Lung Cancer

Patients with lung cancer usually have a history of cigarette smoking. They may complain of persistent cough, recent weight loss, or other symptoms, but they may be totally without symptoms at an early stage. A chest X-ray or CT scan of the chest will usually demonstrate a nodule or mass in the lung. Such a finding in a smoker, in the absence of signs of infection, should prompt early referral to a thoracic surgeon. Sometimes a tissue diagnosis is obtained by bronchoscopy or transthoracic needle biopsy prior to further staging and therapy, but in many cases it is appropriate to proceed directly to surgical procedures with only radiology studies having been completed before surgery. This approach often prevents unnecessary delay in providing what we hope will be curative surgical therapy.

At Stanford, we feel strongly that it is critical to completely assess the stage or extent of spread of the cancer to other parts of the body before therapy is initiated. Chest CT scan will identify the size and location of the lung tumor and any enlarged lymph nodes in the chest. PET scans will give us additional information about possible spread of the tumor to lymph nodes and to other parts of the body. Brain MRI may be indicated to determine if there is spread to this organ, for which PET is not reliable. In some patients, we will recommend performing biopsies of the lymph nodes in the chest. This may be carried out by a procedure called mediastinoscopy or, in some cases, by a new technique called endobronchial ultrasound (EBUS) that allows us to biopsy these lymph nodes from inside the airway. Knowledge about lymph node involvement is important, because if the lymph nodes in the chest contain a tumor, we may recommend giving chemotherapy or chemoradiation prior to surgery. Once the diagnosis of lung cancer is made and the staging process is completed, cancer therapy can begin.

At Stanford, the treatment of lung cancer is comprehensive and involves a collaborative effort between oncologists, radiation oncologists, pathologists, and radiologists at the Stanford Cancer Center. Patients with more straightforward, early stage tumors may be treated by thoracic surgeons alone (with cure rates of approximately 80%), but patients with more advanced tumors will be evaluated and often treated by our multidisciplinary team at the Stanford Thoracic Oncology Tumor Board.

Common stage-based therapies are as follows:

• Stage I - Surgery alone; possibly chemotherapy after surgery if tumor is large
• Stage II - Surgery followed by chemotherapy
• Stage III- Surgery preceded by chemotherapy or chemoradiation; surgery followed by chemotherapy or chemoradiation
• Stage IV –Usually chemotherapy alone; surgery possible with single sites of spread to the brain or adrenal gland

Types of lung resections include:

• Lobectomy - Anatomic removal of a complete lobe of lung (there are three lobes in the right lung and two in the left lung). This is the most common operation and has very low complication and mortality rates.
• Sleeve Lobectomy - Removal of a complete lobe of the lung as well as part of the airway that conducts air to the remaining lobe and then reconnecting that airway and remaining lobe. This more complex procedure may avoid the need for pneumonectomy.
• Pneumonectomy - Complete removal of the lung on one side. Although sometimes required, one would like to avoid this if a complete removal of the cancer can be performed without pneumonectomy.
• Segmentectomy - Only a portion of a lobe is removed. Often used for small tumors or in patients with severe lung disease.
• Wedge Resection - An even smaller portion of the lung is removed. Often used for small tumors or in patients with severe lung disease.

The broad experience and highly specialized training of Stanford's thoracic surgeons allows them to offer you two complex thoracic surgical procedures that are not widely available but that are critical to providing the lowest possible complication rates and highest cure rates following lung cancer surgery. These procedures are video-assisted thoracic surgical (VATS) lobectomy and sleeve lobectomy:

Video-Assisted Thoracic Surgery (VATS) Lobectomy

Lobectomy in most hospitals is performed exclusively by thoracotomy. This means that the ribs are spread apart to provide access to the chest, and this rib spreading and cutting of muscle is associated with a significant amount of discomfort after surgery. VATS lobectomy allows surgeons to carry out exactly the same operation within the chest that is performed by thoracotomy, but it is done through three to four small incisions without rib spreading rather than the large incision with rib spreading that a thoracotomy entails. The surgeon gains his view inside the chest from a small video camera inserted through one of the small incisions, and the procedure is carried out with long instruments passed through the other small incisions. Patients who have undergone VATS lobectomy have less pain and recover faster from surgery. In general, VATS lobectomy is an option only for patients with Stage I lung cancer. Our surgeons are by far the most experienced in northern California in VATS (thoracoscopic) lobectomy for lung cancer, and we have also been deemed a "high performing hospital" in lung cancer surgery by U.S. News and World Report.

Related Article: Video-Assisted Lung Cancer Surgery: Small Incisions Translate Into Big Gains for Pain Reduction and Recovery Speed

Sleeve Lobectomy

A guiding philosophy in the management of resectable lung cancer at Stanford is to avoid pneumonectomy if at all possible. This approach can only be practiced by surgeons skilled in sleeve lobectomy and experienced enough to know when lobectomy will provide an equivalent chance of cure as the more morbid pneumonectomy. Avoidance of complete removal of a lung reduces both early complications and long-term disability due to shortness of breath.

Sleeve lobectomy is possible when a tumor involves the origin (take-off) of the airway that supplies a lobe of the lung. Most surgeons perform removal of the entire lung in this circumstance, because they are not experience in performing sleeve lobectomy. Sleeve lobectomy allows complete removal of the tumor without complete removal of the lung. This is made possible by removing a small portion of the airway that conducts air to the remaining lobe(s), then reattaching that airway and the remaining lobe(s) so that they can continue to function in the usual manner. It is proven that this approach provides the same chance of cure as pneumonectomy with far lower operative complications and better quality of life.