Historically, lung cancer surgeries were all thoracotomies, or what are considered “open procedures,” during which the ribs are spread and the chest wall is cut in order to access the lungs and cancer. Fortunately, techniques for lung cancer surgery have made significant advancements in the last several decades, and there are now more surgical options. In addition to thoracotomies, there are also less invasive procedures that require less recovery time. Dr. Julian Guitron, MD, a general thoracic surgeon at The Christ Hospital in Cincinnati, OH, often utilizes these newer techniques with his patients.
Dr. Guitron explains that there are two minimally invasive approaches today: VATS (video-assisted thoracic surgery) and RATS (robot-assisted thoracic surgery); both techniques can be used for diagnosis and treatment of the disease. VATS has been widely available for about 25 years, while robot-assisted techniques are newer, becoming more broadly adopted within the last 10 years.
When using surgery for treatment, the most important thing to know about minimally invasive surgeries is that while the “approach” changes, the operation does not. Dr. Guitron says, “We don’t cut corners when performing surgeries minimally invasively; the standard of care is still preserved. It is simply a different way to achieve the same procedure and results.”
Minimally invasive surgeries are much better tolerated than traditional open procedures. Those who undergo these types of surgeries experience significant improvements in movement and pain scores compared to those who undergo open procedures, both immediately after surgery and for about two to three weeks after.
Looking at national trends, only 30%-40% of lung procedures are done using minimally invasive techniques. Only over the past five years has the proportion of minimally invasive procedures increased, largely in part due to the increasing adoption of robotic procedures. Nonetheless, there are several reasons for which thoracotomies are still offered and will always be part of the surgical armamentarium, according to Dr. Guitron. Tumor size and location, such as proximity to the heart, among other factors, are indications to proceed with open surgery, says Dr. Guitron.
“My goal is to use minimally invasive procedures whenever possible. Having said that, the safety of my patients is my number-one priority,” says Dr. Guitron. “I will complete the procedure in the safest way possible, which could mean that a thoracotomy is the best way to go.”
Some surgeries might start as minimally invasive, but then have to be converted to open procedure. This could be a result of particular challenges or even complications such as bleeding or unexpected anatomy (what Dr. Guitron calls “sticky lymph nodes”). With VATS techniques, a conversion is necessary when these complications present themselves. RATS approaches, however, are more comprehensive, with enhanced visualization and advanced instrumentation that allow surgeons to navigate around challenging anatomy like sticky lymph nodes and make the need for conversion to an open procedure less likely.
Dr. Guitron says that some patients might need additional treatment before or after surgery. One of the most common reasons for which a patient would need chemotherapy after surgery is because lymph nodes removed during the operation show microscopic cancer. This finding effectively “upstages” the patient (changes the stage used to describe the patient’s cancer from a lower stage to a higher stage), and generally requires the patient to undergo chemotherapy and, depending on which lymph nodes show cancer, possibly radiation therapy as well. There are reports that up to 30% of patients initially thought to be in stage I, which means no lymph node involvement, are upstaged on the final pathology report so that additional treatment that will improve overall survival may be given.
Patients who might need chemotherapy and/or radiation therapy before surgery are generally patients staged at IIIA. “Stage IIIA is a watershed stage; it is the stage at which several groups of lymph nodes are involved, not only within the lung, but also in the middle of the chest, or the mediastinum,” Dr. Guitron explains. “Historically, stage IIIA meant chemo and radiation without surgery. However, data suggest that surgery after chemo and radiation could benefit a number of these patients. It is critically important to select which patients might benefit from this treatment approach appropriately. This decision often happens during a tumor board discussion as part of a multidisciplinary approach to lung cancer care.”
If you are about to undergo lung cancer surgery, Dr. Guiton has some advice for you: “Think of surgery like a boxing match: surgery is an event the body has to train for. You need to work hard to show up in your best possible shape; otherwise, you could get knocked out. The better shape you’re in going into surgery, the better the outcome. Whatever physical activity you’re doing, such as walking or jogging, keep doing it.”
Deep breathing exercises can also be beneficial, according to Dr. Guitron. He advises, “Breathe in as much air as possible, hold it in, and then slowly breathe out. Expand those lung as much as possible. Do this ten times in a row, three times a day, if possible. That, in addition to any physical activity, will help you be successful when recovering from surgery.”
Dr. Guitron is excited for what’s next in lung cancer treatment. “There are technologies coming up the pipeline that show a lot of promise. For example, there’s a new technique called robotic bronchoscopy, which improves the yield of biopsies even if the lesions are relatively small. This technology doesn’t stop at diagnosis; it allows for treatment to be delivered right on the spot, delivering radiofrequency ablation (RFA). There are currently ongoing trials in Europe, but the technique shows promise, particularly for those patients who are not surgical candidates or have very small cancers that otherwise would require major removal of tissue. This will be an alternative to surgery as well as stereotactic radiation therapy (SBRT).”
These advances, says Dr. Guitron, paired with lung cancer screening that results in early detection – because earlier detection means more options for the likelihood of higher survival – make him hopeful for the future of lung cancer. “We need to get the word out of the great benefits of the totally non-invasive lung cancer screening CT scan. It has been offered to the population in general for several years but remains underutilized.”
Learn more about surgery in lung cancer in our comprehensive overview.
Dr. Guitron specializes in general thoracic surgery with particular interest in oncology. He has been in practice for 10 years having graduated from the University of Cincinnati. He offers minimally invasive surgery including VATS and robotic procedures and is an avid advocate of lung cancer screening.