Adenocarcinoma of the lung surgery

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Shanshan Cen, M.D. [2]

Overview

Surgery is the mainstay of treatment for adenocarcinoma of the lung.

Surgery

• Surgery may be used to treat non–small cell lung cancer (NSCLC). It is used to potentially cure the cancer by completely removing the tumor. Surgery is rarely offered if the tumor cannot be completely removed.

Evaluation before surgery

• Diagnostic tests for non–small cell lung cancer help the surgeon plan the surgery. They help doctors determine whether or not the tumor can be removed with surgery.

• Resectable:

• The tumor can be completely removed (resected) during surgery.
• Tissue around the tumor and nearby lymph nodes may also be removed.

• Unresectable:

• The tumor cannot be removed by surgery.
• Tumors are considered unresectable if:

• They are too large to completely remove
• The cancer has spread to certain mediastinal lymph nodes, other organs near the lungs or to distant sites
• There is pleural effusion or pericardial effusion present

• Because surgery to treat non–small cell lung cancer is a major operation, the patient needs to be in good overall health and be able to tolerate surgery. Unfortunately, most people with non–small cell lung cancer have other serious medical conditions. Lung and heart function tests are done to make sure that people are healthy enough to have surgery and that they will have enough lung function after surgery.

• Surgery is offered to people who have a low risk of developing shortness of breath after surgery.
• Some people are at high risk of poor lung function and shortness of breath after surgery. Before surgery is offered to these people, the healthcare team will discuss the benefits of surgery and quality of life after surgery.
• If the person is not well enough to have surgery, the tumor is considered inoperable.

• Lung surgery is done through an incision between the ribs on the side of the chest (thoracotomy). The ribs are spread so the surgeon can reach the lung.

• The type of surgery done depends on the size and location of the tumour and how far it has spread within the lung. Side effects of surgery depend on the type of surgical procedure.

Wedge or segmental resection

• A wedge or segmental resection removes the tumor along with a margin of healthy lung tissue. A segmental resection removes more tissue than a wedge resection.

• A wedge or segmental resection may be offered for very early stage non–small cell lung cancer to preserve as much lung function as possible. These procedures may also be done in people with more advanced non–small cell lung cancer who may have poor lung function after surgery.

• Wedge or segmental resection may also be done for a single tumor that has spread to the lung from other parts of the body (lung metastases).

Lobectomy

• A lobectomy is the removal of the lobe of the lung that has the tumor.

• A bilobectomy is the removal of 2 lobes of the right lung, which has 3 lobes. This surgery may be done if the tumor has spread into 2 joining lobes. The upper and middle lobes or the middle and lower lobes may be removed during a bilobectomy.

Pneumonectomy

• A pneumonectomy is the removal of a whole lung during surgery. This surgery is done if the tumor has spread either:

• Across both lobes of the left lung
• To the hilum of the lung

• There are more complications with pneumonectomy when the right lung (the larger lung) is removed.

Extended pulmonary resection

• Extended pulmonary resection is used to treat tumors that have spread to the chest wall, diaphragm, nerves, blood vessels or other tissues near the lung. During surgery, a complete section (en bloc) of the surrounding tissue is removed to try to take out as much of the cancer as possible.

Sleeve resection

• A sleeve resection is used to treat tumors in the large bronchus of the lung. The tumor is removed from the bronchus, along with a margin of healthy tissue on either side of the tumor. The 2 ends of the bronchus are then joined together (anastomosis).

Lymph node removal

• Lymph nodes play a large part in the staging and prognosis of non–small cell lung cancer, as well as in planning for surgery. During diagnosis, tests may show if the cancer has spread to certain lymph nodes.

• N1 nodes – Cancer that has spread to these nodes can usually be completely removed with surgery.
• N2 nodes – It may not be possible to completely remove cancer that has spread to these nodes, so surgery may not be an option.
• N3 nodes – Cancer that has spread to these nodes cannot be completely removed with surgery, so surgery is not an option.

Stent placement

• Non–small cell lung cancer can grow into the bronchus, causing breathing problems or pneumonia. A stent is a small metal or plastic tube that is placed into the bronchus during a bronchoscopy. It keeps the airway open and allows air into the lungs.

Chest tube placement

• During surgery, a flexible tube will be inserted through a cut in the skin, between the ribs and into the space between the lungs and the wall of the chest (pleural cavity). The tube is connected to a bottle with sterile water and a suction machine. It may be held in place with stitches or tape.

• A chest tube is used to drain blood, other fluids and air from the space around the lungs (pleural space) after surgery. It is left in place until x-rays show that the blood, fluids or air have been drained and that the lung can fully expand.

Thoracentesis

• A thoracentesis is a procedure in which a hollow needle is inserted through the skin and between the ribs into the space between the lungs and the wall of the chest (pleural cavity). It is used to drain fluid or air from the chest cavity.

• Thoracentesis may be used with non–small cell lung cancer to treat:

• Air leaking from the lung into the chest, causing the lung to collapse (pneumothorax)
• Bleeding into the chest (hemothorax)
• A buildup of fluid in the pleural cavity (pleural effusion)

Pleurodesis

• Pleurodesis is done to prevent a buildup of fluid in the pleural cavity and pleural effusion. Excess pleural fluid is drained, and then drugs or chemicals, such as sterile talc, are put into the pleural space through a chest tube. Pleurodesis seals the parietal pleura and visceral pleura together so there is no longer a space between them in which fluid could build up.

Surgery for metastatic non–small cell lung cancer

• Surgery may be done to remove a single metastatic tumor that has spread from the lung to the:

• Brain
• Adrenal gland

Video-assisted thoracic surgery (VATS)

• Video-assisted thoracic surgery (VATS) is a less invasive type of surgery. It uses a small video camera and surgical tools inserted through several small incisions in the chest wall. The surgeon is guided by an image on a video screen.

• VATS may be used to remove small (3–4 cm) non–small cell lung cancer tumors from the outer edges (periphery) of the lung. A lobectomy may also be done using VATS.

References

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