CARDIOTHORACIC II

Cancer of the lung: staging,radiology, surgeryImran Saeed

Jon Anderson

AbstractPrimary lung cancer is the leading cause of cancer-related deaths in indus-

trialized countries. Despite advances in treatment, the overall 5-year

survival remains poor due to the advanced stage of disease at presenta-

tion. Smoking remains the main risk factor being responsible for around

85% of all cases. The most important distinction is that between non-

small cell lung cancer (NSCLC) and small cell lung cancer (SCLC). Surgeons

primarily deal with NSCLC (SCLC is an aggressive tumour that usually

presents with systemic disease). NSCLC has a number of histological

subtypes.

Patient evaluation aims to establish the cell type of the tumour, deter-

mine the stage of the disease, and to determine fitness for surgery.

Staging of NSCLC is based on the tumour/node/metastasis (TNM) classifi-

cation. Procedures used to diagnose or stage lung cancer can include

chest X-ray, chest computed tomography (CT) scan, combined positron

emission tomography/CT, CT or transbronchial guided needle biopsy,

and mediastinoscopy amongst others. Surgery is the only established

method for ‘curing’ NSCLC. However, only a quarter of patients have

resectable disease at presentation. Surgical resection can be performed

using a variety of procedures including lobectomy, pneumonectomy or

wedge resections. The 5-year survival of patients with stage I lung cancer

following surgical resection is 51e60%.

Keywords chest computed tomography; chest X-ray; lobectomy; lung

cancer; mediastinoscopy; needle biopsy; non-small cell; positron

emission tomography/computed tomography; pneumonectomy; small

cell; smoking; staging; TNM classification

Introduction and epidemiology

Primary lung cancer is the leading cause of cancer-related

deaths in industrialized countries. Worldwide, it affects 1.2

million people annually and is presently the most significant

malignancy in men and is second only to breast cancer in

women.

Lung cancer is rare under the age of 40 years, but its incidence

rises steeply thereafter peaking in people aged 75e84 years. Over

the past 50 years the male:female ratio for lung cancer cases has

Imran Saeed MSc MD FRCS (CTh) is a Clinical Fellow in Cardiothoracic

Surgery at the Royal Brompton Hospital, London, UK. Conflicts of

interest: none declared.

Jon Anderson FRCS (CTh) is a Consultant Cardiothoracic Surgeon, Chief of

Service and Lead Thoracic Surgeon at Hammersmith Hospital, London,

UK. Conflicts of interest: none declared.

SURGERY 29:5 221

decreased from 6:1 to 3:2. In the UK, approximately 40,000 new

cases are diagnosed and 29,000 lives are lost annually.

Despite advances in treatment, the overall 5-year survival for

this disease is only 13% in North America, and only 5.5% in the

UK. This is primarily due to the advanced stage of the disease at

presentation.

Aetiology and pathology

Smoking is the primary risk factor for lung cancer being

responsible for around 85% of all cases; furthermore, the inci-

dence of lung cancer in cigarette smokers is dose-related.

There are two main phases of cigarette smoke: the tar or

particulate phase and the gas phase. Candidate carcinogens are

derived from both phases and may include:

� tar phase: polycyclic hydrocarbons, 3,4-benzpyrene, dibenzan-

thracene, nitrosamines, nicotine, cadmium, nickel, polonium-210

� gas phase: free radicals, NO, hydrazine, vinyl chloride, nickel

carbonyl.

Other risk factors for lung cancer include:

� passive smoking (estimated to cause 3% of cases)

� environmental and occupational hazards such as asbestos,

arsenic, nickel, chromium and cadmium, and ionizing radi-

ation (radon)

� diet: insufficient dietary intake of vitamin E and b-carotene

may increase the risk of lung cancer

� genetic factors: ras family oncogenes and the c-myc oncogene

have been found to be activated in lung cancers.

The most commonly used classification of lung cancer is that

developed by the World Health Organization (WHO). The major

types of lung cancer along with their important clinicopathologic

features are shown in Table 1. In current practice the most

important distinction is that between non-small cell lung cancer

(NSCLC) and small cell lung cancer (SCLC).

SCLC (also known as oat cell cancer) is generally considered

separately to NSCLC because of its different biological and clin-

ical characteristics. Although SCLC accounts for 20% of all lung

cancers, it is a clinically aggressive tumour with the majority of

patients presenting with extensive disease. It is, therefore, rarely

amenable to surgery with curative intent.

NSCLC is further subdivided into the following histologic

subtypes:

� adenocarcinoma

� squamous cell carcinoma

� large cell carcinoma.

Diagnosis and staging

The aims of evaluating a patient suspected of having lung cancer

are to establish the cell type of the tumour, determine the

anatomic extent (stage) of the disease, and to determine the

functional status of the patient to assess their suitability for

surgery if this is indicated.

History and physical examination

The symptoms and signs of lung cancer occur as a result of the

primary tumour (local invasion), regional invasion into the

thorax and mediastinum, distant metastases, and as a result of

paraneoplastic syndromes.

� 2011 Published by Elsevier Ltd.

Histological subtypes of non-small cell lung cancer and small cell lung cancer and their clinical features

Tumour Location Features Comments

Adenocarcinoma (45%) Peripheral (75% cases) Lymph node metastases are common

Differentiation from secondary tumours

may be difficult

Bronchoalveolar carcinoma is a subtype:

grows along alveolar septae, often

synchronous, multifocal lesions

Squamous cell (30%) Located centrally near hilum

or major bronchi (70%

cases)

Prominent endobronchial component

Propensity for local invasion

Most likely to produce malignant cells on

sputum cytology

Usually associated with a history of heavy

smoking

Undifferentiated large

cell (5e10%)

Peripherally located Poorly differentiated tumours often

cavitate

Poor prognosis: early spread to distant sites

(e.g. brain and mediastinum are common)

Small cell

(Oat cell)

(20%)

Central (80% cases) Chest X-ray e classically large central

tumour with bulky mediastinal

lymphadenopathy Can express

neuroendocrine neurotransmitters,

hormones or paracrine regulators.

Adrenocorticotropic hormone (ACTH) and

antidiuretic hormone (ADH) commonly

overproduced Most frequently associated

with paraneoplastic syndromes

Clinically aggressive tumours with high rates

of cell proliferation and tendency to early

dissemination

Usually associated with a history of heavy

smoking

Majority of patients present with extensive

disease: median survival 8e12 months

Table 1

CARDIOTHORACIC II

Primary tumours primarily cause respiratory symptoms such

as cough, shortness of breath, haemoptysis, and recurrent or

unresolving respiratory tract infections.

Regional spread can be associated with pleural effusions,

localized pain from chest wall invasion, hoarseness from left

recurrent laryngeal nerve palsy, and dysphagia as a consequence

of subcarinal lymphadenopathy or direct invasion.

Apical lung cancers (Pancoast tumours) invade thoracic

inlet structures and can be associated with Pancoast’s

syndrome: Horner’s syndrome (from invasion of the sympa-

thetic chain and stellate ganglion), pain and atrophy of the

muscles of the hand (from invasion of the brachial plexus) and

shoulder, arm or neck pain (from invasion of chest wall and

ribs).

Metastatic disease commonly affects the liver, bone, brain and

adrenal glands. Paraneoplastic syndromes are distant effects of

the lung cancer (unrelated to metastases) that are due to the

production of substances such as adrenocorticotropic hormone

(ACTH), antidiuretic hormone (ADH) and growth and para-

thyroid hormone.

Signs of lung cancer, therefore, can include cachexia,

anaemia, clubbing, chest signs, and signs of Cushing’s disease,

bone tenderness, hepatomegaly, confusion, peripheral neurop-

athy, and proximal myopathy.

Staging

The precise clinical staging of lung cancer is of particular

importance as it determines prognosis and guides therapy. A

precise classification has been developed for NSCLC whereas

a relatively broad classification is generally used for the classi-

fication of SCLC.

The classification of NSCLC is based on the tumour/node/

metastasis (TNM) classification system. This is shown in Table 2

and different stages of disease based on this system are shown in

SURGERY 29:5 222

Table 3. (This TNM classification of lung cancer is currently

under revision).

In addition to this, a classification of regional lymph node

stations according to anatomic landmarks has been published.

This allows consistent lymph node mapping when staging

patients and is shown in Figure 1.

Tumour size, distance from the carina, the presence or

absence of atelectasis or pleural effusion, and invasion into

neighbouring structures determine the ‘T’ stage.

The ‘N’ descriptor indicates regional lymph node involve-

ment from ipsilateral parenchymal to ipsilateral mediastinal

lymph nodes, and then to more remote spread. N2 (medias-

tinal) disease generally precludes lung resection. The

‘M’ descriptor refers to the presence or absence of

metastatic disease. Figure 2 gives a visual example of stage

IIB disease.

Diagnostic and staging procedures for lung cancer

Procedures used to diagnose or stage lung cancer can be invasive

or non-invasive.

Non-invasive procedures include:

� sputum cytology

� chest computed tomography (CT)

� positron emission tomography (PET) or combined PET/CT

� magnetic resonance imaging (MRI) chest

� mediastinal staging by endoscopic ultrasound.

Invasive procedures include:

� transbronchial needle biopsy

� transthoracic needle biopsy

� endoscopic ultrasound/endobronchial ultrasound

� mediastinoscopy

� left anterior mediastinotomy

� thoracoscopy

� open lung biopsy.

� 2011 Published by Elsevier Ltd.

TNM staging classification system for NSCLC

Primary tumour (T)

TX Primary tumour cannot be assessed, or tumour proven by

presence of malignant cells in sputum or bronchial

washings but not visualized by imaging or bronchoscopy

T0 No evidence of primary tumour

TIS Carcinoma in situ

T1 Tumour <3 cm in greatest dimension, surrounded by lung or

visceral pleura, without bronchoscopic evidence of invasion

more proximal than the lobar bronchus (that is, not in the

main bronchus)

T2 Tumour with any of the following features of size or

extent:

C >3 cm in greatest dimension

C involves main bronchus

C >2 cm distal to the carina

C invades the visceral pleura

C Associated with atelectasis or obstructive pneumonitis

that extends to the hilar region but does not

involve the entire lung

T3 Tumour of any size that directly invades any of the

following: chest wall (including superior sulcus tumours),

diaphragm, mediastinal pleura, parietal pericardium; or

tumour in the main bronchus <2 cm distal to the carina, but

without involvement of the carina; or associated atelectasis

or obstructive pneumonitis of the entire lung

T4 Tumour of any size that invades any of the following:

mediastinum, heart, great vessels, trachea, oesophagus,

vertebral body, carina, or tumour with malignant pleural

effusion or pericardial effusion or with satellite tumour

nodules within the ipsilateral primary-tumour lobe of the

lung

Regional lymph nodes (N)

NX Regional lymph nodes cannot be assessed

N0 No regional lymph node metastasis

N1 Metastasis to ipsilateral peribronchial and/or ipsilateral hilar

lymph nodes and intrapulmonary nodes involved by direct

extension of the primary tumour

N2 Metastasis to ipsilateral mediastinal and/or subcarinal

lymph nodes

N3 Metastasis to contralateral mediastinal, contralateral hilar,

ipsilateral or contralateral scalene or supraclavicular lymph

nodes

Distant metastasis (M)

MX Presence of distant metastasis cannot be assessed

M0 No distant metastasis

M1 Distant metastasis present

Source: Mountain CF, Libshitz HI and Hermes KE. A handbook for staging,

imaging, and lymph node classification. www.ctsnet.org/book/mountain/.

NSCLC, non-small cell lung cancer; TNM, tumour/node/metastasis

Table 2

Stage grouping by tumour/node/metastasis (TNM)subsets

Tumour

T1 T2 T3 T4

N0 IA IB IIB IIIB

N1 IIA IIB IIIA IIIB

N2 IIIA IIIA IIIA IIIBNo

des

N3 IIIB IIIB IIIB IIIB

Key

Patient should be offered surgery if no medical contraindications and adequate lung function

Surgery may be suitable for some patients, based on clinical judgement

Not suitable for surgery

Source: National Institute for Health and Clinical Excellence, ClinicalGuideline 24, February 2005.

Table 3

CARDIOTHORACIC II

The most commonly used screening procedures used in the study

of lung cancer are sputum cytology and chest X-ray (CXR).

Sputum cytology is better at detecting central tumours, whilst

CXR is better for more peripheral tumours.

SURGERY 29:5 223

CXR

Chest X-ray is the initial diagnostic procedure performed in

patients suspected of having lung cancer. Patients should be

referred for urgent CXR if they present with haemoptysis or

unexplained or persistent (>3 weeks) cough, dyspnoea, chest or

shoulder pain, weight loss, chest signs, hoarseness, clubbing,

cervical or supraclavicular lymphadenopathy, or features of

metastasis from a lung cancer (National Institute for Health and

Clinical Excellence guidelines, 2005).

As well as helping to localize the primary lesion, CXR can

detect mediastinal or hilar lymphadenopathy, pleural effusions

or consolidation, phrenic nerve palsy (indicated by a raised

hemidiaphragm), or osteolytic lesions in bone, indicating meta-

static disease.

CT scan

CT is the most widely used method of evaluating patients with

suspected lung cancer. It is usually used to help with diagnosis

and staging after abnormalities have been found on CXR and

provides the surgeon with a roadmap prior to performing lung

resection in suitable cases.

CT can be used to help assess mediastinal lymph node involve-

ment by tumour. Lymph nodes greater than 1 cm in short-axis

diameter are considered to be suspicious for lung cancer. However,

CT has limited sensitivity (0.57) specificity (0.82), and a false-nega-

tive rate of approximately 13%. Its role in staging the mediastinum

has now largely been superseded by PET and PET/CT (see below).

Positron emission tomography (PET) and combined PET/CT

Positron emission tomography (PET) scans use differences in

metabolic activity of structures to provide imaging of metabolic

activity rather than providing anatomic characterization of

structures. In lung cancer, a glucose analogue, fluorine-18 fluo-

rodeoxyglucose (FDG) is generally used. This radioactive tracer

� 2011 Published by Elsevier Ltd.

Map of regional lymph nodes

AO, aorta; PA, pulmonary artery. Source: Mountain C F, Libshitz H I and Hermes K E. A handbook for staging, imaging, and lymph node classification. www.ctsnet.org/book/mountain

Brachiocephalic(innominate) artery

Mediastinal pleura

Azygos vein

Mediastinal pleuraLigamentum arteriosum

Leftpulmonary artery

Phrenic nerve

2R

4R

10R

11R

10L11L

12, 13, 14L12, 13, 14R

AO

AO

PA

PA

Figure 1

CARDIOTHORACIC II

is metabolized at a higher rate by tumour cells in comparison

with non-malignant cells, and areas of increased activity can be

detected by a scanner.

PET scanning has been shown to be superior to CT at

detecting mediastinal disease with meta-analyses showing

a pooled sensitivity and specificity of 0.85 and 0.9 respectively.

All patients who are surgical candidates based on CT should

have PET scans to look for intrathoracic and distant disease

involvement.

Stage IIB disease

Source: Mountain C F, Libshitz H I, Hermes K E. A handbook for staging,imaging, and lymph node classification. www.ctsnet.org/book/mountain

Visceral pleura

T3N0M0

T3N0M0

T2N1M0

T2N1M0

T2N1M0

Figure 2

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Interpretation of PET scans, is, however, limited by their lack

of anatomic detail and this may cause difficulty in localizing

hotspots or differentiating tumour from benign structures with

high uptake (such as inflammatory or infective foci). These

limitations have been addressed by the introduction of combined

PET/CT.

Some studies have shown a more accurate assessment of

T staging with PET/CT compared to PET or CT alone. There are

similar data that suggest that PET/CT may also improve

N staging. Figure 3 shows a PET/CT image.

MRI

MRI scanning of the chest has little advantage over CT scanning

the chest except perhaps for Pancoast tumours where advocates

suggest its usefulness in assessing invasion into structures such

as the brachial plexus or blood vessels.

Figure 3 Positron emission tomography/computed tomography scan of

the chest. The region of bright orange uptake is a T2 non-small cell lung

cancer in the left lower lobe.

� 2011 Published by Elsevier Ltd.

CARDIOTHORACIC II

Endoscopic ultrasound (EUS)

Endoscopic ultrasound (EUS) allows fine-needle aspiration of

lymph nodes through an oesophagogastroscope. It is useful for

posterior mediastinal, aortopulmonary and subcarinal nodes that

may not be accessible by conventional mediastinoscopy. It has

a sensitivity of 88e96% and a specificity of 80e100% for

detecting posterior mediastinal metastases. It may have a utility

in sparing some patients from more invasive staging procedures.

Bronchoscopy and endobronchial ultrasound (EBUS)

Bronchoscopy is performed using either a rigid or flexible bron-

choscope and allows visualisation of up to third order bronchi.

Flexible (fibreoptic) bronchoscopy allows direct biopsy to obtain

tissue, cytology from saline lavage, and bronchial brushings. It

can be undertaken using local anaesthesia. Transbronchial nee-

dle biopsy is a technique that can be used to assess subcarinal

and paratracheal lymph nodes.

Rigid bronchoscopy can be useful if biopsies from flexible

bronchoscopy are inconclusive. It requires general anaesthesia,

and allows the passage of larger biopsy forceps to yield more

tissue for diagnosis. This procedure is also undertaken by

thoracic surgeons prior to lung resection to assess the distance of

the primary tumour from the proposed resection margin.

Endobronchial ultrasound (EBUS) involves the use of an

ultrasound probe mounted on the end of a flexible bronchoscope

with a transbronchial needle being a part of the scope. This

technique allows mediastinal and hilar lymph nodes to be iden-

tified and biopsied under real-time ultrasound guidance.

Transthoracic (percutaneous) needle biopsy

CT-guided percutaneous needle biopsy allows access to most

regions of the mediastinum as well as lung lesions. Sensitivity of

mediastinal staging is of the order of 0.91, however, there is wide

variation in the false-negative rate. Biopsies that are negative for

cancer are considered to be indeterminate unless a firm histolog-

ical diagnosis of benign disease is made. This technique is partic-

ularly useful in the high-risk surgical candidate where other

procedures have failed to obtain a firm diagnosis. Complications

are uncommonbut include pneumothorax at a rate of around 10%.

Mediastinoscopy and video-mediastinoscopy

Mediastinoscopy allows access to paratracheal and subcarinal

mediastinal nodes, and has traditionally been considered to be

the gold standard for the staging of lung cancer. It is a surgical

procedure that involves general anaesthesia, a small incision in

the suprasternal notch and dissection beneath the pretracheal

fascia (undertaken in much the same way as undertaking

a tracheostomy), and then direct visualisation and biopsy of

mediastinal nodes. The insertion of a 5 mm camera (video-

mediastinoscopy) allows visualisation on a monitor screen,

magnifies images and improves overall visibility.

Risks of these procedures include significant bleeding

(causing tamponade or necessitating thoracotomy), but this

occurs in less than 1% of cases. It has a sensitivity of 0.81, and

a false-negative rate of 5.5e8% that is due to detection (at

surgical resection) of nodes not accessible by this procedure.

Mediastinoscopy is not deemed necessary if PET scans are

negative for nodal disease even if mediastinal glands appear large

on CT (NICE guideline, 2005). The low prevalence of mediastinal

SURGERY 29:5 225

involvement in PET negative disease means that relevant lymph

node disease should rarely be missed.

It is suggested, however, that the relatively lower specificity of

PET (and its lower positive predictive value) means that patients

who have PET positive N2 nodes should have this confirmed by

mediastinoscopy. This is so that surgery is not denied to patients

based on false-positive findings due to co-existing granulomatous

or inflammatory conditions.

Left anterior mediastinotomy

Left anterior mediastinotomy is a procedure largely reserved to

assess tumour or nodes in the region of the left aortopulmonary

window (generally in the context of tumours of the left upper

lobe). See Figure 1. This is an area that is not easily accessed by

conventional mediastinoscopy. The procedure involves general

anaesthesia and an incision in the left second intercostal space.

The sensitivity of this procedure approaches 87% when

combined with conventional mediastinoscopy.

Video-assisted thoracoscopy (VATS)

VATS is minimally invasive procedure that allows access to the

thorax via small incisions on the chest wall. It is useful for both the

diagnosis and staging of lung cancer. It allows access to peripheral

lung nodules for biopsy and also allows the sampling of lymph

nodes in the aortopulmonary window. It may also be useful for

examining the pleural space for pleural seeding of tumour.

Surgery for lung cancer

Surgery is the only established method for curing NSCLC,

however, only about a one-quarter of patients have resectable

disease at presentation.

Surgical resection can be performed using a variety of

procedures. The options available include:

� wedge or segmental resection

� lobectomy or bilobectomy

� pneumonectomy

� extended pulmonary resections

� bronchoplastic procedures

� VATS procedures.

Patients need careful evaluation and selection prior to undertaking

surgery as they are often relatively advanced in years and

frequently have associated cardiopulmonary co-morbidity.

Preoperative evaluation

Poor respiratory function is of concern because pulmonary

complications are the most common cause of postoperative

morbidity and mortality, and because of the possibility of post-

operative disability and poor quality of life secondary to respi-

ratory insufficiency.

Most patients are current or ex-smokers with some degree of

pulmonary disease whose respiratory mechanics are further

impaired by undergoing thoracotomy. Pulmonary function tests

are therefore mandatory prior to surgery. As a general rule,

a post-bronchodilator FEV1 >1.5 litres and an FEV1 >2.0 litres

preclude the need for further respiratory function tests for

lobectomy and pneumonectomy respectively. If there is doubt

about operability based on spirometry, a full set of pulmonary

function tests should be undertaken, including estimation of

transfer factor and postoperative lung function predicted using

� 2011 Published by Elsevier Ltd.

CARDIOTHORACIC II

existing anatomic equations that exist or quantitative isotope

perfusion scans. An estimated postoperative FEV1 and transfer

factor of >40% of the predicted value for a patient, and an

oxygen saturation of >90% are thought to place patients in an

average risk category. Estimated postoperative FEV1 and transfer

factor of <40% predicted are thought to place patients in a high-

risk category for surgery. Patients in whom risks may still not be

clear should be referred for exercise testing. (Some of these

guidelines are currently being updated by the British Thoracic

Society).

There is an inverse relationship between exercise capacity

and postoperative complications exists. A best distance on

two shuttle walk tests of <25 shuttles (250 m) or desaturation

during the test of more than 4% SaO2 indicates that

a patient is at high risk from surgery. The management of

such patients should be considered at multidisciplinary team

meetings (MDTs) with chest physicians, radiologists,

oncologists.

An assessment of cardiac status is also important. All patients

require an electrocardiogram (ECG), and patients with murmurs

should have echocardiograms. Patients who have had a myocar-

dial infarction should not undergo lung resection for 6 weeks,

and patients with myocardial infarction within 6 months should

have undergone cardiological review for an assessment of

cardiovascular risk.

Nutritional and performance status may also predict post-

operative outcome and should be assessed preoperatively.

Anaesthesia

The aims of anaesthesia are to maintain a clear airway and

haemodynamic stability, to return spontaneous breathing after

surgery and to optimise postoperative analgesia.

Basic monitoring for all procedures includes ECG, pulse oxi-

meter, non-invasive blood pressure, and an end-tidal CO2 and O2

analyser. Additionally a urinary catheter, arterial and central

venous pressure (CVP) lines may be inserted for higher risk

cases.

Patients are placed in the lateral decubitus position following

the insertion of a double-lumen endotracheal tube (Robertshaw

tube). These tubes allow independent access to either lung, and

allow for one or two lung ventilation and suction. These tubes

are important as they enable adequate surgical exposure, can

limit the soiling of the opposite lung by blood etc and can control

the ventilation of the contralateral lung. At the end of surgery the

non-ventilated lung is reinflated.

Surgery

On the assumption that the primary tumour is completely

resectable and that the patient is fit for surgery, lung resection is

the best form of treatment for stage I and stage II diseases (see

Table 3). Patients with stage III disease may benefit from

a combination of surgery and adjuvant therapy but evidence in

this area is equivocal. Patients with stage IV NSCLC and most

patients with SCLC are not amenable to surgery with curative

intent.

The 5-year survival of patients following surgical resection is:

� stage I, 51e60%

� stage II, 30e35%

� stage III, 16e17%.

SURGERY 29:5 226

The aims of surgery are to achieve a complete resection of the

tumour and its intrapulmonary lymphatics. This is best achieved

with an anatomic resection e usually a lobectomy or

pneumonectomy.

Lobectomy is the most commonly undertaken procedure. Its

advantages are that it allows complete resection of hilar (N1)

nodes, provides adequate resection margins, and at the same

time allows lung function to be relatively preserved. Surgery

involves dissection and then division of the appropriate pulmo-

nary veins, pulmonary artery branches and bronchi. The

mortality following lobectomy is 2e4%.

Pneumonectomy is indicated when tumour invades hilar

structures such as the main bronchi or main pulmonary artery. It

involves identification, dissection and division of the pulmonary

artery, veins, and mainstem bronchus. Though technically easier

to perform than lobectomy, it involves considerable loss of lung

tissue with concomitant risks of respiratory insufficiency. It also

carries a higher mortality of 6e8%.

Sublobar resections (wedge or segmental resections) are

a useful option in patients with peripheral tumours and impaired

function, however, they are associated with higher local recur-

rence rates and reduce long-term survival by 5e10%.

Bronchoplastic or ‘sleeve’ resections are procedures designed

to spare lung tissue often as an alternative to pneumonectomy.

They are typically used to resect endobronchial lesions at or

adjacent to the carina in an effort to preserve distal tissue.

Extended resections refer to the en bloc excision of contiguous

intrathoracic structures (e.g. chest wall or pericardium), that may

be invaded by locally aggressive tumours.

The use of VATS for the resection of lung cancer is increasing.

It appears to have similar long-term results to conventional lung

resection but is associated with less postoperative pain.

Thoracic surgeons also undertake palliative procedures for

patients with advanced lung cancer. These can include VATS and

talc pleurodesis, and the insertion of pleuroperitoneal shunts for

malignant pleural effusions. A

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� 2011 Published by Elsevier Ltd.