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LUNG CANCER
Lung cancer is having a malignant tumor in the lungs especially in the cells lining air passages.
Primary tumor-related signs and symptoms are cough, dyspnea, hemoptysis, and chest discomfort.
Signs and symptoms due to intrathoracic spread may involve the nerves (hoarseness, dyspnea, muscle wasting of upper limb, Horner's syndrome), chest wall and pleura (chest pain, dyspnea) and vascular structures (facial swelling, dilated neck veins, cardiac tamponade) & viscera (dsyphagia).
The signs and symptoms due to metastatic spread are bone pain with or without pleuritic pain, neurologic symptoms, limb weakness, unsteady gait, cervical lymphadenopathy, and skin nodules.

Surgical Intervention

Surgery for Non-Small Cell Lung Cancer (NSCLC)
  • Resectability of tumor, surgical staging and pulmonary resection should be fully assessed
  • May offer the best chance of survival and possible cure in NSCLC patients with stage I-II disease
    • May be considered in patients with N2 disease responsive to induction chemotherapy
  • Surgery is recommended for patients with the following:
    • ≥8 mm solid nodule on LDCT screening that has high probability of cancer as shown on PET/CT scan
    • ≥8 mm solid nodule that increased in size in chest CT with contrast and/or PET/CT scan with high probability for cancer
    • ≥15 mm solid nodule with the same measurements in PET/CT scan with high probability for cancer
    • ≥6 mm part-solid nodule with ≥6-<8 mm solid component in follow-up LDCT with high probability for cancer in PET/CT scan
    • New or growing part-solid nodule with ≥4 mm solid component in LDCT with high probability for cancer in chest CT scan with contrast and/or PET/CT scan
    • Growing NS nodule ≥20 mm in size during follow-up or annual LDCT
  • Treatment of choice for stage I and II NSCLC
    • In the absence of medical contraindications to surgery, complete resection (ie lobectomy) with clear surgical margins should be achieved as much as possible
    • In patients with comorbidities who are not able to tolerate lobectomy, sublobar resection (segmentectomy or wedge resection) is recommended
      • Parenchymal resection margins ≥2 cm or more than the nodule's size is preferred
    • Contraindications to lobectomy/indications for sublobar resection include:
      • Impaired pulmonary function
      • Peripheral nodule ≤2 cm with at least 1 of the following: Pure adenocarcinoma in situ, nodule with ≥50% ground-glass appearance on CT scan, long doubling time of ≥400 days on imaging
    • Nodal dissection is preferred over simple intraoperative sampling for mediastinal lymph node
    • Sleeve lobectomy is recommended for total resection of centrally or locally advanced NSCLC
  • Surgery in stage IIIA N2 lung cancer is controversial
    • Surgery is considered in resectable stage IIIA N0-1 tumors, followed by adjuvant chemotherapy
    • Usually not recommended if with involvement of N2; patient may undergo chemotherapy prior to surgery to decrease the tumor size, eliminate micrometastases and to improve patient’s tolerance to procedure
    • Formal ipsilateral mediastinal LN dissection is indicated for patients undergoing planned resection
    • For patients undergoing video-assisted thoracic surgery (VATS) with N2 disease, procedure may be halted to start induction therapy or may opt to continue with the surgery
  • En-bloc resection of the involved structure with negative margins is required for patients with T3 and T4 local extension tumors 
  • VATS is a less invasive and reasonable approach for patients with no anatomic or surgical contraindication
  • For highly selected patients with recurrent NSCLC, stereotactic radiation surgery and surgical resection of isolated cerebral metastasis are recommended
 
Surgery for Small Cell Lung Cancer (SCLC)
  • Considered only for patients with clinical stage I-IIA and in limited disease (LD) patients with sufficient pulmonary function and no evidence of metastases to mediastinal or supraclavicular lymph nodes
  • Lobectomy or pneumonectomy should be done followed by detailed dissection of the mediastinal lymph nodes
  • Platinum-based adjuvant chemotherapy is recommended after complete resection
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