Surgery

Before an operation

If you are being considered for an operation to remove your lung cancer the team will check your fitness. This is to check you would be able to cope with the surgery and with removal of some of your lung.  This includes breathing tests (pulmonary function). These look at how much lung ‘capacity’ you have and measure whether oxygen passes through your lungs efficiently (gas transfer). It is important to note that not all tumours will be operable for a variety of reasons relating to the tumour itself or your general health. 

If your breathing tests are less than 40% of what is predicted for you, then surgery may be a risk.  We may request extra tests in this situation to check your fitness from your ability to walk fast or to climb stairs.   

You may have other tests before surgery including: 

  • a PET (Positron Emission Tomography) scan (to check the cancer hasn’t spread beyond the chest) 
  • a brain scan (to rule out any spread to the brain) 

Which operation will I be offered?

For the more common type of lung cancer (non-small cell lung cancer) if it is early-stage disease (stage 1 or 2) then surgery is usually recommended.  The preferred surgical technique is to remove the whole section of the lung (lobe/lobectomy) which contains the tumour.  
 
The cancer or tumour tends to spread through the lymph glands in the centre of the chest. The glands will be tested by removing some of them at time of operation.  This checks if the tumour has spread. It also helps guide decisions on whether any further treatment is required after the operation. 
The ideal technique for surgery is via a telescope with small cuts in the chest wall rather than a large scar to cut the chest open completely. This comes with quicker recovery time and less risk. We use this ‘minimally invasive’ approach where possible. You may hear the technique referred to as VATS. In some cases the surgeon may have specialist robotic equipment to do this operation. This surgery is called Robotically Assisted Thoracic Surgery (RATS).
If we think the tumour will be less than 2cm in size and with no lymph node spread then it may be possible to do a smaller operation than a lobectomy. This involves removing just a segment or wedge of lung tissue containing the tumour. This technique can also be used if your breathing tests are not sufficiently good to enable a full lobectomy.

Alternative to Surgery

It may be possible to consider targeted radiotherapy if you have: 

  • a small tumour 
  • poor breathing test results 
  • There is a risk with surgery 

This is given in a high dose to the local tumour area – this is known as stereotactic radiotherapy (SABR) 

Recent research has suggested benefit to giving drug treatment to some patients before their surgery. Our guidelines are being updated to include this. 

More Extensive Surgery

It may be necessary to consider a bilobectomy or pneumonectomy (the removal of more than one lobe or the whole lung) if: 

  • the tumour extends over more than one lobe 
  • extends up to the central airway into the lung  

This operation will:  

  • reduce your lung function 
  • carry more risk of post-operative complications 
  • lead to a longer recovery time.   

We will explain these risks before we agree on this.  

If the tumour has extended into the chest wall there is another possible more extensive surgery option. This can involve resection (removal) of muscle and sometimes ribs to remove it completely. 

Before the operation if lymph node(s) in the middle of the chest are shown to contain tumour, this is called N2 disease. This means tumour in the mediastinal (centre of chest) nodes and makes the cancer stage 3A.  N1 are the nodes around the airway going into the lung at the ‘hilum’. This is the first stopping point from the lung before the tumour passes beyond into the central chest nodes.  It may still be possible to operate on a tumour which has N2 disease but this is weighed up in advance in discussion with the surgeon.  If there is a risk of more widespread mediastinal lymph node involvement it may be worth considering drug treatment prior to surgery to reduce the tumour. This also improves the chances of successful operation.
Rarely when the cancer has spread beyond the chest into other sites for example brain, adrenal gland, but is still confined to one area within the chest then surgery might be considered. This can occur if treatment options (surgery/radiotherapy) are possible for the other sites.  For most patients surgery is not possible once the disease has spread.

Will further treatment be recommended after surgery?

When a cancer is removed the whole amount of tissue taken at surgery is sent to the pathology laboratory.   

The results will describe:  

  • the location and exact size of the tumour 
  • the type of cancer cells 
  • whether it has spread to lymph nodes (aiming to include both hilar and mediastinal nodes in the operation) 
  • whether the edges of what was cut out are clear of tumour (resection margins) 

Incomplete resection

If examination of the edges suggests there may be cancer cells left behind there are more options to consider. Either additional surgery to completely remove all tumours or sometimes post-operative radiotherapy when attempting to remove tumour cells is not possible.

Drug treatment after surgery

There may be benefit from adding in chemotherapy treatment after the surgery to reduce the chance of the cancer coming back if: 

  • The cancer has spread into the lymph nodes or; 
  • if the tumour is bigger than 4cm.   

This will only be helpful where you make a good recovery and fitness is good after surgery.  We will weigh up the risks of this ‘adjuvant’ (after surgery) drug treatment and side effects against the benefits.