Surgery for removal of Lung Cancer
Comprehensive guide from diagnosis to treatment
Receiving a lung cancer diagnosis can feel overwhelming. The purpose of the sections below is to offer a straightforward, step-by-step guide that explains the process, and helps you anticipate what’s to come at each phase. From the moment of diagnosis, getting to know the specifics and stage of your lung cancer, to navigating through the array of treatment possibilities and care after treatment, each segment is thoughtfully prepared to equip you with understanding and ready you for the path forward.
How Lung Cancer is identified inside the body
Computed tomography (CT)
Positron emission tomography (PET)
Positron emission tomography (PET)
A CT scan is crucial for diagnosing lung cancer as it provides detailed images of the lungs. It can detect tumours, measure their size, identify their exact location, and determine if they have spread to other parts of the body.
Positron emission tomography (PET)
Positron emission tomography (PET)
Positron emission tomography (PET)
A PET scan is a special test that shows how the body’s tissues are working. For lung cancer, it can show if and where the cancer might have spread. However, areas of inflammation or infection can also appear as “hot spots” on a PET scan.
Magnetic resonance imaging (MRI)
Positron emission tomography (PET)
Magnetic resonance imaging (MRI)
An MRI scan gives detailed pictures of the body’s tissues and organs. The high-resolution images are especially useful for spotting cancer that has spread to the brain or spinal cord, or when the lung cancer is located near nerves and blood vessels.
Obtaining a Tissue Biopsy to confirm Diagnosis
Bronchoscopy
CT/US guided biopsy
CT/US guided biopsy
A thin tube (bronchoscope) is passed through the nose or mouth to examine the airways inside the lungs. A small tissue sample (biopsy) can be performed from a suspicious area; this sample is then examined under a microscope to look for cancer cells.
CT/US guided biopsy
CT/US guided biopsy
CT/US guided biopsy
Images from a scan are used to guide a needle to a suspicious area in the lung. These methods are particularly useful for lesions that are either deep within the lung, and located near sensitive structures, or when the suspicious areas are close to the chest wall.
Combined techniques
CT/US guided biopsy
Combined techniques
Sometimes cancer may be in hard to reach areas. Navigational Bronchoscopy uses a 3D lung map to guide a thinner bronchoscope to those areas while Robotic Bronchoscopy uses a robot, controlled by the doctor, for precise movements deep within the lungs.
Fitness for General Anaesthesia & Surgery
Lung Function Tests
Cardiopulmonary Exercise Test
Lung Function Tests
Lung function tests, also known as Pulmonary Function Tests (PFTs), are essential in the pre-operative workup for lung cancer surgery. They help assess how well your lungs work by measuring lung volume, capacity, rates of flow, and gas exchange. This information can help predict your lungs’ ability to tolerate surgery and recover afterwards.
Echocardiography
Cardiopulmonary Exercise Test
Lung Function Tests
Lung cancer surgery can be a major procedure and it’s important to ensure that the heart is healthy enough to handle it. An 'echo' can provide detailed pictures of the heart’s size, structure, and motion, helping assess its overall function. It can help detect any underlying heart conditions that might need to be managed before surgery, such as heart disease or valve problems.
Cardiopulmonary Exercise Test
Cardiopulmonary Exercise Test
Cardiopulmonary Exercise Test
In the context of lung cancer surgery, a CPET provides detailed information about how the heart, lungs, and muscles work together during exercise. VO2max, or maximal oxygen uptake, is a key indicator of cardiovascular and respiratory health. A low VO2max might mean that you could benefit from prehabilitation before surgery, or that a less invasive surgical approach might be safer.
How much lung is removed during surgery?
Anatomy and Physiology of the lungs
The lungs are cone-shaped organs located in the thorax, separated by the heart and other structures in the mediastinum. They are responsible for the exchange of oxygen and carbon dioxide with air from the atmosphere, which requires blood from the pulmonary circulation.
Normal Lungs
The lungs divide into lobes, which are separated by fissures, and further divided into bronchopulmonary segments. Each segment is supplied by its own bronchus and artery, making them functionally and anatomically discrete. This allows a single segment to be surgically resected without affecting its neighbouring segments.
Tracheobronchial tree
The trachea bifurcates into the right and left main bronchi, which further branch into secondary and tertiary bronchi, supplying different lobes and segments of the lungs. In lung cancer, a bronchoplastic procedure may be performed to preserve healthy lung parenchyma; this surgical technique involves resection of the affected bronchus and reconstruction of the remaining airway, allowing for the removal of the tumour while sparing as much healthy lung tissue as possible.
Cancer inside the lungs
The amount of lung tissue to be resected during lung cancer surgery depends on several factors including the size, location, and type of the tumour. A lobectomy is the most common operation for early stage lung cancer. A pneumonectomy involves removing the entire lung, and may be done when the cancer is near where the airways enter the lung or more than one lobe of the lung is affected. During the operation nearby lymph nodes are also removed, in case they contain cancer cells that have spread from the main cancer. This is called lymphadenectomy.
Right Lung Lobes
The right lung is larger and has three lobes: superior (upper), middle, and inferior (lower).
Left Lung Lobes
The left lung has two lobes: superior (upper) and inferior (lower). The left lung is smaller than the right lung to accommodate the heart, which is located on the left side of the body.
Right Bronchopulmonary Segments
- Right upper lobe: S1: Apical. S2: Posterior, S3: Anterior.
- Middle lobe: S4: Lateral, S5: Medial.
- Right lower lobe: S6: Superior, S7: Medial, S8: Anterior, S9: Lateral, S10: Posterior.
Left Bronchopulmonary Segments
- Left upper lobe: S1 & S2: Apicoposterior, S3: Anterior, S4: Superior lingular, S5: Inferior lingular.
- Left lower lobe: S6: Superior, S7: Medial, S8: Anterior, S9: Lateral, S10: Posterior.
Minimally Invasive and Open Surgery
Robot Assisted Thoracoscopic Surgery
Robot-assisted thoracoscopic surgery (RATS) is a cutting-edge surgical procedure that leverages the precision and control of robotic technology to perform complex operations within the thoracic cavity. This minimally invasive technique involves making several small incisions in the patient’s chest, through which the robotic arms and a camera are inserted. The surgeon, seated at a console, controls the robotic arms. These arms mimic the surgeon’s hand movements but with a higher degree of precision, reducing the risk of human error. The robot’s enhanced dexterity allows for intricate suturing and dissection, minimizing tissue trauma and improving surgical outcomes.
Video Assisted Thoracoscopic Surgery
In Video-assisted thoracoscopic surgery (VATS), the surgeon makes small incisions in the patient’s chest. A thoracoscope, a tiny camera, is inserted through one incision, transmitting images to a video screen and guiding the surgeon. Other surgical instruments are inserted through the incisions to remove abnormalities.
Thoracotomy
A thoracotomy is a surgical procedure that provides access to the chest cavity and its organs. The patient is positioned on their side, and the surgeon makes a 6- to 8-inch incision below the shoulder blade, between the ribs. The surgeon then divides the muscles and spreads the ribs to reach the lungs. A thoracotomy incision offers better visualization and access into the thoracic cavity, allowing for comprehensive lymph node evaluation and handling of more complex cases, such as large or centrally located tumors. Also, it provides quicker and more effective management in case of emergencies.
Additional procedures may be required
Chest wall resection
Chest wall resection is sometimes necessary, particularly when the tumour is close to or has invaded the chest wall. The goal is to completely remove the cancer, which is crucial in early-stage non-small cell lung cancer. However, this procedure can leave a defect in the chest wall and reconstruction may be required to restore the chest wall’s structure and function.
Chest wall reconstruction
If the resection is extensive, chest wall reconstruction often involves the use of titanium bars to stabilize and fix the ribs, providing a strong yet lightweight support. This helps to maintain the shape of the chest wall and protect the organs inside the chest. Additionally, a mesh prosthesis is inserted to cover the defect left by the resection and prevent the lung from herniating.
Complications associated with Lung Surgery
Fatigue
Prolonged air leak
Infection
After lung surgery, patients can feel tired due to the body’s healing process, effects of anaesthesia, pain medications and reduced physical activity.
Infection
Prolonged air leak
Infection
Post-surgical infections can occur due to bacteria entering the body through incisions, or from the lungs. These risks are managed with sterile techniques and antibiotics.
Prolonged air leak
Prolonged air leak
Prolonged air leak
Prolonged air leaks can occur when the lung’s surface is damaged, causing air to escape into the chest cavity. This can be also due to underlying lung disease.
Pulmonary embolism
Pulmonary embolism
Prolonged air leak
Pulmonary embolism after lung cancer surgery can occur due to blood clots forming and traveling to the lungs, often resulting from immobility or changes in blood clotting.
Heart attack
Pulmonary embolism
Heart attack
Heart attacks after lung cancer surgery can occur due to stress on the heart, changes in blood clotting, or reduced oxygen supply caused by complications in lung function.
Stroke
Pulmonary embolism
Heart attack
Strokes after lung cancer surgery can occur due to changes in blood clotting, reduced oxygen supply to the brain, or fluctuations in blood pressure during or after the procedure.
Neo-Adjuvant and Adjuvant Therapy options
Neoadjuvant treatment for resectable lung cancer
Neoadjuvant treatment for resectable lung cancer
Neoadjuvant treatment for resectable lung cancer
Neoadjuvant treatment for lung cancer is given before surgery to shrink tumors and eliminate any microscopic cancer cells, reducing post-surgery recurrence risk. It also allows for evaluating the tumour’s response to therapy, guiding future treatments. Various neoadjuvant treatments, including chemotherapy, chemoradiotherapy, and immunotherapy, have been shown to improve survival rates. However, the choice of treatment is individualized, considering the cancer type, stage, patient’s health, and preferences.
Adjuvant treatment for resected lung cancer
Neoadjuvant treatment for resectable lung cancer
Neoadjuvant treatment for resectable lung cancer
Adjuvant treatment for resected lung cancer is administered post-surgery to eliminate any remaining microscopic cancer cells, reducing the risk of recurrence. It can include chemotherapy, chemoradiotherapy, or immunotherapy. This approach can improve survival rates by targeting cells that may have spread beyond the primary tumour site. Additionally, adjuvant treatment can prevent the growth of new tumours by destroying any cancer cells that were not removed during surgery.
Options for Alternative Management
Chemotherapy
This involves the use of drugs designed to kill cancer cells. It can be administered alone or in combination with other treatments. Chemotherapy works by targeting rapidly dividing cells, a characteristic common to cancer cells. While effective, it can also affect healthy cells that divide quickly, leading to side effects.
Radiation therapy
This treatment uses high-energy rays (like X-rays) to kill or shrink cancer cells. The rays are targeted to the cancer site, minimizing damage to healthy surrounding tissue. It’s often used when surgery isn’t an option, or in conjunction with other treatments.
Immunotherapy
This is a type of biological therapy that boosts the body’s natural defences to fight cancer. It uses substances made by the body or in a lab to improve or restore immune system function, helping the body recognize and attack cancer cells.
Targeted Therapy
This involves drugs or other substances that specifically target cancer cells, leaving normal cells largely unharmed. By focusing on molecular and cellular changes specific to cancer, targeted cancer therapies may be more effective and less harmful to normal cells than traditional chemotherapy.