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Lung Cancer Surgery (Drs. Mason and Murthy 10/25/10)

Monday, October 25, 2010 - Noon

David Mason, MD
Staff Surgeon, Cleveland Clinic Department of Thoracic and Cardiovascular Surgery.

Sudish Murthy, MD
Staff Thoracic Surgeon, Department of Cardiothoracic Surgery Miller Family Heart & Vascular Institute

Description

Lung cancer is the number one cause of cancer deaths in the United States. Depending on the type and stage of lung cancer you have, surgery may be recommended as part of treatment. When the cancer is caught in the earlier stages, surgery is usually the primary treatment. As such, it is important to have a better understanding of lung cancer surgery so you can discuss with your doctors if it is the best option for you and what type is the best. Cardiothoracic surgeons David Mason, MD and Sudish Murthy, MD answer your questions.

More Information


Medications, Chemotherapy and Lung Cancer

Rob: Is docetaxel & cetuximab the best added treatment for adenocarcinoma?

Dr__David_Mason: There are many different chemotherapy regimens for adenocarcinoma - none is clearly better than the other. Most involve a platinum therapy combined with one other chemotherapy agent.

tomray: Are there any new medical treatments or medicines for metastatic lung cancer?

Dr__David_Mason: Chemotherapy is the mainstay of therapy for metastatic lung cancer although there are many research trials at Cleveland Clinic as well as other research institutions. www.clinicaltrials.gov would have a listing of research trials.

soccerfan1: Are there any studies that use drugs or stem cells during surgery to help prevent return of cancer after surgery?

Dr__Sudish_Murthy: Only for mesothelioma surgery does intra-operative administration of medications have some use. Mesothelioma is a cancer that is related to asbestos exposure.

sarrr0: My mother was recently diagnosed with lung cancer. The Doctors are doing radiation and planning on chemo. They say 1-2 years at best. I was wondering it would be possible to do a surgery to remove the cancerous lung? Would that help her? They say it’s not an option. Thank you

Dr__Sudish_Murthy: My suspicion is that your mother has been deemed an unfit candidate for surgery for one of two reasons. First, the stage of cancer may be advanced and consequently there is no target to base the surgery around.

Second, it is possible that age, lung function, heart disease, or other risk factors would make an operation too difficult for your mother to recover from. I would ask your treating physicians which of these two possibilities, and both may apply at the same time, is behind their thoughts regarding treatment.

coolboot: What are the special considerations for a dialysis patient starting chemo therapy/radiation combined treatments for small cell lung cancer?

Dr__Sudish_Murthy: One of the major toxicities of chemotherapy for small cell lung cancer is renal (Kidney) toxicity. Dialysis patients aren't necessarily affected by this particular toxicity, however, their general state, which is slightly more deconditioned than the average patient presenting with cancer, will make treatment and regulation of volume status more difficult. I would expect no difference in the effectiveness of the treatment regimen regardless of whether someone is on hemodialysis or not.

coolboot: I read that, according to recent studies, melatonin (20 mg/day) before, during, and following chemo therapy can ameliorate the harsh after effects and extend life span. Do you know of this?

Dr__Sudish_Murthy: I am not familiar with that data. My suggestion would be to focus on a balanced diet, robust with whole grains, vitamins and nutrients from cruciferous vegetables (broccoli, cauliflower, etc.), lean sources of protein, and anti-oxidants from dark berries. This is a zero risk treatment strategy and probably reflects the diet that we were meant to have.

timothyr: Are there any alternatives available that might be as effective as surgery?

Dr__Sudish_Murthy: For early stage lung cancer, in medically unfit patients, our strategy has focused on using sophisticated radiation therapy treatments to limit collateral injury of lung and promote rapid recovery of the patient. This novel therapy has not yet been extended to patients with early lung cancer who have reserve to tolerate removal for fear that patients may have a slightly worse survival from radiation therapy than from removal.

It should be noted that the radiation technique used at this center relies on a robot guided imaging system and this is not the standard necessarily elsewhere. Conventional radiation therapy falls short of lung cancer surgery with respect to possibility of cure for patients with early stage lung cancer.

corey: I read that after someone has minimally invasive lung cancer surgery, chemotherapy is more beneficial and works better - is this true?

Dr__Sudish_Murthy: I have not heard that data but in my own practice, the majority of people who undergo minimally invasive (video assisted) operations for lung cancer do not derive any meaningful benefit from chemotherapy, as the vast majority are in an early stage of lung cancer where all the risks of chemotherapy are not fairly balanced by any meaningful benefit.


Diagnostic Testing and Lung Cancer

sambrn: My husband had an x-ray and it showed nodules in his lungs. Does that mean he has cancer?

Dr__David_Mason: No, however, a CT scan and further follow up is certainly necessary.

flwrpwr: My dad has lung cancer and the doctor said he is not a candidate for surgery - they want him to have chemo and radiation - I thought it would be better to get the tumor out of there - When do they say surgery is the best option?

Dr__David_Mason: It would be best to see a thoracic surgeon before surgery is entirely ruled out.

gn123: During a cardiac cath and chest x-ray, they found that I have a node on my lung. They plan to follow me with an x-ray but when is it time to have the node biopsied?

Dr__David_Mason: This depends on the size and location of the node.

jenny_L: I saw on the news some pretty amazing pictures taken by a virtual bronchoscopy - they were 3D but did not really understand how they work. They said it was still in research - but wondered if you use it and what you thought about it.

Dr__David_Mason: Image guided bronchoscopy is used commonly at Cleveland Clinic and aids diagnosis and treatment of tumors that are small and difficult to locate.

Btaylor: I read that they are trying to cut down on the number of x-rays and CT scans they do because of all the radiation exposure - but how do you suggest that they do follow ups for lung nodules and masses before and after surgery?

Dr__Sudish_Murthy: There are no distinct guidelines that currently exist to follow lung nodules or return of cancer after an operation. Our policy is based on the presenting stage of the patient for those with cancer or how suspicious the nodule appears in a patient that does yet not have a diagnosis of cancer. For patients with a suspicious nodule of unclear etiology, there is usually an initial scan that identifies the nodule and has prompted the referral. There is a follow up scan at approx. 3 months time and if growth is identified in this short interval, cancer is suspected and consideration for biopsy or removal is given.

If however there is no growth of the nodule on the follow up scan at three months the interval can be spaced out to a 6 months scan and if stable, a final scan at one year after the last scan. Two years of radiographic stability would construe a diagnosis of a benign nodule as per most radiologic guidelines.

In regards to following a patient after an operation, depending on the stage of the cancer at the time of it's treatment, a yearly chest CT may be requested for 5 years following treatment, particularly for early stage lung cancer. For those with more advanced disease, radiographic survey is generally more intense.

It is the goal to limit the radiation particularly, limit the number of CT scans performed as there is some small amount of radiation exposure with each scan. Most guidelines would suggest that in excess of 10 - 12 CT scans would subject the patient to undo radiation.

I have not yet encountered a patient with a suspected cancer or complication attributable to excess radiographic imaging thus far in my practice, though I try to limit the number of studies for each one of my patients to the minimum required to allow for their safe care.


Candidates for Lung Surgery

carolb: My mom is 67 years old. She has a tumor in her lung and neck. She had radiation and chemo - the tumors shrunk - and I wonder if she would be a candidate for surgery.

Dr__David_Mason: It would be necessary to review your mom's case specifically before making further recommendations.

bball34: Is surgery used to treat small cell lung cancer?

Dr__David_Mason: Surgery is used to treat very early small cell lung cancer.


Types of Lung Cancer Surgery

dorothy: Is lung cancer curable through surgery for a stage 1a cancer?

Dr__David_Mason: The cure rates are very high with surgery alone for stage 1a lung cancer.

mel1220: My father has a lung cancer for 6 months. He has Small Cell Carcinoma and has had chemotherapy. It has shrunk the tumor but it is still there from MR 3 mm wide. Do you do radiosurgery or robotic surgery at Cleveland Clinic?

Dr__David_Mason: We do radiosurgey and robotic surgery at Cleveland Clinic. We would need to specifically review your father's case before making any recommendations.

sara1: How long are the single- and double-lung operations, typically?

Dr__David_Mason: Procedures range from one to four hours. This is dependent on the complexity.

trrrt: I saw something on TV about treating tumors with laser. I am wondering if this is possible in my 25 year old son with a tumor in his lung and brain. Do you work with the neurosurgery dept to treat patients who have two different locations on their tumors?

Dr__David_Mason: There are many new minimally invasive therapies for tumors. These include lasers, radiation therapy, and minimally invasive surgery. Collaborations between surgeons is common. Your son's case would need to be reviewed specifically to get further recommendations.

cherylc: My aunt has lung cancer and needs a lobectomy - but as a long time smoker (she quit last year), she also has COPD - how does this impact her chance of successful surgery and recovery?

Dr__David_Mason: Smoking and emphysema increase the risk of complications after surgery. A careful pulmonary evaluation should be performed before deciding on any interventions.

Gordon: Can thorascopic lobectomy be used where lung cancer appears at multiple sites (but all in the same lung)? 2. - Or, is it limited to those lung cancers which are localized at a single site only? 3. - If it can theoretically be used for multiple sites, has this actually been done? 4. - And finally, since this procedure is so new, what is the best way to find a specialist who is experienced in performing it?

Dr__David_Mason: Thoracoscopic lobectomy can be performed in many different settings including cancers in different sites. The procedure is tested and safe. Research when selecting the surgeon for thoracoscopic surgery should be directed as to their experience or number of procedures. VATS lobectomy is performed commonly at Cleveland Clinic.

applegirl: can you talk about video assisted surgery - when is that an option for lung cancer

Dr__David_Mason: Video assisted surgery is a minimally invasive form of surgery that decreases postoperative trauma and speeds recovery. It is commonly performed at Cleveland Clinic for most stages and types of lung cancer. It is best performed for early stage (stage I) lung cancer.

45_op: I read online that although VAT surgery is just as successful as regular open surgery, the survival long term is less? Is that true?

Dr__David_Mason: VAT (video assisted thoracic) surgery has results in the long term that are just as good in cancer survival as more traditional open surgery.

dorothy: my lung nodule was centimeter in upper left lobe which was removed. would you recommend surgery for removal of the rest of the lobe they found sclc.

Dr__Sudish_Murthy: It sounds as if you have had a wedge resection. Surgery is second line therapy for small cell lung cancer. This cancer tends to be quite sensitive to chemotherapy. My suspicion is that you should be receiving chemotherapy and there is a possibility that your physicians might recommend intracranial (brain) radiation. There is no obvious reason why the remaining portion of your left lung needs to be removed unless this is the only site of cancer, or your cancer was incompletely removed. It sounds as if your operation may have been performed for diagnosis.

dorothy: My nodule grew 1mm, they suggested it should be removed so they did a wedge resection and later pathology report came back sclc stage 1a no cancer anywhere else on the pet scan. now this week they feel for curable intent to remove rest of lube to be safe no cancer is in lymph nodes in lobe

Dr__Sudish_Murthy: Most would suggest that the principle therapy of small cell lung cancer is chemotherapy - you should check with your oncologists as to whether you have small cell lung cancer (SCC), or squamous cell lung cancer often with the same abbreviation. For an early squamous cell lung cancer (stage Ia) a completion lobectomy would be reasonable and would be the standard of care at most institutes

dorothy: He said small cell /adenocarcinoma.

Dr__Sudish_Murthy: Unfortunately, small cell is not adenocarcinoma. Adenocarcinoma falls under the heading of a non- small cell tumor. There are some rare tumors which do have components of both small cell and non small cell. Perhaps this is what you have, and if that is the case, then completion lobectomy is not unreasonable particularly if your regional lymph nodes have been adequately sampled to exclude early spread by the small cell component of the tumor. If lymph nodes are involved then I would not subject a patient to the rigors of the second lung operation. You might need to clarify whether you have a mixed tumor.

kate-m: My cousin will be having surgery, but what is the likelihood that it will cure the cancer?

Dr__Sudish_Murthy: The cure of lung cancer is based on the initial stage of the disease. Hopefully your cousin would have been carefully assessed for obvious and not so obvious spread of lung cancer to their system or more importantly to local lymph nodes. If local lymph nodes are found to have been involved at the time of a cancer operation, the utility of the operation is significantly compromised. For patients with local lymph node involvement and adequate vigor, our usual treatment protocol involves presurgical chemotherapy and radiation treatment followed by possible operation.

This appears to optimize the utility of all three different treatments for lung cancer (chemotherapy, radiation, and surgery). If your cousin is having his operation for an early stage lung cancer, at this institute the expected survival from a lung cancer perspective would be between 75 and 85 percent. Because of staging issues across the country, the expected survival for a stage I lung cancer as reported by all hospitals in the country is between 60 and 70 percent. This difference in survival likely reflects less thorough staging, in particular not understanding or appreciating involvement of local lymph nodes.

timothyr: Are there any alternatives available that might be as effective as surgery?

Dr__Sudish_Murthy: For early stage lung cancer, in medically unfit patients, our strategy has focused on using sophisticated radiation therapy treatments to limit collateral injury of lung and promote rapid recovery of the patient. This novel therapy has not yet been extended to patients with early lung cancer who have reserve to tolerate removal for fear that patients may have a slightly worse survival from radiation therapy than from removal.

It should be noted that the radiation technique used at this center relies on a robot guided imaging system and this is not the standard necessarily elsewhere. Conventional radiation therapy falls short of lung cancer surgery with respect to possibility of cure for patients with early stage lung cancer.

frankm12: I apologize, as I am just joining the chat. Did you address the point at which someone may be considered appropriate to have surgery to remove a tumor on the lung?

Dr__Sudish_Murthy: Candidates for surgery for lung cancer should have heart and lung reserve for such an endeavor. In addition, the lung cancer should be of an early stage, no greater than stage II for meaningful benefit from an operation to be expected.


Post Lung Cancer Surgery

dorothy: If a lung nodule is removed by resection and later reports found non small cell cancer what would your next course of action be?

Dr__David_Mason: That is dependent on the size of the tumor and any signs of spread as well as a patient's other medical conditions.

Mikeyy: I had a lobectomy and chemo. Are there any treatments you recommend to decrease the chances of cancer returning? How often do you recommend follow up CT scans?

Dr__David_Mason: Chemotherapy has the highest chance of preventing recurrence after lung cancer surgery. In general CT scans are performed every 6 months.

peterf: After a lung is removed, what happens to the space that’s left in the chest?

Dr__Sudish_Murthy: The space generally slowly fills with tissue fluid. On serial chest x-rays after an entire lung has been removed it is customary to be able to gradually see this process happening. It takes approximately 2 - 4 weeks to fully fill the chest with fluid.

yellow: How does it work to have partial lung removed? Can they do it through a small incision?

Dr__Sudish_Murthy: Our practice is whenever possible, based on the size of the patient and the size and stage of the cancer, is to consider a video assisted procedure on appropriate candidates. The cure rate from a limited incision procedure using sophisticated video imaging appears to be no different for stage Ia non small cell lung cancer than conventional techniques and as would be expected recovery seems to be faster.


Combined Lung and Other Organ Surgery

sharon: My uncle has lung cancer and also a tumor in his brain. When reading online, that seems pretty common. Why is that?

Dr__David_Mason: Lung cancer spreads through the blood stream and commonly lands in the brain. The reason for this is not clear but in fact is common.

karens: What helps determine if surgery is right for me? and what are the different types?

Dr__Sudish_Murthy: A diagnosis of small cell lung cancer is almost always treated without operation.

Early stage non small cell lung cancer in fit patients is best treated with operation.


Lung Transplant

jemker: How long is Cleveland Clinic's waiting list for lung transplants?

Dr__David_Mason: The average wait time for lung transplantation at Cleveland Clinic is 3 months.

leec: From what I have researched, breathing is easier after a lung transplant, but there are other problems with antirejection drugs and kidney function....is this true?

Dr__David_Mason: There are many side effects, usually well tolerated after lung transplantation. These are occasionally related to the anti-rejection medications.

smith_56: What determines a single- vs. double-lung transplant? Cleveland Clinic survival rates on each?

Dr__David_Mason: The decision is based on underlying patient disease, patient's age, previous medical problems and surgeon interview with the patient. Survival for both is roughly 50 percent at 5 years.

Reviewed: 10/10


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