SURGERY

Surgery has been used extensively in the diagnosis and treatment of lung cancer.  While planning the best approach for your cancer treatment, one of the  questions that your oncology team will have to answer is whether you will be served well with surgery as a part of your treatment plan.  Surgery is typically considered for patients with early stage non-small cell lung cancer (Stage I or II) and for particular patients with Stage III non-small cell lung cancer.  Surgery typically does not have a role in patients with small cell lung cancer.  

When used, surgery can be used by itself (single modality) or as a planned combined approach with radiation therapy and chemotherapy (multi modality).

Patients who are not offered surgery generally fall into two categories:

Surgically Inoperable:     A patient that has a cancer that is too advanced to remove safely or completely.

 Medically Inoperable:     A patient who has a cancer that is technically suitable for surgery but is too weak or sick to live through the surgery.

 The determination of inoperablity is a complicated process that is usually performed by a group of collaborating physcians.  Criteria for determing medical inoperability include stage of the cancer, location of the cancer, presence of other medical conditions, heart function, lung function, ability to tolerate severe physical stress etc.  A detailed list can be found here.

SURGICAL APPROACHES

There are many surgical approaches that serve different perposes.  These will be discussed here.   

Mediastinoscopy

Mediastinoscopy is a surgery that explores a compartment located directly behind the breastbone.  This compartment contains many important structures including lymph nodes that drain the lung.  Typically the surgery removes tissue and lymph nodes from the mediastinum.  The primary purpose of the surgery is to determine whether the cancer has spread from the lung to the lymph nodes and thus more accurately determine the stage of the lung cancer.  Some people believe that the extensive removal of involved lymph nodes improves survival.

The procedure is done under general anesthesia.  A small cut is made at the front of the neck and a tube is inserted and advanced into the mediastinum, which is located behind the breast bone. Lymph nodes and tissue that looks abnormal is then removed for through the tube.  The lymph nodes are given a specific label based on the location from which they were removed.  This is important, as the Stage of the cancer not only depends on whether lymph nodes are involved but also which ones.  Finally the lymph nodes are examined under a microscope to evaluate whether there is any lung cancer present.

Thoracoscopy

Thoracoscopy is a surgery that is used to explore the chest cavity where the lung is located. 

The procedure is done under general anesthesia.  A small incision is made on the chest wall between the ribs.  The lung is then deflated on the side of the surgery.  A lighted tube with a video camera on the end is inserted to examine the area.  If an abnormal area is seen, a sample can be taken for analysis.

Video Assisted Thoracoscopic Surgery (VATS)

In selected patients, a portion of the lung can be removed while the surgeon uses a thoracoscope to look at the tumor.  Additional small incisions are needed to allow for the passage of the cutting and stitching tools.  A large incision is however avoided.  This procedure is typically done when only a portion of the lung needs to be removed.  It can be done for a complete removal of the lung but is usually not the best approach for this.

Thoracotomy 

Thoracotomy is the main way the chest cavity is accessed for lung cancer surgery.  A large incision is made in the chest wall and the ribs are splayed.  This gives the surgeon optimal access to the lung and its attachments.  The level of resection of the lung can vary from taking just a small portion of the lung to taking the entire lung out.  These different types of lung resection include:

Wedge Rizwan Nurani

Wedge Resection.

A small, wedge-shaped portion of the lung is removed around the tumor mass.  Higher recurrence rates are expected with this surgery.  Thus, this is not done unless the patient has very poor lung function or would be unable to tolerate a more extensive surgery or non-surgical treatments. If a wedge resection is done additional treatments for local control, such as brachytherapy (radiatioactive seed mesh) will improves the likelihood of control of the tumor.

       

segmentectomy rizwan nurani

Segmentectomy.

A portion of the lung called a segment, which is larger than a wedge and smaller then a lobe of the lung, is removed.  Typically this is very similar to a the wedge resection surgery described above with similar outcomes.

 



lobectomy rizwan nurani

Lobectomy

The entire lobe of the lung containing the cancer is removed.  In the right lung, which has three lobes, two lobes are sometimes removed (bi-lobectomy).  This procedure results in a higher likelihood of lung cancer control when compared to wedge resection or segmentectomy. 



Pneumonectomy.

The entire lung is removed.  This has the largest effect on the patient’s ability to recover from surgery and  breathe independently in the future.  It is reserved for patients who have good lung function prior to surgery and have the tumor located in a part of the lung very close to the main bronchus (the first division off the wind pipe). It is typically not used if the patient has had chemotherapy and radiation therapy prior to surgery as a planned approach of combination therapy.

 

© Rizwan Nurani 2012