Surgery for Lung Cancer

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Surgery for Lung Cancer

• Jocelyn McLean
• Case Manager for Thoracic Surgery

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Surgery is offered to

• CURE
• Early (Stage 12 Primary NSCLC
• Solitary metastatic lung tumors
• DIAGNOSTIC
• APPROACH
• Thoracotomy open surgery

• PALLIATE
• Advanced NSCLC pleural effusions
• Metastatic pleural effusions from other primary
• Undiagnosed pleural effusions primary unknown
• DIAGNOSTIC
• APPRAOCH
• Thoracoscopy keyhole surgery

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For curative surgery - its as simple as .

• Diagnosis of NSCLC or High suspicion
• PET -ve supporting clinical history
• Increasing size over 3 months
• Localised disease (within the chest)
• Fit enough for an operation
• Anaesthetic
• Respiratory function / capacity
• Technically possible - IF IN DOUBT
• ASK THE LUNG SURGEON !!
• Stopped smoking min of 4 weeks (total cessation)

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General principles

• Safe
• Short anaesthetic time
• Risks include
• bleeding,
• infection,
• cardiovascular event,
• Air-leak
• Low mortality
• Overall (1)
• Pneumonectomy (2)
• More deaths from those with advanced malignancy

• Maximise health prior to op
• Understand procedure and expected recovery -
  short LOS
• Effective pain relief
• Effective physiotherapy
• Early removal of ICC- minimise air leaks
• Early mobilisation
• Reliable ICU/respiratory support

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What makes surgery amenable to more patients?

• Double lumen ETT ?
• 1 lung ventilation
• Stapling techniques
• Glue
• Knowledge from LVRS
• Older patients, worse lungs, shorter operation

Insertion of a Double Lumen Tube W. John Russell
17th May 2000
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Routine pre-op for surgery

• Respiratory assessment
• RFT/spirometry, clinical assessment, What op ?
  pneumon
• Stop smoking
• Stop anticoags- Plavix, Warfarin, Asprin
• Maintain respiratory meds
• Other co morbidities controlled Diabetes,
  cardiac,
• Preadmission clinic- bloods, ECG, CXR,GH, MRSA
  screen, Physio consult, History, Pathway
• Day of surgery admission

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Intentions of surgery

• Surgical resection offers only chance of a cure.
• Gold standard is lobectomy, bi-lobectomy or
  pneumonectomy
• Formal lymph node resection.

• If cure is intended but resp capacity prevents
  lobe etc then wedge resection or segmentectomy.
• price is gt chance of local recurrence

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If the intent is palliative...

• Thoracoscopic approach.
• Improve QOL when reasonable quantity (time) is
  likely.
• Symptom control shortness of breath, pain
• Optimize re-expansion of lung
• Carries significant risk of post operative
  morbidity and mortality
• Obtain diagnosis - significant if young /
  compensation

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Right Lower Lobectomy
Left Upper Lobectomy
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Malignant Pleural Effusion - mesothelioma
Thoracoscopy pleurodesis only
Thoracotomy 6 Weeks after decortication