Understanding Lung Cancer Surgery
A diagnosis of lung cancer is, understandably, very upsetting. In this article, I will try to simplify the type of surgery and, more importantly, explain that a lot has changed in lung cancer care over the years and that there is hope.
Main Types of Lung Cancer Surgery
Surgery for lung cancer can be done differently according to the part of the lung removed and the way to do it. So let’s dive into the details.
The right lung has three lobes, and the left lung has two. Each lobe is then made of smaller parts called segments. Lobes and segments have anatomical landmarks that the surgeon can follow to perform what we call anatomical lung resections.
Lobectomy
This is the most common lung surgery performed for lung cancer, it consists in the removal of an entire lobe of the lung. Roughly resection of a lobe of your lung will remove about 30% of the lung.
Pneumonectomy
This is an operation that consists of the removal of the whole lung, it was widely used in the past, but a lot less now due to the development of newer treatment options.
Sleeve Resection or sleeve lobectomy
This is a complex surgery whose aim is to spare as much lung as possible and avoid a pneumonectomy (removal of the entire lung). Essentially either the airways, the blood vessels to the lung, or both are divided, the tumor removed and then joined back together.
Segmentectomy or segmental resection
This is the smallest anatomical lung resection where a part of a lobe is removed. It used to be popular about 60 years ago, in the era of tuberculosis, then became obsolete, until very recently when several clinical trials demonstrated the non-inferiority of a segmentectomy versus a lobectomy for early-stage lung cancer (cancer less than 2cm in diameter).
Wedge Resection
This is a non-anatomical lung resection where only a smaller part of the lung is removed. It is usually reserved for diagnostic purposes or removal of lung metastasis. It is not a recommended choice for primary lung cancer.
Eligibility for Lung Cancer Surgery
Non-Small Cell Lung Cancer (NSCLC)
Generally speaking, when the tumor is limited to the lung without distant spread (early stage NSCLC), surgery can be considered. There is a growing body of evidence that surgery could be beneficial even in cases with a small number of metastasis (oligometastatic disease).
Small Cell Lung Cancer (SCLC)
The eligibility for surgery is a lot more debated, but most thoracic surgeons would accept to operate on limited disease small cell lung cancer, that is when the cancer is limited to the lung.
General Health Considerations
Any surgery, even when conducted by a minimally invasive approach, represents stress for the body, so it is essential to determine two things when considering an operation for lung cancer:
-Operability: that is can the patient tolerate an operation, retain enough lung function, and likely survive the operation?
-Resectability: can the tumor be completely removed with healthy tissue around it?
Risk Factors and Overall Health
The risk factors associated with thoracic surgery can vary significantly based on a patient’s overall health, age, and the complexity of the operation. Common risk factors include pre-existing medical conditions such as heart disease, chronic lung disease, obesity, and diabetes. Each of these conditions can complicate surgical outcomes and may lead to longer recovery times or increased complications.
Implications for Overall Health
Patients considering thoracic surgery must understand that their overall health significantly influences both their surgical risk and recovery. A well-conducted pre-operative assessment by healthcare professionals can help identify any potential risks
Preparing for Lung Cancer Surgery
Pre-Surgery Diagnostic Tests
CT Scan
This is a basic investigation that everybody gets. It should be performed using thin slices and get what we call staging CT (that is from the base of the neck to the thighs). Contrast dye is always required, unless there are specific contraindications to its use.
Pet Scan
This is another essential test that everybody undergoes. You can imagine a CT scan like a black and white photograph and a PET scan like a colored one. Healthcare professionals get information not only about the inner anatomy but also about the activity in certain areas. In other words, a PET scan can uncover areas that are not immediately visible on CT and that might represent metastasis.
Chest X-Ray
This is something that some GPs and patients still love, but it is a completely useless test in lung cancer diagnosis.
Further investigations
Occasionally further tests such as MRI in case of invasion of the chest wall, head scan, and biopsies might be needed. Biopsies, which involve obtaining tissue samples from suspicious areas, are another critical component of preoperative investigations.
Blood Tests
Those are done to exclude any underlying disease or clotting issues.
Pulmonary Function Tests
Pulmonary function tests (PFTs) are essential for assessing a patient’s lung capacity and functionality. These tests measure how well the lungs are performing and can identify any underlying respiratory conditions that may complicate surgery. By understanding the patient’s respiratory status, surgeons can estimate the risk of postoperative complications and make informed decisions regarding the type of lung cancer surgery that is most appropriate.
Lifestyle Changes Before Surgery
Stopping Smoking
Quitting smoking is a critical recommendation before surgery. Smoking can impair lung function, increase the risk of surgical complications, and prolong recovery times. The benefits of quitting can significantly impact the outcome of thoracic surgery, as it promotes better oxygenation and healing.
Breathing Exercises
They are essential in preparing for surgery and making sure patients are well prepared for the immediate postoperative period.
Your Treatment Plan
Role of Surgery in Lung Cancer Treatment
Surgery plays a critical role in the multimodal treatment of lung cancer, often serving as the cornerstone for curative strategies. In the context of lung cancer management, multimodal therapy typically includes a combination of surgery, chemotherapy, radiation therapy, and targeted therapies. Each of these modalities contributes uniquely to the treatment goal of improving patient outcomes and survival rates.
The sequence and timing of surgical intervention are essential components in developing an effective treatment plan. For early-stage lung cancer, surgical resection may provide the best chance for a cure, often achieved through procedures such as lobectomy or pneumonectomy. In some cases, neoadjuvant chemotherapy or radiation therapy may be employed prior to surgery to shrink tumors, making surgical resection more feasible and potentially improving surgical outcomes. Conversely, adjuvant therapies may follow surgery to eliminate residual cancer cells and reduce the risk of recurrence.
Clinical Trials
Many trials strongly support the use of minimally invasive techniques (either VATS or robotic) over conventional open surgery. Moreover, whilst early-stage lung cancer was historically the domain of the surgeons, we are seeing more and more evidence that combined chemo-immunotherapy approach combined with surgery delivers a much better outcome.
The Lung Cancer Surgery Process
Surgical Management
Open Surgery (Thoracotomy)
The proportion of open surgery has been reducing considerably in the last few years. Nowadays most operations are carried out by a minimally invasive approach, nevertheless open surgery still retains its use in case of very large tumors and those invading critical structures.
Minimally Invasive Surgery
Video-Assisted Thoracoscopic Surgery (VATS)
This is done with only one 3cm cut or several smaller incisions, the vast majority of patients leave the hospital the following day, occasionally on the same day.
Robotic-Assisted Thoracoscopic Surgery
A robot allows to perform complex surgery more conveniently, but there is no evidence that is vastly superior to standard vats for routine cases.
During the Procedure
Anesthesia
Operations are carried out under general anesthetic, in case of contraindications it is possible to do the surgery under deep sedation and spontaneous breathing. Most of the time a special tube is inserted down the throat to isolate the lung that is being operated on.
Once the patient is asleep the surgeon starts working either by making small cuts in the chest or one big cut as in open surgery (Thoracotomy).
The purpose of the surgery is to remove completely all the cancers cells and the lymphnodes that drain a specific part of the lung for analysis.
Keyhole surgery uses a video camera, a robotic arm and 5 to 6 small cuts.
Recovery After Lung Cancer Surgery
Immediate Post-Operative Care
Patients after surgery are woken up in the operating room and transferred to the recovery area and occasionally to the High Dependency Unit (HDU).
Pain Management
This is a key component to ensure a fast recovery. Most of the time a long-acting local anesthetic is injected in the back and patients a given a special pump that delivers pain medication intravenously on demand (PCA).
Chest Drains
All patients get a small tube coming out of the chest. This is essential to ensure drainage of excess air and fluid. most drains come out the following day after surgery.
Recovery at Home
Once at home, there are a few things to be mindful of:
Wound Care
The wound needs to be kept clean and dry, avoiding soaking it, no bath or swimming, but a shower is fine. After it is important to dab it dry with a clean towel without rubbing it.
Breathing Exercises
Those are essential to prevent lung collapse and pneumonia. They need to be done religiously very often during the day. It is the best way to prevent complications. The bed or sofa are the biggest patient’s enemy after surgery.
Follow-Up Appointments
All patients are given an appointment around 2 weeks after surgery and it is very important to stick to it. In case of any problems please inform your surgeon sooner. After patients are discharged from surgery they will be seen by the oncology or respiratory team for long-term follow-up up to 5 years.
Support Groups
Some patients find it very difficult to cope with a diagnosis, and support groups like those from MacMillan can help.
Potential Complications
Blood Clots, Pleural Effusion Risk of Complications and prolonged air leak.
How Mr. Marco Scarci Can Help
Expert Thoracic Surgery
20+ years experience in Thoracic Surgery
I only do thoracic surgery, not cardiac, dedicating all my interest to this area.
My team and I can offer Different Types of Surgery (VATS, robotic, open)
Focus on Minimally Invasive Procedures
Over 90% of procedures are done by keyhole approach.
Personalized Treatment Plan
We agree all cancer treatments at a specialist multidisciplinary team meeting, it is not a single surgeon deciding the best approach.
Collaboration with Healthcare Professionals:
We don’t just do an operation for you, we refer you to the appropriate specialists without you having to do anything.
Comprehensive Support
Pre-Surgery Consultations
Your consultation is aimed at giving you all the information that you need and answering all your questions. It might be the case that one consultation is not enough in which case will see you as many times as needed. We want you to be fully informed so that you can decide which treatment is right for you.
Post-Surgery Follow-Up
If you are self-paying all the follow-ups are included forever, without the fear of spending more money.
Access to Support Groups
We can also refer you to specialist nurses who can point out support groups, or we can support you in clinic.
Frequently Asked Questions
What Are Survival Rates After Lung Cancer Surgery?
The good news is that surgery is no longer that risky, mortality rate is around 1% or less.
How Long is Recovery After Surgery?
Patients can expect to go home in around 1 to 3 days, and be fully back to normal in less than 3 months.
Will I Need Radiation Therapy or Other Treatments?
Patients might need chemotherapy or immunotherapy. It is very rare to be needing radiotherapy.
How Does Robotic-Assisted Surgery Compare to Open Surgery?
Robotic assisted surgery allows to perform the same level of surgery as in open surgery without the big cut. In order words it is the best of both world.
What Are the Main Types of Lung Cancer?
Non-small cell lung cancer accounts for approximately 85% of all lung cancer cases and includes subtypes like adenocarcinoma, squamous cell carcinoma, and large cell carcinoma. On the other hand, SCLC, which constitutes about 15% of lung cancer diagnoses, typically exhibits a more aggressive behavior and is often associated with a history of smoking.
