Surgery for lung carcinoid tumors

Surgery is the main treatment for lung carcinoid tumors whenever possible. If the tumor has not spread, it can often be cured by surgery alone. The type of surgery will depend on a number of factors, including the size and location of the tumor and whether you have any other lung problems or serious diseases. Thoracic and cardiothoracic surgeons are likely to have the most experience with these operations.

Several types of surgery are used to treat people with lung carcinoid tumors. Surgeons usually have to remove some normal lung tissue along with the tumor, but they try not to remove any more normal tissue than they need to.

These operations require general anesthesia (where you are in a deep sleep) and may also require surgical incision between the ribs in the chest (thoracotomy). You will generally need to spend about 5 to 7 days in the hospital after the surgery.

Sleeve resection

To treat central carcinoids in a large airway (such as a bronchus), the surgeon may do a sleeve resection. If you think of the large airway with a tumor to be like the sleeve of a shirt with a stain an inch or 2 above the wrist, the sleeve resection would be like cutting out the sleeve above and below the stain and sewing the cuff back onto the shortened sleeve. The surgeon may be able to do this type of operation instead of removing part or all of lung, as it can preserve more lung function.

Wedge resection

For small carcinoids found at the outer edges of the lungs away from the large airways, the surgeon may remove a wedge-shaped piece of the lung in an operation called a wedge resection or segmental resection.

Lobectomy

If it is not possible to do a sleeve or wedge resection because of the size or location of the tumor, the surgeon will usually do a lobectomy, in which an entire lobe of the lung is removed. In some cases 2 lobes may be removed (bilobectomy).

Pneumonectomy

In rare cases where the cancer is in many spots in a lung or is in a place that makes it hard to remove, the entire left or right lung may need to be removed in an operation called a pneumonectomy.

Lymph node sampling

With any of these operations, lymph nodes near the lungs are usually removed to look for possible spread of the cancer. This is important because about 10% of typical carcinoids and 30% to 50% of atypical carcinoids will have spread to lymph nodes by the time they are diagnosed. If these nodes are not removed, it might increase the risk of the carcinoid tumor spreading even farther, to other organs. If this happens, you may no longer be able to be cured by surgery. Looking under a microscope for cancer cells in the lymph nodes also provides some indication of your risk of having the cancer come back.

Video-assisted thoracic surgery (VATS)

This is a less invasive procedure for treating some cancers in the lungs. During this operation, a thin telescopic tube with a tiny video camera on the end is placed through a small hole in the chest to help the surgeon see inside the chest. One or two other small holes are created in the skin, and long instruments are passed though these holes to remove the tumor. Because only small incisions are needed, there is a little less pain after the surgery. Another advantage of this surgery is a shorter hospital stay – usually around 4 to 5 days.

Most experts recommend that only tumors smaller than 4 to 5 cm (about 2 inches) across be treated with this method. This would apply to most carcinoids. The cure rate after this surgery seems to be the same as using older techniques. It is important, though, that the surgeon doing this operation be experienced since it requires a great deal of technical skill.

Possible side effects of surgery

Possible complications depend on the extent of the surgery and the person's health beforehand. Serious complications can include excessive bleeding, wound infections, and pneumonia.

Because the surgeon must spread the ribs to get to the lung in patients having a thoracotomy, the incision will hurt for some time after surgery. Your activity will be limited for at least a month or two.

If your lungs are in good condition (other than the presence of the cancer) you can usually return to normal activities after a lobe or even an entire lung has been removed. If you also have non-cancerous diseases such as emphysema or chronic bronchitis (which are common among heavy smokers), you may become short of breath with activities after surgery.

Procedures to relieve symptoms from lung carcinoid tumors

If you can't have major surgery because of reduced lung function or other serious medical problems, or if the cancer is widespread, other treatments may be used to relieve some symptoms.

For example, if the tumor is blocking airways and it might lead to pneumonia or shortness of breath, removing most of the tumor through a bronchoscope or vaporizing most of it with a laser can be helpful. These treatments, called palliative procedures, can relieve symptoms, but they do not cure the cancer and are recommended only if you cannot have surgery to completely remove the tumor. If you are treated with these procedures you may also get radiation therapy (see the section called “Radiation therapy”).

Sometimes fluid can build up inside the chest (outside of the lungs), which can affect breathing. To remove the fluid and keep it from coming back, doctors sometimes do a procedure called pleurodesis. A small cut is made in the skin of the chest wall, and a hollow tube is placed into the chest to remove the fluid. Either talc or a drug such as doxycycline or a chemotherapy drug is then instilled into the chest cavity. This causes the linings of the lung (visceral pleura) and chest wall (parietal pleura) to stick together, sealing the space and preventing further fluid buildup. The tube is generally left in for a day or two to drain any new fluid that might collect.

Procedures to relieve symptoms of liver metastases

If the cancer spreads to the liver, treating the liver tumors may help with symptoms. When there are only 1 or 2 tumors in the liver, they may be removed with surgery. If there are more than just a few liver tumors (or if a person is too sick for surgery), other techniques may be used.

Ablation

Ablation techniques destroy tumors without removing them. They are generally not used for large tumors, and are best for tumors no more than about 2 cm (a little less than an inch) across.

Radiofrequency ablation uses high-energy radio waves for treatment. A thin, needle-like probe is placed through the skin and into the tumor. Placement of the probe is guided by ultrasound or CT scans. The tip of the probe releases a high-frequency current that heats the tumor and destroys the cancer cells.

Ethanol (alcohol) ablation (also known as percutaneous ethanol injection) kills the cancer cells by injecting concentrated alcohol directly into the tumor. This is usually done through the skin using a needle guided by ultrasound or CT scans.

Microwave thermotherapy uses microwaves to heat and destroy the abnormal tissue.

Cryosurgery (cryotherapy) destroys a tumor by freezing it with a metal probe. The probe is guided through the skin and into the tumor using ultrasound. Then very cold gasses are passed through the probe to freeze the tumor, killing the cancer cells. This method may be used to treat larger tumors than the other ablation techniques, but it sometimes requires general anesthesia (where you are asleep).

Embolization

Arterial embolization, also known as transarterial embolization (or TAE), is another option for tumors that cannot be removed. Embolization can be used for larger tumors – up to about 5 cm (2 inches) across – than the ablative methods. This technique is used to reduce the blood flow to the cancer cells by blocking the branch of the hepatic artery feeding the area of the liver containing the tumor. Blood flow is blocked (or reduced) by injecting materials that plug up the artery. Most of the healthy liver cells will not be affected because they get their blood supply from the portal vein.

In this procedure a catheter is put into an artery in the inner thigh and threaded up into the liver. A dye is usually injected into the bloodstream at this time to allow the doctor to monitor the path of the catheter via angiography, a special type of x-ray. Once the catheter is in place, small particles called microspheres are injected into the artery to plug it up.

Radioembolization combines embolization with radiation therapy. In the United States, this is done by injecting small radioactive beads into the hepatic artery. The beads travel to the tumor and give off small amounts of radiation only at the tumor sites.

For more general information about surgery, please see our document, Understanding Cancer Surgery: A Guide for Patients and Families.