Surgery

Patients require surgery to survive lung cancer. Surgery alone is curative in stage Ia disease; stage Ib and II disease require adjuvant chemotherapy post-operatively. Stage III disease is treated with chemoradiotherapy. Stage IV disease is rarely operated.

  • Recent staging changes shifted chest wall involvement from IIIA to IIB; this is surgically resectable
  • In patients who are found to have a single lymph node involved in the mediastinum intraoperatively usually proceed with full resection

Pneumonectomy became established in the 1930s; partial lung resections were developed in the 1940s.

Pre-operative Considerations

Anatomical Guidelines

Physiological Considerations

Reduced pulmonary function is the most common limiting factor in surgery. This can be assessed by several techniques; the most common tests are respiratory function tests or exercise tolerance. Patients requiring pneumonectomy should have an FEV of 2 or more; patients with

Metastatic Disease

Patients with isolated brain metastasis have 10-20% improved survival when these are resected in addition to their primary tumour. Metachronos lesions are associated with better outcomes.

Surgical Principles

R2 resection has no survival benefit and reduces quality of life; this is avoided by proper staging.
R1 resection often occurs due to positive bronchial margins or undetected lymphadenopathy. Full lymphadenectomy improves staging accuracy but has no impact on survival.

Lobectomy

Mortality 2% (versus 4% for pneumonectomy). The lobe and lobar bronchus are resected.
Sleeve resection consists of resection of the involved lobe, the main bronchus, and reconstruction of the bronchus to retain air supply to the remaining lobe.

Pneumonectomy

4% mortality. Used for large tumours that involve both/all lobes or are centrally located.
Sleeve pneumonectomy is used when tumour is close to the carina.

Wedge Resection

Smaller procedure with higher risk of local recurrence.

Lymph Nodes

Chest Wall Resections

If the chest wall is involved resection is still possible

Diaphragm

Pericardium

THe pericardium can be removed if involved; repair is necessary to prevent cardiac herniation.

Superior Sulcus Tumours

These tumours require neoadjuvant chemoradiotherapy prior to surgery. Vertebral body involvement, subclavian vessel invasion, or N2 disease is a contraindication to resection (5 year survival 0%).

Post Operative Considerations

Incomplete resections are associated with poor prognosis, particularly macroscopic residual disease. Frozen sections should be performed on bronchial margins to detect involved margins intraoperatively.

Outcomes

IA - 67%
IB - 57%
IIA - 55%
IIB - 35%
IIIA - 25%
IIIB - 3-6%
IV - 1%


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