In my previous blog I reviewed the concerns a surgeon has about the impact of a lung cancer operation—which costs a patient some of their breathing capacity—on a patient’s quality of life and how that determines the amount of lung that the surgeon can remove; quality of life after surgery must be maximized. But the goal of any operation is to cure the cancer; an operation is only appropriate if total removal and cure is a likely outcome. If the cancer has metastasized this requirement is impossible.

The essential oncologic measures includes removal of sufficient tissue including the primary tumor and sufficient surrounding lung that any cancer cells in nearby lymph channels goes also . Including regional lymph nodes from the mediastinum in the resection is a good idea. The evidence that removal of these nodes contributes to cure is not definitive but some studies show it does and this clearly adds to the accuracy of staging and can identify patients who would benefit from adjuvant treatments. So it’s a useful surgical measure.

This assessment of thoracic surgical thought leads to the understanding of the importance of preoperative staging—learning as much as possible about the extent of the primary tumor and detecting any spread to lymph nodes or distant organs. Has the cancer metastasized? If spread has occurred then surgery is no longer in the cards.

It turns out that the most appropriate operation for most patient, balancing these two concerns, is a lobectomy—removal of one of the lobes of the lung (there are three on the right and two on the left) with the lymph nodes alongside the bronchus and in the mediastinum. On occasion only a pneumonectomy—removal of one of the two lungs— suffices to satisfy the oncologic requirements. Conversely, when a patient’s lung capacity is not sufficient to tolerate a lobectomy less lung is removed in the form of a segmentectomy (removal of a segment of a lobe) or “wedge resection.”