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Surgery
For lung cancers that have not spread widely and are confined to a portion of the lungs, surgical removal of the malignancy gives the best chance of long-term survival or cure. Early-stage cancers (Stage I) are usually treated with surgery alone. With Stage II cancers, chemotherapy occasionally is given after surgery. Treatment becomes more aggressive with advanced cancers, such as Stage IIIa, in which there is considerable spread to the lymph nodes. In these patients, chemotherapy and sometimes radiation therapy are offered first. If there is a good response to these treatments, surgery may be proposed as well. Called "induction" or "neoadjuvant" therapy, this approach requires a multidisciplinary team working closely together. For patients with Stage IV disease, surgery is appropriate only in very rare instances, such as when the malignancy in the lung can be removed surgically and the organ or site to which the cancer has traveled also can be treated, surgically or otherwise.
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Increasingly, surgery is offered to patients regardless of their age. Many reports now suggest that elderly individuals with early-stage lung cancer get as much benefit from aggressive surgery as do younger patients. In general, complications are low among the elderly, although older patients in good health obviously do better than those in poor health.
To get to and remove the affected area, surgeons typically make a small incision in one side of the chest in between the ribs. This procedure, known as a thoracotomy, usually doesn't involve breaking or removing ribs. Once inside, surgeons can pursue one of four options:
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Wedge resection: In this operation, a wedge, or pie-shaped, section of the cancerous lung is excised.
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Lobectomy: This operation involves removing the entire lobe in which the cancer is located. In many cases, this will be the treatment of choice.
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Segmentectomy: A segment of the lobe containing the cancer is removed in this procedure, which typically is done when lung function is poor.
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Pneumonectomy: In this operation, the entire lung with the cancer is removed. This is only done if the location of the malignancy makes it difficult to remove a portion of the lung and a patient has sufficient lung capacity to survive with just one remaining lung.
In any of these cases, some lymph nodes in the chest are removed and tested to make sure there is no evidence of further spread. The results of this testing and the size of the tumor determine whether additional therapy, like chemotherapy or radiation therapy, is needed.
Any of the above is a major operation. The hospital stay is typically from three to five days. All patients are encouraged to be as active as possible once they get home, with only minor limitations on what they can do for two to three weeks after surgery. Most of the pain goes away after two to three weeks, and people often return to work within the same period.
At some hospitals, thoracic surgeons are now able to use in selected patients minimally invasive techniques, including video-assisted or robotic surgery. The robot has a 20-mm camera for "eyes," and inside the chest cavity the "arms" have the complete rotating capabilities of a human wrist. The surgeon sits at a console, and using his fingers to control the two robotic arms, makes three ½ inch incisions and one 5-to-6-inch incision below the shoulder blade. With this device, there is generally less scarring, along with less postoperative pain. Also, recovery time is a little shorter. This is still a new technology, and these techniques aren't appropriate for every patient with lung cancer.
Finally, irrespective of the surgical approach, it is very important that your surgeon be well versed in the care of lung cancer patients as well as familiar with all potential treatment options. Just as with other major surgeries, lung cancer operations are typically better handled by specialists--in this case, thoracic surgeons--than by surgeons who do only the occasional lung operation.
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