Recent research data showed the concept that "surgery is still the main treatment for early non-small cell lung cancer (NSCLC)" now has new connotation: (1) Pure ground glass nodule (GGO) like lung adenocarcinoma should be regarded as a new clinical issue compared to solid tumors to avoid over-treatment. (2) The deep meaning of multidisciplinary pathological classification of lung adenocarcinoma should be fully understood to avoid over-diagnosis. (3) The T staging of lung adenocarcinoma mixed with GGO components should be correctly understood to avoid over-staging. (4) We should carefully understand the new data of relationship between lung resection extent and prognosis to avoid excessive resection. (5) Attention should be paid to the research progress of minimal residual disease (MRD) to avoid possible insufficient treatment.
(1) Surgery is the first method to cure early stage non-small cell lung cancer (NSCLC). Ground glass nodule (GGO) like lung adenocarcinoma should be regarded as a new clinical issue to avoid over-treatment. The deep meaning of multidisciplinary pathological classification of lung adenocarcinoma should be fully understood to avoid over-diagnosis. The T staging of lung adenocarcinoma mixed with GGO components should be correctly understood to avoid over-staging. We should carefully understand the new data of relationship between sublobectomy and prognosis to avoid excessive resection. Attention should be paid to the research progress of minimal residual disease (MRD) to avoid insufficient treatment. (2) The treatment strategy of resectable stage Ⅲ NSCLC should be surgery with individualized systemic treatment. Locally advanced NSCLC dominated by Ⅲa-N2 NSCLC is a kind of disease with high multi-dimensional heterogeneity. In theory, preoperative treatment is superior to postoperative treatment, and molecular diagnosis should be made along with pretreatment staging, so as to select preoperative treatment. The patients with negative driver gene mutation obtained better pathological complete response/major pathological response (PCR/MPR) from immunotherapy compared to those from chemotherapy, and the better PCR/MPR is expected to be transformed into overall survival (OS). The data of preoperative treatment in patients with positive driver gene mutation are few, whereas the data of postoperative targeted treatment are much better than those of postoperative chemotherapy. (3) The effective systemic treatment strategy has "created" many long-term survivors with stage Ⅳ NSCLC, and has changed the original concept and population of "oligometastasis". Attention should be paid to the individual ineffective lesions in stage Ⅳ patients with long-term survival. It is also necessary to explore how to intervene in the resection of "oligometastasis" of stage Ⅳ NSCLC at an appropriate time and in an appropriate way, which may be one of the main tasks of lung cancer surgery in the future.
TNM system should be used in the staging of small cell lung cancer (SCLC), especially in the limited stages of SCLC. Preoperative staging should be strengthened to avoid invalid operation due to insufficient diagnosis. Retrospective studies showed that the efficacy of surgery (+ chemotherapy) in early SCLC is comparable to the outcome of resection for early stage non-small cell lung cancer, which shakes the concept of "chemotherapy/chemoradiotherapy as the main treatment of SCLC". The best operative procedure of SCLC is lobectomy. Sub-lobectomy and pneumonectomy are inferior to that of lobectomy, but still better than chemotherapy/chemo-radiotherapy in terms to long term survival. All these findings need to be confirmed by large sample prospective randomized studies.
With the change of coronavirus disease 2019 (COVID-19) prevention and control strategy in China, the number of COVID-19 cases has increased significantly recently, which has also brought new challenges to the perioperative risk control of thoracic surgery. This paper puts forward several suggestions, aiming to standardize the preoperative screening and evaluation during the COVID-19 period, strictly grasp the indications and timing of surgery, optimize the medical management process, individualize surgical decision-making, and minimize the risk of COVID-19 infection to surgery.
Since December 2019, a novel coronavirus (2019-nCoV, SARS-CoV-2) pneumonia (COVID-19) outbreak has occurred in Wuhan, Hubei Province, and the epidemic situation has continued to spread. Such cases have also been found in other parts of the country. The spread of the novel coronavirus pneumonia epidemic has brought great challenges to the clinical practice of thoracic surgery. Outpatient clinics need to strengthen the differential diagnosis of ground glass opacity and pulmonary plaque shadows. During the epidemic, surgical indications are strictly controlled, and selective surgery is postponed. Patients planning to undergo a limited period of surgery should be quarantined for 2 weeks and have a nucleic acid test when necessary before surgery. For patients who are planning to undergo emergency surgery, nucleic acid testing should be carried out before surgery, and three-level protection should be performed during surgery. Patients who are planning to undergo emergency surgery in the epidemic area should be confirmed with or without novel coronavirus pneumonia before operation, and perform nucleic acid test if necessary. Surgical disinfection and isolation measures should be strictly carried out. Among postoperative patients, cases with new coronavirus infection were actively investigated. For the rescue of patients with novel coronavirus infection, attention needs to be paid to prevention and treatment and related complications, including mechanical ventilation-related pneumothorax or mediastinal emphysema, and injury after tracheal intubation.