” was detected marked pulmonary pulmonary fibrosis, emphysema and
pulmonary fibrosis of the contralateral lung, significantly compromised cardiovascular
vascular system (postinfarction cardiosclerosis, insufficiency
blood circulation, atherosclerotic cardiosclerosis, etc.). Cardiac reaction
vascular system on load in these patients, as a rule, wore
“Paradoxical” character. Despite significant tachycardia, IOC increases
almost not observed, on the contrary, in some patients noted its decrease with
gradual slow recovery to the initial level (Fig. 65).
Quantitative characteristics of the parameters of the functioning of blood circulation
and respiration in patients of group “B” allow to refer them to respiratory invalids with
restriction, or lack of hemodynamic compensation of respiratory
failure.
Characteristically, among the patients in the “A” group, only 3 (15.8%) had any
complications during the postoperative period, while among patients
in group “B”, only 3 had no postoperative difficulties with the spreading of the lung residue, the formation of residual pleural cavities,
copious exudation, postoperative pneumonia. Most patients have this
group (66.7%) for the postoperative period was characterized by the presence of
these complications.
Thus, the study of the functional status of operated patients in
remote period, 8-10 years after the operation showed that it is not detected
any significant differences between patients with advanced and
advanced combined pneumonectomy, as well as right and left-sided
operations. Survivors of this period are more or less
homogeneous in terms of physiological characteristics of the group with the compensation of respiration and
blood circulation at rest and identify stress tests or failure
circulatory or limiting cardiovascular reserve capacity
system. In general, after such operations, the functional status can be
better than some of the patients who have undergone partial resection
lungs, as among the last in these terms respiratory invalids with
decompensation of blood circulation and respiration or lack of hemodynamic
compensation of respiratory failure.
Probably, when deciding on the extent of surgery
lung cancer should take into account the above circumstances. By doing
partial lung resection should aim to better evaluate the functional
the consistency of its balance and to ensure the management of the postoperative period with
as fast as possible and its full distribution. The desire of the surgeon “any
cost ”to preserve the damaged, functionally inferior part of the lung, with
point of view of the remote functional results of such operations is
hardly justified.
Thus, in lung cancer patients in advanced stages of the disease,
with the presence of tumor lesions of various extrapulmonary anatomical
formations and organs of the thoracic cavity expanded and dilated
combined surgeries are most responsive
principles of oncological radicalism and allow for a five-year
survival in 26.8% of all patients undergoing surgery. Performed by patients with
the most extensive distribution of the blastomatous process is extended
combined pulmonary resections have the worst long-term prognosis (21.7%) by
compared with advanced resections of the lung (27.8%; p <0.05) and more often
accompanied by the development of postoperative complications and deaths.
However, today’s lack of an alternative to the real help of this
categories of patients allows us to consider their use justified and expedient.
The most reasonable is the implementation of advanced combined
pulmonary resections in patients with stage III A disease with high, medium and even
poorly differentiated forms of the histological structure of the tumor. At
undifferentiated forms of cancer, the presence of pleural carcinomatosis, metastases
tumors in the supraclavicular lymph nodes of the opposite side, as well as
generalization of the tumor process, surgical treatment is
unpromising and can be recommended only in exceptional cases,
in the presence of complications that pose a real threat to the lives of patients.
Adverse factors significantly affecting long-term results
surgical treatments include: the multiplicity of lesions of various
extrapulmonary anatomical structures and organs of the chest cavity, the presence
metastatic lesions of mediastinal lymphatic collectors,
large — more than 6 cm in diameter, sizes of a primary tumor, young age
patients, as well as the germination of the tumor in the chest wall with the defeat of the ribs. The main operation of choice when performing advanced combined
pulmonary resection is pneumonectomy. The desire of the surgeon at any cost
reduce the amount of lung resection is not justified both in terms of cancer
expediency as well as the remote functional consequences of operational
interventions.