Precision Through Incision: Advances in Surgical Techniques to Treat Lung Cancer

After Kenneth Felix fractured 12 ribs in a biking accident near his Erie, Pennsylvania, home in 2015, a CT scan of his chest revealed a suspicious-looking lesion in one lung. A biopsy showed that it was benign, but when Felix had it checked a year later, he received a scary diagnosis: stage 3 non-small cell lung cancer (NSCLC).

Felix traveled to Cleveland Clinic, where he underwent two chemotherapy cycles and 30 radiation treatments, followed by video-assisted thoracoscopic surgery (VATS), a procedure that allows surgeons to remove cancerous segments of the lung using a tiny camera and instruments that pass through small incisions in the chest wall.

The surgery was a seven-hour slog — Felix’s biking injuries, including five rib plates in the area to be operated on, had created scars that made the operation much more challenging — but he had a smooth recovery. “My biggest incision was just two inches,” says Felix, 72, a retired veterinarian. “I went home after four days and had zero pain, and within a week I was walking 15-minute miles.” Felix had another 10 radiation treatments after the surgery and has been cancer-free ever since.

Technology-assisted procedures like VATS or robotic surgery, coupled with advanced radiation techniques, are expanding the treatment choices for patients with lung cancer. A recent review of data from more than 288,000 patients in the United States treated for NSCLC over a nearly 10-year period showed that radiation therapy alone or combined with surgery correlated with increased overall survival. For patients with early-stage tumors confined to the lung, five-year survival rates after surgery are 68% or higher, and radiation produces three-year survival rates of 55% to 91%.

In fact, improvements in lung cancer treatments contributed to a 29% overall decline in cancer deaths between 1991 and 2017, according to the American Cancer Society. New diagnoses of lung cancer dropped by 5% a year in men and 4% in women between 2013 and 2017, thanks to a decline in smoking. For those who do face the diagnosis, a combination of improved screening and treatment techniques, including advanced surgery and radiation, has shortened treatment times and hospital stays.

“With the proliferation of CT screening technologies, we’re diagnosing patients earlier and having a chance to cure them,” says Dr. Daniel Raymond, a thoracic surgeon at Cleveland Clinic. “Formerly, 85% of lung cancer presented in stage 4, which was a terminal diagnosis.” The increasing number of patients receiving diagnoses earlier has “had a dramatic impact on survival,” he says.

NSCLC accounts for 80% to 85% of all lung cancer diagnoses, with the rest being more aggressive small-cell tumors. Patients with NSCLC are often good candidates for surgery, radiation or both. Radiation can be curative in early-stage NSCLC, slow the spread of metastatic

lung cancer and provide pain relief, says Dr. Shruti Jolly, professor and associate chair of community practices at the University of Michigan Rogel Cancer Center Michigan Medicine Medical School in Ann Arbor.

“There’s more data coming out showing that even in patients with metastasis if it’s limited to just a few areas outside of the lungs, there may be advantages to treating them aggressively with radiation,” Shruti says.

Lung cancer treatment is complex, requiring input from multiple physicians. That’s one reason most major cancer treatment centers review new diagnoses at a tumor board made up of radiologists, medical oncologists, pulmonologists, pathologists and lung surgeons, in addition to nurses, social workers and other supportive services. “We review the cases together,” Shruti says.

These multidisciplinary teams determine the best course of drug treatment, radiation and/ or surgery, depending on factors such as the location of the tumor, how far it has spread and whether or not the patient has other medical conditions that could complicate treatment.

SHORTENED RECOVERY TIME

Several types of surgeries can be used to remove lung tumors. The most common procedure is a lobectomy, removal of the entire affected lobe. Alternatively, in a segmentectomy or wedge resection, smaller segments of the tissues encompassing the tumors are removed. As a last resort, a pneumonectomy can be performed, removing the entire affected lung.

In the past, most patients facing surgery had to undergo a thoracotomy, an invasive procedure that involves dividing the muscles of the chest wall and spreading the ribs to reach and remove lung tumors. Some surgeons still prefer this technique, though the less invasive VATS can be equally effective, with shorter recovery times and less pain. At Cleveland Clinic, patients typically stay in the hospital for five to seven days after a thoracotomy, whereas patients who undergo VATS are sent home in two or three days.

VATS can be performed with one to three incisions ranging from one to three inches long, says Dr. Steven Kirtland, a pulmonary medicine specialist at Virginia Mason Medical Center in Seattle. A tiny fiber optic camera inserted into the chest through the incisions transmits images to a video monitor, guiding surgeons as they cut out cancerous tissues with scopes that also pass through the small incisions.

Some surgeons use robotic-assisted VATS, in which high-definition 3D cameras provide a full view of the chest. Robotic instruments are sent to the lungs through small incisions, and a surgeon sitting at a console directs the robot as it removes tumors. “The robot has complete 360-degree articulation, so we can reach areas that were challenging before, even if there are difficult angles,” Kirtland says. The advent of robotic surgery has lowered recovery times even more, he adds: “We often have patients who stay in the hospital just overnight. That used to be unheard of in lung surgery.”

Other emerging techniques also aim to make surgery less onerous for some patients with lung cancer. When CT scans detect very small nodules in the lungs, patients often are advised to wait and then repeat the imaging periodically to watch for growth. That might not be acceptable for some patients who are at high risk because of a history of cancer or smoking. At Cleveland Clinic, surgeons can offer those patients a hybrid imaging-surgery procedure called microcoil localization.

The procedure first involves a radiologist, who uses a needle to insert a tiny coil around a nodule revealed by a CT scanner. Then, using VATS, a surgeon removes a small segment of tissue containing the coil and nodule. The two specialists study the nodule while the patient is still in the surgery room; if they find it’s cancerous, they can proceed to a more involved surgery. Cleveland Clinic reported a 100% success rate, retrieving all the cancerous tissue using just the coil, in its first 20 uses of the technology.

“The standard of care for lung cancer is if you identify a spot in the lung and if it’s cancer, you take out the whole lobe in order to remove surrounding lymph nodes,” Raymond says. “But if the risk of spread to nodes is very small, you may not have to sacrifice the entire lobe.” As techniques such as microcoil localization evolve, he adds, more patients will be able to be treated successfully with minimally invasive surgery that sacrifices less lung tissue.

RADIATION ADVANCES

Radiation plays various roles in NSCLC treatment, including before surgery to shrink tumors and after surgery to ensure the eradication of the cancer. Radiation is also used to curatively treat lung cancer and is sometimes used in patients for whom surgery may be considered too risky.

Over the past 20 years, a type of abbreviated, highly focused radiation treatment called stereotactic body radiation therapy (SBRT) has become more widely used for early-stage

lung cancer than conventional radiation, which can require as many as 30 treatments. SBRT entails just one to five treatments and is less likely to damage healthy tissue nearby.

The patient is placed in an immobilization device, and breath motion is assessed to evaluate how much the tumor is moving. If motion is significant, the patient is instructed to hold their breath at certain intervals to make sure the radiation reaches the tumor safely and limit radiation dose to healthy tissues.

SBRT treats a smaller area and reduces the risk of side effects from radiation, such as difficulty swallowing and long-term lung and heart damage, Jolly says. For complex treatments, SBRT can be combined with intensity modulated radiation therapy (IMRT) to further conform dose to the tumor while avoiding normal tissues. With IMRT, radiation oncologists use advanced techniques to change the shape of photon beams throughout the treatment, making them even more precise. “When tumors are close to the heart, the chest wall or the esophagus, we can use IMRT to paint the doses around the areas that we want to avoid,” she says.

Recent studies have shown radiation therapy to be effective in the treatment of early-stage NSCLC, resulting in three-year rates of tumor control of 85% to 95%.

Patients with small tumors may benefit from radiofrequency ablation and microwave ablation, two new approaches that use imaging technologies such as ultrasound or CT to guide a needle with a probe directly into tumors.

Then either electrical currents or microwaves are sent through the probe, creating heat that kills the cancer cells. These procedures can be effective for patients who may have difficulty with surgery or aren’t candidates for surgery because their cancer has spread.

It may be possible in the future to use new technologies to diagnose and treat lung tumors in a single procedure, according to Kirtland. “Right now, all I can do is give patients the bad news that they have cancer, and then I have to send them to someone else who can cure them,” Kirtland says.

“With the advent of technologies that allow us to drive a probe out to these small lung nodules, my hope is we’ll be able to biopsy them, determine that it’s lung cancer that hasn’t spread, then ablate the tumor all in the same procedure.” Virginia Mason is putting together a small trial of this technique in patients with lung cancer who are eligible for surgery.

With so many advances in radiation and surgery techniques, it’s important that all newly diagnosed patients be evaluated by a multidisciplinary team of physicians, Raymond says. It may even be worth getting a second opinion, he adds, particularly for patients who are

told they are not candidates for the newer, minimally invasive techniques.

“Ideally, lung cancer patients should be at institutions with tumor boards, where their cases can be discussed amongst a panel of experts and a plan for care can be agreed upon,” Raymond says. “The team approach is really essential.”