Authors
Lung cancer is the third most common cancer in the UK and accounts for approximately 13 per cent of all cancers. It also has the highest mortality rate in the UK for both males and females. But with two different surgical approaches available, it is not always clear which option would be best.
At Royal Brompton and Harefield Hospitals, we work closely together across the lung cancer multi-disciplinary team to push the boundaries in finding cures for patients.
Those patients who have been turned down for surgery elsewhere have had a successful surgery with us. These include patients with cancers involving the chest wall and sternum, cancer infiltrating the outer layer of the oesophagus, and those with PET-positive mediastinal lymph nodes and limited disease outside the chest.
All these patients were offered palliative treatment at their local hospital and sought a second opinion with us. With a combination of surgery and oncological input, all were kept alive and well for at least 30 months after treatment.
Large tumours requiring complex surgical reconstruction of the remaining airways are also referred to our team for treatment. Surgery involves removing one or more lobes of the diseased lung along with, if necessary, parts of the rib cage and large blood vessels.
In all cases, a complete mediastinal lymph node clearance is undertaken. This most accurately stages the extent of disease and limits further spread of tumour cells outside the lung, therefore improving prognosis.
With the advent of new immunotherapy drugs for lung cancer, more people are being offered a chance of life-saving treatment. Our lung cancer team works very closely with our specialist oncology colleagues to ensure we explore every option when planning treatment, to enable us to achieve the best outcome for all patients. Each case of lung cancer is discussed at our specialist lung cancer multi-disciplinary team and we agree on the optimal management plan for that case.
Different surgical approaches
In recent years, there has been a shift towards offering patients keyhole surgery and smaller incisions with no rib spreading. This approach is known as video-assisted thoracoscopic surgery lobectomy, or ‘VATS lobectomy’.
The traditional posterolateral thoracotomy has been significantly modified so that the length of the skin incision is considerably smaller than that performed 10 years ago and rib spreading is far less than previously done.
Muscles may or may not be cut, depending on the surgeon. All approaches generally heal very well with smaller, neat scars.
Key questions about lung cancer surgery
Some of the common questions that arise when considering whether to offer a VATS lobectomy or traditional surgery include:
Is the amount of lung removed the same?
Yes, a lobectomy may be done with either approach.
What procedure will cause the least amount of post-operative pain?
The immediate postoperative pain is generally agreed to be less with VATS surgery compared to open thoracotomy. However, as six weeks post-operative, many papers report conflicting results.
How does the survival rate for VATS surgery compare with a traditional thoracotomy?
This relates to early or potentially curative disease. There is a slight perioperative advantage with VATS however the year survival is the same. Our decisions depend on the wider context of illness for each individual patient.
Removing lymph nodes
In general, the lymph nodes tend to be completely removed with an open thoracotomy. With the VATS approach, this is not the case. An American study demonstrated that in a small number of patients, lymph node tissue containing cancer cells was left inside the patient.
These patients would not typically be offered any chemotherapy post-surgery as they would have been thought to be clear. This would put them at risk of developing further complications and illness from the remaining cancerous tissue. At the Harefield, we mitigate this by offering VATS surgery only to the earliest tumours.
Cancer treatment at Harefield
Harefield still offers surgery to patients when their disease has spread outside the chest. If there is a limited spread of disease to lymph nodes, they may be offered a combined approach of chemotherapy and surgery.
In potentially curable cancer, surgery offers patients the best chance while non-surgical options such as SABR and conventional radiotherapy give around half the survival rates compared to surgery.
We know that being diagnosed with lung cancer is very frightening and we strive to make our patients’ pathways from diagnosis through to treatment and follow up as efficient and as positive as we can.
We are here to support them and their families all the way through the journey.