Surgery for Non-Small Cell Lung Cancer

Surgery to remove the cancer might be an option for early-stage non-small cell lung cancer (NSCLC). It provides the best chance to cure the disease. Still, lung cancer surgery is a complex operation that can have serious consequences, so it should be done by a thoracic surgeon who has a lot of experience operating on lung cancers.

Tests before lung surgery

If your doctor thinks the cancer can be treated with surgery, you might need certain tests:

• Pulmonary function tests (PFTs) to see if you would still have enough healthy lung tissue left after surgery
• An EKG (recording of your heart’s electrical activity) and an echocardiogram (ultrasound of your heart) to check the function of your heart  
• Lab work to check other organs to be sure you’re healthy enough for surgery

Your doctor will also want to check if the cancer has already spread to the lymph nodes around the lungs. This is often done before surgery with mediastinoscopy or another technique.

To learn more about these tests, see Tests for Lung Cancer.

Types of lung surgery

Surgery for lung cancer usually involves removing all or part of a lung. This is called lung resection. There are different types of lung resection:

• Pneumonectomy: This surgery removes an entire lung. This might be needed if the tumor is close to the center of the chest.
• Lobectomy: The lungs are made up of 5 lobes (3 on the right lung and 2 on the left lung). In this surgery, the entire lobe containing the tumor(s) is removed. If it can be done, this is often the preferred type of operation for NSCLC.
• Segmentectomy or wedge resection: In these surgeries, only part of a lobe is removed. This approach might be used if a person doesn’t have enough normal lung function to withstand removing the whole lobe.
• Sleeve resection: This operation may be used to treat some cancers in large airways in the lungs. If you think of the large airway with a tumor as similar to the sleeve of a shirt with a stain a few inches above the wrist, the sleeve resection would be like cutting across the sleeve (airway) above and below the stain (tumor) and then sewing the cuff back onto the shortened sleeve. A surgeon may be able to do this operation instead of a pneumonectomy to preserve more lung function.

The type of operation you have depends on the size and location of the tumor and on how well your lungs are functioning. Doctors often prefer to do a more extensive operation (for example, a lobectomy instead of a segmentectomy) if a person’s lungs are healthy enough, as it may provide a better chance to cure the cancer.

Ways to do lung surgery

There are 2 main ways to do lung surgery: open lung surgery (thoracotomy) and minimally invasive surgery. Minimally invasive surgery includes mainly 2 types: video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracoscopic surgery (RATS). With any of these surgeries, the goal could be to diagnose (to get more tissue for diagnosis), stage (to look at nearby lymph nodes for possible spread of cancer), and/or treat lung cancer (to remove all known cancer in the lung). All surgeries require general anesthesia, which puts you in a deep sleep.

Open lung surgery (thoracotomy)

In a thoracotomy, the surgeon makes a large cut between the ribs. Where the cut is depends on which part of the lung needs to be removed. In general, the surgeon will spread the ribs to see the lung and nearby organs inside. 

Video-assisted thoracic surgery (VATS)

Video-assisted thoracoscopic surgery (VATS)is a procedure being used more frequently to treat early-stage lung cancers. It uses smaller incisions, typically has a shorter hospital stay and fewer complications than a thoracotomy.

Many experts recommend that only early-stage tumors of the lung be treated this way. The cure rate after this surgery seems to be the same as surgery done with a larger incision. But it’s important that the surgeon doing this procedure is experienced, because it requires a great deal of skill.

Robotic-assisted thoracic surgery (RATS)

In this approach, the thoracoscopy is done using a robotic system. The surgeon sits at a control panel in the operating room and moves robotic arms to operate through several small incisions in the patient’s chest.

RATS is similar to VATS in terms of less pain, less blood loss, and shorter recovery time.

For the surgeon, the robotic system may provide more maneuverability and more precision when moving the instruments than standard VATS. Still, the most important factor in the success of either type of thoracoscopic surgery is the surgeon’s experience and skill.

Intraoperative imaging

Along with the results of imaging tests (such as CT scans) done before surgery, surgeons also rely on what they can see and feel during the operation to help determine which parts of the lung need to be removed. However, some lung tumors might not be easily seen or felt, so in some situations it’s possible that a tumor (or parts of tumor) might be missed.

Your surgeon might use a special intraoperative imaging system during the surgery to help find tumors that aren’t easily seen or felt. For this approach, a fluorescent drug called pafolacianine (Cytalux) is injected into your blood within 24 hours before your surgery. The drug travels through your body and attaches to a specific protein found on lung cancer cells. Once in the operating room, the imaging system gives off near-infrared light that causes the drug to light up, which can help the surgeon see which areas of the lung need to be removed.

The most common side effects after getting pafolacianine are nausea, vomiting, belly pain, heartburn, chest pain, itching, and flushing. Your doctor will probably ask you to avoid any supplements that have folic acid in them for a few days before the procedure because they might affect how well this drug works.

Possible risks and side effects of lung surgery

Surgery for lung cancer is a major operation and can have serious side effects, which is why it isn’t a good idea for everyone. All surgery carries some risks that depend to some degree on the extent of the surgery and the person’s overall health.

Possible complications during and soon after surgery can include reactions to anesthesia, excess bleeding, blood clots in the legs or lungs, wound infections, and pneumonia. Rarely, some people may not survive the surgery.

Recovering from lung cancer surgery typically takes weeks to months. If the surgery is done through a thoracotomy (a long incision in the chest), the surgeon must spread ribs to get to the lung, so the area near the incision will hurt for some time after surgery. Your activity might be limited for at least a month or two. People who have VATS instead of thoracotomy tend to have less pain after surgery and to recover more quickly.

If your lungs are in good condition (other than the presence of the cancer), you can usually return to normal activities after some time if a lobe or even an entire lung has been removed. If you also have another lung disease, such as emphysema or chronic bronchitis (which are common among people who have smoked for a long time), you might become short of breath with certain levels of activity after surgery.

After surgery

When you wake up from surgery, you may have a tube (or tubes) coming out of your chest and attached to a special container to allow excess fluid and air to drain out. The tube(s) will be removed once the fluid drainage and air leak slow down enough. Generally, you will need to spend 1 to 7 days in the hospital depending on the type of surgery.