The role of surgery in the management of lung cancer consists of obtaining a biopsy to make a correct diagnosis, determining the correct stage of the cancer in order to ensure optimal treatment and treating the cancer by surgical removal in selected situations. The decision to treat lung cancer surgically depends on the type of lung cancer, as well as several prognostic factors. Surgery is a common form of treatment for non-small cell lung cancer (NSCLC), whereas, it is not as commonly used with small cell lung cancer (SCLC).
Types of Surgical Procedures for Diagnosing Lung Cancer
In order to accurately diagnose a lung cancer, a biopsy, or small piece of tissue, must be obtained and examined under a microscope. Because of the use of computed tomography (CT) screening, the detection of small abnormal areas in the lung that may or may not be cancer has become more common. There are several procedures that can be used to perform a biopsy.
CT Guided Fine Needle Aspiration Biopsy: CT guided fine needle aspiration biopsy is the most common way to evaluate possible cancers. A CT scan takes a very detailed picture of a patient’s suspected cancer, allowing the insertion of a thin needle to remove a sample of the tissue. This gives doctors the most information without resorting to a more invasive surgery (thoracotomy) and direct biopsy.
Thoracotomy: During a thoracotomy, a surgeon makes a large incision in a patient’s chest in order to directly access the mass and directly remove part or all of the suspicious area. In some patients with a peripheral lung mass and no evidence of mediastinal or systemic cancer, a wedge resection of the lesion is sometimes performed and diagnosis made on a frozen-section of tissue. If lung cancer is confirmed, a formal cancer resection is then performed.
Endoscopic Ultrasound Guided Fine Needle Aspiration Biopsy: The mediastinum is the area behind the breast bone and consists of blood vessels, lymph nodes and other structures. Because lung cancer frequently spreads to lymph nodes in the mediastinum, biopsies to this area are often necessary. An endoscopic ultrasound guided fine needle aspiration biopsy is often used to evaluate the mediastinum. This technique is performed in order to avoid the more invasive procedures of mediastinoscopy or thoracotomy. Using this technique, more invasive methods of diagnosis can be avoided in approximately 50% of patients. An ultrasound machine is used to take pictures of the mediastinum, allowing a small biopsy needle to be directly inserted into the suspicious area without making an incision in the chest.
Cervical Mediastinoscopy: Mediastinoscopy is another diagnostic procedure used to determine whether mediastinal lymph nodes contain cancer. This procedure is used in cases where endoscopic ultrasound guided fine needle aspiration biopsy is not indicated or was not successful. Medianstinoscopy requires general anesthesia, a small anterior neck incision and insertion of an endoscope, which is a thin, lighted tube. A complete procedure includes extensive sampling of lymph nodes in the upper and lower mediastinum.
Bronchoscopy: During a bronchoscopy, a physician inserts a bronchoscope (thin, lighted tube) through the nose or mouth into the trachea (windpipe) and bronchi (air passages that lead to the lung). Through this tube, the surgeon can examine the inside of the trachea, bronchi and lung and collect cells or small tissue samples.
Thorascopy: During this procedure, an endoscope called a thorascope is inserted through a small incision in the chest wall. Thorascopy is a limited surgical procedure that allows the lining of the chest wall and the lungs to be examined and biopsied to determine if cancer is present.
Small cell lung cancer is not typically treated with surgery because the disease is usually widespread at the time of diagnosis. Once a diagnosis of SCLC is made and the amount of disease is characterized as either limited or extensive, patients typically receive treatment with chemotherapy and possibly radiotherapy. However, good results from surgery alone have been reported in a small subgroup of patients that have a small primary cancer and no lymph node involvement. Sometimes surgery is used in conjunction with chemotherapy and/or radiation therapy, but the contribution of surgery to overall outcome is not clear in this setting.
Approximately 45% of all patients with NSCLC have cancer that is limited to the chest. For these patients, surgical resection is not only an important therapeutic modality, but in many cases, the most effective method of controlling the disease. Patients with stages I-II localized cancer without spread to lymph nodes are considered to have early stage lung cancer and are almost always treated with surgery. Patients with stage III cancer may be treated with either neoadjuvant chemotherapy followed by surgery or combined treatment with chemotherapy and radiation therapy. The following are the types of surgical procedures that may be performed in patients with stage I-III NSCLC. For patients with stage IV disease, surgery is usually not indicated. For more information about stage specific treatment strategies and results, refer to the treatment sections designed for each specific stage.
Thoracotomy: Thoracotomy is a surgical procedure to open the chest and remove cancerous lung tissue. This surgical procedure is performed under general anesthesia.
During a thoracotomy the surgeon may remove part or all of a lung. There are two operations to remove a small part of the lung. A wedge resection removes a very small part of the lung and segmentectomy removes a slightly larger part of lung based on anatomical segments. These types of operation are used when the cancer has been diagnosed early and is only in one very small area. A lobectomy is the removal of one lobe of the lung and is the most frequent operation performed for early stage NSCLC. A pneumonectomy is the removal of the entire lung. This procedure is performed when the cancer is found to involve more than one lobe. Pneumonectomy is associated with more than twice the mortality rate of lobectomy, as well as more long-term pulmonary side effects.
Video-Assisted Thorascopic Surgery (VATS): This is a form of minimally invasive surgery that utilizes a television camera. The advantages of the camera-aided procedures are that smaller incisions can be used and there is no need to cut through a rib, which is necessary for conventional thoracotomy. This results in quicker, less intrusive surgery, with a much smaller scar. However, using these new procedures requires significant skill and a great deal of training. There is less, or at least different, visibility with VATS. If a serious problem arises, VATS can be converted to an open or traditional procedure, creating a small additional risk.
Chest Tube Thoracostomy: This is a procedure performed to drain fluid, blood or air from the space around the lungs (pleural space).