Lung cancer is one of the leading causes of cancer deaths worldwide. Surgical resection has long been the standard curative treatment option for early-stage non-small cell lung cancer found before it has spread. However, advances in surgical techniques and technologies are expanding treatment possibilities for more lung cancer patients.
Types of Lung Cancer Surgery
There are a few main types of lung cancer surgery depending on the size and location of the tumor. For smaller peripheral tumors, a wedge resection or segmentectomy may be performed where a section of the lung is removed. For larger tumors, a lobectomy is usually necessary which removes an entire lobe of the lung. In rare cases where the tumor involves the entire lung, a pneumonectomy may be the only option which removes the entire lung.
The most common type of surgery is a lobectomy where the tumor-containing lobe is removed while sparing as much healthy lung tissue as possible. This surgery has traditionally been recommended for stage I NSCLC up to 7cm located in the outer parts of the lung. Removing the entire lobe provides adequate margins around the tumor to minimize the risk of recurrence.
Minimally Invasive Approaches
Traditionally, lobectomies required large incisions and removal of ribs for adequate access to the lungs. However, minimally invasive surgery using video-assisted thoracoscopic surgery (VATS) techniques have become increasingly common. With VATS, several smaller incisions are made and long rigid instruments with attached cameras are inserted to visualize the lungs. Carbon dioxide is pumped in to expand the space around the lungs to perform the operation.
VATS offers significant benefits over traditional "open" lung cancer surgery including less post-operative pain, shorter recovery times, and better cosmetic outcomes. Multiple studies have demonstrated VATS lobectomies to be as effective as open surgery at controlling the cancer while providing reduced morbidity. VATS requires advanced surgical skills but is becoming the preferred approach when tumors are located appropriately for this technique.
Advances in Anesthesia
Advances in anesthetic techniques are also enabling more lung cancer patients to undergo surgery. Traditionally, lobectomies required placing patients on full lung separation with one lung being deflated while operating on the other. This added complexity and risk.
However, advances in dual lung ventilation allow both lungs to remain inflated and functional throughout the operation. Combined with advanced bronchoscopic tools that can temporarily block individual lung segments, this allows surgery on one section of the lung while ventilation and oxygenation are maintained through the rest of the lungs.
Dual lung ventilation reduces risks, lessens the physiological insult of surgery, and gets patients recovering faster by sparing them from full lung isolation. It has expanded eligibility for surgery to sicker or older patients previously deemed too high risk.
Pushing The Limits of Resectability
Technological advances are also pushing the boundaries of resectability to offer surgery to locally advanced lung cancers previously deemed inoperable. Navigation bronchoscopy using electromagnetic tracking allows safe and accurate airway inspection and biopsy of even very small and deeply located lung lesions under real-time bronchoscopic visualization.
Robotic lobectomy systems are enabling complex dissections around major blood vessels in close proximity to tumors. They provide magnified high-definition 3D views along with enhanced dexterity and range of motion compared to human hands.
Studies have shown robotic lobectomy to be safe and effective even for large and centrally located tumors abutting major structures previously thought only resectable via open techniques. The robotic systems result in less blood loss, quicker recovery, and a lower conversion rate to open compared to VATS for more complex cases.
These developments combined with advanced bronchoscopic tools for airway control and intraoperative oncology assessments are allowing an increasing number of borderline resectable and even technically "unresectable" lung cancers to be treated with curative-intent surgery where no other options existed before.
Expanding Options Through Teamwork
The successful treatment of advanced lung cancers demands a multidisciplinary care approach. Detailed planning between pulmonary and cardiothoracic surgeons, medical oncologists, radiation oncologists, and radiologists is needed to determine resectability while maximizing outcomes and minimizing risks.
Some larger lung cancers previously deemed inoperable may now find surgery an option after receiving preoperative chemotherapy or radiotherapy to significantly shrink the tumor size and make complete resection feasible. Postoperative chemotherapy and radiation are also employed to further reduce risk of recurrence when cancer cells may remain in lymph nodes or tissues around the tumor site despite a complete surgical resection.
The bottom line is that through innovative technology, advanced surgical techniques, multidisciplinary collaboration, and continued refinement of treatment protocols, lung cancer surgery options have expanded tremendously in recent years. More lung cancer patients today can besuccessfully treated with potentially curative surgical resection than ever before. Continued research and experience will undoubtedly further broaden the limits of resectability and improve lung cancer survivorship.
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