With the increase of pulmonary nodules found by examination, multiple ground glass nodules have become a very common situation. Statistics show that multiple nodules account for nearly 10% of our surgical patients in recent years. The consensus of the industry on whether to intervene in the operation of multiple pulmonary nodules and what kind of operation scheme to adopt is: 1. The operation of multiple pulmonary nodules should be cautious; 2. Whether the operation mainly depends on the main lesion; 3. If surgery is needed according to the main lesions, all nodules should be removed at one time as much as possible; 4. Under the same circumstances, if a single lesion needs lobectomy, lobectomy and wedge resection of multiple lesions can be compromised. Therefore, according to whether the lesions are distributed in different lobes or different lungs, there is the following consensus: 1. The primary lesion and the secondary lesion are in the same lobe, and lobectomy is the first choice. 2. Primary and secondary lesions are located in different lobes on the same side. According to the size, shape and density of nodules, the primary lesions can be lobular, segmental or wedge-shaped, and the secondary lesions should avoid lobectomy as much as possible, and segmental or wedge-shaped resection can be considered; 3. The lesions are on different sides, lobectomy should be performed by stages, and segmental resection or wedge resection should be performed at the same time to avoid bilateral lobectomy as much as possible. However, we recently completed a patient with multiple nodules in the upper lobe of the right lung, but did not operate according to the above principles. His multiple nodules were all in the right upper lobe, 65,438+00, but we did a "single-hole thoracoscopic resection of the posterior segment of the right upper lobe and lymph node sampling" for him. Why is this? Do you want to cut him again next time? Let's look at our analysis and thinking:

Patient, male, 70 years old, retired employee of our hospital. Before he retired, he was the director of a clinical department. He found ground-glass nodules in the upper lobe of the right lung in the physical examination of our unit on October 8, 20/kloc, and they still existed on October 9. So at the end of last year, he asked me to show him the film, whether to have surgery or to continue observation and follow-up. The following are three plain CT images examined in June 20 18, July 20 19 and February 2065 438+08:

It can be seen that the size of the lesion has not changed significantly, but it seems that the local density has increased slightly. At first it was almost pure wool glass. Now some areas are a little dense, which can also be considered as mixed ground glass, and the focus is1.3cm. After the target scan, let's take a look at this lesion:

It can be seen that the target still has solid components after scanning, and the maximum diameter is about 1.6 cm, which should be surgical intervention. In addition, I also think that my colleague is 70 years old. From the imaging point of view, this lesion can basically be identified as early lung cancer, which is a little better than before. If you continue to observe and follow up for 2-3 years, it is best to operate now after obvious progress, because the older you are, the worse your tolerance for surgery should be. Colleagues thought what I said was reasonable, and they decided that it was better to remove it surgically. Originally, I wanted to have an operation this year. Later, due to the delay of the COVID-19 epidemic, the epidemic situation improved relatively recently, so I came to the hospital.

What should I do after I really move in? How many lungs do I have to cut? How to grasp the details? This is a problem! Let's look at his target scanning image again, and find that there are many other ground-glass nodules in the posterior segment besides the main lesion, accounting for 10. The following is the target scanning image, and all other secondary lesions are marked:

Except for me, the main lesions are either very light or very small pure ground glass nodules. But it may basically be something in the category of adenocarcinoma such as atypical hyperplasia or carcinoma in situ. Then there are two main options for surgery: 1. Right upper lobe resection: all the lesions detected at present can be solved at one time, but it has certain influence on lung function; 2. Only the main lesion was treated, and the posterior segment of the right upper lobe was removed, and the same segment was removed together. Leave aside the lesions located in the anterior segment and tip segment for the time being. This has little effect on lung function, but it will still leave some small lesions in it, and there is still the possibility of reoperation in the future. How to choose? When my colleagues asked me years ago, I tended to remove the right upper lobe, because it was multiple nodules, which happened to be concentrated in the same lobe. Anyway, I have had surgery, and it is ideal to solve all the nodules at once, which is also in line with the principle of treating multiple nodules. But I feel a little sad. After all, except for the main lesion, other nodules are too small, and it is a pity to have a total lobectomy. This time I really moved in for surgery. This problem has been bothering me for a long time. I think day and night. What is better? I also explained the pros and cons to my colleague truthfully, and let him make his own decision. But my colleague is not a surgeon or a respiratory doctor. In fact, he had no choice. He said: "Anyway, it's up to you, just help you decide to come." . This burden is heavy! I also asked the teachers and professors in the higher hospitals. The main opinion is to see how patients choose. In this way, the final choice still falls on me. I listed the different advantages and disadvantages:

In this way, I feel a little clear. I thought about it for a long time, and finally I prefer to do only posterior resection this time to solve the main lesion! The reasons are as follows: 1. The density of other lesions is still very small or light, so it may take a long time to really develop to require surgical intervention. For example, it may take more than 10 years. 2. For the 70-year-old man, maintaining good lung function and improving postoperative quality of life, if lobectomy is performed, although eating can be eliminated, activity endurance may be limited; 3. Colleagues also have coronary heart disease. A few years ago, they also let go of the stent. Three months ago, other vessels in coronary CT also had lesions, but there were no symptoms of angina pectoris. The surgical trauma is less and the perioperative risk is lower. The following are the results of coronary CT examination:

My idea is that if the patient is young, such as less than 50 years old, if there are multiple nodules in the right upper lobe and the main lesion needs surgery, then the situation is different, and I will suggest lobectomy. Because at present, if the secondary lesion progresses to the point where surgical intervention is needed around 10, then the patient is only in his 60 s, even in his 20 s, and only in his 70 s, which means that the second operation is basically inevitable (regardless of the medical development, early lung cancer can be overcome without surgical treatment). At present, it is best to solve all the nodules at once. After all, other recurrent pulmonary nodules are not inevitable. Maybe there will be no need to operate on new nodules in other lungs in the future!

I think this is the essence of individualized treatment, right? Although it does not conform to the current principles and norms, it is really from the specific situation of patients, and wholeheartedly consider how to be more beneficial to patients!

Treating patients as relatives is not empty talk or a slogan, but judging, suggesting and choosing with heart and emotion!

The decision-making process of clinical treatment is laborious and tangled. But my colleague's operation is not troublesome. A few days ago, we performed resection of the posterior segment of the right upper lobe and lymph node sampling. Because intraoperative pathology does not affect the surgical method, we did not send a quick section. Today, we consulted the Pathology Department. Postoperative pathological results showed that there was an invasive adenocarcinoma (adherent growth type) in the posterior segment of the upper lobe of the right lung, and another lesion was found, which was a slightly invasive adenocarcinoma (adherent growth type).