Often the initial test is a chest x-ray, and if an abnormality is found, a CT scan is typically performed to help better define the problem. If malignancy is suspected, your pulmonologist may order a CT-guided biopsy to obtain tissue from the mass to confirm cancer. A PET scan usually follows to see if the cancer has spread to the lymph nodes in the chest or to other sites in the body. If cancer is suspected in the mediastinal (chest) lymph nodes, they are sampled using either endobronchial ultrasound (EBUS) or mediastinoscopy. A bronchoscopy and pulmonary function tests are also necessary to help determine lung resectability.
There are three ways to access to the lung for surgical intervention: thoracotomy, thoracoscopy (VATS), and robotically using the da Vinci system.
A thoracotomy is an incision in the chest cavity to allow access to the chest organs, such as the lungs, for surgical intervention. The incision is typically located on the patient’s side under the shoulder blade; this is known as a posterolateral thoracotomy. It may also be used anteriorly or in the axilla, depending on the procedure being performed.
VATS stands for video-assisted thoracoscopic surgery. It entails making small incisions in the chest and inserting a camera to inspect the organs and contents of the chest. It is used in surgical procedures such as lung resection, fluid drainage, biopsies and pleurodesis. It is less invasive than a thoracotomy, with faster recovery. Your surgeon will determine if a VATS is appropriate for your particular condition.
Small incisions are made on side of the chest wall near the shoulder blade to place the robotic camera and arms into the chest cavity to operate on the organs of the chest. The surgeon sits at a console controlling the robotic arms remotely. It is less invasive than a thoracotomy, with quicker recovery times and typically a shorter hospital stay. Your surgeon will determine if robotic-assisted surgery is appropriate for your disease process.
The major risk factor for lung cancer is smoking. Lung cancer may be asymptomatic, or you may have symptoms such as a new cough or unexplained weight loss. Often a lung nodule or mass is found on a chest x-ray, which is evaluated further with a CT scan of the chest. If the lesion appears concerning for cancer, a CT-guided biopsy may be obtained. If this is found to be positive for cancer, a PET scan is performed to ascertain whether the cancer has spread to the lymph nodes in the chest or to distant organs (known as metastasis). The lymph nodes may be biopsied using endobronchial ultrasound (EBUS), a mediastinoscopy or a Chamberlain procedure. The purpose of these diagnostic tests is to try to identify the stage of your cancer and determine your appropriate treatment. This could entail surgery, chemotherapy and radiation therapy, or a combination of all three modalities, which would be determined by your pulmonologist, surgeon and oncologist.
Once it is determined you are an operative candidate and you have adequate lung function (based on your pulmonary function tests), a lung resection is performed. Typically, a lobectomy is performed, but if your lung function is marginal, a wedge resection may be the treatment of choice. A complete lymph node sampling is completed during the procedure to determine if the cancer has spread to those areas, which may necessitate chemotherapy once you have recovered from your surgery. Lung resection may be accomplished utilizing a thoracotomy, VATS or a robotic-assisted approach. The best approach will be determined by your surgeon.
The surgery itself will take two to three hours. You will have chest tubes in place, which are typically removed two to three days after surgery. A small percentage of people may have to be discharged home with a chest tube in place because of a persistent air leak; in this situation, the tube will be removed in clinic at a later date. You can expect to be in the hospital for two to five days, depending on the operative approach used. Upon discharge from the hospital, you will be provided with specific instructions, including activity restrictions.
If you develop a recurring pleural effusion (fluid around the lung in the pleural space) or a recurrent pneumothorax (collapsed lung), a pleurodesis may be performed. This is most often accomplished with a VATS and mechanically scratching the lining of the chest wall or removing that lining (pleurectomy) and applying talc over the entire chest wall and surface of the lung. This causes the lung to stick to the chest wall to obliterate the space so that air or fluid has no place to accumulate.
One of the complications of pneumonia is an empyema. This is the accumulation of thick, purulent fluid that covers the lung. It can have long-term consequences of a trapped lung. It is treated by removing the fluid and the peel on the lung to rid the chest cavity of the infection and prevent a trapped lung. This is best accomplished through a thoracotomy incision.
Once conservative treatments have failed, hyperhidrosis of the underarms and hands may be treated with bilateral sympathectomy. This is accomplished using a VATS approach with two small incisions in the axilla and typically requires less than a 24-hour hospital stay. It decreases the sweating of the hands and axilla, but there is often increased compensatory sweating of the trunk.