Surgery

TIP ... The Glossary has more information on the medical and scientific terms you'll see in this section.

Surgery is a treatment option in lung cancer only when the patient is healthy enough for surgery, and the tumor:

  • has been found early,
  • is able to be completely removed safely, and
  • has not spread within the chest or to other organs

If surgery is an option in a patient with non-small cell lung cancer (NSCLC), it provides the best chance for a cure.1 Surgery is rarely used as the main treatment in small cell lung cancer (SCLC) because most patients are diagnosed after the cancer has spread to other parts of the body.2

Patients should discuss with their health care team whether surgery is the best option for them. Lung cancer surgery is a complex operation that can have serious consequences. Therefore, it should be done by a thoracic surgeon—a surgeon specially trained in operating on people with lung cancer. Patients often seek a second opinion with a thoracic surgeon when considering surgery.

Lung cancer surgery may be used in combination with chemotherapy and/or radiation therapy. Chemotherapy and radiation therapy can be given either before surgery (neoadjuvant) or after surgery (adjuvant) in order to eliminate any small amount of cancer that was not detected and removed by surgery.1,2

What is the goal of surgery to treat lung cancer?

The goal of surgery is to remove the lung tumor with a border of healthy tissue surrounding the tumor. If there is no cancer found in the tissue surrounding the tumor, it means that the tumor was removed with clear margins.

During surgery, nearby lymph nodes in the lung and middle portion of the chest are also removed to check them for cancer, and to help determine whether further treatment is necessary.4

What are the different types of surgery used in lung cancer?

The type of surgery the doctor recommends depends on the size and location of the tumor and on how well the patient’s lungs are working. If a patient’s lungs are healthy, a lobectomy is most commonly the preferred operation. Removing more of the lung tissue may provide a better chance to cure the lung cancer.

Following are descriptions of different approaches that may be used.

Lobectomy

Lobectomy is the removal of one of the five lobes of the lung. When non-small cell lung cancer (NSCLC) is detected at a very early stage, a lobectomy is the most effective type of surgery, even when the lung tumor is very small.

Lobectomy

Wedge resection

In a wedge resection, the surgeon removes the tumor and a small rim of normal tissue surrounding it. This is done if the surgeon is unable to remove an entire lobe of the lung. A wedge resection may also be performed if the patient has a peripheral lesion. A wedge resection is only recommended for treating the smallest lung cancers (less than 2 cm in diameter) or for patients with other medical conditions that make removing the entire lobe dangerous.

Wedge resection

Segmentectomy

A segmentectomy removes one of the small segments within the lobes of the lung that contains a cancer. The amount of lung tissue removed is between what is removed in a lobectomy and in a wedge resection. Like wedge resection, it is recommended only for treating stage I lung cancers that are less than 2 cm wide and for elderly patients or those with other medical conditions that make removing the entire lobe dangerous.

Segment resection

Pneumonectomy

The surgical removal of the entire lung. This type of surgery is usually required if the tumor is very large or is close to the center of the chest.

Pneumonectomy

Sleeve resection

This surgery is used for tumors that involve the large airways. The tumor and a portion of the airway are removed and the ends of the airway are rejoined so remaining lobes can be left in place. A surgeon may do this operation instead of a pneumonectomy to preserve more lung function.1,3,4

Sleeve resection

What are the different techniques used to perform lung surgery?

Thoracotomy

This surgery is performed in an operating room with general anesthesia. The surgeon makes an incision between the ribs on the side of the chest or on the back in order to examine the lung and remove the tumor, surrounding tissue, and nearby lymph nodes. After the surgery, a patient will have a tube (or tubes) coming out of the chest to drain excess fluid and air from the space around the lung while the lung heals. Once the fluid drainage and air leak subside, the tube(s) will be removed. Generally, the hospital stay after a thoracotomy is 5 to 7 days, followed by a period of recovery at home.3,5

Thoracoscopy

A thoracoscopy is a minimally invasive surgery that uses small incisions and small instruments to examine and perform operations in the inside of the chest. It is also known as video-assisted thoracic surgery, or VATS. This procedure requires a great deal of technical skill and should only be performed by a surgeon who has specific training and experience in it.

VATS to remove lung cancer is done in an operating room under general anesthesia. During the operation, a thin tube with a light and a tiny video camera on the end is placed through a small incision on the side of the chest. The view inside the chest is transmitted onto a television monitor. The surgeon can look around freely inside the chest, watching the image on the TV screen. One or two other small incisions are used for long instruments that are used to do the same operation that would be done using a thoracotomy. If a lobectomy or pneumonectomy is done, one of the incisions will be enlarged to allow the tumor and lung tissue to be removed.

Since only small incisions are needed in a VATS, there is less pain after the surgery and a more rapid recovery. Chest tubes are required for most VATS procedures, and patients typically remain in the hospital for a few days until the drainage of fluid and air subsides. Research has shown that the cure rate after a VATS is similar to surgery done with a larger incision or a thoracotomy. However, less pain, fewer complications, and shorter hospital stays have been found with VATS.3,5

Robotic-Assisted Surgery

A newer type of operation known as robotic-assisted surgery is being performed at some large cancer centers in the United States. In this approach, a doctor sits at a control panel, inside the operating room, using robotic arms to maneuver long surgical instruments.6 Robotic surgery requires special training and expertise. Results from robotic-assisted lung cancer operations are very similar to those with VATS.

What to expect after lung cancer surgery

Length of hospital stay

How long a person needs to stay in the hospital after surgery will depend on:

  • Which type of surgery was done
  • The patient's overall health before surgery
  • The patient's lung function after surgery
  • Post-surgical complications, if any

Pain

Depending on the type of surgery a person has and how big the incision, the patient's chest and back may be painful for several weeks or longer after surgery. The doctor can prescribe pain medicines that will help. There are some other things people can do at home to help lessen the pain (see Living Well With Lung Cancer). Neuropathy is another common side effect, especially of traditional thoracotomy.

Chest tubes

Chest tubeOne or more chest tubes are typically placed during surgery to keep the patient's chest cavity free of fluid, blood, and air that collect after lung surgery. The tubes will be connected to a machine that gently suctions the fluid from the chest. These tubes are left in place until the fluid and air have stopped draining. Usually this takes a few days.

Respiratory treatments

A patient should expect to feel short of breath after lung surgery. The extent of this depends on how much of the lung was removed and how much pain the patient is experiencing. After a portion of a lung is removed, the remaining lung tissue can expand over time and make it easier to breathe.

A respiratory therapist will help the patient with breathing treatments after surgery. These treatments may include:

  • Deep breathing exercises
  • The use of a spirometer to encourage deep breathing and expand the lungs
  • Medicines to help open the airways

Pulmonary rehabilitation can teach techniques to improve lung function after lung surgery. Read more here.

If respiratory treatments are not prescribed, the patient should ask his or her doctor for a consultation.

Physical therapy

Patients should also ask to have physical therapy prescribed about a month after surgery to overcome post-surgical muscle atrophy and regain strength in their shoulder and arm.1,4,5,6

What are the risks of lung cancer surgery?

Lung cancer surgery carries risks like any surgery, including:

  • Bleeding
  • Infection
  • Blood clot
  • Allergic reaction to anesthesia medications
  • Death

Other risks that specifically may occur after lung surgery include:

  • Failure of the lung to expand
  • Injury to the lungs, heart, or blood vessels
  • Persistent pain
  • Pneumothorax (air or air collection in the space that separates the lung from the chest)
  • Pleural effusion (fluid collection in the space around the lung in the chest)
  • Pneumonia (bacterial infection in one of the remaining lobes of the lungs)1,5,6

Questions to ask your health care team about surgery

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General Questions

  1. What is the name of the surgical procedure?
  2. Why do I need surgery?
  3. How soon should surgery take place?
  4. What might happen if I delay or avoid the surgery?
  5. Will you explain the surgery in simple terms?
  6. How much of my lung(s) do you anticipate will need to be removed?
  7. What are the risks and benefits of this surgery? What results should I expect from the surgery?
  8. Are there any treatments I can have before surgery to shrink the tumor?
  9. Are there any nonsurgical options?
  10. Are there any less invasive surgery options?
  11. What is the next step if this surgery doesn’t work?
  12. How much does the surgery cost? How can I find out?

About the Procedure

  1. What should I do to prepare?
  2. How is the surgery done?
  3. How long will the surgery take?
  4. What kind of anesthesia will be used (general, local, or regional)?
  5. Will I have drains, catheters, or intravenous lines?
  6. Is there a possibility that I will need a blood transfusion, and if so, can I bank my own blood before surgery?
  7. How successful is this procedure?
  8. What are the risks associated with this surgery?
  9. How much experience do you have with this procedure?
  10. Has the procedure been done often in this hospital or surgery center?

About Post-Surgery

  1. How long will I have to remain in the hospital?
  2. How will I feel after surgery?
  3. How much pain is there after this type of surgery? How is it treated?
  4. How long will it take for me to recuperate?

About What to Expect When You Get Home

  1. What kind of care will I need at home? Are there any activity limitations?
  2. How soon can I eat a regular meal?
  3. How long will it be until I can resume normal activities?
  4. What symptoms should I watch for and report?
  5. Will I need other types of treatment after surgery?
  6. How long will it be until I can safely receive other necessary treatments?
  7. Are there alternatives to this treatment?

Reminder

  1. Ask for other information about the surgery.
  2. Ask about a second opinion.
  3. Ask how much the surgery will cost and if there are ways to reduce the costs.
  4. State any concerns you have about having the surgery.

Updated March 7, 2016.


References

  1. Brunelli A, Postmus PE. Section 26: Preoperative Functional Evaluation of the Surgical Candidate. In Pass HI, Ball D, Scagliotti GV, eds. The IASLC Multidisciplinary Approach to Thoracic Oncology. Aurora, CO: IASLC Press, 2014: 373-383.
  2. Small Cell Lung Cancer Treatment-Patient Version (PDQ®): Treatment Option Overview. National Cancer Institute website. http://www.cancer.gov/types/lung/patient/small-cell-lung-treatment-pdq#s.... Updated February 3, 2016. Accessed March 7, 2016.
  3. Non-Small Cell Lung Cancer Treatment-Health Professional Version (PDQ ®). National Cancer Institute website. http://www.cancer.gov/types/lung/hp/non-small-cell-lung-treatment-pdq#se.... Updated January 22, 2016. Accessed March 7, 2016.
  4. Lung Cancer - Non-Small Cell: Treatment Options. American Society of Clinical Oncology website. http://www.cancer.net/cancer-types/lung-cancer-non-small-cell/treatment-.... Updated August 2015. Accessed March 7, 2016.
  5. Lung Surgery. U.S. National Library of Medicine website. https://www.nlm.nih.gov/medlineplus/ency/article/002956.htm. Updated June 2, 2014. Accessed March 7, 2016.
  6. Bryant A, Veronesi G, Cerfolio R. Section 28: Robotic Surgery: Techniques and Results for Resection of Lung Cancer. In Pass HI, Ball D, Scagliotti GV, eds. The IASLC Multidisciplinary Approach to Thoracic Oncology. Aurora, CO: IASLC Press, 2014: 395-401.

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