Lung Cancer Surgery

Lung cancer surgery removes a tumour, a margin of lung tissue and usually chest lymph nodes. It is most often considered for early-stage non-small cell lung cancer (NSCLC) when the cancer can be removed completely, and the person is fit for an operation.

The amount removed may range from a small wedge to an entire lung lobe or, less commonly, a whole lung. The procedure depends on lung cancer type and stage, tumour location, lymph-node findings, lung and heart function, and other health conditions.

When May Lung Cancer Surgery Be Considered?

Surgery for lung cancer commonly forms part of Stage I and Stage II non-small cell lung cancer treatment. It also may be considered for selected Stage III lung cancers after multidisciplinary review. For advanced lung cancer at Stage IV, surgery is not usually the main treatment, although it may have a role in selected cases with limited spread.

Surgery has a limited role in small cell lung cancer (SCLC) because it often spreads early. Lung cancer surgery may be considered for uncommon, very early detection of SCLC confined to the affected lung without lymph-node involvement after thorough staging. Chemotherapy is usually recommended afterwards.

The lung cancer stages and lung cancer diagnosis and treatment pages explain the wider treatment pathways.

Resectability and Operability

Resectability describes whether all known lung cancer can be removed with an appropriate margin and lymph-node assessment. Operability describes whether a person can tolerate the operation and expected reduction in lung function.

A tumour may be removable, but surgery may carry too much risk if too little working lung would remain. A medically fit person may still have developing lung cancer that cannot be removed completely. A multidisciplinary team may compare surgery with radiotherapy, systemic therapy or combined treatment when the decision is uncertain.

Tests Before Lung Surgery

CT scans and PET-CT imaging tests show the tumour’s size, position, nearby structures and whether nearby lymph nodes or distant sites appear abnormal. A brain MRI may be needed depending on lung cancer type, stage and symptoms.

Suspicious lymph nodes may require tissue sampling. Endobronchial ultrasound (EBUS) samples nodes through the airway. Mediastinoscopy may provide further assessment. A biopsy usually confirms the diagnosis, although selected lesions may require surgery when another method is unsuitable or inconclusive.

Once lung cancer is diagnosed, the team confirms its type and stage before recommending surgery.

Lung function tests assess lung function and estimate it after lung resection. Further assessment may include exercise testing, blood tests, an electrocardiogram and heart imaging. Age alone does not determine whether surgery for lung cancer is suitable. Physical function, frailty and other conditions also matter.

Types of Lung Cancer Surgery

Lung cancer surgery depends on tumour size, location, margins, lymph-node findings and lung reserve to guide the choice. It involves removing the lung cancer completely without taking more functioning lung than necessary.

Lobectomy

A lobectomy removes one lung lobe from the right lung or left lung. The right lung has three lobes, and the left lung has two. Lobectomy is commonly used for operable early-stage lung cancer and permits lymph-node assessment.

Segmentectomy

A segmentectomy removes one or more anatomical lung segments, including the related airway and blood vessels. It may suit selected peripheral, node-negative early-stage lung cancer when an adequate margin and lymph-node assessment can be achieved, or when preserving lung tissue is important.

Wedge Resection

A wedge resection removes a small, non-anatomical piece of lung containing the lesion and a margin. It may diagnose a nodule, remove selected peripheral lung cancers or suit someone unable to tolerate a larger resection. A wedge resection is not interchangeable with a segmentectomy. More information is available in the guide to lung cancer wedge resection.

Sleeve Resection

A sleeve resection may be considered when central lung cancer involves a lobe and part of its main airway. The surgeon removes the affected lobe and section of bronchus, then reconnects the remaining airway. In selected lung cancer cases, this can preserve lung that would otherwise require removal.

Pneumonectomy

A pneumonectomy removes one entire lung, or the whole lung. It may be required when central lung cancer cannot be removed with a smaller resection. Because it removes the most lung tissue, detailed lung and heart assessment is essential.

Lymph-Node Sampling or Dissection

Cancer surgery usually includes removing lymph nodes or taking samples within the lung, around the main airways and in the mediastinum between the lungs. Laboratory examination determines the pathological stage and may change treatment after lung cancer surgery.

Surgical Approaches

The resection describes what is removed. The surgical approach describes how the surgeon reaches the lung. Lung cancer surgery may use open surgery or minimally invasive procedures with small incisions. Both aim for complete lung cancer removal, an appropriate margin and lymph-node assessment.

Thoracotomy Open Surgery

A thoracotomy uses a longer chest incision. Open surgery may be needed for a large or central tumour, major blood vessel or chest wall involvement, scar tissue, unexpected bleeding or another complex finding.

An operation started using a minimally invasive approach may need conversion to thoracotomy if this becomes the safer way to complete it. Conversion is not necessarily a complication.

Video-Assisted Thoracoscopic Surgery

Video-Assisted Thoracoscopic Surgery (VATS) uses a camera and surgical instruments through small incisions. For suitable operations, VATS may involve less pain, a shorter hospital stay and faster recovery than thoracotomy. These potential benefits vary, and VATS is not suitable for every lung cancer.

Uniportal VATS

Uniportal VATS (U-VATS) is a keyhole surgery for lung cancer that uses one incision for the camera and instruments. The choice between uniportal and multiportal VATS depends on the operation, tumour anatomy and patient factors. The number of incisions alone does not determine the operation’s completeness.

Robotic-Assisted Thoracic Surgery

Robotic-Assisted Thoracic Surgery (RATS) uses a camera and wristed surgical instruments through small incisions. The surgeon controls them from a console. It may be used for selected lobectomies, segmentectomies and other chest procedures.

No approach is suitable for everyone. The priority is a safe operation that permits complete tumour removal and appropriate lymph-node assessment.

Preparing for Surgery

The surgical and anaesthesia teams provide instructions. Preparation may include:

• Quitting smoking as early as possible to lower the risk of breathing and wound complications and support recovery
• Reviewing prescription medicines, blood thinners, supplements and herbal products
• Regular walking, breathing exercises or a prehabilitation programme, when appropriate
• Maintaining adequate nutrition and reporting unintended weight loss
• Arranging transport and practical support after discharge

Do not stop prescribed medicine without medical advice. Surgery may be postponed if an infection or uncontrolled medical problem makes the operation temporarily unsafe.

Possible Risks and Complications

Lung cancer surgery is major surgery. Risk varies with the amount removed, surgical approach, lung and heart function, and other health conditions.

Possible complications include:

• Prolonged air leak
• Bleeding or a need for transfusion
• Wound infection, chest infection or pneumonia
• Irregular heart rhythm
• Blood clots in the legs or lungs
• Breathing complications or reduced lung function
• Fluid accumulation around the lung, called pleural effusion, or lymphatic leakage into the chest
• Persistent post-operative pain, numbness or altered sensation
• Anaesthetic complications
• A need for another procedure
• Rarely, death during the perioperative period

The surgeon should explain the risks for the planned operation and the person’s health.

Hospital Recovery

After lung cancer surgery, patients wake in a recovery area and move to a hospital room or ward once stable. Some need high-dependency or intensive care after a larger resection or with significant medical conditions.

Grogginess and pain are common after lung surgery. Pain medication supports breathing, coughing and movement. Staff will encourage walking soon after surgery.

Most patients wake with a chest tube and intravenous fluids. Some also have a urinary catheter. The chest tube drains air and fluid and helps the remaining lung expand. A chest X-ray may be done to check lung expansion.

Most patients stay in hospital for a few days after uncomplicated minimally invasive surgery. Thoracotomy, pneumonectomy or complications may require a week or longer. Discharge depends on breathing, pain, mobility, chest-tube removal and support at home.

Recovery at Home

Tiredness, incision discomfort, altered sensation and breathlessness during activity are common at first. Recovery usually takes several weeks and can take months after a larger or open operation. Some programmes advise avoiding lifting more than 4.5 kilograms for the first 3 to 6 weeks, but the limit depends on the procedure and the surgeon’s advice. Return to driving, work and exercise also depends on pain control and progress.

Pulmonary rehabilitation may help selected patients rebuild strength, breathing control and exercise tolerance after lung cancer surgery.

Seek prompt medical advice for new or worsening breathlessness, severe or unusual chest pain, fever, a worsening cough, wound redness or discharge, more than a small streak of coughed-up blood, a swollen calf, fainting, confusion or a rapid or irregular heartbeat.

Pathology Results After Surgery

The final pathology report records the lung cancer type, tumour size, nearby tissue involvement, surgical margins, lymph-node findings and pathological stage. This stage may differ from the stage estimated before surgery because examination under a microscope can reveal changes not visible on scans.

A clear margin means no cancer cells were found at the cut edge. If a margin contains cancer cells or lymph nodes are involved, the multidisciplinary team reviews whether further surgery or another treatment should be considered.

Treatment Before or After Surgery

Treatment before surgery is called neoadjuvant treatment. Treatment after surgery is called adjuvant treatment. Depending on the lung cancer type, stage, pathology and biomarkers, the wider lung cancer treatment plan may include chemotherapy, immunotherapy, targeted therapy or radiotherapy, also called radiation therapy.

Not everyone needs additional treatment. The lung cancer treatment page explains these options in more detail.

Follow-Up

The first follow-up appointment is often within 1 to 3 weeks. It assesses wound healing, breathing, pain and recovery, and allows removal of non-dissolving stitches when needed. The surgeon also reviews the pathology report and explains whether further treatment is recommended.

Long-term follow-up includes clinical review and periodic chest CT scans. The schedule depends on stage, treatment and the person’s health. Surveillance looks for recurrence and a new primary lung cancer. Attend scheduled visits and complete the imaging tests advised by the healthcare team.

Lung Cancer Surgery Cost Factors

The cost of lung cancer surgery in Singapore varies with the resection, surgical approach, hospital and operating theatre charges, anaesthesia, investigations, pathology, length of stay, complications and additional treatment.

Insurance and MediSave use depend on the policy, procedure, hospital and prevailing rules. Pre-authorisation may be required. Neumark Lung & Chest Surgery team can help you understand the costs, insurance and MediSave.

Questions to Ask a Thoracic Surgeon

Questions may include:

• What operation and surgical approach do you recommend, and why?
• How much lung would be removed?
• Will lymph nodes be sampled or dissected?
• What are my individual risks and expected effect on lung function?
• Might I need treatment before or after surgery?
• What should I expect in hospital and during recovery at home?
• When will the final pathology results be available?
• What follow-up will I need?

Thoracic Surgical Assessment at Neumark

Neumark Lung & Chest Surgery Centre specialises in minimally invasive thoracic surgery with a multidisciplinary approach led by Dr Harish Mithiran, senior consultant thoracic surgeon at Gleneagles and Mount Alvernia hospitals.

An assessment for lung cancer surgery may include review of imaging, pathology, lymph-node findings, lung function and the amount of lung that may need removal. When other treatment is required, care may be coordinated with respiratory medicine, medical oncology, radiation oncology, radiology and pathology.

Patients can contact Neumark to discuss whether a thoracic surgical assessment is appropriate.