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 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:

• Pulmonary function tests will be done to see if you would still have enough healthy lung tissue left after surgery.
• Tests will be done to check the function of your heart and other organs to be sure you’re healthy enough for surgery.
• Your doctor will want to check if the cancer has already spread to the lymph nodes between 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

Different operations can be used to treat (and possibly cure) NSCLC. With any of these operations, nearby lymph nodes are also removed to look for possible spread of the cancer. These operations require general anesthesia (where you are in a deep sleep) and are usually done through a large surgical incision between the ribs in the side of the chest or the back (called a thoracotomy).

• 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 and 2 on the left). 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 your doctor recommends 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.

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 belly pain, heartburn, itching, chest pain, nausea, vomiting, 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.

After surgery

When you wake up from surgery, you will 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 5 to 7 days in the hospital after the surgery.

Video-assisted thoracic surgery (VATS)

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

Most 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 with 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.

Robotically-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, blood loss, and 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.

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. While all surgeries carry some risks, these 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.

Surgery for lung cancer that has spread to other organs

If the lung cancer has spread to your brain and there is only one tumor, you may benefit from having the tumor removed. This surgery should be considered only if the tumor in the lung can also be removed or treated (with radiation and/or chemotherapy) completely.

Surgery to remove a tumor in the brain is typically done through a small hole in the skull (called a craniotomy). It should only be done if the tumor can be removed without damaging vital areas of the brain.