Lung Cancer Surgery

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Send the CT and PET scan files together with your breathing tests

No thoracic surgeon can answer either question from a report. Send the CT and the PET-CT as image files, the pulmonary function test with the FEV1 and the DLCO figures on it, the biopsy pathology and any molecular results, and a note of your other medical conditions and how far you can walk before stopping. What comes back is an opinion on whether resection is realistic, which operation would be proposed, whether treatment before surgery would improve the odds, and whether radiotherapy would serve you better. The review costs nothing and carries no obligation.

Whether you can spare the lung

Two numbers dominate this assessment and you should learn them by name, because they will be quoted at you and nobody will stop to explain them. FEV1 is how much air you can force out in the first second, which measures how well the airways move air, while DLCO measures how efficiently oxygen crosses from the air sacs into the blood and is the number people with emphysema fail even when their FEV1 looks perfectly acceptable.

Neither figure is used raw. The surgeon calculates what each will be after the planned resection, by working out what proportion of your functioning lung is being removed, and it is that predicted postoperative value that decides the case.

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Where the picture stays unclear, a perfusion scan is added, showing which parts of the lung are actually working, because a lobe destroyed by the tumour was contributing nothing and its removal costs you less than the arithmetic suggests.

Ask for your predicted postoperative FEV1 and DLCO as percentages. Those two figures summarise your risk more honestly than any adjective, and any thoracic surgeon can give them to you in a sentence.

The operations by name

Three lobes sit on the right and two on the left. Each lobe divides into segments with their own airway and blood supply, which is what makes anything smaller than a lobe possible in the first place.

Less than a lobe

Wedge resection cuts out the tumour with a rim of lung around it, ignoring anatomical boundaries, and it is the quickest option and the one that spares most tissue. A segmentectomy removes a whole anatomical segment along its own vessels and airway, taking the territory the tumour drains into, and it is a technically harder operation that demands the surgeon identify the right plane instead of simply stapling across the lung. Until recently both were regarded as compromises for patients too frail for a lobectomy. That has changed, and the next section explains why.

A lobe or more

Lobectomy removes an entire lobe with its lymph nodes and remains the standard operation for most lung cancers. A sleeve lobectomy goes further, taking the lobe plus a cuff of the main airway and then sewing the remaining airway back together, and it exists specifically to avoid removing the whole lung when a tumour sits at the origin of a lobar bronchus. Pneumonectomy takes the entire lung on one side. Surgeons work hardest to avoid this one, because losing a whole lung carries a considerably higher risk of complications and death and leaves a permanent limitation on what you can do, so a sleeve resection is preferred wherever the anatomy allows one, and being told that a pneumonectomy is unavoidable is a reasonable moment to ask whether a sleeve resection was considered and why it was ruled out.

The standard operation has changed

For thirty years lobectomy was the answer for every fit patient with a resectable lung cancer, on the strength of a single trial from 1995. Two large randomised trials reported in 2022 and 2023 and overturned that for small peripheral tumours. Most published patient information has not caught up.

That trade is real, and it is local. Cancer came back at the original site in 10.5 percent after segmentectomy and 5.4 percent after lobectomy in the Japanese trial, so a smaller operation does leave more disease behind more often. Survival did not suffer, because a local recurrence caught on surveillance can be treated, and because patients who kept more lung died less often of everything else. In that trial 63 percent of the deaths after lobectomy were from causes other than lung cancer, against 47 percent after segmentectomy.

One qualification deserves stating out loud. A later analysis of the solid-appearing tumours in the Japanese trial, meaning the ones with no ground-glass component and therefore the more aggressive biology, confirmed the survival advantage for segmentectomy but found locoregional recurrence at 16 percent against 8 percent. The advantage held. The local control gap widened.

So the reasonable position is a narrow one. For a peripheral tumour of 2 cm or less with clear nodes, segmentectomy is now a first-choice operation and not a compromise, and it is the better choice in an older patient or one whose lungs are already marginal. Lobectomy remains standard for anything larger, for central tumours, for involved nodes, and where a segmentectomy could not achieve a clear margin.

Why the lymph nodes matter

Whether cancer has reached the lymph nodes in the middle of the chest changes the treatment more than the size of the tumour does, and finding out is a job that happens before the operation rather than during it.

PET-CT shows which nodes are metabolically active, and it is good at excluding disease and unreliable at confirming it, because inflammation lights up the same way. So a suspicious node gets sampled. Endobronchial ultrasound passes a bronchoscope with an ultrasound probe on its tip down the airway and takes needle samples of nodes sitting just outside the airway wall, under sedation and as a day case, while mediastinoscopy, a small incision at the base of the neck, is reserved for the stations that ultrasound cannot reach or for a result that comes back unconvincing.

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Skipping that step is the shortcut that costs most.

A patient who goes straight to an operation with unsuspected disease in the mediastinal nodes has an operation that will not cure them, when treatment given first might have. During the resection itself the surgeon samples or removes the node stations systematically, which is what allows the pathologist to stage the disease properly and the oncologist to decide what follows. A resection reported without a node count is a resection nobody can act on.

Keyhole, robotic or open

Open lung surgery means a thoracotomy, an incision between the ribs with the ribs spread apart, and the rib spreading is what produces the pain that lung surgery is remembered for. Keyhole surgery uses one to four small incisions with a camera and no rib spreading at all. That single difference explains most of what follows.

That last point is the one that matters. The worry about keyhole lung surgery was always that a surgeon working through small incisions would take fewer nodes and understage the disease, which would turn a gentler recovery into a worse cancer operation. The trial tested that directly and found no difference between the two groups. Robotic surgery does the same operation with articulated instruments and a three dimensional view, and it is increasingly used for segmentectomy in particular, where the dissection is finer. Open surgery keeps its place for large central tumours, for chest wall involvement, for sleeve resections in some hands, and for the moment a surgeon judges the view inadequate and converts.

Treatment before the operation

For a stage one tumour, surgery comes first and nothing precedes it. For larger tumours and for disease in the nodes, giving drugs before the operation has become standard in the last few years, and understanding why changes how you plan the trip.

What it does to the timetable

Three cycles, roughly nine weeks, then surgery a few weeks after that.

For an international patient that arithmetic decides everything about the trip. It means either a long stay or two journeys, and it means the drugs might reasonably be given at home while the surgery happens abroad, which requires the two teams to agree a plan in writing before anybody starts. Raise it at the first consultation, because discovering in week four that the operating date has moved by three months is the single most disruptive thing that happens to people in this position.

The operation and the drain

Two to four hours for a lobectomy. Longer for a sleeve resection, or where old infection has stuck the lung down.

The drain is the thing that governs your discharge date, and nobody explains this in advance often enough. It stays until the lung has stopped leaking air and the fluid draining has fallen below a set volume. Most drains come out on day two or three. Where the lung continues to leak, and lung tissue does leak, the drain stays longer, and a prolonged air leak beyond five days is the commonest single reason a straightforward lung operation turns into a long hospital stay.

Emphysema makes it more likely, because the tissue is fragile and holds stitches badly. So does an incomplete fissure between the lobes. It is a nuisance more than a danger in most cases, and it is managed by waiting, sometimes with a portable drainage device that lets you go home with it in place where that is offered.

What goes wrong

Prolonged air leak is the commonest problem and it is described above. The rest fall into a short list. Individually uncommon, collectively not rare.

Pneumonia and sputum retention come next. A patient who cannot cough properly because coughing hurts fills the remaining lung with secretions, which is precisely why the physiotherapist appears on the first morning, and why the pain relief exists so that you can breathe deeply and cough hard, and never merely to make you comfortable lying still. Atrial fibrillation, an irregular heart rhythm, occurs in a meaningful minority after lung resection and is more likely after larger operations, and it is usually controlled with medication and settles. Then the uncommon and the serious. Bleeding needing a return to theatre. Injury to the recurrent laryngeal nerve, which runs beside the nodes on the left and produces a hoarse voice and a weak cough if it is bruised or divided. Bronchopleural fistula, where the stapled airway stump breaks down, which is rare, more likely after pneumonectomy, and serious. Empyema, an infection filling the space where the lung used to be, which needs drainage and a long course of antibiotics.

Chronic pain at the incision, sometimes with numbness, persists past three months in a proportion of patients, and keyhole surgery reduces it substantially without abolishing it, which the British trial measured directly. Death within 30 days is uncommon after a lobectomy in a properly assessed patient. Death runs several times higher after pneumonectomy, which is the clearest reason surgeons work so hard to avoid taking a whole lung.

Breathing afterwards

You will notice it. That is the first honest answer. Removing a lobe takes away part of your reserve permanently, and the loss shows up on hills and stairs, never sitting in a chair. Most people find the breathlessness at three months considerably better than at three weeks, and better again at a year as the remaining lung expands to fill the space and the chest wall settles. Segmentectomy costs less function than lobectomy, though the difference measured in the Japanese trial at one year was 3.5 percent of FEV1, which is smaller than patients expect and did not reach the threshold the investigators had set as clinically meaningful, so the case for the smaller operation rests on survival and on what happens over decades rather than on how much easier the stairs feel next spring, and a surgeon who sells segmentectomy purely on breathing is overselling the part of it that was measured smallest.

1. Use the incentive spirometer every hour you are awake for the first weeks, because reinflating the lung base is what prevents pneumonia and nothing else does it as well.
2. Take the pain relief before you need it, ahead of the pain, since the point of it is to let you cough and walk.
3. Walk daily and add distance every few days, and expect hills to be the last thing that comes back.
4. Do not smoke again, at all. A second primary lung cancer is a real risk in this population and stopping is the only thing that lowers it.
5. Report a fever, increasing breathlessness, coloured sputum or new chest pain on the day, without waiting for the next appointment.

Driving comes back at around four weeks after keyhole surgery and six or more after a thoracotomy, judged by whether you could turn the wheel hard and brake sharply without hesitating. Office work follows at a similar point. Heavy physical work waits for three months.

How long you stay

Three to four weeks in the country for surgery alone, and considerably longer where drugs are given first.

Assessment takes four to six days and it is more involved than for most cancers, because the staging and the fitness testing run in parallel. CT and PET-CT, pulmonary function testing with gas transfer, an echocardiogram, endobronchial ultrasound where the nodes need sampling, bronchoscopy where the tumour is central, and a thoracic tumour board before a date is set. Node sampling adds days, and it is not a step to skip. Expect four to six days on the ward after keyhole surgery and six to ten after a thoracotomy, with the drain deciding the exact day. Add a week to ten days nearby afterwards for the wound check, the chest X-ray confirming the lung has stayed up, and the pathology discussion that sets the treatment for the next year, which is a conversation to have sitting in a room and not by reading a document forwarded to you after you have landed.

Flying deserves particular attention after lung surgery, for a physical reason. Cabin pressure at altitude is equivalent to standing at around 2,400 metres, so any air trapped in the chest expands. Nobody flies with a drain in or with a residual air pocket on the X-ray. Most surgeons clear travel at around three weeks after an uncomplicated keyhole resection, with a chest X-ray showing a fully expanded lung, no air leak, no fever, an oxygen saturation that holds up on walking, and an agreed plan for clot prevention. Get that chest X-ray done and read before you book the flight.

What drives the cost

Wedge resection and sleeve lobectomy are both lung cancer surgery and are priced nothing like each other. Eight things move the total, and one of them is peculiar to this operation.

1. Which resection is planned, from wedge through segmentectomy and lobectomy to sleeve resection and pneumonectomy.
2. The number of stapler cartridges the operation consumes, which is a genuine and substantial line item in lung surgery and varies with how complete your fissures are.
3. The approach, since robotic and keyhole platforms carry instrument costs per case that open surgery does not.
4. The staging work, including PET-CT, endobronchial ultrasound and mediastinoscopy, some of which sits outside a surgical quotation.
5. How long the chest drain stays in, since a prolonged air leak converts a four day admission into a ten day one.
6. Intensive care, planned or otherwise, which is more likely after pneumonectomy and in patients with marginal lung function.
7. The pathology, including the node count and the molecular and PD-L1 testing that decides drug treatment afterwards.
8. Chemotherapy or immunotherapy before or after the operation, which is the largest item of all and sits outside almost every surgical package.

Your own condition moves it as much as the operation. Emphysema, poor gas transfer, heart disease, diabetes, low body weight, continued smoking and previous chest surgery or radiotherapy each raise the chance of a longer stay and of care that nobody budgeted for.

A published package here typically buys the transfers, the tests before admission, the surgeon and anaesthetist, a stated number of theatre and ward days, translation, hotel nights and the appointments before departure. Excluded, almost always, are the air tickets, insurance, any night beyond the stated number, unplanned intensive care, the cost of a complication, and the whole of the drug treatment.

Six questions turn a headline into a quotation. Which resection does the figure assume, and what changes if the surgeon has to take a lobe instead of a segment. Are the staplers inside the figure or itemised. Is the endobronchial ultrasound and PET staging included. How many ward nights are covered and what an extra night costs, given that the drain decides. Is the molecular and PD-L1 testing inside the pathology fee. And what proportion of any chemotherapy or immunotherapy, if any, sits inside the quotation.

No figure means anything until a surgeon has read your scans and your breathing tests. That review costs nothing.

Once you are home

Surveillance after lung cancer surgery runs on CT and not on X-ray, at intervals of six months for the first two to three years and annually thereafter, continuing indefinitely. Two things are being looked for and they are different problems. A recurrence of the original cancer, and a second primary lung cancer in the remaining lung, which people in this group develop at a rate high enough that the annual scan never stops.

Take home the operative note naming the resection and the node stations sampled, the full pathology including the node count and the molecular and PD-L1 results, the imaging on disc, the pulmonary function figures before and after, and the surveillance schedule with dates. Get it in English. An oncologist at home cannot choose a drug without the molecular results, and requesting them six weeks later across a time zone wastes weeks that the treatment plan does not have. Expect a scarred lung to look odd on later imaging. Staple lines, scarring at the resection margin and shifted anatomy all read as abnormal to a radiologist who has not been told what was removed, so the operative note travelling with you prevents a round of scans and worry that nothing warranted, and the two minutes it takes to hand that note over at the first appointment save a fortnight of scanning and waiting later on.

Contact the team here for increasing breathlessness, a fever, coloured or bloody sputum, new or worsening chest pain, a wound that opens, or a swollen painful calf. A message with a photograph settles most questions within hours.

Frequently asked questions about lung cancer surgery